J Neurol (2010) 257 (Suppl 1):S1–S246 DOI 10.1007/s00415-010-5575-7

ABSTRACTS

Twentieth Meeting of the European Neurological Society 19–23 June 2010 Berlin, Germany Symposia and Free Communications

The abstracts have been reviewed by: F. Antonaci, Z. Argov, I. Arnulf, A. Arzimanoglou, T. Back, O. Bajenaru, E. Bartels, P.-D. Berlit, K. Bhatia, P. Boon, T. Brandt, B. Brochet, M.J. Brodie, A. Bronstein, H. Cock, G. Comi, J. de Keyser, M. de Visser, L. Deecke, R. Dengler, S. Di Donato, H.C. Diener, M. Dieterich, V. Dietz, M. Donaghy, M. Eraksoy, T. Ettlin, F. Fazekas, L. Ferini-Strambi, J. Ferro, M. Filippi, D. Galimberti, A. Grau, W. Grisold, O. Hardiman, H.P. Hartung, W. Heide, C. Helmchen, D.M. Hermann, G. Ickenstein, L. Kappos, R. Khatami, B. Kieseier, T. Klopstock, C. Krarup, G. Lammers, G. Lauria, A. Luft, P. Lyrer, Z. Martinovic, G. Mayer, S.I. Mellgren, G. Meola, R. Milo, I. Milonas, C. Mo¨ller, X. Montalban, G. Moonen, M. Mumenthaler, N. Nardocci, O. Nascimento, E. Nobile-Orazio, W.H. Oertel, M. Onofrj, D. Pareyson, Y. Parman, H.W. Pfister, D. Pohl, P. Portegies, J. Rees, H. Reichmann, P.F. Reyes, A. Rossetti, M. Rousseaux, E. Ruzicka, G. Said, J. Santamaria, E. Scarpini, N. Schaeren-Wiemers, B. Schalke, P. Schestatsky, E. Schmutzhard, J. Schoenen, M. Seeck, A. Sena, S. Sergay, V. Silani, M. Sinnreich, A. Siva, R. Soffietti, C. Sommer, A. Steck, G. Stoll, D. Straumann, E. Tolosa, A. Toscano, K.V. Toyka, H. Tumani, J. Valls-Sole´, J. van Gijn, P. Vermersch, M.J. Vidailhet, R.D. Voltz, J. Wokke

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Contents

POSTER SESSIONS

Presidential symposium

Poster session 1

Autoimmune disorders of the peripheral nervous system and muscle

1–4

Symposia Small vessel diseases: an increasing health problem The borderland of epilepsy New treatment trials and emerging therapeutic targets in MS Hot topics in movement disorders

16–19 20–23 31–34 35–38

Cerebro vascular disorders: neuro-imaging Dementia/Higher function disorders: higher cortical functions Pain and headache: megrim Preclinical neurology Extrapyramidal disorders: movment disorders Multiple sclerosis: clinical aspects Neuro-rehabilitation

P163–P171 P172–P183 P184–P193 P194–P209 P210–P226 P227–P251 P252–P262

Poster session 2 FREE COMMUNICATIONS Oral Sessions Section Section Section Section Section Section Section Section Section Section Section Section Section Section Section Section Section Section Section Section Section

1: MS: pathology and pathogenesis 2: Headache 3: Movement disorders 4: General neurology I 5: The interesting case 6: Neuro-rehabilitation 7: MS: treatment 8: Epilepsy 9: Motor neuron diseases 10: Child neurology 11: Clinical neurophysiology 12: Stroke I 13: Sleep disorders 14: Dementia I 15: Neuro-imaging 16: Peripheral neuropathy 17: Stroke II 18: General neurology II 19: Dementia II 20: Neuro-oncology 21: Neuro-ophthalmology

O39–O44 O45–O50 O51–O56 O57–O62 O63–O68 O69–O73 O75–O80 O81–O85a O86–O91 O92–O96 O97–O102 O103–O108 O109–O114 O115–O120 O121–O126 O127–O132 O133–O138 O139–O144 O145–O150 O151–O156 O157–O162

Cerebrovascular disorders: vascular disorders/haemorrages Clinical neurophysiology Pain and headache Child neurology Peripheral neuropathy Motor neuron diseases General neurology

P263–P278 P279–P296 P297–P313 P314–P324 P325–P347 P348–P360 P361–P373

Poster session 3 Cerebrovascular disorders: exmperimental stroke/mechanisms Dementia/Higher function disorders: dementia Neuro-imaging Preclinical neurology Neuro-ophthalmology Multiple sclerosis: therapy Neuro-oncology

P374–P390 P391–P402 P403–P423 P424–P432 P433–P440 P441–P464 P465–P479

Poster session 4 Cerebrovascular disorders: genetics/clinical observations P480–P496 Dementia/Higher function disorders: Alzheimer’s disease/mild cognitive impairment P497–P511 Muscle disorders P512–P535 Epilepsy P536–P552 Peripheral neuropathy P553–P565 Multiple sclerosis: cognition/neuro-psychology/treatment adherence P566–P580 General neurology P581–P591

Poster session 5 Cerebrovascular disorders: thrombolises/treatment Neuro-epidemiology Neuro-genetics Infection Extrapyramidal disorders: Parkinson Multiples sclerosis: neuro-immunology/experimental General neurology

Author Index

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P592–P609 P610–P617 P618–P631 P632–P645 P646–P662 P663–P686 P687–P699

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Presidential symposium Autoimmune disorders of the peripheral nervous system and muscle 1 Autoimmune reactions in nerve trunks G. Said (Paris, FR) Two main autoimmune processes can involve nerve trunks and induce focal and multifocal neuropathies: 1) Complement activation through necrotizing vasculitis and ischemic nerve lesions; 2) cell mediated immune reaction with formation of granulomas in peripheral nerves. In both conditions nerve biopsy is key to diagnosis. Vasculitis: necrotizing vasculitis and neuropathy In spite of the recent progress in molecular biology techniques, the etiopathogenesis of vasculitis syndrome in man has been largely unknown. Small-vessel vasculitides associated or not with anti-neutrophil cytoplasmic auto-antibodies (ANCA) are severe systemic diseases that may affect any organ, especially nerve trunks since epineurial arteries are invariably involved in small and medium size vessel vasculitis. However a large majority of primary vasculitis, especially polyarteritis nodosa, is not associated with ANCA. All vasculitis need histological confirmation. Granulomatous neuropathies Cell mediated immune response in the delayed type hypersensitivity reaction (DTH) affects nerve trunks through development of granulomas. Two main conditions are concerned: sarcoidosis and leprosy. Granulomas are made of clustered macrophages and lymphocytes. Lymphocytes and mononuclear phagocytes are attracted to the inflammed area, and in addition, mononuclear phagocytes migrate from the blood to the tissue where they mature into macrophages and phagocytize the antigens in an attempt to neutralize them. These cells are important in the formation of noncaseating granulomas. T-cell lymphocytes are markedly increased in areas of active granulomatous disease. The process of recruiting helper T cells is principally triggered by antigen presenting cells, but the question of autoreactive lymphocytes that would attract helper T cells without the need of antigen presenting cells has been raised. Giant cells are a conglomeration of epithelioid cells which share the same cytoplasm and have multiple nuclei. Granulomas may occasionally exhibit focal coagulative necrosis. The consequences of the DTH reaction in peripheral nerves is devastating in the upgrade reaction in leprous neuropathy. In sarcoidosis nerve granulomas intervenes mainly through destruction and necrosis of blood vessels with subsequent inducing ischemic nerve lesions. It is of interest to note high doses corticosteroids are highly effective both in complement activation and in cell mediated immune responses.

2 Antibody-associated neuropathies A. Steck University of Basel (Basel, CH) We examine briefly the local immune circuitry in the peripheral nervous system and its interaction with systemic immunity. In many inflammatory neuropathies there is a large traffic of T and B-cells involving a vast repertoire of antibodies and macrophages. Autoantibodies targeting peripheral nerve glycoproteins or glycolipids, including myelin-associated glycoprotein (MAG) and cross-reactive glycolipid.

Sulfoglucuronyl paragloboside (SGPG) or gangliosides have been described in inflammatory neuropathies. Anti-gangliosides antibodies have been associated with acute neuropathies such as Guillain-Barre´ syndrome (GBS) or variants like the Fischer Syndrome (FS). It was shown that both the fine specificity and the ganglioside orientation and exposure contribute to recognition by anti-gangliosides antibodies. Antibodies against GD1a/GD1b are related to severe GBS, and antibodies against GQ1b or GT1a are related to opthalmoplegia in both GBS and FS. Molecular mimicry between microbial and self components is thought to be the triggering event. Complement activation is an important nerve injury mechanism for producing anti-gangliosides antibody-mediated neuropathy. A more rational treatment with complement inhibitors may emerge. Other chronic antibody mediated neuropathies are the multifocal motor neuropathy (MMN) and the antiMAG neuropathy. Experimental paranodal demyelination with severely impaired saltatory nerve conduction suggests that focal demyelination is the pathological basis of conduction block in MMN. In the anti-MAG neuropathy the electrophysiological findings generally indicate a predominantly demyelinating neuropathy with a distal accentuation of conduction slowing. Pathological analyses of nerve tissue from anti-MAG patients using classical nerve biopsy or skin biopsy techniques detected IgM deposits at the site of MAG localization, demyelination and axonal degeneration. The finding that in many dysmyelinating experimental models and human diseases, neurofilament spacing, neurofilament phosphorylation and axonal caliber is altered suggests, that myelination, and in particular the presence of MAG exerts a regulatory role on cytoskeletal components and is therefore actively involved in the proper maintenance of structure and function of axons. In conclusion antibody testing in inflammatory neuropathies, including paraneoplastic neuropathy, is now an established diagnostic tool. New advances in the immunobiology of inflammatory neuropathies will help devise new treatment modalities.

3 Antibodies to ion channels and receptors; the widening spectrum A. Vincent John Radcliffe Hospital (Oxford, UK) In myasthenia gravis there are antibodies to the acetylcholine receptor (AChR) in 80% and to muscle specific kinase (Musk) in a proportion of the remaining 20%. The frequency of MuSK antibodies appears to differ with latitude suggesting an environmental influence. The MuSK patients often have severe bulbar symptoms and the reasons for this are not yet clear. In the Lambert Eaton myasthenic syndrome there are antibodies to the voltage-gated calcium channel (VGCC); and in acquired neuromyotonia antibodies to voltage-gated potassium (VGKC) channels. Each of these conditions, which are usually chronic and unremitting, is associated with good clinical responses to immunotherapies (in conjunction with symptomatic therapies), and the roles of the antibodies have been established by a variety of in vitro and in vivo approaches. However, VGKC antibodies are also found in Morvan’s which includes peripheral nerve hyperexcitability, autonomic dysfunction and central involvement. This condition is often associated with thymoma. VGKC antibodies are also.increasingly found in patients

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S4 with a predominantly non-paraneoplastic limbic encephalitis and in patients with adult-onset epileptic disorders. Most of these patients do well with immunotherapies. A more complex encephalopathy is associated with antibodies to NMDA receptors. These patients are often younger and can be children. Females seem to be more common than males, and may have ovarian teratomas. The disease involves seizures, cognitive and neuropsychiatric disorders, movement disorders, autonomic disturbance, reduced consciousness and other brainstem features. The patients respond slowly to immunotherapies and may relapse if not adequately treated. Finally, high levels of antibodies to glutamic acid decarboxylase (GAD) appear to be markers not only for the stiff person syndrome (frequently) but also for other immune-mediated CNS diseases such as limbic encephalitis, and antibodies to glycine receptors are beginning to be found in patients with progressive rigidity and startle syndromes.

4 Inflammatory autoimmune myopathy R. Hohlfeld Ludwig Maximilians University/Max-Planck Institute of Neurobiology (Munich, DE) Traditionally 3 distinct syndromes of inflammatory autoimmune myopathy are distinguished: polymyositis (PM), inclusion body myositis (IBM), and dermatomyositis (DM). IBM is the most common inflammatory myopathy in adults, whereas ‘‘pure’’ PM is rare. In PM and especially IBM, clonally expanded, CD8-positive T cells invade non-necrotic muscle fibers which strongly express MHC class I antigens. Putatively pathogenic autoimmune CD8+ T cells can be ‘‘resurrected’’ from inflammatory lesions in muscle biopsy tissue. The revived T cells can be used as probes for searching their unknown target antigen(s). In the special case of c-delta T cell-mediated myositis, this strategy allowed the molecular identification of a novel autoimmune target ‘‘motif’’. In DM the mechanisms of muscle fiber injury seem to be different from IBM and PM. The infiltrates in DM muscle contain B cells, plasma cells and plasmacytoid dendritic cells. The pathogenetic mechanism of perimysial atrophy, the pathological hallmark of DM, remains controversial. One hypothesis assumes that anti-endothelial antibodies cause capillary injury, leading to perimysial atrophy. An alternative, more recent hypothesis centres on the observation that several interferon-induced genes, especially interferon-stimulated gene 15 (ISG15), are strongly upregulated in DM muscle, triggering a cascade of pathogenic changes.

__________________________________ Symposia Small vessel diseases: an increasing health problem 16 The historic perspective F. Fazekas University Hospital (Graz, AT) In 1984 Otto Binswanger, a Swiss psychiatrist and neurologist, was the first to suggest ‘‘vascular insufficiency’’ as a cause for atrophy of

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the cerebral white matter and subsequent dementia. Support for this idea came from pathological work of Alois Alzheimer and it was also he who coined the eponym Binswanger’s disease in 1902. A clear definition or pathophysiologic understanding remained elusive, however, and for long even the existence of such vascular mechanism was strongly questioned. In 1962 J. Olszewski carefully reviewed accumulated literature and based on two own observations attempted to define the pathological features of Binswanger’s disease as a ‘‘subcortical arteriosclerotic encephalopathy’’. He considered this to be a special form of cerebral arteriosclerosis which affected predominantly the perforating vessels to the subcortical grey substance and white matter thus leading to multiple small infarcts and to demyelination with relative sparing of the subcortical arcuate fibres. The advent of CT promised potential for the in-vivo diagnosis of such damage but the frequent observation of ill defined white matter hypodensities in individuals without obvious neurologic symptoms also raised doubts about the specificity of such changes. This concern increased even further with the abundance of incidental white matter changes detected with MRI in the elderly. In a series of five articles Vladimir Hachinski and coworkers in 1987 thus introduced the term leukoaraiosis as a neutral descriptor for rarefaction of white matter to avoid prejudice when performing research in this area. Nevertheless the conclusion of their studies was that ‘‘white-matter changes are indeed associated with intellectual impairment and somewhat, but not exclusively with vascular disease’’. Likewise MRI researchers had also proposed some neutral terms for describing unexpected signal changes in the white matter such as ‘‘unknown bright objects (UBOs)’’, ‘‘white matter hyperintensities (WMH)’’ or age-related white matter changes (ARWMC). Subsequent radiologic-histopathologic correlations confirmed the diversity of pathologies which may underly CT or MRI changes of the white matter but also indicated vascular mechanisms and especially small vessel disease as a prominent factor for their development. It then took many further years of research to rediscover that white matter changes are only part of the spectrum of morphologic changes associated with small vessel disease (SVD). Overt or silent lacunar infarcts, minimal bleedings into the brain parenchyma through damaged blood vessels, and frank loss of brain parenchyma leading to global brain atrophy were all recognized as possible consequences of SVD. In parallel the spectrum of SVD aetiologies and of their consequences also has significantly widened and has allowed to recognise the almost endemic dimensions of SVD for the ageing population. Present advances in clinical and imaging evaluation as well as pathophysiologic and genetic understanding should now offer the opportunity to move another step forward which has to be directed towards the prevention and treatment of this health problem.

17 Small vessel diseases: an increasing health problem J.M. Ferro Hospital de Santa Maria (Lisbon, PT) Rare (e.g. CADASIL) and common (age and vascular risk factor related) small vessel diseases cause progressive brain damage, depicted in neuroimaging as lacunar infarcts and deep haemorrhages and periventricular and deep white matter lesions. Small vessel disease manifest not only as clinically evident lacunar stroke episodes, but also as a progressive deterioration in gait and balance, urinary control, mood, personality and cognition. In advanced forms pyramidal and pseudobulbar signs became evident. Patient with extensive small vessel disease are at increased risk of further vascular events including ischemic stroke, myocardial infarction and sudden death, dependency and death. Main psychiatric

S5 manifestations consist of apathic personality change, depression and resistance to anti-depressive treatment. Psychomotor retardation and executive function impairment are the most characteristic features of cognitive impairment, which in advanced forms displays the typical features of subcortical vascular dementia. In this lecture we will review the results of recent longitudinal studies of cohorts of independent subjects with imaging evidence of small vessel disease, of CADASIL patients and advances in neuroimaging of small vessel disease. Recent longitudinal studies proved that confluent white matter changes are an independent predictor of dependency in the elderly. Confluent white matter changes also predict higher scores in depression rating scales and slowness of gait and falls. They also predict impairment in timed neuropsychological tests and in executive functions, while memory disturbance seems to be more related to concomitant medial temporal atrophy. Morphometric studies of the corpus callosum showed atrophy of this structure in subjects with white matter changes. Studies using new MR sequences including tensor diffusion, showed abnormalities in normally appearing white matter. Both corpus callosum atrophy and abnormalities in normal appearing white matter correlate with clinical impairments. Although the basic pathophysiological mechanisms of small vessel disease related brain damage need further elucidation, intervention studies to prevent and slow the progression of cerebral small vessel disease are urgently needed.

18 Imaging clues to pathophysiology J. Wardlaw Western General Hospital (Edinburgh, UK) Cerebral small vessel disease (SVD) describes a range of neuroimaging features – lacunar infarcts, lacunes, white matter lesions, enlarged perivascular spaces and microbleeds – that are associated with various clinical features ranging from discrete stroke to cognitive decline, dementia, gait and balance disorders to the truly clinically silent. The onset is insidious, mortality is low and death may occur many years after the process first started, so pathological material is both scant and may represent end stage disease from which it is very difficult to infer the full sequence of pathophysiological events. Therefore, imaging is key to unravelling the pathophysiology of cerebral SVD - it can be used to study sequential changes from very early in the disease and relate these to clinical and cognitive features. Data from other sources, e.g. retinal vessels and blood biomarkers, complements and can help understand the imaging. Imaging studies have now provided substantial evidence that lacunar stroke is a distinct subtype of stroke that is largely to be due to an intrinsic abnormality of the cerebral small vessels, similar to that found in other features of SVD. Although the lacunar stroke may be symptomatically discrete, the underlying process is diffuse, affecting the white matter and basal ganglia predominantly, but also other organs. The cause of the intrinsic SVD is unknown but evidence from neuroimaging in patients and experimental models suggests that the primary initiating underlying cause is derangement of the blood brain barrier which may occur in response to exposure to risk factors such as hypertension. This leads to the small vessel structural changes (vessel wall thickening, disorganisation and eventual breakdown) and perivascular changes (oedema, enlarged perivascular spaces, tissue damage interpreted as ‘‘infarcts’’) and is fundamentally different to traditional ‘‘ischaemic’’ mechanisms. Small vessel occlusion due to thrombus formation on damaged vessel walls is a late secondary phenomenon.

This talk will review the neuroimaging features of SVD and summarise the available evidence from human and experimental imaging, examination of other vascular beds and other sources of information including where available systematic reviews that support the several different possible pathophysiological hypotheses, including microatheroma, intracranial stenosis, emboli, endothelial dysfunction and blood brain barrier derangement, to determine which of these most comprehensively accounts for all the imaging and pathological findings.

The borderland of epilepsy 20 Epilepsy and migraine J. Schoenen Hoˆpital de la Citadelle (Lie`ge, BE) Although migraine and epilepsy have a high 1-year prevalence of 1015% and 0.6–1% respectively, they are associated more often than by chance. In subjects with epilepsy, prevalence of migraine ranges from 14% to 26%, in persons with migraine, epilepsy prevalence is between 1% and 17% (up to 30% in children). The comorbidity is independent of seizure type, aetiology, age at onset, or family history of epilepsy, contrary to previous findings regarding for example benign epilepsy of childhood with centrotemporal spikes (BECT) which for some time was thought to be more frequently comorbid with migraine. The exact causes for the comorbidity are not known; they probably are multiple, depending on the type of migraine and the subform of epilepsy. A unidirectional causal relationship in either direction is unlikely. In most cases, it seems likely that common pathophysiological factors related to cortical dysexcitability and thalamo-cortical dysrhythmia are responsible for the association between the two disorders. In monogenic subtypes, a shared genetic susceptibility cannot be excluded. Rarely, an environmental risk factor, e.g. head trauma, is instrumental. Besides clear phenotypic differences, migraine and epilepsy have many commonalities and it can be difficult to distinguish one from the other. EEG and EEG-video recordings are of uttermost importance in such cases, in addition to careful history taking. Seizures are frequently preceded (10–15%) or followed (45%) by a headache that has most often migrainous characteristics. ‘‘Migralepsy’’, which in ICHD-II is defined as a seizure developing during or within 1 h of a migraine aura, is extremely rare. Out of 50 published cases, Sances et al (2009) found that only 2 had features supporting the diagnosis. Such periictal headaches may artificially increase prevalence data in studies of migraine-epilepsy comorbidity. For clinical practice, remember that not all anticonvulsants are also effective in migraine prevention; the two drugs for which grade I evidence is available are valproic acid and topiramate; lamotrigine is the most effective treatment for migraine with aura. Post-ictal headache, frequently disabling and neglected, merits optimal management. Further studies are needed to better understand the genetic, pathophysiological and therapeutic interplay between migraine and epilepsy. Selected references – Haut SR, Bigal ME, Lipton RBChronic disorders with episodic manifestations: focus on – epilepsy and migraine. Lancet Neurol. 2006 February; 5(2): 148– 157. – Schoenen J. and M. Bolla. Migraine and epilepsy. Two of a kind? K-Opinions 2007, 3: 2–5

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S6 – Winawer M. New evidence for a genetic link between epilepsy and migraine. Neurology 2007;68:1969–1970 – Sances G, Guaschino E, Perucca P, Allena M, Ghiotto N, Manni R. Migralepsy: A call for a revision of the definition. Epilepsia, 50(11):2487–2496, 2009

21 Epilepsy and autoimmune disorders C.E. Elger University Hospital (Bonn, DE) Many syndromes are based on an autoimmune disease which present primarily with epileptic seizures. The first is Rasmussen’s encephalitis, which is also known as chronic focal encephalitis, and was first described in 1941 by Theodore Rasmussen. It is characterized by frequent and severe seizures, loss of motor skills and speech, and a hemiparesis. A second type of autoimmune disease is limbic encephalitis in which pathogens attack primarily the limbic system and often cause memory deficits similar to those observed in Alzheimer’s disease. It does not, however, cause the same cognitive deficits as these diseases. Back in the 1960s, limbic encephalitis was described as being a clinical-pathological syndrome in adults related to cancer (paraneoplastic syndrome). Recently however, it has been receiving more and more attention by both clinicians and neurologists. In the beginning, the paraneoplastic form was the center of interest. An increasing number of diagnostically relevant autoantibodies in the patient’s sera (and cerebrospinal fluid) have been observed and the impact of non-paraneoplastic limbic encephalitic cases has also been acknowledged. In the serum of some of these patients, anti-bodies against voltage-dependent potassium channels (VGKC antibodies) were found. For patients with limbic encephalitis, the characteristic MRI course was recently described: hippocampal swelling and T2/FLAIR signal increase are initial findings. Afterwards, the swelling recedes, and the hippocampal atrophy occurs with continuous signal increase. However, no general agreement has been reached with regard to the formal diagnostic criteria for all limbic encephalitis sub-syndromes. It should be considered a differential diagnosis for adult patients who have just recently acquired temporal lobe epilepsy. Typical psycho-pathological symptoms include affective disturbances, and possibly a loss of inhibition and mood lability. Because none of the described symptoms are necessarily observed in limbic encephalitis, the disease can be monitored in a neurological centre and other centers specializing in epilepsy, memory disturbances and mood disorders. If limbic encephalitis is suspected, then an MRI of the brain should be performed and thin T2/FLAIR slices perpendicular to the hippocampal axis should be acquired.

23 Epilepsy and sleep disorders M. Walker University College of London (London, UK) There is considerable evidence of an interaction between epilepsy and sleep. Seizures can disrupt sleep and can alter sleep architecture (in particular reducing REM sleep time). In addition, antiepileptic drugs can have adverse or even beneficial effects upon sleep. Conversely, lack of sleep can predispose to seizures and treatment of conditions that disrupt sleep such as sleep apnoea can improve seizure control. Seizures also commonly occur at specific points in the sleep-wake cycle (such as the occurrence of seizures in idiopathic generalised epilepsy shortly after wakening). However, the greatest challenge in

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the field of sleep and epilepsy is in diagnosis, especially in those instances where seizures occur solely at night. Patients and partners often poorly describe events at night, and if there is no bed partner, seizures can go completely unrecognised. With the advent of video-EEG telemetry, there nocturnal seizures have been increasingly recognised. In particular, many patients previously diagnosed with a movement disorder, nocturnal paroxysmal dystonia, have been found to have epilepsy. Nocturnal frontal lobe epilepsies usually present as stereotypical hypermotor events but can also present as nocturnal wanderings and brief nocturnal arousals in which the diagnosis can be particularly difficult. Even with the benefit of video-EEG telemetry, there can be uncertainty about the diagnosis of such events. Perhaps the greatest area of error lies in differentiating parasomnias from frontal lobe seizures. The temporal patterns of these conditions can be particularly helpful: non-REM parasomnias occur once or twice in the first third of the nights from deep sleep; REM behavioural disorders occur towards the morning, and frontal lobe seizures tend to occur many times throughout the night, arising from both light and deep sleep. There are also specific clinical features that may help to differentiate these diagnoses. Yawning, external triggers, indistinct offset and prolonged duration ([2minutes) are all associated with non-REM parasomnias, whilst stereotypy and dystonic posturing are common features of seizures. Importantly, however, these diagnoses are not mutually exclusive and it is not uncommon for non-REM parasomnia and nocturnal seizures to coexist. In such instances, it is likely that the nocturnal seizures trigger the non-REM parasomnia by disrupting sleep. Indeed, any adult with new onset and frequent non-REM parasomnia should be investigated with polysomnography and video-EEG telemetry. Despite considerable advances in our diagnostic tools, the diagnosis of nocturnal events continues to be problematic. The EEG during such events is often obscured by artefact and rhythmic EEG patterns can occur both in seizures and with arousal. Very often, the diagnosis of brief nocturnal events remains a matter of clinical judgement.

New treatment trials and emerging therapeutic targets in MS 31 Monoclonal antibodies G. Comi Scientific Institute San Raffaele (Milan, IT) Monoclonal antibodies (mAbs) are a group of therapeutic agents that target specific molecules expressed on the cell surface. Many monoclonal antibodies are under evaluation for their potential efficacy in multiple sclerosis, having as a target molecules expressed on the surface of immune cells. These emerging therapies have potential selective immunomodulatory effects, both direct and indirect. Among mAbs treatment, four are in an advanced phase of development: Natalizumab has been approved for treatment of relapsing remitting multiple sclerosis (RRMS) and, at present, more than 70.000 patients are treated worldwide; Rituximab failed a phase III clinical trial in primary progressive multiple sclerosis (PPMS) and showed positive results in a phase II clinical trial in RRMS; Alemtuzumab resulted highly active in a phase II clinical trial against an active comparator and is now tested in a phase III clinical trial in early RRMS; three small, open-labeled, baseline-to-treatment phase II trials established Daclizumab as a potential therapy for RRMS. Common and specific adverse effects have been described for each treatment, infections being the more relevant problem. This

S7 review summarizes the known or hypothesized mechanisms of action of these 4 mAbs and the results of pre clinical and clinical studies. Moreover, other mAbs in an earlier phase of development will also be shortly presented.

34 Antigen based immune therapy—DNA-derived immunisation E. Havrdova´ Charles University (Prague, CZ) There has been a lot of efforts to find the way of influencing the immune system of MS patients using more specific tools than immunosuppression or immunomodulation by unspecific means like interferons or cytotoxic drugs. Since myelin-reactive T cells are present in the blood of healthy individuals as well as in MS patients, MS most likely involves impaired regulation of myelin-reactive T cells. Selective antigen-specific interventions target the trimolecular complex in an attempt to induce tolerization of the autoreactive T cells. The idea of vaccination against the T cell receptor (TCR) with the attempt to induce an immune response that eliminates self-specific T cells has been tested in many animal models of EAE. Development of TCR peptide vaccination requires identifying target TCR b variable genes and creating a vaccine capable of reliably boosting TCR reactive T cells. Small recent trial using a trivalent TCR peptide vaccine showed also the ability of this treatment approach to restore FoxP3+ immunoregulatory T cells. Altered peptide ligand (APL) is a native peptide, which is modified by amino acid substitutions at essential contact residues for the TCR. APLs can modulate T cell responses to native peptide antigens implicated in the pathogenesis of autoimmune diseases. These molecules may block the MHC molecule, may mediate TCR antagonism, induce T cell anergy and affect T cell differentiation, therefore determining Th1/Th2 balance. The regulation of the strength of Th2 response is crucial as APL may easily shift the reaction towards hypersensitivity. This happened in 9% of patients in phase II clinical trial with NBI 5788. Recent animal studies with APLs have been working with MBP cyclic analogs to overcome the induction of proteolytic enzymes by classical APLs. DNA vaccine appears to act by tolerizing the immune system in such a way that the ongoing autoimmune response against MBP and other myelin-specific antigens is downregulated. The data on the high anti-MBP–reactive MS patients who benefited the most from DNA plasmid vaccine encoding myelin basic protein (MBP), BHT-3009, suggest that in future we may be able to identify those patients who could experience the greatest benefit from DNA vaccination. All these therapeutic approaches has been successfully studied in animal models for years, however, there have been difficultiesin making successful transitions from animal models to human clinical trials. Despite all these problems this approach retaines a lot of attractive force.

Hot topics in movement disorders 35 Neuroprotection in Parkinson’s disease: a never-ending story H. Reichmann University Hospital Carl Gustav Carus (Dresden, DE) Neuroprotection in Parkinson’s disease (PD) may be defined as measures undertaken to protect neurones from degenerative

processes by the use of medication designed to interfere with the underlying cell death mechanism(s), and thus either halt or slow down the rate of cell death. In the past, because no objective method for determining the extent of dopaminergic cell death was available, it was not possible to ascertain if neuroprotection was being achieved in the treatment of PD. However, imaging techniques such as b-CIT-SPECT or F-Dopa-PET which come close to this goal, are now available. To date, there are two excellent studies on the possible neuroprotective effect of the dopamine agonists, pramipexole and ropinirole. Compared to these two drugs, levodopa is associated with a significant decrease in dopamine cell function, but nonetheless, there may still be some hesitation to accept that there is a good correlation between imaging techniques and dopamine cell function. Obviously, ethical considerations forbid a period of 2–4 years without treatment, hence neither study included a placebo arm, and thus it is not possible to determine whether these two dopamine agonists really afford neuroprotection in PD or if instead, levodopa increases cell death. For this reason, modern studies with the second-generation MAO-B-inhibitor, rasagiline, have focused on disease modification by use of the so-called delayed-start design. In the TEMPO and ADAGIO study, one group of de-novo PD patients were treated immediately after diagnosis with rasagiline whilst the other group was first treated with placebo and then received the drug 6 or 9 months later. The results were not unequivocal, and thus it may well be that rasagiline is a disease-modifying agent. In contrast, pramipexole did not show disease-modification in the PROUD study in which newly diagnosed patients were either treated with pramipexole immediately or else received placebo for 6 or 9 months prior to receiving the drug. In conclusion, there are certainly clinically relevant evidence that several anti-Parkinsonian agents, when used early, may alter the course of the disease but definite proof of a neuroproctective effect in PD is still lacking.

36 Brain iron and movement disorders S.J. Hayflick Oregon Health and Science University (Portland, US) High levels of brain iron are associated with common and rare neurodegenerative disorders. Over the past decade, substantial progress has been made in delineating the genes that underlie major forms of neurodegeneration with brain iron accumulation (NBIA, formerly Hallervorden-Spatz syndrome). This heterogeneous group of disorders includes pantothenate kinase-associated neurodegeneration (PKAN), neuroaxonal dystrophy (NAD), aceruloplasminemia, and neuroferritinopathy. Recently, two new NBIA genes have been identified, bringing to six the total number of known causative genes, yet additional genes remain to be discovered. Each genetically distinct form of NBIA encompasses a broad phenotypic spectrum. PKAN ranges from severe dystonia with pigmentary retinopathy in childhood to prominent neuropsychiatric defects with parkinsonism in adults. The same gene that is mutated in classic infantile neuroaxonal dystrophy (INAD or Seitelberger disease) can also cause ataxia and autism with high brain iron in childhood or dystonia-parkinsonism in adults without brain iron accumulation. Discovery of the genes underlying these two forms of NBIA have focused attention on pathways common to both. PKAN is caused by mutations in PANK2, encoding pantothenate kinase 2, which is essential for coenzyme A biosynthesis. CoA is used by the cell to generate energy via its involvement in the Krebs cycle and in fatty ` -oxidation. INAD is caused by mutations in PLA2G6, acid ƒO encoding phospholipase A2 group VIa, which is essential for

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S8 membrane lipid turnover and repair. These two pathways intersect at fatty acid metabolism, and the recent identification of a new NBIA gene further highlights the central role that disturbances in fatty acid metabolism play in different forms of NBIA. Animal models for PKAN and INAD recapitulate key disease features to a limited degree. Whereas the Pank2 knockout mouse shows no clinical neurological disease, the fruitfly mutant has neurological and eye problems and has enabled advances in the dissection of disease pathogenesis and the development of promising rational therapeutics. The Pla2g6 knockout mouse shows only late neurological disease; however, two other mutants manifest severe early neurodegeneration and have focused attention on novel aspects of this disorder. New insights into disease pathogenesis and rational therapeutics will be presented.

FREE COMMUNICATIONS Oral Sessions Oral session 1 MS: pathology and pathogenesis

37 The genetics of parkinsonisms J. Hardy

O39 Accumulation of natalizumab at the VLA-4 receptor as a potential molecular basis of enhanced treatment efficacy and occurrence of opportunistic infections P. Wipfler, K. Oppermann, G. Pilz, A. Harrer, E. Haschke-Becher, A. Kunz, S. Golaszewski, G. Ladurner, J. Kraus

University College of London (London, UK)

Paracelsus Medical University (Salzburg, AT)

In my talk I will discuss both the mendelian genes for Parkinson’s disease and parkinsonian disorders as well as the risk variants which are being identified by genome wide association studies. I shall also discuss the remarkable discovery of glucosecerebrosidase loss of function variants as high impact risk variants for the disease. I will try and integrate these findings into a discussion of pathway analysis for the pathogenesis of the disorder and finally, I will discuss what proportion of risk for the disorder has now been elucidated.

Objective: To determine regulatory processes of very late activation antigen-4 (VLA-4) on peripheral blood mononuclear cells (PBMCs) during Natalizumab treatment. Background: Natalizumab (Tysabri) is the first monoclonal antibody used in the treatment of multiple sclerosis (MS). This humanized IgG4 antibody binds directly to the a4 subunit of VLA4. VLA-4 is a heterodimer consisting of an a4- and a b1-integrin subunit. In a former study we found a continuous decrease of unbound a4 on PBMCs during 12 months of Natalizumab treatment. Design/Methods: We measured the cell surface bound expression of a4- and of b1-integrin on PBMCs (T cells, B cells, monocytes/ macrophages) determined by five colour flow cytometry. Moreover, we investigated IgG4 expression levels to assess cell surface binding of Natalizumab. Blood was sampled from 8 MS patients before and three months after onset of Natalizumab treatment and from 4 out of the 8 patients again after 6 months. Results: Besides the known continuous decrease of a4 (p\ 0.001) we found a significant reduction of cell surface bound expression of b1 on all investigated PBMC subsets (p\ 0.01) after 3 months of Natalizumab. The effect on b1 on T cells was even stronger after 6 months. Moreover, we determined an enhanced expression (p\ 0.05) of IgG4 on the cell surface of T cells and B cells after 6 months compared to the 3 month level. Conclusions/Relevance: Our results suggest both a continuous down-regulation of VLA-4 during six months of Natalizumab treatment and also a potential accumulation of Natalizumab at the VLA-4 receptor. Both findings might contribute to the enhanced therapeutic efficacy in the second year of Natalizumab treatment but also to the increasing prevalence of progressive multifocal leukoencephalopathy (PML) after long-term Natalizumab treatment. Our data might provide a basis for establishing a biomarker system to optimize Natalizumab treatment efficacy and also to determine patients at risk for PML. This study was supported by Biogen-Idec Austria

38 Restorative therapies for Parkinson’s disease R.A. Barker Cambridge Centre for Brain Repair (Cambridge, UK) Parkinson’s Disease (PD) is a common neurodegenerative disorder that is characterised by widespread pathology throughout the central, enteric and autonomic nervous system. Consequently the disease presents with a range of motor and non-motor features. However, at the heart of the disease is the loss of the dopaminergic nigrostriatal pathway, and replacing this transmitter dysfunction with drugs such as L-dopa and dopamine agonists offer significant symptomatic benefit to many patients especially in the early stages of the disease. As a result, various strategies have been explored to restore this network back to normal using cell transplants and growth factor delivery systems. In this talk I will: (a) Describe the rationale behind these restorative approaches; (b) The progress made to date using dopaminergic cell based therapies and the problems that such treatments have thrown up; and (c) The use of neurotrophic factors to encourage endogenous repair of this network and the clinical data relating to this approach. I will conclude with a discussion on the problems with the clinical translation of novel restorative therapies in PD and how this can best be resolved in the new emerging treatments including stem cells.

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O40 Expression profile of miRNAs involved in CD4+ cell activation and differentiation in patients with multiple sclerosis D. Galimberti, C. Fenoglio, D. Scalabrini, C. Cantoni, M. Serpente, M. de Riz, L. Mellesi, S. Valzelli, A. Pietroboni, M. Piola, E. Venturelli, F. Cortini, C. Villa, N. Bresolin, E. Scarpini

baseline thalamic fraction [p=0.01, odds ratio (OR)=0.62], and average lesion MTR percentage change after 12 months (p=0.04, OR=0.90) as independent predictors of disability worsening at 8 years (r2=0.29). The discriminating ability of such a model in predicting the individual patients’ outcome was 69%. Baseline thalamic fraction was significantly correlated with T2 (r=-0.75, p\0.0001) and T1 (r=-0.60, p\0.0001) lesion volumes. Conclusion: Thalamic damage predicts the long-term accumulation of disability in MS. Trans-synaptic and Wallerian degeneration are likely to contribute in causing thalamic tissue damage and loss in MS.

University of Milan (Milan, IT); Bayer Schering Pharma (Milan, IT) Background: Emerging evidence underlines the potential importance of micro(mi)RNAs in the pathogenesis and course of Multiple Sclerosis (MS). Objective: to determine the expression profile of miRNAs involved in CD4+ activation and differentiation using the TaqMan technology in Peripheral Blood Mononuclear Cells (PBMC) from 29 patients with MS as compared with 19 controls. Methods: Expression profile of miR-150, miR-155, miR-146a and -b, miR21 was tested in 16 patients with Relapsing-Remitting (RR)MS, 6 with Secondary Progressive (SP)-MS, 7 with Primary Progressive (PP)-MS and 19 age matched controls. mRNA was specifically retrotranscribed for each miRNA and subsequently real time PCR was performed using an ABI PRISM 7500 FAST instrument (ABI). RNU48 was used as endogenous control. Sigma Stat software was used to compare expression levels. Results: Significant differences in the expression profile of miR146a and -b, miR21 were found in RRMS versus controls (1.53±0.11 versus 0.85±0.08, P=0.017; 1.48±0.08 versus 0.87±0.08; P=0.005, 1.44±0.13 versus 0.82±0.06 P=0.032, respectively) but not in SP and PPMS patients as compared with controls (P[0.05). No significant differences were found in expression levels of miR150 and miR155 (P[0.05). Conclusion: These results support a role of miR146a and -b, and miR21 in RR-MS. Interestingly these miRNAs have been involved in the differentiation and regulation of CD4+ cells. Since the activation of CD4+ cell is considered to have pivotal role in MS pathogenesis, the identification and the study of miRNAs which influence and regulate this pathogenic process could contribute to find new therapeutic targets.

O41 Relation between thalamic atrophy and long-term disability progression in multiple sclerosis: 8-year follow-up study M.A. Rocca, S. Mesaros, E. Pagani, M.P. Sormani, G. Comi, V. Martinelli, M. Filippi University Hospital San Raffaele (Milan, IT) Objectives: In multiple sclerosis (MS), tissue loss and microscopic disease-related abnormalities in the overall gray matter (GM) have been associated with disability progression. The objective of this study was to assess the value of thalamic damage, taken in isolation, and its short-term changes in predicting the long-term accumulation of disability in MS. Methods: Conventional and magnetization transfer (MT) MRI scans of the brain were obtained at baseline and after 12 months in 73 patients with relapse-onset MS, who were followed prospectively with clinical visits for 8 years. Volumes of T2-hyperintense lesions, T1-hypointense lesions, GM, thalami, and white matter (WM) were measured at baseline and 12 months. Average lesion MT ratio (MTR) and MTR histograms of the GM, thalami, and WM were also computed. A multivariate analysis, adjusted for follow up duration, was performed to establish which variables were significant predictors of long-term neurological deterioration. Results: At the end of follow up, 44 patients (60%) showed a significant disability worsening. A multivariable model included

O42 Definition of regional distribution of grey matter loss in multiple sclerosis patients with fatigue: a voxel-based morphometry study G. Riccitelli, M.A. Rocca, C. Forn, B. Colombo, G. Comi, M. Filippi University Hospital San Raffaele (Milan, IT) Objective: Fatigue is one of the most frequent and disabling symptoms in patients with multiple sclerosis. MS-related fatigue has been associated with metabolic, hormonal and neurotransmitter disturbances, and, more recently, to dysfunction of cortico-subcortical networks, measured using functional magnetic resonance imaging (MRI). The main objective of this study is to define the topographical distribution of gray matter (GM) atrophy, if present, in MS patients with fatigue, in comparison to MS patients without fatigue and matched healthy volunteers, using voxel-based morphometry (VBM). Methods: This study included 24 patients with relapsing-remitting (RR) MS and 14 healthy volunteers (mean ages: 38.4 + 8.0 and 38.7 + 8.4, respectively). MS patients were divided into two groups according to the presence/absence of fatigue. In all the subjects a high-resolution T1-weighted scan was acquired using a 1.5 Tesla scanner. VBM analysis was performed using SPM5 and an ANCOVA model (p value \ 0.001 uncorrected; k [ 100). Results: Compared to healthy volunteers and to MS patients without fatigue, patients with fatigue had significant reduced GM volume in several areas of the left frontal lobe, including the middle frontal gyrus (MFG) (BA6 and 9), the precentral gyrus (BA4), the superior and inferior frontal gyrus (BA8 and 47), and the cingulate gyrus (BA31). Compared to MS patients with fatigue and to healthy volunteers, MS patients without fatigue showed GM atrophy in the left MFG (BA6) only. In the whole group of MS patients, fatigue severity scale was significantly correlated with atrophy of the left precentral gyrus (r=0.76, p\0.001). Conclusions: Patients with fatigue exhibit a more severe GM atrophy than healthy controls or MS patients without fatigue in several frontal lobe areas of the left hemisphere, which are part of the sensorimotor network.

O43 Comprehensive symptom profile for symptom assessment in patients with multiple sclerosis: applicability and characteristics A.A. Novik, T.I. Ionova, S.A. Kalyadina, D.A. Fedorenko, N.E. Mochkin, K.A. Kurbatova, G. Gorodokin Pirogov National Medical Surgical Centre (Moscow, RU); Multinational Centre of Quality of Life Research (St. Petersburg, RU); Center for Health Outcomes Research and Evidence Based Medicine (Hackensack, US)

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S10 Symptom severity is an important treatment outcome for patients with multiple sclerosis (MS). Comprehensive symptom assessment and monitoring before and during treatment as well as at follow-up is worthwhile. We aimed to develop a new symptom assessment tool – Comprehensive Symptom Profile in Patients with Multiple Sclerosis (CSP-MS) and test its applicability in this patient population. CSP-MS is developed to assess the severity of 22 symptoms specific for MS patients. It consists of numerical rating scales, scored from ‘‘0’’ (no symptom) to ‘‘10’’ (most expressed symptom). There have been identified 4 clusters of symptoms, which were clinically relevant and increased the practicability of the tool. Applicability of CSP-MS with preliminary analysis of psychometric properties was tested in a pilot study which included 83 patients with different types of MS: secondary progressive –29 (35%), primary progressive –13 (16%), progressive-relapsing –4 (5%), relapsing-remitting –37 (44%). Mean age was 31.8 years; male/female distribution –33/50. Mean EDSS was 3.5 The utility of CSP-MS was demonstrated: all the items were easy to read and understand by the patients; the data of the tool were clear for interpretation by physicians and were used by them in clinical decision making. Reliability of CSP-MS was satisfactory (Chronbach’s a coefficient varied from 0.78 to 0.93). The construct validity of CSP-MS was proved by factor analysis. High sensitivity to changes in symptom status was demonstrated by a statistically significant difference (p\0.05) in symptom severity at different time-points post transplant. Thus, CSP-MS is an appropriate and practical tool to assess symptom severity in MS patients. The utility of the questionnaire was shown; preliminary psychometric properties appeared to be satisfactory. Further studies are needed before the wide-spread use of CSPMS in clinical practice and clinical trials.

O44 Evaluation of the risk of malignancy in patients with multiple sclerosis treated with subcutaneous interferon b-1a M. Sandberg-Wollheim, G. Kornmann, M. Moraga, M. Miret, E. Alteri University Hospital (Lund, SE); Merck Serono S.A. (Geneva, CH) Background: In chronic conditions, risks that may potentially be associated to long-term therapy, such as malignancies, must be assessed. Currently there are insufficient published data to allow meaningful assessment of the risk of malignancy in patients with multiple sclerosis (MS) who are receiving immunomodulatory drugs compared with patients not using these treatments. Objective: To determine the risk of malignancy in patients with MS receiving subcutaneous (sc) interferon (IFN) b-1a, using data from the Merck Serono Global Drug Safety (GDS) database and pooled safety data from placebo-controlled and comparative Merck Serono-sponsored clinical trials of sc IFN b-1a in MS. Methods: The Merck Serono GDS database records all individual case safety reports (ICSRs) received in the post-marketing setting and all serious ICSRs from clinical trials of sc IFN b-1a. The Standard MedDRA Query (SMQ) ‘‘malignancies’’ (narrow scope) was used to retrieve all relevant cases from the two databases. From the GDS database, retrieved events were grouped by cancer localization (e.g. breast, lung). The number of observed cases of each type of cancer was compared (using age- and sexstandardization) with the expected number from general population data from the World Health Organization–International Agency for Research on Cancer Globocan 2002 database to obtain the observed-to-expected ratio. For the pooled clinical trial safety data,

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the incidence of events of interest (retrieved with the same SMQ) was calculated. Results: The estimated total exposure to sc IFN b-1a in the postmarketing setting over the last 11 years was 720,123 patient-years. Data for the observed-to-expected ratios of individual malignancies do not suggest an increased risk with sc IFN b-1a use: for medically confirmed cases, observed-to-expected ratios ranged from 1:18 to 1:6 for solid tumours and from 1:9 to 1:2 for lymphohaematopoietic tumours. Twelve clinical trials with a total of 3746 patients exposed to sc IFN b-1a and 824 to placebo were identified for analysis. These data showed no increased incidence of malignancy per 1000 patientyears with sc IFN b-1a (4.0 [95% confidence interval (CI): 2.9–5.5]) compared with placebo (6.4 [95% CI: 3.3–11.2]). Conclusions: Extensive safety data, obtained in both clinical practice and clinical trial settings, suggest that treatment with sc IFN b-1a does not increase malignancy risk in patients with MS. Sponsored by Merck Serono S.A.–Geneva, Switzerland

__________________________________ Oral session 2 Headache

O45 Voxel-wise assessment of white and grey matter damage in patients with migraine and different disease phenotypes M. Absinta, M.A. Rocca, B. Colombo, A. Falini, G. Comi, M. Filippi University Hospital San Raffaele (Milan, IT) Objectives: Seminal studies in small and selected groups of migraine patients suggested an involvement of the white matter (WM) and gray matter (GM) beyond the resolution of conventional imaging. In this study we wished to assess the patterns of damage regional distribution in the normal-appearing WM and GM in a large group of migraine patients with different clinical (aura vs. no aura) and radiological (T2 lesions vs. no lesions) characteristics, using tract-based spatial statistics (TBSS) and voxel-based morphometry (VBM). Methods: High-resolution T1-weighted and diffusion tensor MRI scans were acquired from 82 migraine patients (40 with aura, 34 with T2-visible lesions) and 27 matched healthy controls. VBM analysis was performed using SPM5 and an ANCOVA model, including age, gender and intracranial volume as nuisance variables. TBSS analysis was performed using FMRIB’s Diffusion Toolbox. Results: No abnormalities of the brain WM were detected in patients with migraine (considered as a whole and subdivided in the different study groups). Compared to controls, the whole sample of migraine patients had decreased GM volume in regions in the left frontal, parietal and temporal lobes. Temporal lobe atrophy was more pronounced in patients with vs. those without aura. Compared to controls, migraine patients with T2-visible lesions had additional areas of GM loss in the right frontal lobe, whereas compared to patients without lesions they had severe GM loss in the visual cortex, bilaterally. They also showed significant increase of GM volume in the right hypothalamus. Significant correlations were found between regional GM loss and disease duration and T2 lesion volume (r ranging from -0.42 to -0.71). Conclusion: The regional patterns of GM involvement differs among migraine patients according to their clinical and radiological

S11 characteristics. The correlations found between the extent of GM changes and disease duration and T2 lesion load support the notion of migraine as a progressive disease.

O46 Pathophysiology of prolonged migraine aura S. Viola, P. Viola, P. Litterio, M.P. Buongarzone, L. Fiorelli Hospital of. S. Pio Vasto (Vasto, IT); Emergency Medical Service (Lanciano, IT) Background: In 20% of cases, the migraine headache is preceded by an aura (MA+). Leao first suggested a relationship between migraine aura and cortical spreading depression (CSD) an electrophysiological phenomenon which slowly moves over the cortex. Some human neuroimaging studies have indirectly suggested that CSD was associated a cerebral hypoperfusion due to a decreased metabolic demand. During migraine aura some studies by Transcranial Doppler (TCD) showed a decrease of blood flow velocities and increase of the Pulsatility Index (PI) suggestive of hypoperfusion of cerebral microcirculation. Objective: To identify the pathophysiology of migraine attack with prolonged migraine aura. Patient and methods: We studied the cortical cerebral microcirculation by an innovative Near-Infrared Spectroscopy (NIRS) and the cerebral macrocirculation by TCD in 8 subjects (3 M and 5 F, range age 12–41) during spontaneous prolonged migraine aura in according to ICHD-II criteria and after 1, 2, 4, 6,12 hours the end of aura. No neuroimaging study has never monitored subjects with spontaneous migraine for some hours after the end of aura. We used a portable NIRS system (760 nm & 850 nm as source, 4 cm source-detector separation) that measures Cerebral Tissue Oxygen Saturation (StcO2), and the Arterial Pulse Wave of Cerebral Microcirculation (APWCM) reflecting respectively function and blood flow of cortical cerebral microcirculation. Results: During aura NIRS showed a significant decrease of the APWCM amplitude (35 %) p\0.002, and an increase of StcO2 (15 %) p\0.008 ipsilateral to the headache pain and contralateral to the symptoms of aura compared with the headache-free periods, TCD showed a significant increase of PI (38 %), p\0.001 and a decrease of the diastolic velocity in the posterior and middle cerebral artery ipsilateral to the headache pain compared with the headache-free periods. NIRS and TCD parameters normalized after 4-6 hours the end of aura. Conclusion: During prolonged migraine aura we found areas of cortical hypoperfusion corresponding to the topografy of aura symptoms that were the result of a decreased metabolic demand rather than ischemic mechanism and normalized later the end of aura.

O47 Dissociable prefrontal cortex activity during pain relief following perceived and exerted control on pain in heat-hyperalgesia: an event-related fMRI study S. Leyendecker, C. Mohr, D. Petersen, C. Helmchen University of Lu¨beck (Lu¨beck, DE) Perceived control over pain can attenuate pain perception by mechanisms of endogenous pain control and emotional reappraisal irrespective of whether this control is exerted or only perceived.

Self-initiated termination of pain elicits different expectations of subsequent pain relief as compared to perceived pain control. It is unknown whether and how this perceived vs. exerted control over the noxious stimulus during pain affects subsequent pain relief. Using fMRI we studied 15 volunteers in a 2 x 2 factorial design during capsaicin-induced heat-hyperalgesia. Short and long painful stimuli were applied in a randomized order, either controllable by the volunteer or not. Subjects usually terminated controllable long lasting stimuli (exerted control) whereas controllable short stimuli were terminated automatically (perceived control). Uncontrollable long stimuli were automatically terminated after an interval comparable with the duration of the controllable stimuli. Using controllability as a factor, there was dissociable neural activity during pain relief: following the perceived control condition neural activity was found in the orbitofrontal and mediofrontal cortex; and, following the exerted control condition, in the anterolateral and dorsolateral prefrontal cortex, anterior insular cortex, anterior cingulate and posterior parietal cortex. We conclude that (i) controllability has an impact on pain perception during pain relief, and (ii) the prefrontal cortex shows dissociable neural activity during pain relief with exerted vs. perceived control. This might reflect emotional reappraisal during exerted control mediated by the lateral prefrontal cortex and the higher challenge of decision-making processes during perceived control mediated by the orbitofrontal and medial prefrontal cortex.

O48 Calcitonin gene-related peptide triggers migraine-like attacks in patients with migraine with aura J.M. Hansen, A.W. Hauge, J. Olesen, M. Ashina University Hospital of Copenhagen (Glostrup, DK) Objectives: Calcitonin gene-related peptide (CGRP) is a key molecule in migraine pathogenesis. Intravenous CGRP-infusion triggers delayed migraine-like attacks in patients with migraine without aura (MO). In contrast to patients with MO, patients with familial hemiplegic migraine (FHM) did not report more migraine-like attacks compared to controls. Whether CGRP triggers migraine in patients with typical (non-hemiplegic) migraine with aura is (MA) unknown. In the present study we examined the migraine inducing effect of CGRP infusion in patients suffering from MA and healthy controls. Methods: 14 patients suffering exclusively from migraine with typical aura (MA) and 11 healthy volunteers received a continuous intravenous infusion of 1.5 lg/min CGRP over 20 min. Headache and other migraine symptoms were scored every 10 minutes for one hours and self recorded hourly thereafter and until 13 hours postinfusion. Results: CGRP infusion induced significantly more delayed headaches in MA patients (12 out of 14) than in controls (2 out of 11) (P = 0.001). Furthermore, significantly more MA patients (57%; 8 out of 14) fulfilled criteria for an experimentally induced migraine attack after CGRP than controls (0 %; 0 out of 11) (P = 0.003). Four patients (28 %) reported aura symptoms after CGRP infusion. Conclusion: CGRP triggered migraine-like attacks without aura in patients suffering exclusively from MA. It also triggered a typical aura in 28 % of the patients. These data indicate similar neurobiological pathways responsible for triggering migraine headache in MA and MO patients, and suggest differences between MA/MO and FHM. This work was supported by grants from the University of Copenhagen, The Danish Headache Society and through The Lundbeck Foundation Center for Neurovascular Signalling (LUCENS).

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O49 Prophylaxis of migraine with melatonin—a randomized controlled trial K.B. Alstadhaug, F. Odeh, R. Salvesen, S. Bekkelund Nordlandssykehuset HF (Bodø, NO); University of Tromsø (Tromsø, NO) Objective: No current, well-tolerated, prophylactic therapy for migraine has a success rate exceeding 50%. A previous open-label study of melatonin, a key substance in the circadian system, has shown effects that warrant a placebo-controlled study. The objective of this study was to evaluate the effect of melatonin as prophylactic medication for migraine. Methods: Men and women, aged 18-65, with migraine but otherwise healthy, experiencing 2-7 migraine attacks per month, were recruited by advertisement in the main local newspapers. A randomized, double-blind, placebo-controlled crossover study was carried out in two centers, the local hospital of Bodø and the university hospital of Tromsø, from March to October 2009. After a 4week run-in phase with recording of migraine attacks in a headache diary, 106 patients were assessed for eligibility. Only 48 met the inclusion criteria. They were randomized to receive either placebo or melatonin (Circadin) at a dose of 2 mg (prolonged-release) 1 hour before bedtime for 8 weeks. After a 6-week wash-out period treatment was switched from placebo to melatonin or vice a versa for another 8 weeks. The primary outcome was migraine attack frequency. Secondary endpoints were sleep quality assessed by the Pittsburg Sleep Quality Index (PSQI) and tolerability of melatonin. Results: Forty-six patients completed the study (96%). In the runin phase an average attack frequency of 4.2 (± 1.2) per month was recorded. During melatonin treatment the attack frequency dropped to 2.8 (± 1.6). However, the drop in attack frequency during placebo was almost equal (p = 0.497). A highly significant time effect was found (p = 0.006). There was no carry-over effect (p = 0.880). Also the mean global PSQI-score improved during the trial and a trend to benefit, in favor of melatonin over placebo was seen with the global PSQI-score (p = 0.09). Regression analysis showed no relationship between attack frequency and global PSQI-score. Only a few minor side effects were reported, not significantly different during melatonin treatment compared to placebo. Conclusion: Prolonged-release melatonin, 2 mg 1 hour before bedtime, was well tolerated, but did not provide any significant effect over placebo as migraine prophylaxis. There was a trend to benefit, in favor of melatonin over placebo on sleep quality. (ClinicalTrials. Gov number, NC00849511)

O50 Proteome analysis of cerebrospinal fluid: does the renin-angiotensin system contribute to idiopathic intracranial hypertension? H. Tumani, N. Hartmann, V. Lehmensiek, H. Mogel, D. Gro¨tzinger, A.C. Ludolph, J. Brettschneider University of Ulm (Ulm, DE) Objectives: The etiology of idiopathic intracranial hypertension (IIH), also known as pseudotumor cerebri (PTC), remains poorly understood. The hypothesis that disturbance of cerebrospinal fluid (CSF)blood homeostasis contributes to disease pathology encouraged the search for CSF biomarkers of IIH. We analyzed the CSF proteome of patients with IIH to detect biological markers that could offer new insight into the pathomechanisms underlying the disease. Methods: We used two-dimensional fluorescence differential in gel electrophoresis (2-D DIGE) to compare the CSF of 18 patients

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with IIH to 18 age-and sex-matched normal controls. Validation of the identified proteins was done by ELISA, including 21 additional normal controls, 24 inflammatory neurological diseases (IND) and 16 patients with neurodegenerative diseases (ND). Results: We identified 71 spots corresponding to 11 different proteins and their isoforms that were significantly altered in IIH (angiotensinogen, hemopexin, albumin, immunoglobulin G heavy chain A1, sterol regulatory element binding transcription factor 1, Vitamin-D-binding protein, serpin A1, Zn-a-2-glycoprotein, transthyretin, transferrin, haptoglobin). Conclusions: Our study provides a panel of new CSF candidate markers of IIH, including angiotensinogen. Previous studies showed the intrinsic brain renin-angiotensin system (RAS) to regulate blood flow to the choroid plexus and CSF production. Consequently, altered CSF levels of angiotensinogen could indicate a dysbalance of the RAS and CSF production in IIH. Intervention in the RAS may provide new strategy for therapeutic intervention in IIH.

__________________________________ Oral session 3 Movement disorders O51 Defining the phenotypic signature of DYT11 mutations in myoclonus-dystonia patients M. Carecchio, M. Bonetti, M. Magliozzi, M.J. Edwards, A. Ferraris, I. Torrente, E.M. Valente, K. Bhatia University College London (London, UK); CSS-Mendel Institute (Rome, IT); IRCCS Casa sollievo della sofferenza (Rome, IT); University of Messina (Messina, IT) Objectives: The classical phenotype thought to be associated with DYT11 mutations includes early onset (B20 years) myoclonus, alone or in combination with dystonia, involvement of the upper body and positive family history. However, it is not clear whether the spectrum of DYT11 mutations includes also ‘‘non classical’’ patients with a partial combination of these clinical features. In this study we aimed at evaluating the frequency of DYT11 mutations in classical and non classical patients, in order to better delineate the clinical phenotype associated with DYT11 positivity and negativity. Methods: Fifty two patients were enrolled at the National Hospital for Neurology and Neurosurgery, London, and gave their informed consent for DYT11 genetic test, that was performed by denaturing high performance liquid chromatography and direct sequencing and multiplex ligation-dependent probe amplification. Clinical details were obtained from notes review and/or clinical examination. Results: Eight patients had a classical myoclonus-dystonia phenotype and forty four had a non classical phenotype. Average age at onset was 8.6 and 20.1 years, respectively. In non classical negative patients (39) age at onset was [20 years in 22/39 (43.6%), symptoms at onset included myoclonus alone or in combination with dystonia in 12/39 (30.7%), distribution of symptoms at onset involved only the upper body in 28/39 (71.8%) and family history was positive in 16/39 (41%). Alcohol responsiveness was present in 7/8 (87.5%) classical patients and unknown in 1/7, and in 13/39 (33.3%) of non classical subjects. 2/8 classical (25%) and 5/44 non classical (11.3%) subjects carried DYT11 mutations. Of these, we found four novel frameshift mutations (c.443delT, c.780dupA, c.788dupA, c.694delT), one complete DYT11 deletion,

S13 and two missense mutations (c.1114C[T, c.289C[T) previously reported. Conclusions: In our cohort, only 25% of patients who met the criteria for classical myoclonus dystonia were DYT11 positive. However, 11.3% of non classical patients tested positive for DYT11 mutations, thus suggesting that the clinical spectrum of DYT11 mutations encompasses also patients with a non classical clinical phenotype. This included onset of symptoms in the lower limbs (2 patients) or with a generalized distribution (1) and absence of family history (3). Further studies on larger cohorts are needed to differentiate in more detail the clinical phenotype of non classical DYT11 patients.

O52 The topographical distribution of white matter damage in Parkinson’s disease and progressive supranuclear palsy F. Agosta, S. Galantucci, T. Stojkovic, A. Tomic, I. Petrovic, E. Pagani, V. Kostic, M. Filippi University Hospital San Raffaele (Milan, IT); University of Belgrade (Belgrade, RS) Objective: To investigate microstructural changes of white matter (WM) in patients with Parkinson’s disease (PD) and different progressive supranuclear palsy (PSP) syndromes using diffusion tensor (DT) MRI. Methods: Brain conventional and DT MRI was obtained in 20 PSP patients (mean age: 65; mean UPDRS III: 32.8), 39 PD patients (mean age 66, mean UPDRS III: 20.4), and 26 age- and sex-matched healthy subjects (mean age: 63). PSP patients were classified as Richardson’s syndrome (PSP-RS, 10 patients) or PSP-Parkinsonism (PSP-P, 10 patients) based on clinical criteria. Tract-based spatial statistics (TBSS) was used to compare fractional anisotropy (FA) values between groups. Results: Compared with controls and PD patients, PSP-RS patients had areas of significantly decreased FA in the superior cerebellar peduncle (SCP), the cerebral peduncle, the pontine commissural WM, as well as in multiple supratentorial areas including corpus callosum, middle cingulum, corona radiata, internal capsulae, fornix, and fronto-parietal WM (p\0.05, corrected for multiple comparisons). In all these regions, FA was also decreased in PSP-RS vs. PSP-P patients (p\0.001, uncorrected). A similar pattern of FA decrease (except for the SCP) was found when PSP-P patients were compared with controls and PD patients, but only at a less stringent level of significance (p\0.001, uncorrected). No regions of decreased FA were found comparing PSP-P vs. PSP-RS patients. Conclusion: This study suggests impaired structural integrity affecting WM tracts in PSP patients but not in PD. In keeping with pathological data, WM microstructural damage was more pronounced in PSP-RS vs. PSP-P patients. The less prominent involvement of WM in PSP-P patients might be associated to their favorable clinical status.

O53 Health-economic burden of Parkinson’s disease in six European countries: multicentre study of the EuroPa study group Y. Winter, S. von Campenhausen, J.P. Reese, M. BalzerGeldsetzer, K. Boetzel, P. Barone, A. Guekht, W. Poewe, E. Ruzicka, C. Sampaio, U. Siebert, W.H. Oertel, R. Dodel Philipps-University (Marburg, DE); Ludwig-Maximilians-University (Munich, DE); Frederico II University (Naples, IT); Russian Medical

State University (Moscow, RU); Medical University (Innsbruck, AT); Charles University (Prague, CZ); Medical University (Lisbon, PT); University of Health Sciences, Medical Informatics and Technology (Hall i.T., AT) Background: As the global population continues to age, the prevalence of Parkinson’s disease (PD) is expected to double within the next 25 years. PD is a progressive neurodegenerative disorder with growing disability, which imposes a considerable economic burden on the society and individual patients. The objective of the multi-country study of the EuroPa study group (http://www. EuroParkinson.net) was to evaluate health-economic burden of PD in six European countries. Methods and patients: 600 patients with idiopathic PD (100 patients per participating country) were recruited between 2003 and 2005 in Movement Disorders centers in Austria, Czech Republic, Germany, Italy, Portugal and Russia. Clinical status was evaluated using the Unified PD Rating Scale and Hoehn & Yahr stages. Health-economic data were collected over a 6-month period using a bottom-up approach. Direct costs included costs for inpatient and outpatient care, formal and informal care, special equipment, drugs and out-of-pocket costs. The human capital approach was used for estimation of indirect costs. Costdriving factors were identified in multiple regression analysis. Results: The total mean annual costs per patient ranged from EUR 5,240 in Russia to EUR 19,620 in Austria. Direct costs accounted for 60-70% of total costs. Depending on the country, 47% to 88% of direct costs were paid by the national health insurance systems. Expenditures for medication and home care were the major components of direct costs. Informal care was the most prevalent form of home care for PD patients across all countries. PD imposed significant economic burden on patients and their families. In Eastern European countries, out-of-pocket costs made up to 43% of patients’ net income. Cost-driving factors were disease severity, motor and non-motor complications and age. Costs of PD were higher in Western European countries than in Eastern European countries due to more expensive standards of medical care and larger proportion of older population. Conclusion: We present results of the first large-scale multicountry European study on costs of PD. The results show that PD represents a major burden on the individuals, families and society in Europe. Demographic changes will cause a substantial increase of the health-economic burden of PD. Cost-driving factors identified in this study should be considered in the development of healthcare programs aimed at reducing the health-economic burden of PD. This study was supported by a grant of the European Commission (QLRT-2001-000 20) and the German Ministry of Education and Research (Competence network Parkinson syndromes; Nr.: 01GI9901/1)

O54 Subthalamic nucleus stimulation induced changes in affective ratings of negative emotional stimuli in Parkinson’s disease T. Serranova, R. Jech, P. Dusek, T. Sieger Charles University (Prague, CZ); Czech Technical University (Prague, CZ) Objective: We investigated whether deep brain stimulation of the subthalamic nucleus (STN DBS) may affect emotional processing in patients with Parkinson’s disease (PD). Beside the motor symptoms improvement, STN DBS may cause several non-motor effects. As reported previously, these PD patients can develop behavioral and mood disturbances (impulsivity, abulia, depression). Hence we tested if STN DBS will influence subjective rating of pictures with emotional content selected from the International Affective Picture System.

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S14 Methods: Sixteen PD patients treated with bilateral STN DBS (males; mean age 57.9 ± (SD) 5 years, PD duration 16.2 ± 5 years, 3.2 ± 2 years after DBS implantation) and 12 age matched controls were assessed by an affective task. Patients were tested after an overnight withdrawal of L-Dopa in two conditions – with STN DBS switched ON and OFF in a random order. The task consisted in the presentation of 84 pictures with various emotional content of three categories: i) positive – erotica and food, ii) negative – victims and threat, and iii) neutral. Each picture was presented on a touch sensitive screen for period of 6s. Every subject was required to rate each picture separately along the dimension of emotional valence (qualitative measure of emotion from negative to positive, with neutral stimuli in the middle) and arousal (quantitative measure of emotion from calm to excited) by touching appropriate symbol on two independent visual scales ranging from 1 to 9. Results: In the condition with the STN DBS switched ON the PD patients scored the valence of negative pictures significantly lower compared to the condition with the STN DBS OFF (P\0.05 corrected). Post-hoc analysis revealed that this STN DBS-related decrease of valence reached significant levels only for pictures showing victims (P =0.014) and not threats. No differences in arousal score were found for any condition or picture category. Any of the emotional dimension parameters did not differ between the two groups. Conclusions: As our results suggested, STN DBS may affect the emotional processing of negative affective content. Changes in the subjective rating of specific emotional stimuli may reflect an increased activation of the aversive motivational system. Supported by grants IGAMZ1A8629-5 and GACR309/09/1145 and by the research program MSM0021620849.

O55 Persistence with anti-copper treatment among patients with Wilson disease A. Czlonkowska, W. Maselbas, G. Chabik, A. Czlonkowski Institute of Psychiatry and Neurology (Warsaw, PL); Medical University of Warsaw (Warsaw, PL) Objective: Wilson disease is genetically determined failure of copper metabolism. If untreated, it usually leads to death within several years from the development of clinical symptoms. Drugs which deplete copper should be continued over the whole span of patient’s life after diagnosis. Clinical observations show that patients with Wilson disease frequently stop the treatment. The aim of the study was to evaluate drug compliance (defined by us as persistence with treatment) among Wilson disease patients prescribed different anti-copper drugs, and to assess how it translates into clinical improvement and the total well-being. Methods: Our study was based on a retrospective analysis of information received from self-completion questionnaires given to patients attending Wilson disease clinic. The following data were obtained from each patient: prescribed medication, duration of treatment, persistence with treatment, subjective assessment of health status. EQ-5D questionnaire with visual analogue scale (VAS) of well-being was also used. Results: Response was obtained from 120 subjects, but only 104 questionnaires could be used for further processing. Fifty fife percent of patients were treated with d-penicillamine, and the rest were treated with zinc sulphate. The mean duration of treatment was 10.3 (SD ± 4.4) years. Our analysis did not reveal differences in persistence with d-penicillamine or zinc sulphate treatment (75.0% vs. 73.0% respectively), nor in efficacy of above medications. We have discovered, however, that regardless of used medication, persistence with drug therapy resulted in significantly better results of selfassessment: ‘‘total improvement’’: 39.7% of vs. 7.7% in persistent vs.

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non-persistent group, respectively, p=0.003; ‘‘partial improvement’’: 53.8% vs. 30.8%, respectively, p=0.045; ‘‘deterioration’’: 0.0% vs. 42.3%, respectively, p\0.0001. Patients persistent with treatment obtained higher scores in VAS than non persistent (76 vs.67, p=0.05). Conclusion: Persistence with anti-copper treatment is a major factor influencing the long-term clinical outcome in Wilson disease.

O56 Treatment of upper limb tremor with functional electrical stimulation (FES). Case report and description of the Tremor Project (FP7-ICT-2007224051) G. Grimaldi, S. Camut, M. Manto on behalf of the Tremor Consortium Research Group Background: Current therapies of tremor include drugs and surgery. The Tremor Project aims to use functional electrical stimulation (FES) for management of upper limb tremor. FES is integrated with a matrix of surface-EMG electrodes and EEG recordings in a framework of a brain-computer interface (BCI) distinguishing voluntary commands from tremor. Methods: We report a 48-years-old man affected by essential tremor (ET) for 10 years and exhibiting a postural, action and kinetic tremor in upper limbs (grade 2/4). The ADL-T24 score was 12/24. The Nine-hole Peg test score was 26.5 secs (right) and 23.4 secs (left), and the Box and Block test score was 63 blocks/min (right) and 60 blocks/min (left). Tremor was refractory to conventional drugs. FES was delivered to forearm muscles. Tremor was recorded with accelerometers located on the dorsal portion of the right hand. Stimulating electrodes were located at the level of the flexor radialis carpi (FRC) and extensor radialis carpi (ERC). Current intensity was 11mAmp for the FRC and 15mAmp for the ERC. A number of 10 successive finger-to-finger trials (30 secs for each trial) were recorded in basal condition and during the delivery of electrical current in phase. Results: Frequency of tremor was 5Hz. Clinically, FES reduced the grade of tremor to 1/4. Power spectral density (PSD) markedly decreased by 68 % with FES, as compared to the basal PSD value. Conclusion: we report a first patient with ET who was refractory to conventional medications and who responded successfully to FES delivered in upper limbs.

__________________________________ Oral session 4 General neurology I O57 The chemokine CXCL13 as a diagnostic and therapy response marker in acute neuroborreliosis M. Senel, T. Rupprecht, H. Tumani, H.W. Pfister, A.C. Ludolph, J. Brettschneider University of Ulm (Ulm, DE); University of Munich (Munich, DE) Objective: Recent studies have suggested an important role of the B-cell chemoattractant CXCL13 in acute neuroborreliosis (NB). We aimed to confirm the diagnostic role of CXCL13 and to evaluate its relevance as a therapy response and disease activity marker in NB. Methods: CXCL13 was measured in cerebrospinal fluid (CSF) and serum of patients with NB (NB, n= 28), systemic borreliosis without

S15 affection of the nervous system (SB, n=9), Guillain-Barre´ syndrome (GBS, n=11), Bell’s palsy (BP, n=19), other cranial nerve palsies (CNP, n=5), cephalgia (C, n=20), bacterial-CNS-infections (B-CNS-I, n=16) and from patients with viral-CNS-infections (V-CNS-I, n=18). For follow-up studies serial sample pairs were evaluated from 25 patients with NB (n=56), 11 with B-CNS-I (n=25) and 14 with V-CNS-I (n=36). Results: CSF-CXCL13 was significantly elevated in CSF of NB patients as compared to other neurological diseases (p\0.001). Using ROC analysis, 337 ng/g was determined as cut-off with a sensitivity of 96.4 % and a specificity of 96.9 %. CSF CXCL13 correlated neither with serum CXCL13 (R=0.372 p[0.05) nor with albumin CSF/serum concentration ratio (Qalb, R=0.350 p[0.05). Of all the parameters investigated, CSF CXCL13 showed the fastest response to antibiotic therapy, decreasing significantly (p=0.008) within one week. In untreated patients, CSF CXCL13 was elevated in patients with a short duration of disease. Borrelia burgdorferi antibody index (BB-AI) showed no significant (p=0.356) change over follow-up. Conclusions: Our study confirms the relevance of CXCL13 as a diagnostic biomarker of NB and reveals that CSF CXCL13 is mainly produced intrathecally. It suggests that CSF CXCL13 in NB is linked to the duration of disease and could be a marker of disease activity as well as a response marker to antibiotic therapy.

O58 Leukodystrophy in adults: a series of 46 cases E. Salsano, M. Savoiardo, L. Farina, V. Scaioli, M. Rimoldi, A. Bizzi, C. Marchesi, L. Nanetti, G. Uziel, D. Pareyson Neurological Institute C. Besta (Milan, IT) Objective: Information on aetiology of leukodystrophies (LDs) in adults is limited; our aim is to gain insight into this topic. Methods. We used the diagnosis related group code for LD to identify all LD cases discharged from our unit from January 1, 2004 through December 31, 2009. We reviewed all diagnoses, clinical courses, imaging study results, laboratory test results (including arylsulfatase, galactocerebrosidase, urinary sialic acid, phytanic and pristanic acids, very long chain fatty acids, needle muscle biopsy and respiratory chain enzymatic activities, cholestanol, serum and urine aminoacids, urinary organic acids, search of mutations in PLP1, GJC2, GFAP and LMNB1, karyotype, CSF analysis, auto-immunity screening), and neurophysiologic investigations, as recorded in the patient dossier. Results: We found 46 cases of LD – 7 from three families and 39 sporadic, 24 males and 22 females, mean age 40±12 years (range 19– 66). The most common LDs were aetiologically heterogeneous hypomyelinating LDs (n=11), including 2 brothers and their cousin with Pelizaeus-Merzbacher-like Disease due to a GJC2 mutation (n=3); adrenoleukodystrophy (n=4), Alexander Disease (n=3), and metachromatic LD (n=2). There were 2 sisters with Leukoencephalopathy with Brainstem and Spinal Cord Involvement and Lactate Elevation, 2 individuals with Leukoencephalopathy with Vanishing White Matter (genetic test in progress), a Sicilian man with Adult Polyglucosan Body Disease, a case of LD with calcifications and cysts, one non-syndromic mitochondrial LD, one LD with CSF interleukin-6 overproduction (likely a novel entity under study), 4 with acquired forms (neurodegenerative Langerhans cell histiocytosis, antiphosholipid syndrome, lymphomatosis cerebri, and possible neurolupus). Strikingly, there were 22 cases of LD of unknown etiology – 8 of whom were hypomyelinating (with no PLP1 mutations) and two incidentally found by brain MRI (we termed them as ‘‘radiologically isolated LD’’).

Conclusions: Adults with LD still represent a diagnostic challenge. In our retrospective analysis of 46 cases, almost 50% of patients (n=22, of whom 8 hypomyelinating) remained undiagnosed despite extensive investigation; in 4 of 46 cases (about 10%), an unexpected diagnosis of acquired leukoencephalopathy was made, suggesting that acquired forms of white matter disease may occasionally mimic a genetic leukoencephalopathy, and they should be always considered in the differential diagnosis of adults with LD.

O59 High-resolution ultrasound in the diagnosis and management of Bell’s palsy N. Yassin, Y.L. Lo National Neurosciences Institute (Singapore, SG) Background: Ultrasound (US) is an increasingly recognized technique for visualization of peripheral nerve entrapment. Clinical diagnosis of Bell’s palsy is usually supported by electrophysiology, but imaging evidence is not commonly utilized. Previous MRI studies have demonstrated mainly intracranial facial nerve enhancements. Objectives: Delineate extracranial facial nerve abnormalities in Bell’s palsy with US and correlate with clinical features, in comparison with normal controls. Methods: We studied 34 patients with unilateral Bell’s palsy clinically in a prospective fashion. Severity grading by the HouseBrackmann score was recorded. All underwent US of the extracranial facial nerve from the stylomastoid foramen exit to the parotid substance. An average diameter was obtained from 3 separate readings at the most proximal, distal and midway points along its course. Blink reflex and facial motor nerve conduction studies were performed bilaterally. Findings were compared with those from 25 normal subjects. Results: 14 of 34 patients (41%) of patients exhibited increased facial nerve diameter, compared to abnormalities in facial motor latency (32%), facial motor amplitude (44%) and blink reflex (71%). No significant correlations were found for severity grading with US diameter, facial latency, amplitude or blink reflex findings (p [ 0.05 all). Conclusions: US has comparable sensitivity with facial nerve conduction studies in the evaluation of Bell’s palsy, and demonstrates a relatively high proportion of extracranial abnormalities. These findings contribute to the understanding of the pathophysiology of Bell’s palsy and ongoing studies in prognostication for recovery.

O60 Genome-wide association study and two-stage replication phase in primary progressive multiple sclerosis F. Martinelli Boneschi, F. Esposito, P. Brambilla, J. Wojcik, M. Rodegher, V. Martinelli, L. Moiola, B. Colombo, G. Giacalone, A. Ghezzi, R. Capra, E. Lindstrom, T. Kilpatrick, B. Taylor, J. Rubio, J. Hillert, H. Abderrahim, G. Comi Scientific Institute San Raffaele (Milan, IT); Merck-Serono Genetics Research Center (Geneva, CH); Hospital of Gallarate (Varese, IT); Hospital of Brescia (Brescia, IT); Karolinska University Hospital (Stockholm, SE); University of Melbourne (Melbourne, AU)

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S16 Objectives: The aim of this study is the identification of genetic risk factors involved in the susceptibility to progressive course of multiple sclerosis (MS). Methods: We applied a genome-wide single-nucleotide polymorphism (SNP) genotyping approach (Affymetrix 500k chip) in a discovery sample of 200 patients affected with primary progressive (PP), progressive relapsing (PR) and single attack progressive (SAP) MS and 200 age- and sex-matched controls. Most significantly associated SNPs (n=20) have been tested in a independent replication sample of 200 PPMS cases of Australian Origin and matched controls. Seven out of 20 SNPs were confirmed to be associated with the disease, and they have been further tested in a second replication sample of 200 additional PPMS cases and matched controls of from Nordic Countries. Results: The HLA class II region (SNP rs3129934) was confirmed to be strongly associated with progressive forms of MS (p\0.0001 in discovery and replication sample). Moreover, additional snps in several genes involved in inflammation and neurodegeneration, including DPP6, NRG2, CCDC39, have been replicated in the Australian sample, and they are going to be genotyped in the sample from Nordic Countries. Conclusion: It is still inconclusive the search for genetic risk variants which influence the course of disease in MS. However, novel targets have been identified in our approach and represent potential candidates for further studies.

O61 A hospital survey of neonatal tetanus at a district general hospital in northeast Nigeria F. Salawu, B. Hassan, A. Abare, M. Stephen, A. Olokoba, A. Danburam Federal Medical Centre (Yola, NG); State Specialist Hospital (Maiduguri, NG); Federal Medical Centre (Nguru, NG); University of Ilorin (Ilorin, NG) Neonatal tetanus (NNT) is now a rare disease in the developed world. However it remains among the leading causes of morbidity and mortality in Nigeria and a huge challenge in achieving the fourth goal of the Millennium Development Goal. Objective: We reviewed the morbidity and mortality pattern among neonates with NNT admitted into District General Hospital in northeast Nigeria from 2003 to 2006. Methods: All neonates who were hospitalized with a final diagnosis of NNT were longitudinally followed up from admission to clinical outcome (discharge or death). Information on age, sex, clinical presentation, duration of symptoms, length of hospital admission, condition of umbilical cord stump, place of delivery, who conducted the delivery (midwife/nurse, traditional birth attendants), how cord was cut and what was used to dress cord, immunization status of mother, educational attainment of parents, clinical outcome. Results: There were 63(70.8%)males and 26(29.2%) females. The yearly number of neonates admitted varied from fifteen to twentyfive, with a mean of twenty. Mean age at admittance was 8.5+/-1.6 days, with a range of 4-21 days. Mean age at onset of symptoms was 6.2+/-1.6 days. Half of the patients were from rural areas, had no formal education and were delivered at home by untrained traditional birth attendants with no prior antenatal healthcare services. Razor blade (79%) and scissors (21%) were the instruments used to cut the cord in non hygienic conditions. Twenty two mothers had prior vaccination with tetanus toxoid during their pregnancy. Spasticity (80%), lack of sucking (70%), trismus (49%), fever (40%), omphalitis

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(40%), risus sardonicus (24%) and opistotonus (26%) were the most common presenting signs and symptoms. Age at admission\6.5 days and symptoms of onset \4.5 days, risus sardonicus and opistotonus were associated with fatal outcome. All patients were treated with equine tetanus antitoxin, antibiotic therapy and intravenous diazepam. Overall mortality was 56%. Conclusions: NNT remains a major health problem in Nigeria in the twenty first century. Health education of mothers and traditional birth attendants, promotion of hospital delivery and antenatal tetanus immunization of all pregnant women particularly in rural areas are recommended, if NNT is to be prevented.

O62 Depressive states in patients with SMON and various intractable neurological disorders T. Konishi, K. Hayashi, M. Fujita, S. Hashimoto Utano National Hospital (Kyoto, JP); Fujita Health University (Nagoya, JP) Objectives: We investigated the depressive mental states in patients with subacute myelo-optico-neuropathy (SMON), caused by clioquinol intoxication more than 30 years ago and characterized by subacute onset of sensory and motor disturbance in the lower extremities with visual impairment in comparison with various intractable neurological disorders using Zung Self-rating Depression Scale. Materials and methods: Depressive conditions were evaluated in 24 SMON patients living in Kyoto prefecture using the Zung Selfrating Depression Scale (SDS) questionnaires. Patients with other neurological diseases also used SDS questionaires included 36 patients with multiple sclerosis (MS), 28 patients with multiple system atrophy (MSA), 12 patients with amyotrophic lateral sclerosis (ALS), 100 patients with Parkinson didease (PD) and 28 patients with myasthenia gravis (MG). Patients with SMON and other various neurological disorders less than 23 points of Mini-mental state examination (MMSE) were excluded from this study. 25 healthy old people, age-matched with SMON patients, were included as a control for SMON. Clinical symptoms of SMON were evaluated using medical checkup records established by the SMON Research Committee in Japan. Statistical analysis was made using Student’s t test, Spearman’s rank correlation, or Fisher’s exact probability test using SPSS statistics 17. A level of p \ 0.05 was considered to be statistically significant. Results: The mean total SDS scores were 48.7 in SMON patients, 44.3 in MS, 43.3 in MSA, 42.3 in ALS, 41.1 in PD, 38.6 in MG and 35.0 in healthy old people. Among 20 questions in SDS questionaires, SMON patients showed significantly worst morning symptoms and greatest lack of hope compared with other neurological disorders. Among various clinical symptoms in SMON, the total SDS scores in SMON patients significantly correlated with the disability of activity of daily life (ADL) represented by the inverse total Barthel scores or bad walking ability, but did not correlate with the disturbance of visual acuity nor unpleasant dysesthetic sensory disturbance of lower extremities. Conclusion: The patients with SMON showed the highest scores of SDS compared with other neurological disorders suggesting that depressive states in SMON patients are strong enough to require for their mental health care. This study was supported by a Grant-in-Aid from the Ministry of Health, Labour and Welfare, Japan, for Research on Intractable Diseases.

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Oral session 5 The interesting case O63 A case of hyperekplexia with positive antiglycine receptor antibodies: PERM syndrome G. Contessa, S. De Mercanti, R. Sciolla, M. Iudicello, M. Clerico, B. Ferrero, M. Coletti Moja, L. Delfico, F. Franchino, E. Viglietta, A. Vincent, L. Durelli University of Turin (Orbassano, IT); John Radcliffe Hospital (Oxford, UK) Introduction: Limb and trunc rigidity, muscle spasms, brainstem signs and hyperekplexia characterize a disorder called PERM (Progressive Encephalomyelitis with Rigidity and Myoclonus) that was described in the spectrum of stiff-man syndrome, with positivity for anti-GAD antibodies, or as a paraneoplastic syndrome,with anti-amphiphysine antibodies. In hereditary hyperekplexya, mutations in the gene for glycine receptor were identified; receptors, located in the brain stem and in the spinal cord, mediate the inibitory control,which is impaired in hyperekplexia. Clinical summary: A 60-y old man,with a history of diffuse vasculopathy and bladder cancer, was admitted in January 2009 for progressive left leg rigidity with muscle spasms.He showed increased reflexes, disphagia, dysarthria,nocturnal dyspnea with laryngospasm,trismus and nystagmus.Tapping his forehead evoked massive startle reflex and muscle spasms.His symptoms improved slightly with clonazepam and carbamazepine.The EMG activity of the SCM, massereteris, deltoides and vastus medialis was suggestive for myclonus reticularis reflex. Tetanic antitoxin,paraneoplastic,rheumatologic and occult neoplasm screening were negative,as were serum anti-Hu, Yo, amphyphisine, Ri, Ma2, CRMP5/Cv2, recoverine, Ma1, GAD and VGKC antibodies. MRI of brain and spinal cord was normal.CSF examination showed a pleyocytosis. Anti-GlyR antibodies(courtesy of A. Vincent, Oxford)tested positive. Steroids and immunoglobulins was admistered, without significan improvement to the point of ICU admission, with intubation.After further steroid and immunoglobulin therapy, a progressive improvement was observed and he was readmitted to our ward. Episodes of delirium with delusions and agitation were observed, that responded to neuroleptic treatment. Remaining spasms slowly abated. After three months he was discharged on valproate, clonazepam, baclofen, olanzapine. Monthly immunoglobulin cycles are still being carried on. At 5-month follow up the patient is alert, well oriented, without significant muscle spasms, bulbar signs or startle response. Due to a right femur fracture, which occurred during hospitalisation, he is still wheelchair bound, but able to stand. Conclusions: When confronted with stiff person ‘‘plus’’ disorders, a suspicion of PERM should arise and a search for antibodies against glycine receptor performed. Compared with other PERM etiologies, anti-GlyR antibodies associated PERM seems to have a better prognosis.

O64 A new subtype of neurodegeneration with brain iron accumulation caused by mutations in the MIN gene: a case report M.C. Claussen, M. Hartig, H. Prokisch, B. Hemmer, R. Ilg Klinikum rechts der Isar der Technischen Universita¨t (Munich, DE) Introduction: Neurodegeneration with brain iron accumulation (NBIA) encompasses a group of progressive extrapyramidal disorders characterised by focal iron accumulation in the basal ganglia of the brain. The most frequent form of NBIA is pantothenate kinase associated neurodegeneration (PKAN), caused by mutations in the PANK2 gene. Recently, Hartig and Prokisch identified mutations in the MIN gene that obviously account for a significant proportion of so far idiopathic NBIA. Case report: The patient is a 35 year old woman. Symptoms started approximately at the age of 7 years with a decrease of spontaneous language, weakness of the lower limbs, gait disturbance, frequent falls and pain in the ankle joints. The symptoms slowly progressed and spreaded to the upper limbs, leading to a progressive weakness and clumsiness of the hands. The neurological examination revealed a distal accentuated tetraparesis with prominent atrophy of the small hand muscles, contracted plantar flexors, weak tendon reflexes of the lower limbs, positive Babinski‘s sign, and low amplitude tremor of the hands. At the age of 27 years an MRI was performed that showed prominent susceptibility artefacts of the bilateral globus pallidus leading to the suspected diagnosis of a Hallervorden-Spatz syndrome. At the age of 34 years, the patient presented in our clinic. Meanwhile she required a wheel chair and showed significant cognitive and behavioural symptoms such as impulsive behaviour and labile affect. Cerebral MRI (3T) indicated increased iron accumulation in the globus pallidus and substantia nigra. The eye of the tiger sign was negative. The electrophysiological examination showed a distal axonal motor polyneuropathy of the upper and lower limbs. The sensory nerves were normal. PKAN and infantile and atypical NAD were excluded by molecular testing that finally revealed a mutation in the MIN gene. Conclusion: We report one of the first cases of the new MIN associated NBIA subtype (MPAN). MPAN should be considered as a differential diagnosis in young patients with slowly progressive gait disturbance due to spastic tetraparesis, cognitive impairment with behavioural symptoms, iron accumulation in the basal ganglia without eye of the tiger sign and no cerebellar atrophy, and prominent axonal motor neuropathy.

O65 Bilateral palato-lingual myoclonus and unilateral supratentorial lesion M.N. Cardoso, B. Moreira, M. Magalha˜es Hospital Santo Antonio (Porto, PT) Introduction: Palatal myoclonus is characterized by unilateral or bilateral rhythmic movements of the soft palate, sometimes with involvement of pharynx and lower facial muscles. The association with lingual myoclonus is present in 7% of essential and in 17% of symptomatic palatal myoclonus patients. Symptomatic cases are often related to lesions through the triangle of Guillain-Mollaret with late

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S18 transsynaptic degeneration. We present a rare case of an unilateral frontal lobe lesion presenting as epileptic palato-lingual myoclonus. Case report: A 32-year-old woman, with no previous history of neurological disorder, experienced sudden onset of difficulty to articulate words, while she was talking, that lasted 10 minutes. One month later, she had another episode: her husband described a 10 minutes episode of mouth going to the right with a right limbs shacking. The frequency of similar episodes progressively increases, reaching a focal status epilepticus. When she was first observed by a Neurologist the neurological examination was normal. A diagnosis of focal epileptic seizures was made. Under carbamazepine the frequency of focal right motor partial seizures decreases but she started to note involuntary twitching of the tongue with intermittent loud clacking sounds in her mouth. When observed she presented bilateral palate and tongue myoclonus. A MRI scan showed a single cortical and subcortical lesion in the posterior portion of the left inferior frontal gyrus. Although there was some sulci effacement, the enhanced images were unremarkable and it was only noticed some linear cortical high signal in diffusion. Nevertheless, the neuroradiologist has become concerned about a low grade glial tumour. Now, she is seizures free for one and a half month treated with carbamazepine associated with clobazan. A MRI scan performed two months later was unremarkable, and it was presumed that the previous findings would be related to postictal vasogenic edema. Comments: All the above clinical features indicated an epileptic origin. Due to bilateral innervation of the tongue muscle, a unilateral hemispheric lesion can cause lingual myoclonus. In conclusion, our case confirms the concept that paroxysmal palato-lingual movements could be an unusual form of subcortical seizures.

O66 Primary Sjogren’s syndrome presented with lateral medullary syndrome J.H. Kwon, Y.E. Shin Ulsan University Hospital (Ulsan, KR); Dong-Gang Hospital (Ulsan, KR) Sjogren’s syndrome (SS) is a chronic, slowly progressive autoimmune inflammatory disease characterized by lymphocytic infiltration of the exocrine glands such as parotid and lacrimal glands. SS is associated with variable neurologic diseases involving peripheral nerves, spinal cord or cerebral white matter, and usually confused with multiple sclerosis. However, the involvement of brainstem has been rarely reported. We report a patient with SS presented with Wallenberg syndrome-like symptoms. A 21-year-old woman was admitted complaining of dizziness, tingling sensation in the left face and extremity, swallowing difficulty and dyspnea suddenly developed 3 days before admission. She had no risk factor of stroke such as hypertension, diabetes mellitus, hyperlipidemia, smoking and cardiac disease. She has been complaining of dry eye and mouth for several months before admission. On neurologic examination, she had ptois and dysmetria on the right side, gaze-evoked nystagmus, decreased sensation to pinprick, which was compatible with the right lateral medullary syndrome. Laboratory test showed elevated titer of rheumatoid factor, anti-nuclear antibody (1:160, homogeneous), anti-ds-DNA and antiRo in serum. T2 weighted image taken at 3 days after symptom onset showed high signal intensity lesion in the medulla without definite enhancement. Salivary scan revealed decreased excretion in the left parotid gland. Lymphocytic infiltration was present in minor salivary gland. These findings led to the diagnosis of SS. She was treated with intravenous methylprednisolone, and her symptom and signs due to the involvement of medulla improved. SS may present as a brainstem syndrome. SS should be considered when clinicians encounter a patient with lateral medullary syndrome with uncertain diagnosis.

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O67 Tremor and opsoclonus-myoclonus syndrome as a para-infectious complication of the pandemic virus, novel 2009 H1N1 influenza A infection D. Costigan, M. Short, M. Hannan Mater Private Hospital (Dublin, IE) Objectives: Approximately 50% of adult opsoclonus-myoclonus syndrome (OMS) is idiopathic or para-infectious. We document a case of OMS, a previously unreported para-infectious complication of Novel 2009 H1N1 influenza A (H1N1 flu) infection. Methods: Clinical observation and laboratory investigations. Results: A 28-year old female developed acute onset fever, aching and subsequent vomiting and diarrhoea. Symptoms lasted two weeks. H1N1 flu was identified by reverse transcription polymerase chain reaction (RT–PCR) on a nasal swab. A fine postural tremor was noted some days prior to flu-like complaints, persisting unchanged until initial neurological assessment 6 weeks later, when occasional asymptomatic ocular flutter was added. One week later there was rapidly worsening tremor and ataxia, predominantly axial myoclonus, and opsoclonus, consistent with OMS. There was significant improvement following high dose c globulin (HDGG), partially relapsing days later with another febrile episode, and subsequently improving on steroids following a further course of HDGG. Brain scans, general imaging and paraneoplastic serological markers were negative. At peak neurological symptoms, extensive microbiological cultures, virological PCR, immunofluorescence, and viral culture studies failed to identify alternate sources of infection. Cerebrospinal fluid was normal, except for positive oligoclonal banding. Conclusion: This illness, consisting of initial tremor and later acute and debilitating OMS, appears to represent a para-infectious complication of H1N1 flu. Tremor anticipated overt systemic disease, suggesting an unusually early dysimmune reaction rather than primary infection. The response to HDGG is consistent with reports of non-paraneoplastic OMS. The late surge of symptoms may correspond to a rise in convalescent antibody titres to H1N1 flu, but the technique of quantifying this antibody response is currently unavailable. This illness appears to be unique and distinct from previously reported cases of neurological involvement due to H1N1 flu infection.

O68 Visuo-motor deficits and damage to white matter tracts in a posterior cortical atrophy patient R. Migliaccio, F. Agosta, M. Toba, F. Corlier, L. Cruz De Souza, S. Lehericy, M. Sarazin, D. Samri, B. Dubois, M. Filippi, P. Bartolomeo Research Centre of the Institute for Brain and Spinal Cord (Paris, FR); University Hospital San Raffaele (Milan, IT) Objective: Posterior Cortical Atrophy (PCA) is a clinical syndrome characterized by progressive complex visual and visuo-motor dysfunctions associated with grey matter atrophy in posterior brain areas. A few studies have explored the involvement of white matter (WM) in PCA. Our objective is to explore the anatomical correlates of cognitive and visuo-motor deficits in a patient with PCA, by using Diffusion Tensor (DT) MRI-based tractography. Design/methods: Clinical and cognitive data were acquired in a 58-years-old patient with PCA (woman, right-handed, disease duration 18 months). Brain structural and DT MRI, and 18F-fluoro-deoxyglucose positron emission tomography (FDG-PET) were also obtained. DT MRI-based tractography was used to assess the integrity of the major WM cerebral tracts.

S19 Results: PCA patient had a clinical syndrome characterized by left visual neglect, optic ataxia, and left limb apraxia. Structural MRI showed a pattern of focal atrophy in the parietal lobe, bilaterally. FDG-PET demonstrated bilateral parietal hypometabolism, with right side predominance. DT MRI-based tractography demonstrated severe WM damage in the right inferior fronto-occipital (IFOF) and superior longitudinal (SLF) fasciculi, while the left IFOF and SLF were relatively spared. Reduction of WM structural integrity was also observed in the parietal projections of the corpus callosum (CC). No damage was detected in the inferior longitudinal fasciculus and the corticospinal tract, bilaterally. Conclusions: This study suggests that damage to IFOF, SLF and posterior CC contributes to the development of cognitive deficits in PCA, consistent with evidences from focal brain lesions that these WM tracts are involved in neglect (IFOF and SLF), optic ataxia (SLF), and limb apraxia (CC).

__________________________________ Oral session 6 Neuro-rehabilitation O69 fMRI correlates of early aphasia rehabilitation after stroke: preliminary results F. Mattioli, M. Magoni, C. Ambrosi, R. Gasparotti Citizens Hospitals Brescia (Brescia, IT) Objective: The reorganization of language related areas (LRA) in acute aphasia (A) after left hemisphere (LH) stroke is reported to have a biphasic pattern, with an early reduction in left LRA activation, followed by an hyper activation of right homologues LRA and than by a gradual increase in left LRA. The role of language therapy in this reorganization is still unknown. We compared in a 15 days post stroke observation, the fMRI activations of LRA in 4 non rehabilitated and 2 rehabilitated aphasic patients. Methods: Six right-handed patients with non fluent aphasia due to LHS were examined by means of standard aphasia assessment (AAT) and fMRI twice:\3 days post stroke (T1) and 2 weeks post stroke (T2). Two patients were submitted to aphasia therapy (1 hour per day) between the first and the second examination, the others were not. An event-related fMRI study was performed (EPRIME, Psychology Software Tools) by using a sentence comprehension task (4 sessions, 7 randomized meaningful, 7 with semantic violation sentences and 14 reversed phrases as control). Acquisitions were done by a 1.5 T Siemens, Avanto with an 8-channel receive coil (Invivo-Gainesville), BOLD and morphological sequences (SE-EPI TR=2500ms, TE=50ms, Matrix 64*64, 3.5mm thickness- 3D MPRAGE TR=2050ms, TE=2.56ms, 1mm thickness), processed by Brain Voyager QX (vs. 1.9Brain Innovation – Maastricht). A general linear model approach was used for the contrast evaluations. Patients’ data were compared with age and education matched control subjects at T1 and between T1 and T2. Results: Rehabilitated patients showed a greater improvement in AAT score than non rehabilitated ones. Rehabilitated and not rehabilitated patients showed at T1 a similarly decreased activation in both LH and RH language areas, compared to controls. Rehabilitated patients showed at T2 a greater activation in LH language areas, compared to RH LRA and did not show right Broca Homologue (Bho) and insula activation, as not rehabilitated ones. Conclusions: Functional correlates of early aphasia rehabilitation may be represented by a LH earlier activation of LRA, compared to spontaneous recovery.

Our preliminary data do not support a positive role of RH in recovery of aphasia and do not support an aspecific activation of right Bho due to training.

O70 Italian paediatric severe brain injury and rehabilitation multicentre study (GISCAR) S. Strazzer, S. Gazzellini, E. Beretta, V. Torri Clerici, F. Locatelli, M. Stortini, E. Castelli IRCCS Eugenio Medea (Bosisio Parini, IT); Children’s Hospital Bambin Gesu‘ (Rome, IT) Severe acquired brain injuries (ABI) represent an increasing medical, economical and social problem. Few studies describe the epidemiological and clinical characteristics of severe ABI in developmental age. However, it is essential to know these data in order to address therapeutic, rehabilitative and social programs tailored on the patient’s needs. Objectives: The main aims of the GISCAR study are a) to draw the clinical and demographic features of pediatric patients with severe neurological disabilities, caused by both traumatic and non-traumatic events, entering to specialized rehabilitation centers, b) to point out the etiology and the onset modality of the cerebral lesions, c) to analyse the characteristics of the rehabilitation processes and the patients’ outcome in terms of disability, strategies and clinical outline. Methods: Data collection has been executed by means of an assessment protocol created and shared between some Italian neurorehabilitation centers that look after pediatric patients affected by severe ABI. The study includes patients with ABI causing a coma state with Glasgow Coma Scale \8. Traumatic and non traumatic etiologies have been treated separately. We have evaluated the clinical parameters at the first admittances in a rehabilitation unit, for both incoming and discharge. The following structured scales have been employed: Levels of Cognitive Functioning, Glasgow Outcome Scale, Disability Rating Scale. Results: A group of 184 pediatric patients with severe ABI has been recruited. The mean age at the moment of the injury is 5.7 years. The etiology includes 51.6% of traumatic injury (TBI), 48.4% of nontraumatic etiology (NTBI). The improving trend for the TBI group is steeper than NTBI’s. In fact, a fewer amount of TBI patients remains at the same functional level between incoming and discarge. Infections seem to play the major role in NTBI during the first two years of life. Motor disability, visual and cognitive impairments, language and behavioural disorders are the prevalent clinical characteristics of severe ABI. Conclusion: Our study is the first Italian descriptive study on paediatric patients affected by ABI of both traumatic and non traumatic aetiologies. The main point concerning rehabilitation in these patients is that ABI of any severity in acute phase may lead to long term disability, conferming the high social and economic impact of this pathology.

O71 Evaluation of a pilot project of the Fu¨rst Donnersmarck Foundation: people with multiple disabilities moving from permanent residential care into ‘‘living with intensive care’’ K. Wolf-Ostermann, C.-F. Zimmermann Alice Salomon University of Applied Sciences (Berlin, DE) Objectives: ‘‘Living with intensive care’’ (LIC) is a new living facility which provides people with (multiple) severe disabilities caused by

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S20 brain injuries the chance to regain a self-determined life. It is expected that the relocation of this specific group of handicapped persons from permanent residential living in the outskirts of Berlin to two new LIC-facilities in more urban living areas in Berlin will improve their quality of life as well as their health situation in the long term. The new way of life will enhance self-responsibility and will enable the residents to become active members of society again. Methods: In a longitudinal design all residents from the ‘‘permanent residential living’’ will be surveyed for two years (12/2009-11/ 2011). They are assessed at the time shortly before moving into the new facilities as well as six, twelve and eighteen months later. Emphasis of this analysis is on the social and health-related aspects of the current as well as the future life and living situation of every single resident. Therefore data will be collected by interviewing the handicapped themselves as well as the nursing and socio-paedagogical staff. Applied assessments are inter alia: Extended Barthel-Index, WHODAS II, WHOQoL-Bref, CIRS, Rivermead Life Goal Questionnaire, HADS, Metzler-Procedure and several specially devised questionnaires. Results: 43 persons (62,3 % male) are participating in the longitudinal analysis. The average age of the residents is 48,9 years. The youngest participant is 19 years old and the oldest 66 years. In a classification indicating levels of required help from 0 (no help needed) to 5 (severe help needed) 17,6% of the participants belong to level 3, 76, 5% to level 4 and 5,9% to level 5. Most of the participants have been living in the permanent residential care facility for more than five years. Further results of the longitudinal analysis will be presented. Conclusion: Despite long-lasting rehabilitation none of the participants could be cured. As a result of their severe disabilities caused by different types of brain injuries they will rely on special care all of their lives. The LIC-project offers the residents the chance to bear a self-determined life and to participate actively in new social networks for the first time in many years. Therefore the pilot project ‘‘LIC’’ could help to improve the current situation through care and health services for this specific group of handicapped in Berlin and furthermore.

O72 From fluent to non-fluent, from right to left—atypical evolution of speech fluency in a case of aphasia M. Lauterbach, J. Fonseca, G. Leal, I. Martins, G. Leal University of Lisbon (Lisbon, PT); Santa Maria Hospital (Lisbon, PT) Objectives: Language is normally lateralized into the left hemisphere (LH). Cerebral vascular accident (CVA) of the middle cerebral artery causes typical aphasic syndromes. In only about 1-2 % of the population the eloquent areas of the brain are localized in the right hemisphere (RH). In these cases CVA in the RH causes identical aphasic syndromes. During the evolution of an aphasia the aphasic syndrome normally evolves from a more severe syndrome to less severe one. Post-central CVA mainly cause fluent aphasia, whereas pre-central CVA cause non-fluent aphasias. In some cases the fluency shifts from non-fluent to fluent, but very rarely vice-versa. We report a case of a crossed aphasia that showed this inverse pattern regarding the evolution of speech fluency. Methods: A 33 year old, left handed woman, suffered 2 CVA (in 2002 and 2004) of the RH. From the first fronto-parietal CVA she recovered without sequelae. The latter was due to an occlusion of the right carotid artery that caused a border zone infarction of the middle and posterior cerebral artery. She suffered a severe

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Wernicke aphasia with a fluent jargon aphasic discourse. She underwent two linguistic evaluation, at aphasia onset in 2004 and in 2009. Structural and functional MRI were performed in order to describe the dimension of the cerebral lesions and to visualize the cortical areas that are activated by semantic decision and naming paradigm. Results: In the first evaluation the patient presented a severe Aphasia with an aphasia quotient (QA, Kertesz, 1974) of 6,25 and a jargon aphasic discourse. Five years later she presented an aphasia with a QA of 66,4, however the discourse had become non-fluent. The ratio between function and content words shifted from 0.36 in the first to 0,05 in the actual evaluation. Structural MRI showed the two known lesions of the RH without the evidence of any new lesion. The language paradigms activated exclusively the LH. Conclusion: Since aphasia onset the patient transferred the language areas into the LH. Although presenting still an aphasic and nonfluent discourse the patient improved her communicative abilities from a functional point of view. The observed change of hemispheric dominance was possibly facilitated by the presence of two lesions of the original eloquent RH, leaving no margin for an intra-hemispheric reorganization. The originally non-dominant LH is unable to produce a fluent discourse. This study was supported by FCT grant PTDC/PSI/74294/2006

O73 Virtual reality assessment of navigation impairments in right brain damaged patients A. Peskine, C. Rosso, A. Galland, E. Caron, P. Pradat-Diehl Assistance publique, Hoˆpitaux de Paris (Paris, FR) Objectives: Right brain damaged patients are subject to visuospatial neglect that can induce incapacity for navigation. Virtual reality integrates real-time computer graphics, body tracking devices and visual displays that may assess visuospatial skills and navigation abilities. Our main objectives are to test the applicability of virtual reality device in right brain damaged patients and to assess navigation with virtual reality tools. Our secondary aim is to ask whether virtual reality assessment can discriminate patients from matched control in a navigation task. Finally we will search correlation between paper and pencil test, behavioural assessment and virtual reality task for all patients with group and individual analysis. Methods: In this prospective study, right brain damaged patients and matched controls were proposed a head-mounted-display virtual reality system. Subjects were asked to navigate through a virtual town, to count the targets (busstops) and to find one single target (swings in a park). Number of omitted busstops and their localisation (right of left from the subject’s point of view) and the ability to locate the swings was noted and compared with the results of matched controls with the sign test. Tolerance was assessed. All patients sustained also a standardized assessment for visuospatial neglect with the bells test and Catherine Bergego Scale. Results: 9 right brain patients and 9 matched controls were included. Patients differed significantly from controls in the virtual reality task for the number of omitted targets (Sign Test p 0.0078). For the ability to locate the swings, the difference did not reach significance. Individual analysis for visuospatial assessment showed dissociations between paper and pencil test and virtual reality task that need further investigations. Tolerance of the head mounted display was lower for the patients than for the controls.

S21 Conclusion: We had no major difficulty to use virtual reality device with a head mounted display in brain injured patients. Patients and controls results were significantly different with a lower score for the patients. Correlation between standardized tests and virtual assessment was not possible but the small number of patients can account for this finding. We now propose the assessment to all right brain-injured patients and begin a virtual reality therapy when the tolerance is acceptable for the patient.

__________________________________ Oral session 7 MS: treatment O75 Analysis of clinical and radiological disease activity-free status in patients with relapsing–remitting multiple sclerosis treated with cladribine tablets, in the doubleblind, 96-week CLARITY study G. Giovannoni, G. Comi, S. Cook, K. Rammohan, P. Rieckmann, P. Soelberg Sørensen, P. Vermersch, P. Chang, A. Hamlett, R. Verjee, B. Musch, S. Greenberg Barts and The London School of Medicine and Dentistry (London, UK); University Vita-Salute San Raffaele (Milan, IT); University of Medicine and Dentistry (Newark, US); Ohio State University (Columbus, US); Bamberg Hospital (Bamberg, DE); Copenhagen University Hospital (Copenhagen, DK); University of Lille, Nord de France (Lille, FR); Merck Serono S.A. (Geneva, CH) Objective: Novel multiple sclerosis (MS) therapies currently in latestage development may improve the opportunity for achieving complete remission of disease activity, an important goal in the treatment of immune-mediated diseases. These analyses were carried out to determine the effect of short-course treatment with cladribine tablets on stringent composite measures of clinical and radiological disease activity in patients with relapsing–remitting multiple sclerosis in the CLARITY study. Methods: Clinical (relapse-free, and disability progression-free) and radiological (absence of active T2 lesions or T1 Gd+ lesions on magnetic resonance imaging [MRI]) outcomes and combinations of these outcomes were assessed at 48 and 96 weeks (prespecified and post-hoc assessments) in the CLARITY study in patients (n=1326) randomised to cladribine tablets (cumulative doses of 3.5 and 5.25 mg/kg) and placebo. Results: For all pair-wise combinations of individual disease activity endpoints (relapse-free, disability progression-free and MRI activity-free), significantly more patients treated with cladribine tablets 3.5 or 5.25 mg/kg vs. placebo were activity-free over 96 weeks. In the 3.5 and 5.25 mg/kg vs. placebo groups, respectively, 71.8% and 70.4% vs. 52.6% of patients were relapse- and disability progressionfree; 51.3% and 51.8% vs. 21.7% were disability progression- and MRI activity-free; and 48.0% and 49.6% vs. 17.8% were relapse- and MRI activity-free (all p\0.001). On the most stringent composite outcome incorporating all 3 measures of disease activity, 43.0% and 44.3% of patients in the 3.5 and 5.25 mg/kg groups were disease activity-free vs. 16% in placebo (odds ratio [95% CI] of being disease

activity-free vs. placebo: 3.99 [2.89, 5.49] and 4.24 [3.09, 5.82], respectively; both p\0.001). Additional outcomes stratified across different time periods, and in other clinically important patient subgroups, will be presented. Conclusion: A substantial proportion of patients treated with cladribine tablets were free from clinical and radiological disease activity over 96 weeks suggesting cladribine tablets could be a promising addition to the MS therapeutic armamentarium. Sponsored by Merck Serono S.A.–Geneva, Switzerland

O76 Oral fingolimod (FTY720) reduces relapse rate in patients previously treated with disease-modifying therapies for multiple sclerosis and in patients who are treatment naı¨ve: subgroup analysis of data from a 24-month phase III study (FREEDOMS) R. Hohlfeld, P.A. Calabresi, P. O’Connor, C.H. Polman, C. Agoropoulou, D. Ha¨ring, L. Zhang-Auberson, L. Kappos on behalf of the FREEDOMS (FTY720 Research Evaluating Effects of Daily Oral therapy in Multiple Sclerosis) Study Group Objectives: Oral fingolimod (FTY720) leads a new class of sphingosine 1-phosphate receptor modulators and is being assessed in patients with relapsing–remitting multiple sclerosis (RRMS). In the 24-month phase III FREEDOMS study, fingolimod 0.5mg and 1.25mg reduced the annualized relapse rate (ARR) by 54–60% compared with placebo. However, because many patients switch disease-modifying therapies (DMTs) owing to suboptimal efficacy or tolerability issues, subgroup analyses of FREEDOMS data were performed to assess ARR in patients who have previously received DMTs and in treatment-naı¨ve patients. Methdos: In this randomized, double-blind, placebo-controlled, multicentre study, patients aged 18–55 years with RRMS and with Expanded Disability Status Scale (EDSS) score 0–5.5, who had had C1 relapse in the previous year (or C2 in the previous 2 years) were randomized equally to once daily fingolimod 0.5mg or 1.25mg or placebo capsules for 24 months. In a pre-specified analysis, data were analyzed by prior treatment status (none or prior DMT, including interferons (IFN) and glatiramer acetate (GA) mainly but could include natalizumab, mitoxantrone or unapproved immunosuppressive drugs). Prior use in FREEDOMS was at least 3 months, and frequently more, before study start. ARR was estimated using a negative binomial model adjusted for treatment group, country, relapse count in the 2 years before baseline, and baseline EDSS score. Results: Of the 1272 enrolled and randomized patients, similar proportions had received DMT before baseline in the groups receiving fingolimod 0.5mg (43%; n=181), 1.25mg (40%; n=170) and placebo (40%; n=169). In treatment-naı¨ve patients, ARR was reduced over 24 months with fingolimod 0.5mg (0.14) and 1.25mg (0.14) compared with placebo (0.39; both p\0.001). In patients who had previously received a DMT, ARR was lower with fingolimod 0.5mg (0.25) and 1.25mg (0.17) than with placebo (0.42; both p\0.001). Conclusions: Fingolimod significantly reduced ARR compared with placebo regardless of prior treatment. These data suggest that patients previously treated with other DMTs such as IFN or GA and who subsequently start fingolimod treatment benefit from therapy as well as those naı¨ve to MS treatments. This study was supported by Novartis Pharma AG, Switzerland

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O77 Impact of interferon b-1b and glatiramer acetate on the evolution of T1-hypointense permanent black holes M. Filippi, M.A. Rocca, F. Camesasca, S. Cook, G. Comi, D.S. Goodin, P. O’Connor, D. Jeffrey, H.P. Hartung, B. Arnason, L. Kappos, C. Pohl, K. Beckmann, R. Sandbrink, T. Bogumil, D. Arnold, G. Cutter, J. Wolinsky, V. Knappertz University Hospital San Raffaele (Milan, IT); University of Medicine and Dentistry of New Jersey (Newark, US); University of California (San Francisco, US); St. Michael’s Hospital (Ontario, CA); Wake Forest University (Winston-Salem, US); Heinrich-Heine-University (Du¨sseldorf, DE); Surgery Brain Research Institutes (Chicago, US); University Hospital (Basel, CH); Bayer Schering Pharma AG (Berlin, DE); Bayer Health Care Pharmaceuticals Inc (Montville, US); Montreal Neurological Institute (Quebec, CA); University of Alabama (Birmingham, US); The University of Texas Health Science Center (Huston, US) Objective: Permanent black holes (PBH) are considered a marker of irreversible brain tissue damage. The BECOME trial generated the hypothesis that interferon b-1b (IFNB-1b) is more effective than glatiramer acetate (GA) in reducing the conversion of inflammatory brain lesions into PBH in patients with multiple sclerosis (MS). The current analysis assesses this hypothesis using the Bseron Efficacy Yielding Outcomes of a New Dose (BEYOND) dataset. Methods: BEYOND was a large (n=2244), Phase III, multicenter clinical trial with IFNB-1b 250 lg, IFNB-1b 500 lg, and GA treatment arms (2:2:1). Magnetic resonance imaging (MRI) scans of all patients were re-examined post-hoc to the primary trial analysis. However, these black hole analyses were pre-planned and rater-blinded. The pre-defined co-primary endpoints compared IFNB-1b 250 lg with GA on (1) the number of PBH per patient at Year 2 evolving from NL at Year 1, and (2) the proportion of NL at Year 1 that evolved into PBHs at Year 2. NLs included both new gadolinium-enhancing and new T2 lesions. Sensitivity analyses were performed, including data from the IFNB-1b 500 lg treatment arm. Approximately 90% of all patients qualified for this analysis. Results: Mean numbers of PBH per patient at Year 2 evolving from NL at Year 1 were lower for individuals receiving IFNB-1b 250 lg than GA (0.30 vs. 0.43; P=0.0451). Conditional, sequential testing allowed for the assessment of the proportion of NL at Year 1 that evolved into PBH at Year 2, which was similar for IFNB-1b 250 lg- and GA-treated patients (IFNB-1b 250 lg 21.6%; GA 23.5%). Sensitivity analyses revealed that differences in the mean numbers of PBH per patient at Year 2 were driven by new T2 lesions with T1-hypointensity at Year 1. Mean numbers of PBH per patient at Year 2 were also lower for IFNB-1b 500 lg than GA (IFNB-1b 500 lg 0.26; GA 0.43; P=0.0037). Interestingly, the proportion of NL at Year 1 evolving into PBH at Year 2 was significantly reduced for IFNB-1b 500 lg compared with GA (IFNB-1b 500 lg 16.3%; GA 23.5%; P=0.0409). Conclusions: IFNB-1b affected the development of PBH at Year 2 to a similar or better extent than GA. These data confirm that IFNB1b favorably influences an MRI outcome indicative of permanent tissue destruction in the brains of MS patients. This study was partially funded by Bayer Schering Pharma AG, Berlin, Germany

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O78 Long-term safety and impact of natalizumab on disease activity and disability progression in patients with relapsing-remitting MS in clinical practice: TYSABRIÒ Observational Program (TOP) H. Wiendl, L. Kappos, M. Trojano, H. Butzkueven, F. Pellegrini, S. Belachew, A. Pace, D. Desgrandchamps University of Wu¨rzburg (Wu¨rzburg, DE); University Hospital Basel (Basel, CH); University of Bari (Bari, IT); The Royal Melbourne Hospital (Victoria, AU); Consorzio Mario Negri Sud (Chieti, IT); University Hospital of Lie`ge (Lie`ge, BE); Biogen Idec, Inc. (Cambridge, US) Objectives: To evaluate the long-term safety of natalizumab and its impact on disease activity (relapses) and disability progression (Expanded Disability Status Scale [EDSS]) in 3000 patients with relapsingremitting multiple sclerosis (RRMS) in a clinical practice setting. Methods: TOP is a 5-year observational study in which patients treated with natalizumab according to local prescribing information are monitored for serious adverse events (SAEs), relapses, and EDSS status, whether or not they continue natalizumab. Results: As of 14 July 2009, 1011 patients have been enrolled in TOP. Seventy-three percent of patients were women; mean age was 38 years. Median duration of disease was 7.5 years (range, 0.2–43.9). Among all patients, 4.3% experienced at least 1 SAE, with infections (1%) and hypersensitivity reactions (0.9%) being most frequent. One case of progressive multifocal leukoencephalopthy (PML) occurred after 29 natalizumab infusions. In patients followed for at least 6 months (n = 587), annualized relapse rate (ARR) decreased from 2.07 at baseline to 0.26 (median per-patient change in ARR –2.0, P \.0001). A post hoc analysis of comparable patients from preregistration trials demonstrated similar ARR kinetics in the natalizumab cohort, whereas placebo-treated patients exhibited higher disease activity. In patients followed for 12 months (n = 292), mean EDSS remained stable (3.8 +/– 1.7 at baseline vs 3.6 +/– 1.8 after 12 months). Conclusion: To date, patients in TOP exhibit a very low level of disease activity. No unanticipated serious events have occurred, and natalizumab demonstrates a safety profile consistent with preregistration trials. Updated data will be presented, further characterising the long-term efficacy and safety of natalizumab in the real world. This study was supported by Biogen Idec, Inc., and Elan Pharmaceuticals, Inc.

O79 Clinical effects of natalizumab on multiple sclerosis appear early in treatment course, regardless of baseline disease activity L. Kappos, R. Rudick, C.H. Polman, P. O’Connor, P. Vermersch, H. Wiendl, A. Pace, D. Desgrandchamps, C. Hotermans University Hospital (Basel, CH); Cleveland Clinic Foundation (Cleveland, US); VU Medical Centre (Amsterdam, NL); St. Michael’s Hospital (Toronto, CA); University of Lille Nord de France (Lille, FR); University of Wu¨rzburg (Wu¨rzburg, DE); Biogen Idec, Inc. (Cambridge, US); Biogen Idec International GmbH (Zug, CH) Objectives: To determine how soon clinical therapeutic effects become apparent after initiation of treatment with natalizumab in patients with multiple sclerosis (MS) of varying levels of disease activity by analyzing data from randomised trials and clinical practice settings.

S23 Methods: Clinical measures of disease activity, including annualised relapse rates (ARR) per 3-month period and time to first relapse, were analysed for patients who participated in the pivotal phase 3 studies of natalizumab (AFFIRM and SENTINEL). These parameters are also being assessed in patients enrolled in the multinational TYSABRI Observational Program (TOP), which is an open-label prospective study of natalizumab use in clinical practice. Results: Overall in AFFIRM, ARR was significantly lower in the natalizumab-treated group than in the placebo-treated group within the first 3 months of treatment (ARR 0.30 vs 0.71; P\0.0001); the low ARR was maintained throughout the 2-year study period. The effect of natalizumab on ARR within the first 3 months was consistent in patients with highly active disease (ARR 0.30 vs 0.94; P=0.0039). Similar results were observed in SENTINEL. Natalizumab treatment also significantly prolonged the time to first relapse in both clinical studies (AFFIRM: hazard ratio [95% CI]=0.42 [0.34, 0.52]; P\0.0001). The rapid reductions in ARR observed in clinical trials are also evident in preliminary analyses from TOP (ARR [95% CI] baseline=2.03 [1.96, 2.09] vs 0–3 months=0.16 [0.11, 0.22]). Conclusion: Treatment of MS with natalizumab results in rapid, sustained reductions in disease activity in both randomised trials and clinical practice. This effect on clinical measures of disease activity occurred within the first 3 months of treatment even in patients with more active disease at baseline. This study was supported by Biogen Idec, Inc., and Elan Pharmaceuticals, Inc.

O80 Analysis of the outcomes of high-dose immunosuppressive therapy with autologous haematopoietic stem cell transplantation in 156 patients with multiple sclerosis A.A. Novik, A.N. Kuznetsov, V.M. Kitaev, V.Y. Melnichenko, D.A. Fedorenko, T.I. Ionova, R.V. Kruglina, K.A. Kurbatova, G. Gorodokin Pirogov National Medical Surgical Center (Moscow, RU); New Jersey Center for Quality of Life and Health Outcome Research (New Jersey, US) During the last decade high-dose immunosuppressive therapy with autologous haematopoietic stem cell transplantation (HDIT+ASCT) has been used with increasing frequency as a therapeutic option for multiple sclerosis (MS) patients. We aimed to study clinical outcomes in patients with different types of MS after HDIT+ASCT. 156 MS patients (secondary progressive -54 patients, primary progressive -28, progressive-relapsing -5, relapsing-remitting -69) were included in this study (mean age -33.0; male/female -63/93). BEAM or mini-BEAM conditioning regimens were used. Median EDSS at base-line -4.0. The median follow-up duration -20.6 months (range 6 – 126). Neurological evaluation was performed at baseline, at discharge, at 3, 6, 9, 12 months, and every 6 months postransplant. Transplantation procedure was well tolerated by the patients with no transplant-related deaths. The efficacy analysis was performed in 101 patients at 6 months post transplant, the following distribution of patients according to clinical response was observed: 48 patients (48%) achieved an objective improvement of neurological symptoms, 52 patients (51%) had disease stabilization, and 1 patient (1%) progressed. At long-term follow-up (median follow-up 27.5 months) clinical response was classified as improvement in 41 (62%) patients, stabilization - in 20 (30%); progression - in 5 (8%) patients. No active, new or enlarging MRI lesions were registered in patients without disease progression.

Thus, HDIT+ASCT appears to be an effective and safe treatment for MS. Further studies should be done to establish the best timing for transplantation and to validate conditioning regimens in patients undergoing HDIT+ASCT.

__________________________________ Oral session 8 Epilepsy O81 Lamotrigine increases hippocampal neurogenesis in rats D. Kondziella, J. Strandberg, C. Lindquist, F. Asztely University Hospital Sahlgrenska (Gothenburg, SE) Objectives: Lamotrigine has antiepileptic, antidepressive and moodstabilizing effects. The antiepileptic effects have been attributed, among others, to inhibition of voltage-sensitive sodium channels. Very little is known, however, about the antidepressant and moodstabilizing properties of lamotrigine. Antidepressant medication and electroconvulsive therapy increases hippocampal neurogenesis, and may thereby stabilize mood symptoms. In the present study we examined whether also lamotrigine increases neurogenesis in the hippocampus. Methods: Twenty-one days after birth 30 rats received lamotrigine, valproate or saline intraperitoneal once daily for seven days. To detect the proliferation of newborn cells all animals received four intraperitoneal injections of bromodeoxyuridine (BrdU; 75 mg/kg) on the last day of the experiment. Hippocampal slices were incubated with primary monoclonal mouse anti-BrdU IgG antiserum and secondary horse anti-mouse IgG antiserum. Results: Quantification of BrdU-labeled cells in the granule cell layer of the dentate gyrus revealed increased neurogenesis induced by lamotrigine (43±4 cells/slice; p\0.05) compared to valproate (33±2; p=0.79) and controls (32±2). Conclusion: In contrast to valproate, lamotrigine is associated with increased hippocampal neurogenesis in rats. Increased neurogenesis may explain the mood-stabilizing and antidepressant effects of lamotrigine.

O82 Acute unstable depressive syndrome is associated more frequently with epilepsy than major depression A. Vaaler, G. Morken, V.C. Iversen, D. Kondziella, O.M. Linaker Haukeland University (Bergen, NO); Norwegian University of Science and Technology (Trondheim, NO); Copenhagen University Hospital (Copenhagen, DK) Background: Depression is frequent in epilepsy, yet almost 50% of interictal depressive disorders have to be classified as atypical depressions according to DSM-4 criteria. Research has mainly focused on depressive symptoms in defined populations with epilepsy. In order to examine this topic from a different angle, we have chosen the opposite approach. We hypothesized that it is possible to define by clinical means a subgroup of psychiatric patients with higher than expected prevalence of epilepsy and seizures. We hypothesized further that these patients present with an Acute Unstable Depressive Syndrome (AUDS) that does not meet DMS-4 criteria of a Major Depressive Episode (MDE).

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S24 Methods: 16 AUDS patients and 16 age- and sex-matched MDE patients were assessed by neurological bedside examination, MR of the brain and standard and quantitative EEG as well as (among others) the Symptomatic Organic Mental disorder Assessment Scale (SO˚ sberg Depression Rating Scale, the MAS), the Montgomery and A Mini-Mental State Test, at day 2, day 4-6, day 14-16 and 3 months after admittance to a psychiatric emergency unit. We also screened for medication serum levels and illicit drug metabolites in urine. Results: AUDS patients had significantly higher SOMAS scores (average score at admission 6.6 ± 0.8), reflecting increased symptom fluctuation and motor agitation, and decreased insight and concern compared to MDE patients (2.9 ± 0.7; p\0.001). Degree of mood depression, cognition, life events, drug abuse and medication did not differ between the two groups. Compared to MDE patients, AUDS patients had more often a history of seizures (6/16 vs. 0/16, p = 0.018); fulfilled more often clinical criteria for epilepsy (5/16 vs. 0/16, p = 0.043); and had more abnormalities on standard and quantitative EEG (8/16 vs. 1/16, p = 0.015). Cerebral MRI findings, neurological bedside examination and medication did not differ significantly between the two groups. Conclusions: AUDS patients present with rapidly fluctuating mood symptoms and motor agitation, as well as relative lack of insight and concern. Seizures, epilepsy and EEG abnormalities are overrepresented in AUDS patients compared to MDE patients. We suggest that the study of AUDS patients may offer a new approach to better understanding epilepsy and its association with depressive disorders. The funding of the study came from the Research Council of Norway, St Olavs Hospital, Trondheim, Norway, and GlaxoSmithKline.

O83 A survey of epilepsy awareness amongst staff at a national health service trust and medical school E. Zhukova, H. Cock St.George’s University of London (London, UK) Objectives: While previous surveys of the general public have often revealed a lack of knowledge about epilepsy and how it affects people, awareness in a medical setting among doctors and healthcare professionals in the UK has not been studied widely. This study aimed to ascertain levels of epilepsy knowledge among staff at St.George’s Hospital (SGH) and Medical School (MS). Methods: An electronic questionnaire was sent by e-mail to all staff at SGH and MS. Results: 223 people completed the questionnaire, of these 26 were doctors, 39 nurses, 24 other trained health professionals, and 134 ‘other’ staff (e.g. administrative, reception). 22% of all staff gave the correct answer on epilepsy prevalence in the UK (currently 1/100), while the majority (61%) thought epilepsy to be less common. 13% of staff think that one should put something in the mouth of a person suffering a seizure, an action not advised. Most (64%) realise that the risk of premature death in patients with poorly controlled epilepsy is increased relative to general population. Among healthcare staff, only 21% had ever attended an epilepsyrelated training course; only 25% are familiar with key NICE guidelines. Healthcare staff gave good answers when asked to describe how they would help a person suffering a seizure. Top 3 answers were: Clearing the area to prevent patient injuring themselves (77%), waiting with the patient until seizure ends (43%), and putting patient in recovery position (39%). Conclusion: In summary, we identified some weaknesses in knowledge and training of staff at St.George’s, pointing to the need for further training and awareness campaigns.

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O84 Survivors of very long duration status epilepticus F. Drislane, R. Lopez, A. Blum, D. Schomer Harvard Medical School (Boston, US); University of Miami (Miami, US); Brown Medical School (Providence, US) Objective: Predictors of survival in status epilepticus (SE) have been determined in several large case series. Among the most important are etiology and presentation in coma. Beyond the first few hours, duration of SE is not a good predictor of survival, especially when considered independently from etiology. By investigating individual case histories of patients with particularly prolonged episodes of SE, we sought details of their clinical courses that would predict utility or futility of prolonged treatment – especially for those who did not follow established predictive factors. Methods: We compared clinical features of 10 survivors of prolonged episodes of SE with a matched cohort treated for similarly prolonged episodes – but unsuccessfully. Patients with SE caused by anoxia were excluded. We compared etiologies, age, history of epilepsy, presence of multiple medical problems, level of consciousness upon diagnosis of SE, generalized or focal clinical and EEG features of the SE, and number of anticonvulsants used in treatment. Results: All survivors had episodes of SE lasting at least 4 days (range: 4–9 days); those treated unsuccessfully were treated for at least 5 days (range: 5.5–17 days). Between the two groups, there was no significant difference in age, generalized or focal forms of SE, or the numbers of anticonvulsants used. Similar portions of the two groups had had earlier diagnoses of epilepsy, but the survivors were more likely to have epilepsy as the most important cause of the episode of SE (p \ 0.05). Also, those treated unsuccessfully were more likely to present in coma and to have multiple medical problems (p \ 0.01; for each factor). Individual case histories of exceptions to these rules will be displayed [e.g. a young man with encephalitis who presented in coma but was treated successfully] to illustrate that some individual clinical features can be used to refine predictions of who will survive despite prolonged episodes of SE. Conclusion: Etiology and presentation in coma are significant predictors of successful treatment in SE, as in other studies. Individual clinical features help to point out when these predictive rules might not apply. Many patients with episodes of over 4 days of SE can be treated successfully, especially if they have certain favorable clinical features, and some patients with unfavorable predictive factors survive.

O85 Aura in complex partial seizures: clinical and electroencephalographic correlation N. Kitchener, A. AbdelKader, M.A. Ghoraba, N. Nagy, A. Abdelkarim, S. Samy General Organization for Teaching Hospitals (Cairo, EG); Cairo University (Cairo, EG); Ain Shams University (Cairo, EG) Objectives: Several reports in the literature have emphasized the importance of the aura in the clinical diagnosis of complex partial seizures (CPS). Current study aims to describe the types of auras seen in Egyptian patients with CPS and their correlation with the site of the EEG abnormality. Methods: Evaluation of the aura in relation to the site of the EEG abnormality has been made in 385 patients with CPS. Each patient had a detailed clinical and neurological examination at time of the first visit. Auras were grouped according to the guidelines

S25 recommended by the Commission of the ILAE. There were 205 females and 180 males and the age range was 12-63 years. Most patients had a long history of epilepsy. EEGs were taken on digital machines using the International 10/20 electrode placement system, and the records were examined visually, and coherence analyses were done in a trial to localize exact origin of epileptic discharge. The lateralization of EEG abnormalities was based on the finding of localized spikes, sharp waves, slow waves, or phase reverses alone or in combination. Results: The EEG abnormality was clearly lateralized in 332 patients, being right-sided in 52.1% and left-sided in 47.9%. Of the 173 patients with right-sided abnormality, 36% had a psychic aura, 34% an autonomic aura, 16% a sensory aura, 1% a motor aura and 13% did not have an aura. Of the 159 patients with left temporal abnormality, the aura was motor in 14%, psychic in 29%, sensory in 10%, autonomic in 12% and there was no aura in 35%. In 78 (23%) patients there was no aura and of these 78, the EEG abnormality was most commonly on the left (61%), less common on the right (17%) and 10% had bilateral abnormality. The EEG was normal in 12%. Conclusion: Autonomic and psychic auras were more frequently associated with right-sided temporal lobe lesions. Aura classification and exact description empower its diagnostic and localizing value. DEEG coherence analysis may increase power of diagnostic yield of EEG.

O85a Non-convulsive status epilepticus in ischaemic stroke and its impact on prognosis N. Kitchener, H. Zakieldine, A. Abdelkarim, M.A. Ghoraba, S. Helmy General Organization for Teaching Hospitals and Institutes (Cairo, EG); Ain Shams University (Cairo, EG); Cairo University (Cairo, EG) Objectives: Emerging data support a higher than previously thought incidence of Non-Convulsive Epileptic Activity in Ischemic Stroke Patients, which is an important consideration affecting prognosis. Study aimed at determining frequency of non-convulsive status epilepticus (NCSE), in the form of continuous electrographic Seizures with no motor manifestations, in ischemic stroke patients and how it affects outcome. Methods: We prospectively and consecutively studied 3168 patients with acute stroke, collected from January 2006 to December 2009. DEEG was done for every stroke patient within 24 hours of admission to ICU, and repeated if his level of consciousness changed. We determined initial stroke severity, mortality, and outcome in survivors. Stroke severity was assessed, clinically and by imaging. Multiple logistic and linear regression outcome analyses included age, gender, stroke severity, atrial fibrillation, ischemic heart disease, blood glucose level, claudication, and hypertension. Results: NCSE were detected in 197 (6.2%) patients in the first EEG. With second EEG done after change in level of consciousness of 1054 patients, total number of patients showed NCSE increased to 579 (18.27%). Patients with early NCSE Mortality rate is higher than that of late NCSE, Mortality rate is higher in patients with disturbed level of consciousness and no NCSE, than those with NCSE. ICU stay duration is shorter and clinical outcome is better for patients with disturbed level of consciousness and NCSE. Conclusions: NCSE is a frequent finding in acute stroke, reaching 18%, Patients with stroke would benefit from an EEG. Early NCSE increase Mortality rate. Treating NCSE improves outcome.

Oral session 9 Motor neuron diseases O86 Clinical phenotypes in amyotrophic lateral sclerosis: a population-based study in Italy A. Chio`, A. Calvo, L. Mazzini, M. Balma, E. Bottacchi, C. Moglia, S. Gallo, A. Canosa, R. Mutani, G. Mora University of Turin (Turin, IT); University of Eastern Piedmont (Novara, IT); Aosta Regional Hospital (Aosta, IT); Salvatore Maugeri Foundation (Milan, IT) Objective: Several clinical phenotypes of ALS have been identified (bulbar, classical [Charcot], pyramidal, flail leg, flail arm, and respiratory), but their characteristics remain poorly understood. No studies have been performed on these phenotypes in an epidemiological setting. Our aim was to assess the epidemiological and clinical characteristics of ALS phenotypes in the patients included in an Italian prospective epidemiological register. Methods: The patients prospectively diagnosed and followed-up between 1995 and 2004 in Piemonte and Valle d’Aosta have been classified according to their clinical phenotype. The effect of the phenotypes on ALS prognosis has been also analyzed. Results: Of the 1260 incident patients, 1241 (98.5%) had complete phenotypic data. The most common phenotype was bulbar ALS, that accounted for 36.7% of patients (mean incidence rate 1.1/ 100,000/year, with no difference between genders). Classic ALS accounted for 32.6% of cases (incidence rate, 1.2 men and 0.9 women; men to women rate ratio 1.7:1). Pyramidal phenotype was present in 9.7% of cases (incidence rate, 0.3 for both genders). Flail arm syndrome was found in 6% of patients (incidence rate, 0.3 men and 0.1 women, men to women rate ratio 4.0:1) and flail leg syndrome in 13.9% (incidence rate, 0.4 in both genders). Respiratory phenotype accounted for 1.1% of cases, mostly men. The oldest age at onset was found in the bulbar phenotype (68.8 years) and the lowest in the pyramidal phenotype (58.3 years). Significantly different outcomes were found: pyramidal and flail arm phenotypes had the better prognosis (median survival, 6.3 and 4.0 years, respectively), while bulbar and respiratory phenotypes had the worst prognosis (2.0 and 1.4 years, respectively). Conclusion: ALS phenotypes are largely related to a complex interplay between gender and age. The reasons for the strong influence of these factors on ALS biology remains unknown. In turn, ALS phenotypes are the amongst the main factors determining the clinical outcome.

O87 Magnetic resonance imaging predictors of long-term evolution in amyotrophic lateral sclerosis F. Agosta, E. Pagani, M. Petrolini, M.P. Sormani, D. Caputo, M. Perini, A. Prelle, F. Salvi, M. Filippi University Hospital San Raffaele (Milan, IT); University of Genoa (Genoa, IT); Scientific Institute Fondazione Don Gnocchi (Milan, IT); Hospital of Gallarate (Gallarate, IT); Hospital Fatebenefratelli e Oftalmico (Milan, IT); Hospital Bellaria (Bologna, IT) Objective: To investigate whether conventional and diffusion tensor (DT) MRI features of the corticospinal tracts (CST) contribute to the prediction of the long-term clinical evolution in patients with amyotrophic laterals sclerosis (ALS).

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S26 Methods: Brain conventional and DT MRI were obtained from in 18 healthy subjects and 24 patients with sporadic ALS, who were followed up prospectively for a median period of 3.4 years. DT MRI tractography was used to obtain mean diffusivity (MD) and fractional anisotropy (FA) of the CST. The ALS Functional Rating scale (ALSFRS) progression rate during follow up was estimated. Clinical and MRI predictors of patient’s survival were investigated. Results: Two patients were lost at follow up and eight died during the observation period. The mean ALSFRS progression rate was 0.7/ month (range=0.0-2.0/month). At baseline, ALS patients showed significantly increased MD (p=0.01) and decreased FA (p=0.02) of the CST compared with controls. CST FA was inversely associated with ALSFRS progression rate (r=-0.42, p=0.04). Bulbar-onset (p=0.01, hazard ratio [HR]=6.9, 95% confidence interval [CI]=1.629.7) and CST FA (p=0.07, HR=0.97, 95% CI=0.92-1.00) were independent predictors of time to death in ALS patients. Survival at year three was 42% (standard error [SE]=14%) in patients with CST FA B 0.56 compared with 90% (SE=9%) in patients with CST FA [ 0.56 (p=0.02). Conclusions: More severe CST DT MRI abnormalities predict a poorer long-term clinical outcome in ALS patients. The prognostic value of DT MRI calls for a more extensive use of this technique as a paraclinical tool to monitor ALS evolution.

O88 Prognostic factors in primary lateral sclerosis V. Almeida, S. Pinto, A. Pinto, B. Ohana, M. de Carvalho Hospital de Santa Maria (Lisbon, PT) Objectives: Primary lateral sclerosis (PLS) is a rare form of motor neuron disease in which the lower motor neurons (LMN) are spared. Its prognosis is better than of Amyotrophic Lateral Sclerosis (ALS). Our aim was to study the prognostic factors of a population with PLS followed in our Unit. Methods: All patients included had the Pringle criteria for PLS and are followed in our Unit. In addition to clinical absence of LMN signs, regular electrodiagnostic evaluation (EMG) ruled-out signs of active denervation. We analysed demographic data and phenotype, ALS functional scale (ALSFRS) score, Forced vital capacity (FVC) values, EMG findings and transcranial magnetic stimulation (TMS) responses. The Kaplan-Meier method was used to plot survival curves, and a log-rank test was performed for comparing Kaplan-Meier curves. A value of ALSFRSB30 points was defined as the endpoint. We evaluate the following parameters for differences: sex, age and site of onset and neurophysiological findings. The association between TMS changes and clinical phenotype was tested with non-parametric tests (Exact Fisher and Mann-Whitney tests). Results: A total of 22 patients (13 men) were included. The mean age at onset was 51.2 (range, 28-75), mean disease duration 11.9 years (range, 3.6 15.5) and with a mean follow-up of 8.9 years. Two patients died. Bulbar-onset was observed in 32%, upper limb-onset in 18% and lower limb-onset in 50%. 67% patients with spinal PLS developed bulbar symptoms on follow-up. FVC was B80% in 6 patients, in spite of normal diaphragm on EMG, and abnormal nocturnal oxymetry recording indicated non-invasive ventilation in 6. A more rapidly progression was associated with a later onset of symptoms (p=0.004), but not with the site of onset. Sex, phenotype (spinal vs. bulbar), disease duration, FVC and EMG changes (normal vs. minor changes) were not associated with outcome. TMS was abnormal in all patients and in 64% no response was elicited in lower limbs. These changes were not related to clinical features or EMG changes. Conclusion: Our study showed that age of onset is a prognostic factor for PLS, as in ALS, in contrast to bulbar-onset or disease duration. Respiratory involvement was also found in PLS, although

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later and milder than in ALS, and independent of EMG changes in respiratory muscles. TMS was sensitive as a diagnostic tool but its results were not associated with outcome.

O89 Callosal dysfunction in amyotrophic lateral sclerosis M. Wittstock, S. Meister, R. Benecke, A. Wolters University of Rostock (Rostock, DE) Objectives: Amyotrophic lateral sclerosis (ALS) involves primarily lower and upper motor neurons. Recent reports demonstrated a disturbance of transcallosal inhibition (TI) in ALS using a transcranial magnetic stimulation (TMS) paradigm [1]. Furthermore, mirror movements (MM) may be observed in ALS [2]. Occurrence of MM might be explained in the context of involvement of transcallosal fibre tracts in ALS. Methods: 24 patients (8 women, age 62 ± 9years) with ALS were clinically investigated for disease severity measured by the revised ALS functional rating scale (ALSFRS) as well as the occurrence of MM, and electrophysiologically by TMS. MM were assessed according to Woods and Teuber [3]. TMS investigation comprised routine investigation and measurement of TI (latency, duration of the ipsilateral silent period [iSP]) from the ipsilateral first dorsal interosseus muscle. Results: 10 patients had suspected, 6 patients possible, 4 patients probable and 4 patients definite ALS according to the El Escorial criteria. Mean ALSFRS was 35±12 (maximum score 48). MM were observed in 7 patients. 15 of patients showed a pathological iSP (12 without prolongation of central conduction time, 18 of 30 hemispheres with loss of iSP, 6 prolongation of its latency [+4.1ms]). There was a significant correlation between pathological inhibition parameters and ALSFRS (Spearman-Rho correlation coefficient [SRCC9 -0.296 and -0.329, resp.; p=0.027 and 0.017 resp.) as well as ALSFRS and occurrence of MM (SRCC -0.315; p=0.044 resp.). Conclusions: Our findings suggest an affection of transcallosally projecting cortical output neurons in ALS. The involvement of this cortical output system is significantly correlated to the clinical state and presence of MM in ALS. Therefore, it is suggested that occurrence of MM is not caused only by affection of the pyramidal tract in ALS but also by impaired transcallosal inhibition. 1. Wittstock M, Wolters A, Benecke R. Transcallosal inhibition in amyotrophic lateral sclerosis. Clin Neurophysiol 2007;118(2): 301–7. 2. Krampfl K, Mohammadi B, Komissarow L, Dengler R, Bufler J. Mirror movements and ipsilateral motor evoked potentials in ALS. Amyotroph Lateral Scler Other Motor Neuron Disord 2004;5(3): 154–63. 3. Woods BT, Teuber HL. Mirror movements after childhood hemiparesis. Neurology 1978;28(11):1152–7.

O90 Linking neuron and skin: matrix metalloproteinases in amyotrophic lateral sclerosis L. Fang, M. Teuchert, F. Huber-Abel, C. Hendrich, D. Schattauer, K. Scharffetter-Kochanek, H. Tumani, A.C. Ludolph, J. Brettschneider University of Ulm (Ulm, DE) Objectives: Matrix metalloproteinases (MMP) have been suggested to play an important role in the pathology of amyotrophic lateral sclerosis (ALS). We aimed to determine whether gelatinase MMP-2 and

S27 MMP-9 could provide a link between neuronal degeneration and skin alterations observed in ALS and whether they were influenced by oxidative stress. Methods: We measured CSF, serum and skin tissue homogenate concentrations of MMP-2 and MMP-9 using ELISA and malondialdehyde (MDA), an established marker of lipid peroxidation, using High Performance Liquid Chromatography (HPLC) in 54 ALS patients and 36 controls as well as in transgenic SOD1(G93A) mice and WT mice. Results: We found CSF and skin MMP-9 concentrations to be elevated in patients with ALS as compared to controls (p \ 0.001, p = 0.03, respectively). We observed the elevation of MMP-9 in CSF to be highest in patients with a rapid progressive course of disease (p = 0.008). In contrast, we found no significant difference of CSF, serum or skin concentrations of MMP-2 as compared to controls. MDA was elevated in serum of ALS (p \ 0.001), though no correlation with MMP-2 or MMP-9 was observed. MMP-9 was elevated in spinal cord and skin of SOD1 mice at 90 days (p=0.009, p\0.001) and 120 days (p\0.01, p=0.04). MMP-2 was elevated in spinal cord at 90 days (p = 0.01) and in the skin at 120 days (p=0.039). We observed a correlation of MMP-9 in spinal cord and skin of SOD1 (p= 0.04). Conclusion: Our data indicates that gelatinase MMPs are a common factor linking neurodegeneration and skin changes in ALS. It suggests that the skin may function as a biomarker for specific aspects of disease pathology in ALS.

Conclusion: Our results clearly show mitochondrial impairment in extracerebral tissue (fibroblasts) of patients with ALS. The findings are in line with earlier reports showing mitochondrial dysfunction in skeletal muscle of patients with ALS. The found mitochondrial alterations may be best explained by oxygen radical-induced damage of mtDNA. Consequently, our findings may have implications for early diagnosis and for monitoring in the context of establishment of novel neuroprotective strategies for treatment of ALS. In addition, biochemical phenotyping may become helpful for the necessary stratification of ALS patients with various clinical subtypes before they are included in clinical trials.

__________________________________ Oral session 10 Child neurology O92 Clinical characteristics of paediatric onset neuro-Behc¸et’s disease D. Uluduz, M. Ku¨rtu¨ncu¨, S. Saip, Z. Yapici, G. Akman-Demir, A. Siva Istanbul University (Istanbul, TR); Acibadem University (Istanbul, TR)

O91 Impairment of mitochondrial function in fibroblasts of patients with amyotrophic lateral sclerosis I. Minin, G. Debska-Vielhaber, A.P. Kudin, S. Scho¨ler, W. Kunz, S. Vielhaber University Hospital Magdeburg (Magdeburg, DE); University Hospitals Bonn (Bonn, DE) Objective: Amyotrophic lateral sclerosis (ALS) has been commonly regarded as a neurodegenerative disorder primarily involving the pyramidal motor system. There is however increasing evidence that disease-related degenerative changes also occur in extramotor areas of the CNS. Since sufficient fresh brain tissue of ALS patients is generally unavailable for comparison, and multiple findings suggest that ALS is a multisystem neurodegenerative disease, skin fibroblasts were investigated. Methods: To verify the putative impairment of mitochondrial function in fibroblasts of patients with ALS, the oxygen consumption (respiration rate) of fibroblast was measured at 37 degree Celcius using an Oroboros high resolution oxygraph. To check possible metabolic consequences of altered mitochondrial function enzyme activity of aconitase (which harbors a highly ROS-sensitive iron-sulfur-cluster) were determined. Furthermore, mitochondrial DNA copy number analysis and deletions screening in fibroblast cultures were performed. Age matched healthy subjects served as controls. Results: We observed slightly lower maximal rates with NADdependent substrates glutamate+malate in the fibroblasts of ALS patients compared to controls. The succinate supported maximal respiration rates in the fibroblasts from these patients were also lower. Statistically significant deficiencies of respiratory chain complex I (NADH:CoQ1 oxidoreductase) and IV (cytochrome c oxidase, COX) were identified by determination of elevated flux control coefficients of respiration in titrations with specific inhibitors (amytal for complex I and azide for complex IV). Aconitase activity was lower in the fibroblasts of the investigated patients and diminished levels of mitochondrial DNA copies were also observed.

Objective: BD is a chronic, multi-system vascular-inflammatory disease with the average age of onset being in the third decade. Neurological involvement is seen in 5-10% of these patients. The frequency of BD is low during childhood (2.4%) and the information on neurologic involvement in pediatric population is limited to case reports. The aim of this work is to study the frequency of neurologic involvement in the pediatric patients with Behcet Disease (BD) and define the clinical characteristics of children with Neuro-Behcet Syndrome (NBS). Methods: Patients diagnosed with BD according to the International Criteria and who had onset of both the systemic disease and the neurologic involvement at or before age 16 were defined and included as Pediatric-NBS. Records of the well documented 645 patients with a diagnosis of NBS (NBS-Cohort), who had been seen and followed since 1984 at the NBS outpatient clinics of the neurology departments of two medical schools (Cerrahpasa and Istanbul Medical Schools) affiliated with Istanbul University were evaluated. The demographic and clinical characteristics of pediatric and adult cases were correlated. Results: There were 26 cases with Pediatric-NBS in our whole NBS-cohort, resulting in a prevalence rate of 4 % for Pediatric-NBD. The gender ratio was equal in the general Pediatric-BD cohort, whereas male/female ratio was 5.5/1 in Pediatric-NBS cases. Mean age at BD onset and neurological involvement onset were 13.0 2.9 and 13.5 2.4 respectively, whereas in the adult population mean age at onset of BD was 26.7 8.0 and neurological involvement occurred with a mean of 5.3±4.5 years later. Clinical and MRI evaluation revealed that of the Pediatric-NBS cases, 3 had central nervous system parenchymal involvement and 23 had dural venous sinus thrombosis (88.4%). Parenchymal involvement was seen in 76.8% of the adult NBS-cases, contrary to the low 20.3% of cases with venous sinus thrombosis. Conclusion: Pediatric NBS was seen in 4.0% of our whole NBS cohort, with a male dominance and neurological involvement being mainly in the form of dural venous sinus thrombosis, whereas in the adult NBS population the the dominant form of neurological involvement is parenchymal, suggesting that the pathogenesis of NBS may be different according to the age of disease onset.

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O93 As, Cd and Pb synergistically promote apoptosis in astrocytes, damage blood-brain barrier in developing rat brain and alter neurobehaviour A. Rai, S. Maurya, P. Khare, S. Bandyopadhyay Indian Institute of Toxicology Research (Lucknow, IN) Objective: To understand the cellular and molecular pathogenic mechanism of action of metal mixture (Arsenic As, Cadmium (Cd) and Lead (Pb))on brain development. Method: In vitro: To characterize the mechanism of developmental neurotoxicity of metal mixture (MM) we used 50% of IC-50: 40microM As, 8 microM Cd and 40microM Pb in combination/ individually on rat primray astrocytes. We measured intracellular Ca2+-release (flow cytometry), MAPkinase pathway adopted (western blotting, WB, and pathway inhibitor study). NF kappa B activation was determined through luciferase reporter assay. In vivo: The dams were and weanling rats were treated with As (1 ppm), Cd (0.2 ppm) and Pb (1ppm) and the postnatal pup brains were isolated. The glial fibrillary acidic protein (GFAP) and myelin basic protein (MBP) expression were determined through IHC and WB. The dendritic arborisation were determined through IHC. The metal level in brain was determied through atomic absorption spectroscopy and blood brain barrier (BBB) damage through Evans Blue staining of brain sections. The neurobehavioral studies of developing rats were locomotor studies, grip strength and learning memory performance. Results: MM synergistically reduced viability and enhanced apoptosis of rat primary astrocytes with the increased intracellular Ca2+-release and involvement of the MAPKs. ERK appeared to be the most proximal followed by JNK, which was independent of NFkappaB, p38-MAPK and PI3 kinase activation. Treatment of developing rats with MM exhibited reduced glial fibrillary acidic protein (GFAP) and MBP expression that was partially recovered upon withdrawal of MM. There were impaired dendritic arborisation and reduction in number and size of the GFAP positive cells in the cerebellum and hippocampus of MM treated rats. As functional correlates, MM treatment resulted in enhanced spontaneous locomotor activity and reduced learning-memory performance. In addition, MM treatment increased the blood-brain barrier (BBB) permeability indicating impaired astrocyte functions. Furthermore, there were reduction in the number and intensity of MBP- positive regions in the optic nerves of the MM-treated rats, suggesting impaired oligodendrocyte function. MM treatment resulted in increased levels of As, Cd and Pb in the developing rat brain. Conclusion: MM adversely impacts glial cell physiology such that there are impairments in BBB and myelination leading to impaired neurobehavior.

O94 Overnight pulse oximetry and iron status in children with epilepsy V. L’esperance, E.V. Blake, C. Banks, L. West, F.J. Kirkham University of Southampton (Southampton, UK); Southampton General Hospital (Southampton, UK); Portsmouth Hospital (Portsmouth, UK) Background: The prevalence of and risk factors for low nocturnal haemoglobin oxygen saturation (SpO2) and obstructive sleep apnoea (OSA) have received little attention in children with epilepsy. Mean and minimum SpO2 of \97% and \90% respectively are rarely seen in the general paediatric population [1]. Iron plays an important role in the developing brain and deficiency has been linked to difficulties

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in behaviour, cognitive ability and paediatric sleep disturbance. In the general population, iron deficiency has been linked to adenotonsillar hypertrophy and OSA[2] (measurable as a delta 12 index of [0.4 on pulse oximetry), which may in turn affect seizure control in epileptic children[3], although there are few data. Methods: This was a retrospective cohort study of epileptic children undergoing haematology and overnight pulse oximetry from January 2000 to December 2009. Results: Of 74 children (37 boys; median age [range] 8 [0.4-17] years undergoing overnight pulse oximetry, 37 (50%) had mean SpO2 \97% and 23 (31%) had minimum SpO2 \90%. Delta 12 index was available in 27 and was abnormal in 4 (15%). Of 45 children with haematology data, 13 (29%) had haematocrit lower than 2 standard deviations for age. There was no relationship between haematocrit and mean or minimum overnight SpO2 but in 16 children for whom data were available, haematocrit explained 37% of the variation in Delta 12 index (p=0.01) independent of age and gender. Discussion: Epilepsy, iron deficiency and sleep-related breathing disorders are all common paediatric problems. Overnight SpO2 lower than normal is prevalent in childhood epilepsy. Low haematocrit is also common and is associated with an index of OSA. Further research is needed to confirm or exclude iron deficiency as an aetiology and explore the effect of supplementation on sleep. As treatment of OSA improves seizure control in adults, the possibility that restoring iron stores or improving SpO2 or OSA reduces seizure frequency or improves cognitive function, e.g. attention, should be explored in this patient group. 1. Urschitz MS, et al. Reference values for nocturnal home pulse oximetry during sleep in primary school children. Chest 2003;123:96–101. 2. Kerstein R, et al. Iron deficiency and sleep disordered breathing in children - cause or effect? Int J Pediatr Otorhinolaryngol 2009;73:275–80. 3. Koh S, et al. Sleep apnea treatment improves seizure control in children with neurodevelopmental disorders. Pediatr Neurol. 2000;22:36–9.

O95 Dynamic splinting for toe walking: a case report P. Lundequam, B. Willis Methodist Hospital (St Louis Park, US); Texas State University (San Marcos, US) Introduction: Toe walking is a condition that impairs ambulation and development in children. A substantial number of patients suffer from this pathology, which may be due to underlying neurological disease (i.e. cerebral palsy) or this may be idiopathic in nature. Excessive ankle plantarflexion affects a child’s gait pattern and disables the ability for functional play, such as single leg standing, jumping or hopping, and all symmetrical bilateral coordination activities. Objective: The purpose of this case report was to reveal the benefit of dynamic splinting in restoring dorsiflexion and functional ambulation in a 5 year old female patient with hemiparesis. Serial casting has been the standard of care for this condition and this report demonstrates how contracture reduction can be achieved without disrupting the child’s activities and physiotherapy. Methods: A five year old, Caucasian, American girl with cerebral palsy presented with right hemiparesis; below average motor skills and a gait pattern of toe contact (without ankle foot orthosis). Treatment plan included one set of Botox injections, four months of physiotherapy, and nightly wear of the Ankle Dorsiflexion Dynasplint (mean 6 hours/night). Tension on Dynasplint was changed every two weeks to accommodate changes in the maximal end range (of motion). Results: After concurrent treatment with physiotherapy twice a month and nightly wear of the dynamic splint, the patient’s passive

S29 dorsiflexion increased 14. She gained the ability to walk with ‘‘flat foot’’ contact without wearing an Ankle Foot Orthosis and single leg hop. This treatment achieved improved gait pattern and strength training which would not possible with casting. Conclusions: The combined protocols of Botox for tone management, Dynamic Splinting for contracture reduction, and Physiotherapy for motor skill development has been shown beneficial in this case. The controlled, dynamic tension adapted to gains in ROM, while maintaining the ankle joint stretching at end range for 68 hours each night. Physiotherapy combined with 720 hours of Ankle Dorsiflexion Dynasplint end range stretching (home therapy tracked through weekly reports) changed the patient’s ambulation pattern and dynamic splinting should be investigated in a future multi centre, randomized, controlled trial of gait patterns.

O96 Vitamin B12 deficiency, involuntary movements and seizure in a 11-months-old boy: a case report and review of the literature M. Eraksoy, N. Pulur, Z. Yapici, C. Gurses Istanbul University (Istanbul, TR) Epileptic seizures and involuntary movements are frequently caused by diagnostic and therapeutic challenges in infancy.Benign and treatable forms of involuntary movements and seizures should be differentiated from malign forms.Many reports have described vitamin B12 deficiency in infants of mothers with undiagnosed pernicious anemia and exclusively breast-fed infants whose mothers are vegan. Megaloblastic anemia always present with vitamin B12 deficiency in infants and children is accompained by apathy, developmental delay, involuntary movements, and tremor. We describe a 11-months of age boy whose mother with undiagnosed pernicous anemia; presented with tremors, infantile spasms-like jerks- therefore, he formerly diagnosed West syndrome-; and adversive seizures with multifocal, long-lasting epileptogenic activity in the electroencephalogram (EEG).His brain MRI was in normal limits. His motor and mental developments were normal. After receiving vitamin B12, his tremors, involuntary movements resolved, but adversive seizures continued. This epileptic seizures dramatically responded to clonazepam without remarkable EEG changes in the early period. In conclusion, vitamin B12 should be tested in all tremors, involuntary movements and epileptic syndrome in the infancy period and it should be kept in mind that these clinical pictures may respond to vitamin B12 and clonazepam therapy.

__________________________________ Oral session 11 Clinical neurophysiology O97 Mirror movements in Parkinson’s disease: electromyographic occurrence according to disease severity and dopaminergic therapy F. Spagnolo, M.A. Volonte´, E. Coppi, R. Chieffo, L. Straffi, G. Comi, L. Leocani Scientific Institute San Raffaele (Milan, IT) Objectives: Mirror Movements (MM) represent involuntary movements occurring during voluntary activity in contralateral homologous

muscles. They have been described in several neurodegenerative disorders, including Parkinson’s disease (PD), but their evolution during disease progression is uncertain. We evaluated the effect of disease severity and dopaminergic therapy on the electromyographic (EMG) occurrence of MM in two selected groups of PD-patients and we compared it with controls. Methods: PD-patients underwent EMG recordings from three upper-limb muscles during ten trials at intertrial intervals of 4 sec. For each trial subjects were instructed to perform a brisk and selected unilateral movement at a slight strength level. Patients were subdivided in two groups, the former (n=10), drug-naı¨ve, presenting an early, asymmetric left-PD (early-PD), the latter (n=9) suffering from a quite advanced PD, with clinical onset and worst lateralization on the left-side (advanced-PD). Within the same experimental session, subjects were studied during a basal condition (OFF), and after levodopa administration (ON). Lateralized Unified Parkinson’s Disease Rating Scale (UPDRS) subscores were calculated in every experimental condition. Data were compared with a group of 12 controls. Results: No differences were detected in mirroring activity between advanced-PD and controls, nor between dominant and non-dominant hands and between OFF and ON conditions in any of these two groups. In early-PD, the less affected side revealed a significant higher mirroring activity compared to the contralateral one (p\0,001; t-test) and also versus both advanced-PD and controls (p=0,04 and p=0.01 respectively), while no significant differences were detected between the most affected side and both controls and advanced-PD. Levodopa intake did not modify these findings. Moreover in early-PD a significant negative correlation appeared between right hand MM and left lateralized UPDRS (r=-0,79 and r=-0,77 in OFF and ON respectively), being MM only confined to the early and asymmetrical PD phase. Conclusion: Altered movement lateralization, responsible for MM, seems to be typical of early PD stages and may represent the expression of a different inter-hemispheric inhibition, non influenced by levodopa therapy. We hypothesize that compensatory cortical mechanisms are involved in the early phase of the disease, disappearing during its progression, possibly depending upon more symmetric PD-involvement.

O98 Probing command following in patients with disorders of consciousness using a brain-computer interface Q. Noirhomme, C. Chatelle, S. Kleih, M. Thonnard, A. Demertzi, M.-A. Bruno, A. Vanhaudenhuyse, O. Gosseries, C. Schnakers, R. Lehembre, A. Soddu, A. Ku¨bler, S. Laureys, D. Lule´ University of Lie`ge (Lie`ge, BE); University of Tu¨bingen (Tu¨bingen, DE); University of Wu¨rzburg (Wu¨rzburg, DE); University of Ulm (Ulm, DE) Objective: In the recovery from coma, the acquisition of command following represents an important milestone, indicating emergence from the vegetative state. In some patients, recovery of consciousness may precede motor recovery. Brain-computer interfaces (BCI) might permit these patients to show non-motor dependent signs of awareness and in a next step might enable communication. This study aimed at testing to what extent an EEG-based BCI could help detecting signs of awareness and communication in disorders of consciousness. Methods: We studied 13 patients with a minimally conscious state (MCS, 5 TBI – 8 anoxic, mean time post injury 70±109 months; mean age 42±21) and 16 healthy controls (aged 45±19). Patients were evaluated using the Coma Recovery Scale Revised. 16-Channel EEG was recorded using a g.tec USBAmp amplifier. An auditory P300 four choice speller paradigm based on the BCI2000 system was used. Subjects were asked to answer yes or no to simple questions by paying attention to one

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S30 out of four auditorily presented stimuli (‘yes’, ‘no’, ‘stop’, ‘go’). A trial constituted of 15 presentations of each sound the order of presentation being randomized. After a training session, patients and healthy subjects were required to answer 10 to 12 questions. A stepwise linear discriminant analysis based on the training session was used to classify the data. Offline, all training and testing trials were pooled and a leave-one-out approach was used to classify the data. Results: Healthy subjects presented a mean correct response rate of 73% online and 93% offline. Three MCS patients had a correct response rate of C50% offline (10, 18, 0% online and 50, 53, 57% offline). Two of these three patients did not show any command following at the bedside. The 10 remaining MCS cases showed online and offline correct answers \50% (mean 33±9% online and 25±13% offline). Conclusion: Our auditory P300-based BCI permitted functional interactive communication in 15/16 controls (online) and in all offline. Our data obtained in patients with disorders of consciousness demonstrate the potential clinical usefulness of the technique following coma but also show lower accuracy in patients as compared to healthy volunteers. This might be due to fluctuating attentional levels and exhaustibility in the MCS and to the suboptimal EEG recording quality due to movement, ocular and respiration artifacts in these challenging patients.

O99 Evoked potentials scores: a useful tool in monitoring and predicting the course of multiple sclerosis? M. Bianco, S. Medaglini, J.J. Gonzalez-Rosa, M. Rodegher, U. Del Carro, S. Amadio, L. Moiola, M. Radaelli, V. Martinelli, G. Comi, L. Leocani University Hospital San Raffaele (Milan, IT) Background: The usefulness of Evoked Potentials (EPs) in monitoring and predicting the evolution in the early phases of Multiple Sclerosis (MS) is still a matter of debate. Objective:to investigate the value of multimodal EPs in detecting and predicting clinical disability progression in a sample of early Relapsing Remitting MS (RRMS) patients. Methods: Forty patients with RRMS (26 women, 14 men; age 37.8+/-9.5 yrs; median EDSS 1.5, range 0-4; disease duration 99.1+/82.02 months) underwent Expanded Disability Status Scale (EDSS) and Functional System (FS) scoring at study entry (T1) and after 2 years (T2). All patients entered immunomodulatory therapy (22 Glatiramer acetate, 15 IFN b 1a, 3 IFN b 1b) within 3 months after basal assessment. Multimodal EPs (visual-VEP, somatosensory-SEP, motor-MEP and brainstem auditory-BAEP) were obtained at T1 in all patients and in 21 at T2, and quantified with a conventional score (normal, abnormal latency or amplitude, abnormal latency and amplitude, absence). Results: EDSS and FS did not significantly change over time evaluation in the whole group and in the 21 patients. No significant treatment effects were found for clinical and neurophysiological parameters. SEP sum score (p=0.05; Wilcoxon) and SEP+MEP and SEP+MEP+VEP sum scores significantly worsened at T2 (p\0.02). Basal global and individual EP sum scores modestly correlated with EDSS at study entry (Spearman r=0.32-0.67; p\0.04) but more strongly after two years (r=0.50-0.69; p\0.01). SEP sum score correlated with sensory FS at T1 (r=0.486;p=0.025) and T2 (r= 0.36-0.41;p[0.06). VEPs at T1 (57%) and T2 (67%) and SEPs at T2 (62%) were more frequently abnormal than their FS (visual 19% T1, 5% T2; sensory 66.7% T0, 57.1% T1). Correlation between basal EPs and FS change at T1 was significant for MEPs (r=0.55; p\0.01) and SEPs (r=-0.30; p=0.05). Conclusions: Our findings suggest that EPs may be more sensitive to change than clinical assessment in monitoring MS. Moreover, they can predict future disability progression, especially for the motor and

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somatosensory modality, probably in reason of to their ability to detect subclinical lesions that may became manifest later.

O100 Early changes in cortical excitability and interhemispheric inhibition after cortical and lacunar mild stroke: a TMS study R. Chieffo, L. Straffi, A. Poggi, E. Coppi, F. Spagnolo, A. Inuggi, M. Comola, G. Comi, L. Leocani Scientific Institute San Raffaele (Milan, IT) Objective: after stroke cortical excitability changes occur to lesioned and unlesioned hemispheres. We investigated early and later changes in cortical excitability and inter-hemispheric inhibition using Transcranial Magnetic Stimulation-TMS after cortical or subcortical stroke. Methods: Thirteen patients were studied at 7+/-3 days (T1) and 30+/-10 days (T2) after a first acute mild (NIHSS\5) stroke (6 cortical-CS, 7 lacunar-LS), and compared with 11 control healthy volunteers of similar age and sex distribution. Bilateral cortical mapping, with simultaneous recording from 3 upper limb muscles was obtained with focal-TMS at intensity 15% above motor threshold (MT). Motor Evoked Potentials (MEPs) amplitude (MA) and number of responsive sites (RS), mirror EMG to isometric contraction of the same muscles of both sides, and APB ipsilateral silent period (iSP) to focal TMS (90% maximum output). Results: Clinical measures and motor performance on the paretic side did not significantly differ between groups at T1 and T2. Both groups significantly recovered at 1 month (NIHSS p\0.038; Wilcoxon). MT was reduced over the unaffected hemisphere in CS patients vs LS and controls (p\0.015; Mann-Whitney) at T1 and T2, and increased RS (vs controls p=0.027; vs LS p=0.062) only at T1. No significant group effects on MA were found. On affected hemisphere, MT was increased (p=0.016) and MA reduced (p=0.035) in LS vs CS patients and controls, while in CS MA was increased vs LS at both times (p\0.027) and RS increased at T1 (p= 0.019) with significant decrease over time (p=0.039). MM to movement of the paretic side were increased at T1 in both patients groups compared to controls (p\0.04), and their frequency significantly decreased at T2 in LS (p=0.0039). iSP was significantly delayed on unaffected APB in CS vs LS and controls at T1 and T2 (p\0.05). Conclusions: Our finding of increased amplitude and number of responsive sites after mild cortical stroke over the affected hemisphere suggests a perilesional hyper-excitability. Moreover, cortical stroke leads to greater increased excitability over the unaffected hemisphere, persisting after one month, as suggested by decreased motor threshold and increased number of responsive sites. This can be related to damage of inhibitory callosal fibres, as revealed by delayed iSP to voluntary movement of the healthy side. The latter finding may also explain a greater tendency to persistence of mirror movements after cortical stroke.

O101 Sympathetic dysfunction in sensory polyneuropathies: abnormalities in the sympathetic skin response and sweat gland innervation N. Sola`, J. Casanova-Molla`, J. Valls-Sole´ Hospital Clinic of Barcelona (Barcelona, ES) Introduction: Sweating disturbances are an infrequently studied aspect of small fibre neuropathies (SFN). However, some of the techniques

S31 used to assess function of small sensory fibers allow us to obtain information on sudomotor sympathetic dysfunction. Objective: We aimed at investigating the sweat gland nerve fibre density (SGNFd) and how it related to the abnormalities in sympathetic skin response (SSR) in patients with SFN. Methods: We selected 10 SFN patients and 10 healthy subjects, whose skin biopsy sample contained a sweat gland section. We measured the amplitude and latency of the SSR elicited by electrical and nociceptive (contact heat termode) stimuli. In skin biopsy samples, we calculated the SGNFd and the density of intraepidermic nerve fibers (IENFd) stained with the panaxonal marker PGP 9.5. In confocal microscope images, we quantified the area of sweat gland PGP 9.5 immunoreactive with respect to the total sweat gland area. Results: Patients had a significant reduction of SGNFd in comparison to controls (0.05 ± 0.04 vs. 0.27 ± 0.06, t-test p\0.001). There was a positive significant correlation between SGNFd and IENFd (Pearson’s coefficient r=0.69, p\0.001). The SSR induced by nociceptive stimuli was of lower amplitude and longer latency in patients than in control subjects, but the SSR induced by electrical stimuli was not different between groups. Conclusion: The decrease of SGNFd reveals the impairment of efferent sympathetic fibers in SFN patients. Abnormalities in the nociceptive SSR must be attributed to afferent dysfunction, while normal SSR to electrical stimuli, which bypass the defect in skin innervation, suggests that a few remaining sympathetic axons innervating sweat glands are enough to generate the SSR.

O102 Cellular immune response in prognosis of Bell’s palsy and its relation to clinical and electrophysiological findings N. El Sawy, E. Shahine, A. El Hadidi, G. Osman, N. El Habashi Faculty of Medicine (Alexandria, EG) Objective: to determine the cellular immune response in Bell’s palsy and its prognostic value in relation to clinical and electrophysiological findings. Subjects and methods: Twenty patients with Bell’s palsy were subjected to: Facial nerve paralysis assessment according to House and Brackmann grading system (H&B), bilateral facial nerve conduction study, blink reflex, electroneurography (ENoG) and needle electromyography (EMG) for the affected side after one week from the onset. At initial visit and before the start of medical treatment, peripheral blood mononuclear cells subsets were analyzed to reveal the percentage of total T cells (CD3+), T helper/ inducer cells (CD4+), T cytotoxic (CD8+) and B cells (CD19+). Patients were followed up by (H&B) grading system, ENoG and needle EMG up to 3 months from the onset (end point). Fifteen age and sex matched healthy control subjects for ENoG and laboratory tests were included. Results: The percentage of CD3+, CD4+ & CD8+ subsets were significantly depressed in Bell’s palsy patients group than age matched control subjects (PB0.05). However, percentage of CD19+ subset did not show significant difference between them. On follow up assessment, H&B grading revealed significant improvement (P=0.001). Neither electrophysiological parameters nor electroneurography showed significant difference between initial and follow up assessment (P[0.05). Initial percentage of CD4+ subset correlated negatively with disease duration (P=0.02). While Initial percentage of CD8+ subset correlated positively with follow up compound muscle action potential (CMAP) amplitude of orbicularis oris muscle (P=0.04) and electroneurography of orbicularis oculi and nasalis muscles (P=0.04). Initial percentage of CD19+ subset correlated

negatively with follow up H&B grading (P=0.003) as well as R1 & R2 responses of follow up blink reflex. Initial CD3+ percentage did not correlate with any of follow up measures. Conclusion: Decreased percentage of the peripheral blood CD3+, CD4+ & CD8+ subsets in Bell’s palsy patients emphasizes the role of cell mediated autoimmune pathogenesis in the acute stage of the disease. These cells have a prognostic significance for prediction of the disease duration and outcome. Analysis of T lymphocytes subsets may provide an additional parameter to differentiate patients with favorable from those with poor prognosis.

__________________________________ Oral session 12 Stroke I O103 Dabigatran compared to warfarin in patients with atrial fibrillation and prior TIA or stroke: the RE-LY study H.C. Diener, S.J. Connolly, M. Ezekowitz, S. Yusuf, L. Wallentin, P. Reilly, J. Pogue, S. Wang, D. Xavier, G. Di Pasquale on behalf of the RE-LY steering committee and investigators Objectives: Warfarin reduces stroke in atrial fibrillation (AF), but increases haemorrhage and is difficult to use. Dabigatran is a new oral direct thrombin inhibitor with no need to monitor coagulation. Methods: In a non-inferiority trial, 18,113 patients with AF at risk of stroke were randomized to blinded fixed doses of dabigatran 110 mg (D110) or 150 mg bid (D150) versus unblinded adjusted warfarin. Median follow-up was 2.0 years. (ClinicalTrials.gov number, NCT00262600) Results: Stroke or systemic embolism (primary outcome), occurred in 199 patients (1.69 percent (%) / year) on warfarin, in 182 (1.53% /year) on D110 (relative risk (RR) 0.91;p (non-inferiority) \0.001) and in 134 patients (1.11% /year) on D150, (RR 0.66; p (both non-inferiority and superiority) \0.001. The rate of stroke and systemic embolism was significantly higher in patients with prior stroke or TIA (pST) (170/3623 = 2.37% /year versus 345/14489 = 1.98% / year p\0.001. The primary outcome occurred in 64 patients with pST (2.74% /year) on warfarin, in 55 (2.32%/year) on D110 (relative risk 0.85; p = 0.37), and in 51 (2.07% /year) on D150 (RR 0.76, p = 0.14). Major haemorrhage occurred in 397 patients (3.36% /year) on warfarin, in 322 (2.71% /year) on D110 (RR 0.80, p = 0.003) and in 375 (3.11% /year) on D150 (RR 0.93; p=0.31). In patients with pST, major haemorrhage was significantly lower in patients on D110 compared with warfarin (RR 0.68, p = 0.02) and similar between D150 and warfarin (RR 1.07, p=0.63). Hemorrhagic stroke occurred in 45 patients on warfarin (0.38% per year), 14 (0.12% per year) on D110 (RR 0.31, p\0.001), and 12 patients (0.10% per year) on D150 (RR 0.26; p\0.001). In patients with pST, hemorrhagic stroke occurred in 18 patients (0.77% /year) on warfarin, 2 (0.08% /year on D110 (RR 0.11 p = 0.003) and 5 (0.20 /year) on D150 (RR 0.27 p = 0.009). Conclusion: In the subgroup of patients within RE-LY who already suffered from a stroke or TIA dabigatran D110 was as effective as warfarin, dabigatran D150 was superior to warfarin and both doses of dabigatran had a lower rate of cerebral hemorrhages. This study was supported by Boehringer Ingelheim

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O105 Diffusion-weighted MR imaging in basilar artery occlusion A. Karameshev, M. El-Koussy, G. Schroth, L. Kappeler, P. Stein, J. Gralla, H. Mattle, K. Nedeltchev, P. Shotekov, M. Arnold Medical University Sofia (Sofia, BG); University of Berne (Berne, CH); Triemli City Hospital (Zurich, CH) Introduction: The extent of early ischemic damage on pre-treatment diffusion-weighted imaging (DWI)-MR has a potential to predict the outcome in patients with acute basilar artery occlusion (BAO) and influences the response to intra-arterial thrombolysis (IAT). The predictive value of previously published DWI-scoring systems has not been compared yet. Materials and methods: We studied patients with BAO treated with IAT within 12 hours after symptom onset. The association between pre-treatment DWI-MRI and clinical variables with functional clinical outcome at 3 months was analyzed. Three recently published DWI-scoring systems were compared and a modified scoring system is proposed. Results: Thirty-six patients (13 women, 23 men; mean age 60, SD15) were included. The median NIHSS-score on admission was 17. The median GCS was 10. Mean time-to-treatment was 5.6 hours. Partial or complete recanalization after IAT was achieved in 26 patients (72%). Functional outcome at 3 months was good (mRS 0-3) in 19 (53%) and poor (mRS 4-6) in 17 (47%) patients. In univariate analysis, National Institute of Health Stroke scale score (NIHSS), GCS on admission and all 4 DWI-scoring systems were significantly associated with clinical outcome. After regression analysis our modified DWI-score was the only predictor that remained independently associated with clinical outcome at 3 months (P=0.004). Conclusion: The proposed DWI-scoring in BAO was an independent predictor of clinical outcome. Nevertheless, the therapeutic decision should also be guided by clinical variables.

O106 High-grade internal carotid artery stenosis and chronic cerebral damage: a volumetric MRI study T. Gattringer, C. Enzinger, S. Ropele, C. Langkammer, R. Schmidt, F. Fazekas Medical University of Graz (Graz, AT) Background and purpose: Experimental data suggest that high-grade vascular stenosis may induce chronic tissue damage. We tested this hypothesis in patients with a unilateral 70–99% internal carotid artery (ICA) stenosis by volumetric MRI measurements. Methods: We retrospectively identified 97 patients with a C70% ICA stenosis (mean age 69.1+/-10.2 yrs; 68M/29F) who were asymptomatic (n=61) or had a history of an earlier cerebrovascular event without (n=23) or only a small (\1.5cm) infarct (n=13). 1.5T MRI studies served to measure side to side differences in volumes of hemispheric brain tissue using a modified SIENAX technique and of white matter hyperintensity (WMH). Visual ratings assessed sulcal width and WMH severity. Results: In the entire group, there were no significant differences regarding brain and CSF volumes or sulcal width between hemispheres supplied by a stenotic or non-stenotic ICA. The median WMH volume was higher in the hemisphere ipsilateral to the stenotic ICA (1.13cm3, IQR 2.65; other hemisphere: 0.77cm3, IQR 2.26, p=0.005). When analysing the subgroup of patients with moderate and severe WMH (n=41; 21 asymptomatic), the hemispheric volume ipsilateral to the stenotic ICA was significantly lower (543.46±22.17 vs.

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548.66±26.7cm3, p=0.03). Regression analysis revealed an independent effect of WMH grade on hemispheric volume differences. Conclusions: Chronic tissue damage occurs independently of cerebrovascular events in a subset of individuals with C70% ICA stenosis characterized by more extensive WMH. This warrants further studies using neuropsychological testing and perfusion measurements in individuals with an asymptomatic C70% stenosis.

O107 Incidence of small cerebral bleeds in patients with a neurodegenerative dementia: a neuropathological study J. De Reuck, C. Cordonnier, V. Deramecourt, F. Pasquier, D. Leys, C. Maurage University of Lille, Nord de France (Lille, FR) Background: Small cerebral bleeds are frequently demonstrated on magnetic resonance imaging in patients with Alzheimer dementia (AD). However, histological confirmations of this high incidence in post-mortem brains are scarce. Objectives: The present study analysis the incidence of the cerebrovascular lesions and quantify the ‘‘bleeding load’’ in postmortem brains of patients with neurodegenerative dementias and of agematched controls. Patients and methods: Forty-five brains of AD patients, 8 of dementia with Lewy bodies (DLB), 12 of fronto-temporal dementia (FTD) and 7 controls were examined. The presence of large infarcts, hemorrhages and lacunes was evaluated on macroscopic examination. Histological examination was performed for evaluation of cerebral amyloid angiopathy (CAA), white matter changes, micro-infarcts and, cerebral micro- and minibleeds (MnBs). The latter were evaluated semi-quantitatively on a coronal section of a whole cerebral hemisphere and on a horizontal section through pons and cerebellum. Results: MnBs, consisting of small perivascular recent or old bleeds, were observed to different degrees in the majority of brains with neurodegenerative dementias and in more than 40% of the controls. They occurred most frequently in the cerebral cortex and the cerebellum of AD and DLB brains. Their presence was, however, more widespread in AD brains. CAA was found in 57.8% of AD and in 12.5% of the DLB brains. Combined AD and DLB pathologies were observed in 15.1%. Conclusion: The high incidence of MnBs in AD and DLB brains is due to the frequent co-existence of both pathologies and the presence of CAA.

O108 Single nucleotide polymorphism rs2634073 at chromosome 4q25 and the risk of stroke in Polish population M. Wnuk, J. Jagiella, K. Spisak, E. Szczygiel, A. Ferens, W. Turaj, J. Burkot, A. Slowik Jagiellonian University Medical College (Krakow, PL) Objectives: Recent genome-wide association study followed by replication studies in three populations of the European descent revealed that few single nucleotide polymorphisms (SNPs) at chromosome 4q25 were associated with atrial fibrillation (AF). One of these SNPs, rs2634073, has never been tested for the association with ischaemic stroke before. Thus, we studied the significance of the SNP rs2634073 at chromosome 4q25 in patients with ischaemic stroke in a Polish population sample. Methods: We genotyped 881 patients and 428 controls. We divided all patients into 6 following subgroups according to the TOAST criteria:

S33 129 patients with stroke caused by large-vessel disease, 130 with smallvessel disease, 302 with cardioembolic stroke, 51 with both cardioembolic stroke and large-vessel disease, 33 with other type of stroke and 236 with undetermined etiology of stroke. We recorded the presence of the following vascular risk factors: hypertension, ischaemic heart disease, diabetes mellitus, AF, smoking habits and hypercholesterolemia. The SNP rs2634073 was analysed using RT-PCR. Results: The distribution of the studied SNP was similar among patients and controls (CC – 60.6%, CT – 33.3%, TT – 6.1% vs. CC – 65.5%, CT – 31.3%, TT – 4.2%; p = n.s.). However, there were significantly more cases who presented with coexisting AF and the Tallele of studied SNP among patients in comparison to controls (13.2% vs. 2.8%; p\0.05). Logistic regression models including all studied risk factors showed that: 1) the T-allele of the SNP rs2634073 was not a risk factor for stroke when all stroke patients were analyzed without considering stroke etiology (OR = 0.91, 95%CI: 0.71–1.17); 2) the T-allele of studied SNP was not a risk factor for stroke when the cases without AF were analyzed (OR = 1.07, 95%CI: 0.77–1.49); 3) the T-allele of studied SNP affected the risk of stroke but only if it coexisted with AF (OR = 4.43, 95%CI: 2.04–9.63). Interestingly, the coexistence of AF and the T-allele of studied SNP increased the risk of stroke (OR=4.43) by more than 2 times than AF alone (OR = 2.36). Conclusions: The T-allele of the SNP rs2634073 at chromosome 4q25 does not increase the risk of stroke in patients without AF. However, when AF appears in these cases, they have 2 times higher risk of stroke than those who have AF without the risk allele. Carriers of the risk allele should be carefully monitored in respect of the appearance of AF. The study was supported by the grant of Polpharma Company no. PBJ/000017.

showed cognitive impairment with MMST values \ 26, vs. 14% of PD-RBD patients (p.026). Daily dosage of L-dopa was 733±357 mg in PD+RBD patients and 640±357 mg in PD-RBD patients (p 0.007). In the PD+RBD group 60% were on atypical neuroleptic medication vs. 25 % of PD-RBD patients. Concerning PSG parameters, significant differences were found in PLM index with 36±40 in the PD+RBD group vs. 29±44 in the PD-RBD group (p.001), PLMS index with 35±43 in the PD+RBD group and 22±40 in the PD-RBD group (p.000) and the proportion of REM sleep calculated as % of total sleep time with 18±12% in the PD+RBD group and 14±11 in the PD-RBD group (p 0.000). No significant difference was found for gender distribution, for all other PSG parameters, for medication with dopamine agonists, amantadine, benzodiazepines, SSRI and opiates. Conclusion: RBD affected 46% of PD patients in this large cohort and was associated with older age, higher disease severity, longer disease duration, more falls and more cognitive impairment. This is reflected by a higher intake of L-dopa and more concomittant use of atypical neuroleptics. PD patients with RBD also showed more REM sleep and higher PLM and PLMS indices, suggesting more severe sleep impairment.

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Objectives: RLS is often associated with affective disorders, such as depression, somatoform disorders or attention deficit hyperactivity syndrome (ADHS), but the relationship between RLS and psychiatric disorders is complex. On the one hand, RLS appears to facilitate the development of psychiatric disorders, but on the other hand affective disorders (and/or antidepressant treatment) may lead to deterioration of RLS. The presence of comorbid psychiatric disorders therefore has a major influence on therapy outcome. The aim of the study was to systematically characterize RLS patients concerning psychiatric disorders and to study therapy outcome in patients with and without psychiatric comorbidities (PC). Methods: We prospectively included 49 consecutive patients fulfilling diagnostic criteria for RLS. All were ‘‘de novo’’ patients with idiopathic RLS. Responses to RLS (e.g. IRLS), standard sleep, and psychiatric questionnaires (e.g. Beck Depression Inventory, BDI) were analyzed before and at three months follow-up. In all patients, blood tests and PLMS analysis were performed. Detailed psychiatric assessments were based on a computer-supported personal interview using the Composite International Interview (CIDI/ DIA-X) for DSMIV. Patients requiring treatment received dopaminergic therapy with pramipexole. Results: In 19 (39%) out of 49 patients, a psychiatric diagnosis could be identified according to DIA-X. Nine (18.3%) patients were suffering from a somatoform disorders (SD), eight (16.3%) from a depressive (DD) and six (12.2%) from an anxiety disorder (AD). Two patients (4.1%) fulfilled criteria for a posttraumatic stress disorder; one patient was suffering from an eating disorder. No sociodemographic differences between patients with and without PC were found. Out of the 49 patients, 21 initially required RLS treatment. The majority (n=13) were patients without a comorbid psychiatric disorder. From the eight patients with PC, four were suffering from depression, anxiety disorders (n=2) and SD (n=2). Five patients (DD, n=3; AD, n=1; SD, n=1) were treated with pramipexole over three months. RLS symptoms then had improved, and psychiatric

Sleep disorders O109 Polysomnographically validated RBD in Parkinson patients with nocturnal disturbances F. Sixel-Do¨ring, E. Trautmann, B. Mollenhauer, C. Trenkwalder Paracelsus-Elena-Klinik (Kassel, DE) Objective: To investigate the frequency and associated factors of RBD in PD patients with nocturnal disturbances. Methods: Video-supported polysomnography (PSG), comparative statistical analysis of PSG, demographic, clinical and medication data. Significance was calculated with Mann-Whitney U-test and cut-off defined at p \0.05. Results: Between 1/2005 and 10/2009 altogether 457 PD patients with moderate to severe sleep disturbances were investigated with video-supported PSG for 1 night. RBD was diagnosed in 210 patients (46%), according to the International Classification of Sleep Disorders (ICSD-2) criteria. Significant differences between the group of PD patients with RBD (PD+RBD) and the group without (PD-RBD) were found for the following parameters: Mean age for PD+RBD was 69±8 yrs, and 66±11 yrs for PD-RBD (p.000). Disease duration was 8.7±4.4 yrs in the PD+RBD group and 7.3±5.6 yrs in the PD-RBD group (p.001). 50% of PD+RBD patients suffered falls vs. 35% of PD-RBD patients (p.002). Average Hoehn & Yahr stage in the PD+RBD group was 3.24±1.08 vs. 2.87±0.87 in the PD-RBD group (p.000). 22% of PD+RBD patients

O110 Psychiatric co-morbidities in restless legs syndrome: frequency, characteristics and therapy outcome U. Kallweit, E. Werth, A. Seiz, S. Trulec, U. Ehlert, C. Bassetti University Hospital Zurich (Zurich, CH); University Zurich (Zurich, CH)

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S34 questionnaires indicated a strong trend towards an improvement of depression and/or anxiety. Conclusion: RLS is often accompanied by psychiatric disorders, in particular somatoform and affective disorders. Dopaminergic treatment not only improves RLS symptoms but also seems to have a positive effect on depression and anxiety.

O111 Coincidental Parkinson’s disease in patients with narcolepsy with cataplexy C. Gaig, J. Santamaria, A. Iranzo, F. Martı´ Hospital Clinic (Barcelona, ES) Objectives: Narcolepsy is a chronic sleep disorder characterized by excessive daytime sleepiness (EDS), cataplexy, and other rapid eye movement sleep abnormalities such as, hypnagogic hallucinations, sleep paralysis or REM behaviour disorder (RBD). Insomnia also occurs commonly in narcolepsy. Patients with Parkinson’s disease (PD) frequently have sleep problems, such as EDS, insomnia or RBD. Symptoms in narcolepsy with cataplexy are caused by a loss of hypocretin producing neurons in the lateral hypothalamus, and some authors have suggested a similar physiopathology for some sleep disturbances in PD. Whether sleep disturbances could change in patients with narcolepsy who develop a concomitant PD (i.e; EDS worsening, or even improvement in cataplexy), is unknown. To the best of our knowledge, there are no reported patients suffering coincidentally both disorders. We present two patients with a long lasting history of narcolepsy with cataplexy who developed PD. Methods: A 77 year-old man and a 62 year-old woman with a history of EDS since their twenties had been diagnosed of narcolepsy with cataplexy when they were 63 and 52 year-old, respectively. A PD was diagnosed in both patients at the age of 71 and 61. We compare in these two narcoleptic patients the sleep disturbances (EDS, insomnia, cataplexy, RBD, sleep paralysis and hypnagogic hallucinations), as well as the features of nocturnal polysomnography and multiple sleep latency test (MSLT), before and after the development of PD. Results: In both patients, EDS did not worsen after the development of PD. Cataplexy, which had improved during ageing, remained unchanged after parkinsonism. Insomnia, RBD and sleep paralysis did not change in severity. Hypnagogic hallucinations were absent after and before the development of PD, although one patient developed visual hallucinations secondary to dopaminergic treatment. Nocturnal polysomnography results (i.e sleep latency and efficiency, signs of RBD) and MSLT findings (mean sleep latency and sleep-onset REM periods) did not show significant differences before and after the development of PD. Conclusion: Sleep disturbances in patients with narcolepsy with cataplexy did not seem to worsen or improve when a concomitant PD develops, suggesting that physiopathological factor other than hypocretin deficiency are responsible for EDS, RBD and other sleep disturbances in PD.

O112 Restless legs syndrome in a population of patients on haemodialysis J.M. Roriz, P. Carneiro Hospital Pedro Hispano (Matosinhos, PT); Uninefro Matosinhos (Matosinhos, PT) Introduction: Restless Leg Syndrome (RLS) is defined by the NIH consensus criteria (Bethesda, 2003) and occurs in 2-15% of the population, with 25–30% of all cases having a secondary etiology.

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Hemodialysis patients are a population at particular risk for RLS, with reported prevalences of 6–60%, but still under-characterized. Objectives: To characterize the frequency and possible causal associations of RLS in a population of northern Portuguese patients on chronic hemodialysis. Methods: Descriptive transversal study based upon the application of individual questionnaires and revision of clinical files from 151 patients on hemodialysis at Uninefro – Matosinhos (Oporto, Portugal), during January 2010. Results: 95 of the 151 target patients (63%) answered the inquiry, 23 of witch (24,2%) fulfilled the 4 diagnostic criteria for RLS. Among these, 19 (82,6%) assured they had already mentioned these complaints to their assistant physician, although only 3 (13%) had a previous established diagnosis of RLS. The complaints were daily in 8 patients and only occasional in 15. Comparing to the 50 patients not fulfilling any of the diagnostic criteria, RLS patients revealed a trend towards: female gender predominance, older age (*5 years), longer time on hemodialysis (*10 months), higher frequency of peripheral venous insufficiency (*2,2 times), analogous values of hemoglobin but lower serum iron and ferritin (*20 and 10% lower), lower prescribed doses of erythropoietin and iron (*30% lower), similar serum calcium and phosphorus with higher PTH (*50% bigger), and lower frequency for known diabetes or polyneuropathy (*40 and 50% lower), with lower values of fasting glucose and HbA1c (*20% lower). Conclusions: Although the number of RLS diagnoses found did not allow the withdrawal of statistically significant conclusions, the inferred frequencies and causal relations are in line with previous reports from the literature, even if, paradoxically, trends for lower values of hemoglobin or PTH and higher frequencies of diabetes or polyneuropathy have been usually described.

O113 Sleep pattern of Egyptian migraineurs M. Dahab Azhar University (Cairo, EG) Relation between migraine and sleep has been known over a century. Short sleepers exhibit significantly more frequent and more severe migraine than long sleepers. Our aim was studying the relationship between sleep pattern and migraine in a sample of Egyptian migraineurs. We studied all migraineurs attended Azhar University hospital over the last couple of months in 2009 whose age 10-50 years fulfilling the criteria of International Headache Society classification of 2004. We also studied a control group matching patients in age, sex and other demographic criteria. Polysomnography was recorded before, during and after the migraine attacks. Sleep parameters e.g. sleep efficiency, arousal index, respiratory disturbance index, periodic limb movements and cardiac changes. Sample collected was 32 migraineurs and 21 control subjects. Our results were not far away from that of the literature. Sleep architecture changes were observed during REM stage and slow wave stage prior to migraines attack. Excessive somnolence was detected post migraines spells. We find similar finding of sleep pattern of epileptic patients at pre- and post-ictal phases which might support the neurogenic pattern of migraine spells.

O114 Sleep disturbance impedes stroke recovery in the rat C. Zunzunegui, B. Gao, E. Cam, A. Hodor, C. Bassetti University Hospital of Zurich (Zurich, CH); Neurocenter of Southern Switzerland (Lugano, CH) Introduction: Sleep disturbance (SDis) represents a risk factor for stroke recovery. We have previously showed that SDis over 3 days

S35 aggravates brain damage in rats subjected to focal cerebral ischemia. The aim of this study is to further investigate the effects of SDis on long term stroke recovery. Methods: Focal cerebral ischemia was induced by occlusion of the distal branches of Middle Cerebral Artery (MCAo). 12 hours after ischemia, one group of rats (n=9) was subjected to SDis (12h of sleep deprivation over 3 days) by gentle handling and another group (n= 8) left undisturbed (w/o SDis). Sham-operated animals were also assigned to either SDis (n=6) or left undisturbed (n=6). Rats were allowed to survive for 5 weeks after surgery. Single Pellet Reaching test (SPR) was used for assessing sensorimotor function, Nissl staining for infarct size, biotinylated dextran amine (BDA) tracing for axonal sprouting and bromo-desoxyuridine (BrdU) staining for neurogenesis. Results: After MCAo the SPR performance dropped to 4 % of baseline (100%). At day 35 the recovery in the SDis group was less than 50% whereas in the w/o SDis group was almost complete. Repeated measures ANOVA indicated a significant difference (p = 0.001) in group*time interaction (F (12, 101) = 11). Independent t-tests showed significant difference at day 14 (w/o SDis 45%±17 vs. SDis 19%±25, p=0.031), 21 (w/o SDis 55%±26 vs. SDis 21%±21, p=0.008), 28 (w/o SDis 50%±24 vs. SDis 25%±24, p=0.045) and 35 (w/o SDis 71%±30 vs. SDis 38%±34, p=0.052). There was significant increase (p=0.035) in the damage area in the SDis group (18%±4.3) compared with the w/o SDis group (11%±4.5). The BDA stained area in the contralateral motor cortex and striatum was significantly smaller (p\0.05) in the SDis than in the w/o SDis group. Furthermore there was significant (p=0.01) decrease in the number of BrdU positive cells in the peri-infarct area in the SDis group (50±20cells/section) compared with the w/o SDis group (141±36cells/section). Double staining showed that in both groups about 70% of BrdU stained cells were associated with a neuronal marker (NeuN) and about 30% with the endothelial marker Von Willebrand factor. Conclusion: Sleep disturbance over 3 days has a significant detrimental effect on stroke recovery. It reduces ischemia-related axonal sprouting, neurogenesis and angiogenesis.

whether WMC locations predicted dementia and dementia subtypes, adjusting for confounders such as age, gender, education and the presence of medial temporal lobe atrophy (MTA). Results: Six hundred and thirty-nine participants aged 65 to 84 were included in this study. A total of 90 patients developed dementia during the follow-up (54 VaD, 22 AD, 12 AD+CVD and 2 other dementia subtype). Higher severity of pvWMC [t(635) = -5.77; p \ 0.001] and dWMC [t(634) = -4.29; p \ 0.001] increased the risk of dementia. When controlling for potential confounders, the severity of pvWMC (p=0.003) and MTA (p\0.001) were the only variables associated with the risk of dementia. When similar analysis were performed for dementia subtypes, we found that pvWMC [t(635) = -5.18; P \ 0.001] and dWMC [t(634) = -4.16; P \ 0.001] were associated with VaD. An association between pvWMC [t(635) = -2.0; P \ 0.05] and the risk of AD+CVD was also found. After adjustments, only dWMC (p=0.002) and MTA (p\0.001) remained associated with the risk of VaD. Conclusion: Our results highlight the importance and clinical implications of regional WMC assessment in elderly patients. The differences found between the locations of WMC may reflect distinct pathogenesis. The LADIS Study is supported by the European Union within the Vth European Framework Program Quality of life and management of living resources (1998–2002), contract No. QLRT-2000-00446 as a concerted action.

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Objectives: Pathological and imaging studies indicate that, besides grey matter (GM) atrophy, white matter (WM) damage occurs in Alzheimer’s disease (AD). The relationship between WM changes and GM atrophy however has been poorly investigated. Aim of this study was to assess in vivo the association between damage to WM tracts and GM atrophy in subjects with incipient (iAD) and overt Alzheimer’s disease (AD). Methods: Twenty-three AD patients (MMSE:19+6), 15 iAD (26+1) and 15 healthy controls (HC; 29+2) underwent diffusion tensor (DT) and structural MRI scans. Mean diffusivity (MD), fractional anisotropy (FA), axial (DA) and radial (DR) diffusivity were assessed voxelwise with tract-based spatial statistics (TBSS). Voxelwise GM atrophy was assessed with DARTEL and regional atrophy was measured in the hippocampus, frontal, parietal, and posterior cingulate cortex with the WFU Pickatlas. The correlation between WM changes and regional GM atrophy was assessed within each patients group by means of TBSS. Results: GM atrophy: AD patients showed a pattern of diffuse GM atrophy, affecting the hippocampus, cingulate cortex, frontal and parietal cortex, and thalamus (p\0.05, FDR), whereas in iAD atrophy was mostly confined to the hippocampus and temporal lobe (p\0.05, FDR). WM changes: AD patients compared with HC were characterized by widespread MD increases, DA increases in the cortico-cortical tracts, and DR increases in the temporal lobe and WM tracts projecting to the posterior cortex (p=0.05, FWE). Compared with HC, iAD patients showed significant DA increases in the cortico-cortical tracts (p=0.05, FWE), without relevant changes in MD, FA and DR values. There were no FA differences

Dementia I O115 Location of white-matter changes and risk of dementia B. Miranda, S. Madureira, A. Verdelho, J.M. Ferro on behalf of the LADIS Study Objectives: To determine whether the location of white matter changes (WMC) is an important predictor of dementia after 3 years follow-up in an elderly independent population with leukoaraiosis. Methods: Data were drawn from the LADIS (Leukoaraiosis and Disability) prospective multinational European study that investigates the impact of WMC on global functioning in a cohort of independent elderly subjects. WMC at baseline were categorised into periventricular (pvWMC) and deep (dWMC) using the semi-quantitative Scheltens rating scale. The main outcome measure was incident dementia after 3 years follow-up. Further analysis was performed for dementia subtypes: vascular dementia (VaD), Alzheimer’s disease (AD), and AD with cerebrovascular disease (AD+CVD). Multiple logistic regression with backward analysis was used to determine

O116 White-matter tracts changes in Alzheimer’s disease and their association with grey-matter atrophy M. Filippi, M. Pievani, F. Agosta, E. Pagani, C. Geroldi, G.B Frisoni University Hospital San Raffaele (Milan, IT); IRCCS Centro San Giovanni di Dio - Fatebenefratelli (Brescia, IT)

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S36 between patients and HC. Correlation analysis: in AD patients, but not in iAD group, hippocampal atrophy correlated with DA and MD increases in fibers projecting to the posterior cortex (posterior cingulum, inferior longitudinal fasciculus, splenium of the corpus callosum; p=0.05, FWE), whereas DR values showed a trend for an association with hippocampal atrophy (p=0.06, FWE). No association was found between WM changes and GM atrophy in other cortical regions. Conclusion: This study shows that WM changes in posterior regions are associated with hippocampal atrophy in AD. These changes may reflect disrupted structural connectivity between the hippocampus and core regions of the default mode network and might help in understanding the temporal sequence of GM and WM changes in AD.

O117 fMRI evidence for an effect of white-matter hyperintensities on the functional organization of the motor system with ageing F. Fazekas, P. Linortner, R. Schmidt, S. Ropele, B. Pendl, K. Petrovic, C. Neuper, C. Enzinger Medical University of Graz (Graz, AT); Karl-Franzens-University (Graz, AT) Objectives: Severe white matter hyperintensities (WMH) predict global functional decline in the elderly. Besides cognitive impairment, depression and urinary incontinence, walking difficulties constitute a main contributor to loss of functional independence with ageing. However, the functional effects of WMH on motor system (re)organization are largely unknown. We here used simple motor paradigms to test for such subclinical changes related to WMH severity, using functional MRI (fMRI). Methods: We randomly invited 30 healthy right handed/-footed elderly subjects (M=67.8±7.5 years) from the Austrian Stroke Prevention Study on the basis of their WMH grade (defined by the Fazekas scale) to undergo detailed clinical testing, structural MRI and fMRI at 3.0T, involving repetitive active right ankle and finger movements. 17 subjects had absent or punctuate WMH (group A), 13 individuals showed early confluent and confluent WMH (group B). Results: Both groups did not differ significantly in mobility or cognition data (after adjustment for age, education, and sex). However, on fMRI, subjects with more severe WMH demonstrated excess activation in the pre-supplementary motor area (SMA), inferior frontal and occipital regions. Activation differences were noted with ankle movements only. Pre-SMA activation correlated positively with frontal WMH load for ankle movements, but not for finger movements. Conclusions: With simple ankle movements, fMRI reveals excess activation in elderly subjects with more severe WMH, despite absence of behavioral performance deficits regarding mobility. Pre-SMA usually becomes activated by more complex tasks. Together with the correlation analyses, this suggests compensatory activation related to disturbance of fronto-subcortical circuits with increasing frontal WMH burden. Final exhaustion of these processes might explain the rapid functional decline observed in some elderly subjects with more severe WMH.

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O118 Factors predicting clinical progression in frontotemporal lobar degeneration T. Kontaxis, A. Kyrozis, C. Routsis, A. Ghika, A. Bonakis, V. Pappas, S. Matsi, M. Nikaki, N. Kalfakis, S.G. Papageorgiou Athen’s University (Athens, GR) Purpose: To identify factors that may predict clinical progression, as assessed by standard scales, among Frontotemporal Lobar Degeneration (FTLD) patients and compare progression between FTLD and Alzheimer’s disease (AD). Methods: Subjects included patients diagnosed with FTLD (subdivided into language and behavioral subtypes) or Alzheimer’s disease on the basis of clinical and ancillary evidence who had at least 2 quantitative cognitive scale assessments spaced by at least 6 months. Scales included Mini Mental Status Examination (MMSE), modified MMSE (mMMS), Frontal Assessment Battery (FAB), Frontal Behavioral Inventory (FBI), Neuropsychiatric Inventory (NPI) and Clinical Dementia Rating (CDR). Outcomes consisted of a change between the first and last score divided by the corresponding time interval (units/year) for each one of the 6 scales. Predictors were examined in univariate and multivariate linear regression models and included: Gender, years of formal education, age at symptoms onset, time between first symptoms and seeking of medical attention, presence or absence of early memory impairment or depression, FTLD subtype (behavioral or language) and score in the first assessment of the corresponding scale. Results: Out of 139 patients satisfying the repeat assessment criterion, 28 were diagnosed with FTLD, of which 16 with behavioral and 12 with language subtype, and 55 with AD. Among FTLD patients, associations of borderline statistical significance with higher MMSE and modMMS rates of decline were found independently for language subtype and for memory impairment reported as early symptom. No consistent associations were evident for the other 4 scales. Compared to AD, FTLD patients had significantly higher MMSE and modMMS rates of decline. No consistent associations were evident for the other 4 scales. Conclusions: The language subtype of FTLD and early memory impairment may be independently associated with faster decline in MMSE and modMMS scales. Compared to AD, FTLD appears to be associated with faster cognitive decline, as assessed with these scales.

O119 Cognitive impairment in congestive heart failure versus atrial fibrillation in elderly stroke-free patients N. Kitchener, B.E. Fouad, M. Abdalla, A. Abdelkarim, M.A. Ghoraba General Organization for Teaching Hospitals and Institutes (Cairo, EG); National Heart Institute (Cairo, EG) Objectives: Congestive heart failure (CHF) has been proposed as a possible cause of cognitive dysfunction. Can atrial fibrillation (AF) in stroke-free patients lead to impaired cognition? Aim of the study was to compare the cognitive patterns of nonstroke patients with CHF, AF without CHF and patients having cardiovascular diseases, other than AF, uncomplicated by CHF.

S37 Methods: In an observational case control study, we studied 162 hospitalized elderly CHF patients in the Egyptian National Institute of Heart and Mataryia Teaching Hospital class II (CHFm, m: moderate), 134 CHF patients in class III–IV (CHFs, s: severe), 138 stroke-free individuals with AF and 434 no-CHF, no-AF patients. Subjects underwent MRI to exclude stroke. Subjects with stroke, dementia, or depression were excluded. Cognitive function was assessed by Stanford Binnet test battery version 4 (Arabic version) covering the domains attention, visual-spatial intelligence, verbal attainment, verbal and visual-spatial memory. Results: Neuropsychological performances of groups were compared by multivariate analysis. Correlates of an abnormal performance on at least three neuropsychological tests were assessed by logistic regression analysis. CHFs performed worse than no-CHF, no-AF patients and AF, which was worse than no-CHF, no-AF patients. The largest difference being in tests of attention, verbal learning and visual-spatial memory (p \ 0.001). Prevalence of abnormal performance on at least 3 tests was 57.9 % in CHFs, 53.2% in AF, 43% in CHFm and 34.3 % in no-CHF groups (v2 = 17.3, p \ 0.0001). Conclusion: Cognitive impairment is common among CHF and AF patients and seems to be causally related to CHF severity, and probable hypoxia resulted from unstable cardiac output. The cognitive dysfunction also characterizes a relevant fraction of patients with cardiovascular diseases uncomplicated by CHF. Also, cognition should be considered in the evaluation of patients with AF and any suggested treatments.

O120 Screening of post-stroke cognitive impairment: is the Montreal Cognitive Assessment better than the Mini-Mental State Examination? A. Fickl, M. Roussel, C. Auribault, G. Petitnicolas, J.M. Bugnicourt, S. Canaple, C. Lamy, O. Godefroy Soissons Hospital (Soissons, FR); University Hospital of Amiens (Amiens, FR) Background: Post-stroke dementia and cognitive impairment are underestimated. The aim of the study was to examine the ability of Montreal Cognitive Assessment (MoCA) (1) for detection of poststroke cognitive impairment, (a) by comparison to Mini-Mental State Examination (MMSE)(2) and (b) using neuropsychological tests as gold standard. Methods: The study included 115 patients (76 men; mean age: 68.3 years) hospitalized in the Acute Stroke Units of a general (Soissons) and university (Amiens) hospitals for an ischemic (105/ 115) or hemorrhagic stroke \3 months. MoCA and MMSE were performed in the Stroke Units (mean post-stroke delay: 6.6 days) and we used published cut-off values (1,2). The neuropsychological battery assessed executive functions, visuospatial, language, long-term memory abilities and psychomotor speed (mean post-stroke delay: 24 days). Results: MoCA scores (19.8 ± 6.5) were lower (p=0.0001) than those of MMSE (23.2 ± 6.1), and impairment was more frequent (p=0.0001) on MoCA (92/115, 80%) than MMSE (49/115, 42.6%). Using performance on neuropsychological battery as criterion, MoCA was sensitive (85 %) but poorly specific (35 %), contrary to MMSE (sensitivity: 33%; specificity: 88%). The stepwise regression logistic selected MMSE score (p=0.04) as predictor of deficit on neuropsychological battery. The frequency of pre-stroke dementias was also confirmed (16/115, 16 %, of which more than half undiagnosed). Conclusion: This study shows that MoCA has a good sensitivity but a poor specificity to detect post-stroke cognitive impairment. This

should be improved by a refinement of the norms. References 1. Nasreddine et al. J Am Geriatr Soc. 2005; 53(4):695–9. 2. Kalafat et al. Neuropsychology Review 2003; 13:209–236.

__________________________________ Oral session 15 Neuro-imaging O121 Global and thalamic grey matter damage predicts the evolution of primary progressive multiple sclerosis at 5 years M. Filippi, M.A. Rocca, S. Mesaros, E. Pagani, M.P. Sormani, V. Martinelli, G. Comi University Hospital San Raffaele (Milan, IT) Objective: Reliable prognostic markers of primary progressive (PP) multiple sclerosis (MS) evolution are still needed. We investigated whether conventional and diffusion tensor (DT) magnetic resonance imaging (MRI) derived measures from the overall brain gray matter (GM) and thalamus predict the long-term clinical evolution of PPMS. Methods: Brain conventional and pulsed-gradient spin-echo echoplanar (PGSE) scans were obtained at baseline and after mean followup of 15 months in 54 PPMS patients and eight healthy controls (HC). Patients were followed up with clinical visits for five years. At baseline and follow-up, measures of lesion load, brain and cord atrophy and normalized thalamic volume (NTV) were obtained. Histograms of the mean diffusivity (MD) and fractional anisotropy (FA) values from the normal-appearing (NA) WM, GM, and thalami were produced. A multivariate analysis was used to evaluate the predictors of long-term neurological deterioration. Results: At five year follow up, 35 patients (65%) showed a significant disability worsening. NTV was significantly lower in PPMS than in HC, and significantly decreased during the follow-up. NTV was significantly lower in patients with thalamic T2 lesions than in those without such lesions. Thalamic MD and FA values were significantly different between PPMS patients and HC and worsened significantly over the follow-up. These values were significantly different between PPMS patients with and without thalamic T2 lesions. The multivariable model included average GM MD (odds ratio [OR]=1.36, p=0.005) and FA thalamic change (OR=0.80, p=0.009) as independent predictors of disability worsening at 5 years (discriminating ability=85%). Conclusion: A more severe occult damage in the overall brain GM and thalamus significantly contributes to the long-term accumulation of disability in PPMS.

O122 Patterns of regional grey matter atrophy and cognitive impairment in multiple sclerosis patients with different disease phenotypes G. Riccitelli, M.A. Rocca, C. Forn, A. Falini, E. Pagani, M. Rodegher, M. Falautano, P. Rossi, G. Comi, M. Filippi University Hospital San Raffaele (Milan, IT) Objective: Impairment of several cognitive domains is frequently encountered in patients with multiple sclerosis (MS). Voxel-based morphometry (VBM) allows identification of gray matter (GM) volume loss at a regional level. Aim of this study was to investigate

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S38 whether cognitive impairment in MS patients with different disease phenotypes is associated with an involvement of different GM structures. Methods: High-resolution T1-weighted images were acquired from 73 MS patients (22 primary progressive [PP], 22 relapsingremitting [RR], and 29 secondary progressive [SP] MS) and 39 healthy controls. All MS patients underwent an extensive neuropsychological evaluation, exploring different cognitive domains. Patients with deficits in more than two tests were defined as cognitively impaired (CI). VBM analysis was performed using SPM5 and an ANCOVA model, including age, gender and intracranial volume (ICV) as nuisance variables. Results: Cognitive impairment was found in 53% of the patients. Compared to cognitive preserved (CP) RRMS, CI RRMS patients had GM volume loss in the deep GM nuclei as well as in several cortical regions in the frontal, parietal and temporal lobes. Compared to CP SPMS, CI SPMS patients had GM volume loss in several regions of the fronto-temporal lobes, bilaterally, the anterior cingulate cortex (ACC), and the hippocampus. Compared to CP PPMS, CI PPMS patients showed GM volume loss in the ACC, right superior temporal gyrus, right inferior frontal gyrus and right cerebellum. In SPMS patients, brain T2 lesion volume was correlated with regional GM volume loss. In SPMS and PPMS patients, regional GM volume loss was correlated with PASAT performance. Conclusion: Distinct patterns of regional distribution of GM damage are associated with cognitive impairment in MS patients with different clinical phenotypes. Regional GM loss in CI MS patients is only partially correlated with the extent of T2-visible lesions, suggesting that it does not simply reflect secondary degenerative phenomena. The study was partially supported by a grant from Fondazione Italiana Sclerosi Multipla (FISM/2008/R/13).

O123 Similar global N-acetylaspartate concentration in clinically benign and non-benign multiple sclerosis patients with more than 15 years of disease duration L. Achtnichts, O. Gonen, D. Rigotti, J.S. Babb, Y. Naegelin, K. Bendtfeld, J. Hirsch, M. Amann, R.I. Grossman, L. Kappos, A. Gass University Hospital Basel (Basel, CH); New York University School of Medicine (New York, US) Objective: To investigate whether multiple sclerosis (MS) patients with a clinically benign disease course show overall neural integrity, reflected by the preservation of the MR marker N-acetylaspartate (NAA), and higher NAA concentrations than in MS patients with similar disease duration but more pronounced disability. Methods: T1 and T2 lesion loads and fractional brain parenchymal volume (fBPV) were determined on structural MRI and whole brain NAA concentration (WBNAA) was obtained from proton MR spectroscopy in: (i) 24 (20F) benign MS patients 50.9±10.5 years old (mean±standard deviation), of 23.1±7.2 years disease duration from first symptom and Expanded Disability Status Scale (EDSS) score of 2.1±0.7; (ii) 30 non-benign patients (19F) 53.6±9.0 years old, 22.9±5.8 years disease duration and 4.7±1.0 EDSS; and (iii) 17 controls (9F) 34.0±6.0 years old. Results: The T1 hypointense lesion load of the non-benign patients: 4.1±5.4 cm3, was significantly higher than the 2.1±2.2 cm3 of the benign (p=0.029), but their T2 hyperintense lesion volumes: 8.4±8.0 cm3 and 6.2±5.5 cm3, respectively, were indistinguishable (p›0.1). The controls’ fBPV (86.2±3.3%) was significantly higher than in both, the benign (76.4±6.7%) or the non-benign patients (76.2 ±8.4%) (p‹0.0001). The controls WBNAA ‘ (12.2±2.3 mM) was

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significantly higher than in the benign (10.5±2.4 mM, p=0.03) and non-benign patients (9.7±2.2 mM, p=0.002) with no significant difference between the 2 patient groups (p[0.2). Conclusions: This study stresses similarly to other MRI measures that a clinically benign MS course is not directly associated with less pathology load than in more disabled MS phenotypes. This low association of MRS and clinical findings is likely to be due to the interference of other mechanisms such as brain plasticity or the relative sparing of clinically eloquent brain regions.

O124 Region-specific patters of white-matter diffusivity changes in Leber’s hereditary optic neuropathy: a tract-based spatial statistics study M.A. Rocca, J. Milesi, S. Bianchi-Marzoli, M. Petrolini, L. Melzi, A. Falini, G. Comi, M. Filippi University Hospital San Raffaele (Milan, IT) Objectives: Leber’s hereditary optic neuropathy (LHON) is a mitochondrial disease leading to retinal ganglion cells degeneration, optic nerve atrophy and consequent isolated central visual loss, which is typically severe, painless and bilateral. We explored the structure of the white matter (WM) of the whole brain with diffusion tensor (DT) MRI in patients with LHON and defined the regional distribution of WM damage using Tract-Based Spatial Statistics (TBSS). Methods: Dual-echo and DT MRI scans with diffusion gradients applied in 35 non-collinear directions were acquired from 13 LHON patients and 25 matched controls. TBSS analysis was performed using FMRIB’s Diffusion Toolbox (FDT). A complete neuro-ophthalmologic examination, including standardized automated Humphrey perimetry as well as average and temporal peripapillary RNFL thickness measurements were obtained in all the patients. Results: All patients showed bilateral optic nerve pallor and a central scotoma of variable size in all affected eyes. Mean average and temporal PRNFL thicknesses were significantly decreased in LHON patients. In LHON patients, compared to controls, TBSS analysis revealed significant diffusivity changes, characterized by decreased fractional anisotropy and increased mean diffusivity and axial diffusivity, exclusively affecting the optic tracts and optic radiations, with a sparing of the remaining WM tracts. Conclusion: In LHON patients, axonal damage is not limited to the retinal ganglion cells and the optic nerve, but causes a microstructural disruption of the WM along the optic pathways, presumably due to postsynaptic degeneration or primary disease localization.

O125 Clinical, imaging and pathological characterization of adult-onset diffuse leukoencephalopathy with axonal spheroids—a consortium study K.J. Schweitzer, C. Wider, D.F. Broderick, J. Lash, J. Aasly, M. Baker, C.W. Christine, S.J. DeArmond, J.Y. Gabern, B. Goodman, N. Graff-Radford, W. Kupsky, A. Maues De Paula, B.F. Michel, B. Miller, S. Owygarden, J.E. Parisi, J. Pelissier, R. Rademakers, E.A. Shuster, A.J. Stoessl, R.H. Swerdlow, A. Tselis, B.K. Woodruff, J. van Gerpen, D.W. Dickson, Z.K. Wszolek on behalf of the HDLS Consortium Objective: Adult-Onset Diffuse Leukoencephalopathy with Axonal Spheroids (ADLS) is a neurodegenerative disorder pathologically

S39 characterized by myelin and axon disruption with axonal spheroids. The disease present with psychiatric, cognitive and motor symptoms. Most cases are inherited but sporadic patients have also been described. Methods: Ad hoc consortium has been formed to study ADLS. We collected the clinical, imaging and pathological studies of 22 pathologically proven ADLS patients. 7 familial cases from autopsy proven ALDS kindred were also included. Results: The mean age of onset (29 patients, 11 women) was 48 ± 15 years (range: 16–73) and the mean disease duration was 7 ± 5 years (range: 2–17, in 22 deceased patients). The disease was familial in 20 cases (12 kindreds). Autopsy material was reviewed in 19 cases and brain biopsy was available for 3 cases. Probable Diagnosis of HDLS was established in 7 cases (4 families) based on clinical and radiological findings. Initial symptoms were neuropsychiatric in 14 patients (depression, anxiety, personality change, apathy, cognitive impairment), motor in 9 (gait impairment, parkinsonism, spasticity or ataxia) and mixed in 1 (sensory symptoms, speech and gait impairment). Other symptoms included seizures, ataxia, dysphagia/ dysarthria, apraxia, headache mainly migraine and lower motor neuron signs (EMG-confirmed). MRI was available in 18 patients and showed patchy or confluent fronto-parietal and colossal white matter (WM) T2 abnormalities with cortical atrophy. In 3 cases, WM abnormalities could be found in brainstem. The temporal lobe were spared in all except one case. Consecutive scans of eight patients demonstrated progression of WM abnormalities and cortical atrophy. In two patients a hypoplasia of the septum pellucidum and in 6 patients a cavum septum pellucidum was observed. Pathological studies showed patchy grey discoloration and disruption of white matter with myelin rarefaction and vacuolization, gliosis, argyrophilic neurofilament-positive axonal spheroids, and pigmented macrophages. Discussion: This study expands the phenotypic variability found in ADLS. This disorder is most likely under-diagnosed, as clinical and imaging features may resemble parkinsonism, Multiple Sclerosis, fronto-temporal dementia, cerebrovascular or psychiatric diseases; and at the present time pathological confirmation is required for diagnosis. Further studies will establish the genetic cause of ADLS. CW and KJS contributed equally.

O126 Correlation between hypoperfusion in cerebral cortical segments and mental dysfunction of Parkinson’s disease and dementia with Lewy bodies K. Ohta, M. Seki, Y. Shinohara Tachikawa Hospital (Tokyo, JP); Keio University School of Medicine (Tokyo, JP) Objectives: This study aimed to introduce a practical tool for displaying a quantitative and anatomical cerebral hypoperfusion map, and to reveal its correlation with mental dysfunction in a spectrum of Parkinson’s disease (PD) and dementia with Lewy bodies (DLB). Methods: The subjects were 52 patients with PD (age 72±7, Hoehn & Yahr 1–5). Their mental function was assessed by Mini Mental State Exam (MMSE), Alzheimer’s Disease Assessment Scale (ADAS)-cog and Frontal Assessment Battery (FAB). IMP-SPECT data were collected for brain perfusion. Three-dimensional stereotactic surface projections (3D-SSP) analysis (Minoshima S, 1995) evaluated the cortical distribution of hypoperfusion. Normalized brain activity of each patient was compared with normal controls by pixelby-pixel Z-score = (control mean value - patient value) / control standard deviation. Stereotactic extraction estimation (SEE) method (Mizumura S, 2003) classified anatomically the cerebral cortex into

31 segments for each hemisphere on the basis of gyrus, and estimated the extent of hypoperfusion of each segment (E(Z[2)) by calculating the rate of pixels with Z-score [2 in each segment. Results: As differences in E(Z[2) were often found between the right and left sides of a patient’s brain, the major E(Z[2) of each segment was employed for the statistical analyses. Among 52 subjects, 26 patients scored MMSE \24 and fulfilled consensus diagnostic criteria for probable DLB. Irrespective of MMSE score, the middle and inferior occipital and fusiform gyri showed extensive hypoperfusion (E(Z[2) [30%). 26 patients with low MMSE score (\24) showed more extensive hypoperfusion (E(Z[2) [40%) in the angular, supramarginal, superior and middle temporal, superior occipital gyri compared to 26 patients with normal MMSE score (p\0.05, t-test). In each of these gyri, a negative correlation (R2=0.13–0.31, n=52) was found between MMSE score and E(Z[2). A positive correlation (R2=0.09-0.26, n=48) was found between ADAS-cog score and E(Z[2) in these gyri except for the superior occipital gyrus. A negative correlation (R2=0.68-0.95, n=6) was found between FAB score and E(Z[2) in the inferior parietal lobule, angular and supramarginal gyri. Conclusion: Not only DLB with parkinsonism but also PD irrespective of mental function shows hypoperfusion in the occipital lobe. Extensive hypoperfusion develops in the outer surface of temporal lobe and adjacent area with worsening of mental function in PD.

__________________________________ Oral session 16 Peripheral neuropathy O127 Phenotypic profile of autosomal dominant GDAP1 mutations causing Charcot-Marie-Tooth disease R. Sivera, M. Martinez Rubio, J.J. Vilchez, M.J. Chumillas, F. Mas, E. Freyre, J. Millan, F. Mayordomo, F. Palau, C. Espinos, T. Sevilla University Hospital La Fe (Valencia, ES); Insitute for Biomedicine of Valencia (Valencia, ES); Network of Biomedical Research Centres for Neurodegenerative Diseases (Valencia, ES) Objectives: Mutations in the ganglioside-induced-differentiationassociated-protein 1 (GDAP1) gene have been reported in Charcot Marie Tooth (CMT) patients with demyelinating and axonal forms of the disease. Inheritance in most causative mutations is autosomal recessive, being autosomal dominant (AD) mutations exceedingly rare in most published series. We present the phenotypic profile of our patients with AD GDAP1 mutations. Methods: A systematic search for GDAP1 mutations was performed in a large well characterized CMT series in which mutations in the most prevalent genes involved in CMT had been excluded. 17 patients from 4 families were identified with the same point mutation in the GDAP1 gene (p.R120W) which was inherited as an AD trait. Extensive clinical assessments and electrophysiological data are provided. Magnetic resonance imaging (MRI) of the lower limbs was performed to 8 patients so as to define the distribution of fatty substitution and atrophy. Pathological data obtained from 2 sural nerve biopsies is also presented. Results: The clinical picture comprehends a mild-moderate phenotype with marked heterogeneity. Disease onset varies (3 patients are asymptomatic), and duration is not clearly related to phenotypic severity. Weakness was first manifested distally in the lower limbs

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S40 with the peculiarity that ankle dorsiflexion and plantar flexion were impaired to a similar degree. Distal upper limb involvement appeared later in the course of the disease. Sensory loss was mild and distal in lower limbs. Nerve conduction studies exhibited motor velocities in the axonal range with mildly reduced or normal CMAP amplitudes. The pattern of muscle abnormalities in MRI was quite homogeneous and concordant with disease severity. The main abnormalities in these patients were fatty substitution, atrophy and occasionally edema (in subacute muscle denervation). The first muscles affected were the intrinsic foot muscles, and the distal calf muscles. In the latter there was a predominance of fatty substitution in the posterior compartment (gastrocnemius and soleus) over the anterolateral one. Sural nerve biopsy revealed loss of large myelinated fibers, a reduction in the myelin sheath thickness, and occasionally clusters of small thinly myelinated fibers, and few onion bulb-like formations. Conclusion: The description of such an extensive series of CMT patients with AD GDAP1 mutations is novel and may provide insight about the pathogenic mechanisms involved.

O128 Variable severity of early onset CMT2 with compound heterozygous MFN2 mutations M. Laura, J. Polke, D. Pareyson, F. Taroni, M. Milani, J. Blake, V.S. Gibbons, C. Devile, M.G. Sweeney, M.B. Davis, M. Reilly MRC Centre for Neuromuscular disease (London, UK); National Hospital for Neurology and Neurosurgery (London, UK); Neurological Institute C. Besta (Milan, IT); Norfolk and Norwich University Hospital (Norwich, UK); Great Ormond Street Hospital (London, UK) Mutations in Mitofusin 2 (MFN2) are the most common cause of axonal Charcot-Marie-Tooth (CMT) disease type 2. Over 50 mutations have been reported so far, mainly causing autosomal dominant disease, though 6 families with recessive or semi-dominant inheritance have been described. Objectives: To report three further families with index cases that are compound heterozygotes for two MFN2 mutations. Methods: Sequencing of MFN2 gene and blood MFN2 mRNA expression analysis in patients with early onset axonal neuropathy. Results: All patients presented an early onset axonal neuropathy with variable severity between pedigrees. Their parents were not consanguineous and had no signs or symptoms of peripheral neuropathy; all of them, except one (who was dead at the time of testing) were confirmed to carry the relevant heterozygous MFN2 variation. In family 1 Multiplex Ligation Probe Amplification (MLPA) and DNA sequencing identified a paternally inherited deletion of MFN2 exons 7 and 8 and a maternally inherited previously reported missense mutation (c.647T[C; p.Phe216Ser) in both severely affected children. Blood mRNA analysis in the children showed expression of c.647T[C and a truncated transcript where exon 6 is spliced to exon 9. Translation of this allele would result in a truncated out of frame protein. In family 2 MFN2 sequencing revealed two novel sequence changes in a moderately affected child: a nonsense mutation (c.922G[T; p.Glu308X) inherited from the mother and a paternal missense mutation (c.1556G[C; p.Arg519Pro). Blood mRNA sequencing of the child and both parents showed nonsense-mediated decay of c.922G[T and expression of c.1556G[C. A previously described missense mutation (c.1085C[T; p.Thr362Met) and a novel in-frame single codon deletion (c.112_114delAAG; p.Lys38del) were identified in three affected siblings in Family 3. The missense mutation was identified in the mother.

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Conclusions: Our findings confirm that MFN2 mutations can cause peripheral neuropathies with apparent recessive inheritance, although the parents in these families may be too young to show signs of neuropathy, therefore a semi-dominant mechanism is possible. The findings also include the first report of an intragenic rearrangement of MFN2 (deletion of exons 7 and 8). Further work is required to establish the molecular mechanism underlying the pathogenesis of MFN2 mutations.

O129 Variable phenotypes are associated with pmp22 missense mutations M. Russo, M. Laura, J. Polke, M.B. Davis, J. Blake, S. Bradner, R.A. Hughes, H. Houlden, M.P. Lunn, M. Reilly MRC Centre for Neuromuscular disease (London, UK); National Hospital for Neurology and Neurosurgery (London, UK); Norfolk and Norwich University Hospital (Norwich, UK); Institute of Neurology (London, UK) Charcot-Marie-Tooth disease (CMT) is the most common inherited peripheral neuropathy encompassing a large group of clinically and genetically heterogeneous disorders. CMT1A is the most common form of CMT and it is caused by a duplication of the 1.4 Mb region on chromosome 17 containing the peripheral myelin protein 22 (PMP22) gene. Point mutations in PMP22 are less common than the duplication and they can cause a variety of neuropathy phenotypes. Objectives: To describe the clinical, electrophysiological and molecular findings of 10 patients belonging to eight families carrying PMP22 missense mutations. Methods: Sequencing of the PMP22 gene in patients with variable CMT phenotype. Results: The phenotype was variable among the families. It varied from mild hereditary neuropathy with liability to pressure palsies (HNPP) to severe CMT1. Neurophysiology showed variable upper limb motor nerve conduction velocity ranging from 2 to 48 m/s. Sequencing of the PMP22 gene identified six different point mutations: two families carried two novel mutations (Ser131Cys and Met69Arg), three families carried mutations that have been already reported and three families were found to harbour the controversial Thr118Met mutation. The latter has been identified in heterozygous unaffected individuals as well as in patients affected by mild HNPPlike neuropathy. Conclusions: Although PMP22 point mutations are not common, our findings highlight the importance of sequencing PMP22 gene in patients with variable CMT phenotypes and confirm the pathogenicity of the PMP22 Thr118Met mutation.

O130 An unusual presentation of hereditary neuropathy with liability to pressure palsies with lower limb hyperreflexia and respiratory muscle weakness in two sisters V.E. Drory, D. Gross, I. Artmann, S.C. Blumen Tel-Aviv Sourasky Medical Center (Tel-Aviv, IL); Hillel Yaffe Medical Center (Hadera, IL) Background: Hereditary neuropathy with liability to pressure palsies (HNPP) is a relatively frequent autosomal dominant disorder that causes recurrent episodes of weakness and sensory loss in the distribution of single peripheral nerves due to pressure injury at common entrapment sites. Electrophysiologically, besides the focal nerve lesions, usually a mild chronic diffuse symmetric neuropathy is

S41 observed that is not or minimally expressed clinically. The genetic abnormality is a deletion in the gene encoding peripheral myelin protein 22 on chromosome 17p11.2. Objective: to describe two sisters of Jewish Ashkenazi origin with genetically proven HNPP that developed an unusual form of disease, with severe permanent proximal and distal limb weakness, and respiratory muscle involvement. Case reports: The elder, 38 years old sister has a history of progressive multifocal neurological deficit since age 16. She presented with severe symmetric proximal[distal weakness in the lower[upper limbs, distal sensory loss, lower limbs hyperreflexia and early fatigability, and shortness of breath during mild effort. She walks aided by two canes. Her pulmonary function testing revealed a forced vital capacity (FVC) of 31%, maximal inspiratory pressure (MIP) was 14%, and maximal voluntary ventilation (MVV) was 28% of predicted. The younger 30 years old sister began to have focal neurological features at age 16. She has a milder chronic neuropathy and is able to walk unaided. She has hyperactive reflexes and easy fatigability and shortness of breath disturbing sleep. Her pulmonary function testing showed a FVC of 48%, MIP 20% and MVV 15% of predicted. Both sisters have normal brain MRIs. Their 64 years old mother has a mild gait disturbance and walks unaided. She was diagnosed with HNPP following the diagnosis of her daughters. During the last few years she complains of fatigue, excessive day-time sleepiness and shortness of breath. Conclusion: This family represents a severe variant of HNPP with more pronounced permanent muscle weakness and with early severe involvement of respiratory muscles that was not previously described. This broadens the spectrum of clinical phenotypes of this disorder and emphasizes the importance of genetic testing in patients with demyelinating polyneuropathies with atypical presentation.

O131 Neuropathy: an integral component of cerebellar ataxia neuropathy vestibular areflexia syndrome D. Szmulewicz, J. Waterston, M. Halmagyi, S. Mossman, A. Chancellor, C. McLean, E. Storey Alfred Hospital (Melbourne, AU); Royal Prince Alfred Hospital (Sydney, AU); Capital Coast Health (Wellington, NZ); Tauranga Hospital (Wellington, NZ) Introduction: In the original report of the syndrome of cerebellar ataxia with bilateral vestibulopathy)Migliaccio AA, Halmagyi GM, McGarvie LA, Cremer PD. Cerebellar ataxia with bilateral vestibulopathy: description of a syndrome and its characteristic clinical sign. Brain. 2004;127:280-93) sensory neuropathy was noted in 3 of the 4 patients described. Methods: We now characterize and estimate the true frequency of peripheral neuropathy in this syndrome and determine its typical MRI features. To do this reviewed of 20 patients (including 4 from the original description) who met the criteria for bilateral vestibulopathy with cerebellar ataxia. Results: The estimated age of onset range was 39–71 year and symptom duration was 3–38 years. The syndrome was identified in one sibling pair, suggesting that it could be a late-onset recessive disorder, although the other 18 cases were apparently sporadic. All 20 had sensory neuropathy with absent sensory nerve action potentials,although this was not apparent clinically in two, and the presence of neuropathy was not a selection criterion. In 5, the loss of pin-prick

sensation was virtually global, mimicking a neuronopathy. At least 4 patients presented with a neuropathy and then months to years later developed progressive cerebellar and vestibular impairment. However, findings in the other 13 with clinically manifest neuropathy suggested a length-dependent neuropathy. MRI scans showed cerebellaratrophy in 16, involving anterior and dorsal vermis, and hemispheric crus I, while two were normal. The inferior vermis and brainstem were spared. Conclusion: We conclude that sensory neuropathy is an integral component of this syndrome. It may result in severe sensory loss, which contributes significanctly to the disability. The MRI changes are not specific, but, coupled with loss of sensory nerve action potentials, may aid diagnosis. We propose a new name for the condition: CANVAS (Cerebellar Ataxia Neuropathy Vestibular Areflexia Syndrome). Supported by the IZKF Wuerzburg grant F-25.

O132 Imaging of inflammation in the peripheral nervous system by 1H/19F MRI: a pilot study G. Ladewig, T. Basse-Luesebrink, C. Wessig, P. Jakob, G. Stoll University of Wu¨rzburg (Wu¨rzburg, DE) Objectives: Inflammatory cells play a pivotal role in the pathophysiology of numerous disorders of the peripheral nervous system. Up to now, visualization of neuroinflammation by magnetic resonance imaging (MRI) is limited to the use of iron oxide contrast agents. However, local hemorrhages, blood pool effects and passive diffusion of iron oxide particles through a defective blood nerve barrier are confounding factors that can make interpretation difficult. Recently, 19F MRI was introduced as a promising technique for cell tracking. In contrast to iron-oxide contrast agents 19F markers provide a unique signal in vivo due to the negligible 19F background signal of the body. In the present study we used 19F MRI for in vivo visualization of macrophage infiltration in the lysolecithin model of focal peripheral nerve demyelination. Methods: 10ll of 2% lysolecithin in saline were injected into the proximal left sciatic nerve of male Lewis rats. Upon intraneural injection lysolecithin dissolves myelin sheaths and leads to subsequent macrophage infiltration. At days 0 and 3 a fluorine MR contrast emulsion was administered intravenously. In vivo 19F MRI was performed seven days after the surgery. Afterwards rats were sacrificed and both sciatic nerves were excised. An additional ex vivo scan of the lesioned and contralateral sciatic nerve was acquired. Results: In vivo 19F MRI seven days after intraneural injection of lysolecithin revealed a strong fluorine signal which could be assigned to the left sciatic nerve by concomitant acquisition of 1H images. After removal of the sciatic nerves ex vivo scans confirmed the localization of the 19F marker within the left sciatic nerve and not the surrounding soft tissue. The contralateral nerve served as negative control and did not exhibit any fluorine signal. Histological evaluation confirmed the presence of ED-1 positive macrophages within the area of lysolecithin application. Conclusion: This proof-of-principle study in rodents shows that macrophage infiltration in areas of peripheral nerve injury can be detected background-free by in vivo 19F MRI. Further technical developments are under way to improve the sensitivity of this promising cellular MR imaging technique.

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Oral session 17 Stroke II O133 Cognitive and emotional changes in the behaviour of rats after occlusion of the anterior cerebral artery H. Mertgens, G. Mies, R. Graf, H. Endepols Max Planck Institute for Neurological Research (Cologne, DE) Objectives: The anterior cerebral artery (ACA) supplies cingulate and frontal cortical regions in both humans and rats. Ischemic lesions in the ACA territory of humans impair cognitive functions and reduce incentive drive. We studied in a rat model of ACA occlusion (ACAo) loss and recovery of function longitudinally over one year using various behavioral paradigms combined with lPET and MRI. Methods: ACAo (n=13) or sham operation (n=7) was performed in male Lister hooded rats by stereotactic injection of the vasoconstrictor endothelin-1 (150 pmol in 0.3 ll phosphate buffer) or vehicle. Behavioral testing assessed decision-making during foraging (food-carrying task), anxiety (elevated plus maze), spatial working memory (spontaneous alternation; Y-maze), exploratory behavior (open field), and working memory (object recognition task). Tests were carried out before, a week and a year after ACAo. Additionally, an odor discrimination task in combination with [18F]fluorodeoxyglucose PET was performed in 5 sham and 5 ACAo animals. Results: Early and late after ACAo, rats carried less food pellets in the food-carrying task, moved more slowly, and went on fewer trips than before. The number of pellets per trip increased with distance between food and cage before, but no longer after ACAo. In the elevated plus maze, lesioned animals spent more time on the open arms than before ACAo. Arm alternation rate in the spontaneous alternation task decreased from approximately 80% to chance level in the early measurements but recovered to approximately 70% after one year. Locomotor activity in the open field stayed constant in all testing phases apart from early impairment of homebase-behavior in animals with big lesions, which recovered considerably after one year. Object recognition was not impaired after ACAo. Animals were able to perform odor discrimination before and after ACAo, while PET showed decreased glucose metabolism in the anterior cingulate cortex (ACC) during the task. Conclusion: Like in humans, ischemic lesions in the ACA-territory of rats cause cognitive and emotional deficits which are reflected by structural and metabolic cerebral changes. One year after occlusion, some functions recover spontaneously, while others remain impaired.

O134 Differential propagation patterns of peri-infarct depolarizations in rat focal cerebral ischaemia T. Kumagai, M. Walberer, H. Endepols, H. Nakamura, S. Vollmar, M. Sue´, G. Mies, M. Schroeter, R. Graf Max Planck Institute for Neurological Research (Cologne, DE); University of Cologne (Cologne, DE) Objectives: Cortical spreading depression (CSD) and peri-infarct depolarization (PID) contribute to infarct growth, however, the

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temporal and spatial aspects of this process are not well understood. Alterations of cerebral blood flow (CBF) coupled to CSD serves as a surrogate measure to assess CSD propagation patterns in the surrounding of ischemic foci. We studied CBF using Laser Speckle Flowmetry (LSF) in the cerebral cortex of rats in an embolic (macrosphere) stroke model. Methods: In 14 male anesthetized Wistar rats, a catheter was inserted into the left internal carotid artery. The left cranial bone was thinned to a thickness transparent enough to measure indicative CBF using LSF (CBFLSF). The LSF system acquired images at 40 frames/min. During continuous LSF imaging, one TiO2 macrosphere (diameter 0.335mm) was injected, and CBFLSF recording was continued for up to 3 hours. Spatiotemporal patterns of CBFLSF changes were analyzed in 25 regions of interest (ROI: 1.4x1.4 mm) covering the whole field of view over frontal, parietal and temporal lobes. Results: In 8/14 rats, macrospheres caused occlusion of the middle cerebral artery (MCAo), while in the other animals, ischemic territories were less clear in their spatial dispersion. In all rats, CSD/ PID was observed after arterial occlusion. In MCAo animals, the first wave of CSD/PID propagated outwards starting from the primary ischemic center. This first wave acted like a ‘‘switch’’ establishing an ischemic core with clearer borders than those seen before wave appearance. Subsequent waves of CSD/PID emerged at the border of the ischemic core and propagated circumferentially along the border. Conclusion: In embolic focal ischemia in rats, concentric propagation of CSD/PID develops immediately after the first ischemic reduction of CBF followed by circumferential propagation around the emerging ischemic lesion. It is conceivable that the various CSD/PID patterns are involved in infarct maturation.

O135 ADAMTS13 may be neuroprotective against brain ischaemia-reperfusion injury by improving postischaemic microcirculation and inflammation M. Fujioka, K. Hayakawa, K. Mishima, A. Kunizawa, C. Muroi, K. Irie, S. Higuchi, T. Nakano, F. Banno, K. Kokame, T. Miyata, Y. Yonekawa, T. Sakaki, K. Nishio, K. Okuchi, M. Fujiwara, B. Siesjo Fukuoka University (Jyonan, JP); Zurich University (Zurich, CH); National Cardiovascular Center (Suita, JP); Nara Medical University (Kashihara, JP); Lund University (Lund, SE) ADAMTS13 (A Disintegrin And Metalloproteinase with ThromboSpondin type-1 motifs 13) specifically cleaves the bond between tyrosine-1605 and methionine-1606 in the A2 domain of von Willebrand factor (VWF) multimers and thus reduces VWF activities. VWF can activate the platelet and the leukocyte on the stimulated vascular endothelial cells. These activated platelets and leukocytes together contribute to both microcirculation impairment and inflammatory reactions after reperfusion in the ischemic brain. Therefore, ADAMTS13 may ameliorate the ischemia-reperfusion injury of the brain by cleaving the VWF. We investigated the role of ADAMTS13 in the ischemia-reperfusion pathology in the brain with using middle cerebral arterial occlusion (MCAO) model of ADAMTS13-geneknockout mice. The ADAMTS13-deficient (ADAMTS13 KO) and wild-type (WT) mice were subjected to 30 minutes‘ MCAO followed by 23.5 hours of reperfusion. The infarction volume was estimated on the brain tissue stained with TTC 23.5 hours after reperfusion. Plasma HMGB1 (high-mobility group box1) level was analyzed by

S43 Westernblot 24 hours after MCAO. The immunoreactivity of the ischemic brain tissue against HMGB1/NeuN or HMGB1/MPO (double immunofluorescent labeling) was also analyzed. The regional cerebral blood flow (rCBF) of the ischemic cortical tissue was measured by laser Doppler flowmetry during the period between 30 minutes before and 24 hours after MCAO. ADAMTS13 KO mice had increased volume of brain infarction compared with WT. The plasma HMGB1 increased more in ADAMTS13 KO mice than in WT after MCAO. Ischemia induced more remarkable neuronal death and more inflammatory cells expressing HMGB1 in ADAMTS13 KO-mice cortical tissue compared to WT. The CBF in ADAMTS13 KO mice progressively decreased more remarkably than that in WT during reperfusion phase after ischemia. ADAMTS13-gene-deletion aggravates brain damage, systemic and local inflammatory responses, and rCBF after ischemia-reperfusion. This suggests that ADAMTS13 plays a possible neuroprotective role against brain ischemia by regulating the VWFdependent thrombosis and inflammatory reactions in the reperfusion injury.

O136 Von Willebrand factor binding to collagen and glycoprotein Ib-a, but not glycoprotein IIb/IIIa contributes to ischaemic stroke in mice T. Schwarz, S.F. De Meyer, H. Deckmyn, C.V. Denis, B. Nieswandt, K. Vanhoorelbeke, G. Stoll, C. Kleinschnitz University Hospital (Wu¨rzburg, DE); Immune Disease Institute, Inc. (Boston, US); KU Leuven Campus (Kortrijk, BE); University of Paris South (Le Kremlin-Biceˆtre, FR); University of Wu¨rzburg (Wu¨rzburg, DE) Objectives: Thrombus formation at the site of the injured endothelium is a pathological hallmark of cerebral ischemia. Von Willebrand factor (VWF) is essential for platelet adhesion at vascular lesions in normal hemostasis. We have recently demonstrated that VWF-/- mice are protected from acute ischemic stroke. VWF contains different binding sites for collagen, platelet glycoprotein (GP) Ib-a and GPIIb/ IIIa which can principally participate in thrombus formation. The relative contributions of these different interactions in stroke development are unclear however. Methods: VWF-/- mice received gene transfer to express mutants of VWF defective either in binding to fibrillar collagen, GPIb-a or GPIIb/IIIa and underwent 60min of middle cerebral artery occlusion (tMCAO). Infarct volumes and functional deficits were assessed on day 1 and the extent of thrombus formation within the infarcted brains was determined by Western blot analysis. Results: VWF-/- mice developed significantly smaller infarct volumes (p\0.05) and less severe neurological deficits (p\0.05) on day 1 after tMCAO compared to wild-type controls. In VWF-/- mice reconstituted with VWF mutants defective in binding to collagen or GPIb-a, protection against stroke was sustained (p\0.05) while VWF lacking the GPIIb/IIIa binding domain restored full susceptibility to stroke similar to naive VWF. In line with these findings, deposition of fibrin(ogen), i.e. thrombus formation was reduced in ischemic brains from VWF-/- mice receiving VWF defective for collagen or GPIb-a binding. Conclusion: This data indicate that VWF-collagen and VWF-GPIb interactions are instrumental in thrombus formation after tMCAO, while VWF-GIIb/IIIa interactions are not involved herein. Thus, targeted inhibition of VWF-collagen and/or VWF-GPIb-a binding could become a promising strategy for stroke treatment. Supported by the DFG SFB688

O137 Promotion of post-ischaemic neurological recovery by erythropoietin involves an early anti-inflammatory effect followed by coordinated changes of brain plasticity ipsi- and contralateral to the stroke R. Reitmeir, E. Kilic, U¨. Kilic, M. Bacigaluppi, S. Pluchino, G. Salani, M. Gassmann, M.E. Schwab, D.M. Hermann University Hospital (Essen, DE); San Raffaele Scientific Institute (Milan, IT); University Hospital (Zurich, CH); Univeristy of Zurich (Zurich, CH) Objectives: Erythropoietin (Epo) is a potent neuroprotectant, which was investigated in experimental and clinical stroke studies in the past. Whether Epo in addition to its survival-promoting actions also exhibits plasticity-promoting effects in the sub-acute stroke phase remained unknown. Using behavioural, histochemical and molecular biological studies we now examined Epo’s effects on brain plasticity and functional neurological recovery using a post-acute delivery protocol. Methods: Male C57Bl6/j mice weighing 20-25 g were submitted to 30 min middle cerebral artery occlusion (MCAO). 3 days after surgery miniosmotic pumps (Alzet 2004) were implanted into the lateral ventricle, via which normal saline (vehicle group), Epo (1 I.U./day) or Epo (10 I.U./day) were administered over the next four weeks. Six weeks later two anterograde tract tracers, biotinylated dextrane amine and cascade blue, were injected in the contralasional and ipsilesional motor cortex. Two weeks thereafter, animals were transcardially perfused. For gene expression studies, additional animals were submitted to focal cerebral ischemia or sham surgery that did not receive tract tracer injections. These animals were sacrificed at 3, 14 or 30 days after the stroke and used for PCR and immunohistochemistry. Results: Epo administered at 10 I.U./day but not 1 I.U./day significantly increased grip strength in the paretic contralesional forelimb and improved motor coordination. Tract tracing studies revealed that Epo delivery went along with increased contralesional sprouting at the level of rubral and facial nucleus that was accompanied by a compensatory decrease of ipsilesional projections in the same structures. Analyzing the temporal-spatial gene expression showed that Epo 10 I.U./day has profound anti-inflammatory effects at 14 days after stroke followed by a decreased expression of antiplasticity genes at 30 days in the contralesional hemisphere. Conclusion: Our study establishes for the first time a plasticitypromoting restorative action of Epo in vivo. The coordinated plasticity changes associated with anti-inflammatory actions exemplify that Epo’s post-acute effects are finely tuned. In view of negative results of the German Epo multicenter trial in acute ischemic stroke, post-acute studies with Epo in stroke patients should be considered. The author gratefully acknowledges a grant from ‘‘Dr. Werner Jacksta¨dt Stiftung’’ and Roche Foundation for Anemia Research

O138 Mild hypothermia enhances functional recovery and the proliferation and migration of endogenous neural stem cells in rats after cerebral ischaemia Y.C. Xie, C.Y. Li, Z.N. Lu, J.X. Guan, H.J. Dong Renmin Hospital (Wuhan, CN) Objective: To investigate the influence of mild hypothermia on behavioral recovery and the proliferation and migration of neural stem cells(NSCs) in rats with focal cerebral ischemia. Methods: Male Sprague-Dawley rats underwent unilateral middle cerebral artery occlusion (MCAo) and were randomly divided into two groups: control group and mild hypothermia group. The neurological score were evaluated at 2h,3d,7 d,14 d and 21d after MCAO.

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S44 We use bromodeoxyuridine (BrdU) labeling method to identify the proliferation NSCs. The rats were killed at 3d,7d,14d,21d and immunohistochemical staining was used to observe the BrdU positive cells in SVZ and infarct cortext boundary. Results: There was no difference in neurological scores between the two groups at 2h after MCAO, but there were significant difference between the two groups at 3d,7d,14d and 21d after MCAO. In control group, the number of BrdU-positive cells in the in subventricular zone (SVZ) and infarct cortex boundary increased at 3 day, reachedmaximum at 7 day, decreased at 14 day and 21 day. Compared with control group, mild hypothermia treatment increased the number of BrdUpositive cells in SVZ and infarct cortex boundary at every time point. Conclusions: Mild hypothermia can enhance function recovery and promote the proliferation and migration of NSCs after cerebral ischemia.

__________________________________ Oral session 18 General neurology II

When the whole sample is considered, the H5a subgroup of molecules, harboring the 4336 transition in the tRNAGln gene, already associated to AD in early studies, was about threefold more represented in AD patients than in controls (2.0% vs 0.8%; p=0.031), and it might account for the increased frequency of H5 in AD patients (4.2% vs. 2.3%). The complete re-sequencing of the 56 mtDNAs belonging to H5 revealed that AD patients showed a trend towards a higher number (p=0.052) of sporadic mutations in tRNA and rRNA genes when compared with controls. Conclusions: On the whole our results indicate that high resolution analysis of inherited mtDNA sequence variation can help in identifying both ancient polymorphisms defining sub-haplogroups and the accumulation of sporadic mutations associated with complex traits such as AD.

O140 Awakening from coma? Systematic review of reports on late recovery from the vegetative state R.J. Jox, K. Kuehlmeyer, G.D. Borasio Munich University Hospital (Munich, DE)

O139 Subhaplogroup H5 of mitochondrial DNA is a risk factor for late onset Alzheimer’s disease A. Santoro, V. Balbi, E. Balducci, C. Pirazzini, F. Rosini, F. Tavano, A. Achilli, P. Siviero, N. Minicuci, E. Bellavista, M. Mishto, S. Salvioli, F. Marchegiani, M. Cardelli, F. Olivieri, B. Nacmias, A.M. Chiamenti, L. Benussi, R. Ghidoni, G. Rose, C. Gabelli, G. Binetti, S. Sorbi, G. Crepaldi, G. Passarino, A. Torroni, C. Franceschi University of Bologna (Bologna, IT); University of Pavia (Pavia, IT); National Council for Research (Padua, IT); National Institute for Rehabilitation and Nursing of the Elderly (Ancona, IT); University of Marche (Ancona, IT); University of Florence (Florence, IT); Regional Centre for Cerebral Aging (Vicenza, IT); Scientific Institute for Rehabilitation and Nursing (Brescia, IT); University of Calabria (Cosenza, IT); University of Florence (Florence, IT); University of Calabria (Cosenza, IT); University of Pavia (Pavia, IT) Background: Alzheimer’s Disease (AD) is the most common neurodegenerative disease and the leading cause of dementia among senile subjects. It has been proposed that AD can be caused by defects in mitochondrial oxidative phosphorylation. Given the fundamental contribution of the mitochondrial genome (mtDNA) for the respiratory chain, there have been a number of studies investigating the association between mtDNA inherited variants and multifactorial diseases, however no general consensus has been reached yet on the correlation between mtDNA haplogroups and AD. Methods/results: We applied for the first time a high resolution analysis (sequencing of displacement loop and restriction analysis of specific markers in the coding region of mtDNA) to investigate the possible association between mtDNA-inherited sequence variation and AD in 936 AD patients and 776 cognitively assessed normal controls from central and northern Italy. Among over 40 mtDNA subhaplogroups analysed, we found that sub-haplogroup H5 is a risk factor for AD (OR=1.85, 95% CI:1.04–3.23) in particular for females (OR=2.19, 95% CI:1.06–4.51) and independently from the APOE genotype. Multivariate logistic regression revealed an interaction between H5 and age, and AD patients younger than 75 years carrying sub-haplogroup H5 harbor a four-fold increased AD risk than subjects belonging to other sub-haplogroups. Age resulted to be the strongest risk factor after age 75, neutralizing the effect of the other risk factors.

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Aims: There is a growing number of patients living in a vegetative state for several years. Relatives and physicians often place high hopes on late recoveries which have been anecdotally reported in the lay media. We aimed to review all scientific publications on late recoveries from the vegetative state and identify possible predictors for late recovery. Methods: We performed a systematic literature review in PubMed and EMBASE using the keywords ‘‘vegetative state’’, ‘‘recovery’’ and ‘‘case’’ without any time restriction. In addition, the reference list of all identified reports were screened. We included only cases of patients who fulfilled the criteria for permanence issued by the MultiSociety Task Force in 1994.The publications were analysed using Quantitative and Qualitative Content Analysis. Results: We found 40 scientific publications on 33 cases of late recovery from the vegetative state. The quality of most publications was rather poor as several lack sufficient information on diagnostic work-up, prognostic indicators and applied therapies. About half of the publications were single case reports and there was no single prospective study. The patients had a median age of 25 years, 59% were male and 41% female. Traumatic injuries were found in 55% of the cases. Altogether, 88% of the recoveries occurred within 3 years after the injuring event. At least 6 of the 33 reported cases could be revealed as misdiagnoses of minimally conscious states. The most powerful predictors of recovery were young age, traumatic injury and a short duration since the injury. There was no consistent evidence for any form of treatment having produced the recovery. Conclusion: There are several scientific reports on cases of late recovery from the vegetative state. Due to their low quality and many misdiagnoses, however, no conclusive predictors can be inferred for late recovery. Large prospective studies and comprehensive case series are necessary.

O141 Vitamin-B12-deficiency and nervous system disorders: two paradigmatic cases of a wide clinical and neuroradiological spectrum of a potentially reversible disease D. De Feo, B. Colombo, L. Moliola, D. Dalla Libera, F. Sangalli, V. Martinelli, G. Comi San Raffaele Hospital (Milan, IT) Background: The association between cobalamine deficiency and nervous system involvement has been reported since the 1950s. The

S45 overlapping syndrome described by Wilson include peripheral neuropathy, the ‘‘subacute combined degeneration of the cord’’ (SCD), autonomic dysfunction, optic atrophy, psychosis, cognitive decline. The lack of S-adenosyl-methionine, as observed in vitamine-B12deficiency leads to synthesis of abnormal methylated phosphilipids, causing myelin breakdown. The typical imaging pattern is degeneration of white matter fibres in the posterior columns of spinal cord visible on MRI hyperintense on T2-weighted images or enhanced on T-weighted images after gadolininum. Instead, cerebral leukoencephalopathy is a rare finding. An early cobalamine-substitution therapy can ameliorate clinical outcome as well as MRI lesions, possibly due to remyelination. Objective: we report two paradigmatic cases. Results: A 36 year-old man was referred to our clinic because of a sub-acute presentation of progressive gate impairement, visual disturbances, paresthesia of left arm and both the inferior limbs. Brain and spinal cord MRI revealed diffuse bilateral leukoencephalopathy, without spinal cord involvement. EMG and VEPs exclude peripheral and optic neuropathies. Vitamine-B12 resulted mild reduced, whereas complete screening for malabsorption resulted negative. He was treated with cobalamine and folate supplementation therapy with a complete clinical recovery and a mild amelioration of MRI findings after 3 months. The second case is a 45-year-old woman who developed bilateral optic neuropathy associated with progressive bilateral weakness and paresthesia of lower limbs, 4 months after a surgical resection of distal ileum without a following vitamine-B12 prophylaxis. Correct diagnosis was done only 3 years and half later when MRI of spinal cord showed typical pattern of hyperintensity in T2-weighted and FLAIR images on posterior and lateral columns. Supplementation therapy was eventually started with neurological stabilization. Conclusions: Since the degree of functional recovery correlate with the duration and the severity of symptoms before treatment, an early diagnosis and an immediate treatment are mandatory for a better outcome. Our two cases are paradigmatic examples both of a good clinical response due to a prompt therapy and of a poor outcome due to a delayed diagnosis and treatment of neurological involvement in vitamine-B12 deficiency.

O142 Defining the line between Hydromyelia and Syringomyelia. A differentiation possible based on electrophysiological and magnetic resonance imaging studies F. Roser, F.H. Ebner, M. Tatagiba University of Tu¨bingen (Tu¨bingen, DE) Objective: With the frequent use of magnetic resonance imaging (MRI), patients with subtle and diffuse symptoms due to small syrinx cavities increasingly present to neurosurgical care. In this respect a dilated central canal – called hydromyelia – must be separated from patients with true syringomyelia with an underlying disorder as they do not share clinical and radiological features. We hypothesize that a differentiation of these two entities with distinct diagnostic tools is possible. Methods: To describe the entity of hydromyelia, we excluded all patients from the syringomyelia database with any obvious cause of a syringomyelia, any objective neurological deficits on clinical examination, pathological results on electrophysiological monitoring (SSEP, MEP, silent periods) or a widening of the spinal cord cavity of more than 5 mm on MR imaging (routine acquisitions with FLAIR,

T1-/T2 weighted images, CINE/CISS-studies). Life quality in patients with hydromyelia was assessed through standardized SF-36 questionnaires, a Syringomyelia Disability Index (SDI) and an individualized questionnaire for the clinical history, pain and alternative therapies. Results: Forty patients (14 males/ 26 females) matched the criteria of a hydromyelia. With a mean age of 36.7 years (range 11-62) they almost all present with pain (82%) or dysesthesia of the limbs, with some had an incidental finding (18%). Over a follow-up time of 36.9 months (range 6-93) there was no neurological or radiological deterioration. Conclusion: Patients with a dilated central canal do not share any feature with patients harboring a syringomyelia. As a hydromyelia does not represent a disease with an underlying pathology, no clinical or radiological progression has been seen. With sophisticated diagnostic tools to rule out any pathology this subset of patients can be identified.

O143 Near-death experiences: real or imagined? M. Thonnard, S. Laureys, S. Bre´dart, M.-A. Bruno, A. Demertzi, O. Gosseries, C. Schnakers, A. Vanhaudenhuyse University of Lie`ge (Lie`ge, BE) Objective: Clinical studies suggest that characteristics of Near-Death Experiences (NDEs) are culturally invariant and can be investigated neuroscientifically. Many biological theories have been proposed to explain NDEs, but they only explain some components. It has been proposed that the false memories phenomenon (i.e., memories of events that never happened or altered memories of real events) can mediated NDEs. Our objective is to determine whether NDEs are true or false memories. Methods: With the a priori assumption that false memories have fewer characteristics than true memories, characteristics of 5 memories have been collected using a modified version of the Memory Characteristics Questionnaire (MCQ, Johnson et al., 1988): (1) target memories (i.e., NDE, coma or first childhood memories), (2) recent and (3) old real event memories, (4) recent and old (5) imagined event memories (e.g. dreams). Characteristics encompassed 6 categories: sensory details, memory clarity, self-referential information, emotional information, reactivation frequency, confidence in their own memories. 5 patients who recovered from coma with NDE memories (Greyson NDE scale score C7; Greyson, 1983), 6 with coma memories (Greyson NDE score \7), 7 without memories, and 18 control subjects were evaluated. For each memory, the Kruskall-Wallis statistic was used to estimate the effect of group and Mann Whitney tests were used to identify between-group differences. First, comparisons were made on the total score and later on the category subscores of the questionnaire. Results: The analysis of total scores revealed a group effect on target memories only. NDEs memories were found to have more characteristics than coma or childhood memories (p\0.003). The analysis of category subscores showed an effect of the group only on target memory in each category (p\0.05) except in ‘‘reactivation frequency’’ and ‘‘confidence in their memories’’ categories, with NDE memories having higher scores than coma and first childhood memories (p\0.05). Conclusion: NDEs remain fascinating phenomena that are abundant in popular beliefs, mythology and spiritual experiences of many ancient and modern societies. Our results showed that NDEs are different from simple memories of coma and have more characteristics than real event memories, but it cannot be considered here as a

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S46 false memory. Ongoing studies are aiming to better understand the neural correlates of NDEs and find an explanation to this phenomenon.

O144 Pain while sitting, a common symptom in patients with Tarlov’s cysts A. Aceituno Gonza´lez, N. Mas, J. Casanova Molla, J. Valls-Sole´ Hospital Clinic of Barcelona (Barcelona, ES) Objectives: Tarlov’s cysts are perineural dilatations that frequently grow at or distal to the junction between the posterior nerve root and the dorsal root ganglion, or distal to this union, usually in the lumbar and sacral region. They have a high incidence in the population, observed in people submitted to lumbosacral magnetic resonance imaging studies (usually for low back pain) and are considered often a non-pathogenic concurrent finding. Nevertheless Tarlov’s cysts could produce unspecific and different symptoms, and up to date there is no clinical clue that leads to their diagnosis. Methods: We present four cases of patients with Tarlov cysts who reported a common symptom: impossibility to remain seated for more than a few minutes because of pain in their buttock and numbness in their legs. They were four women, aged between 36 to 55 years. The main symptom was accompanied by different degrees of pain during sexual intercourse or defecation, together with abdominal and limb pain and paresthesias, that motivated magnetic resonance imaging and various electrodiagnostic tests. Gynaecological causes of pelvic pain were excluded. Results: Neuroimage revealed no vertebral lesions or malformations but showed sacral cysts, in a variable number, and of a mean diameter of 1.5 centimetres (none of the cysts was larger than 2 centimetres). Electrodiagnostic tests ruled out polyneuropathy. The electrodiagnostic tests were normal or showed unspecific signs: a radicular S1 lesion was present in one patient. A significant delay of the latency of the pudendal nerve in the side of the Tarlov’s cyst was found in another patient. Conclusions: Our observations suggest that Tarlov’s cysts may cause symptoms of pelvic pain worsening while sitting apart from other less specific abnormalities, and they should be suspected in patients that refer these unspecific symptoms, and submit them to a lumbosacral neuroimage. A likely pathophysiological mechanism is compression-related irritation of various roots at sacral level.

__________________________________ Oral session 19 Dementia II O145 Combining near-infrared spectroscopy and transcranial Doppler to study mild cognitive impairment S. Viola, P. Viola, P. Litterio, M.P. Buongarzone, L. Fiorelli Hospital of. S. Pio Vasto (Vasto, IT); Emergency Medical Service (Lanciano, IT) Introduction: Mild Cognitive Impairment (MCI) has a prevalence between 17 and 34% in the population aged over 65 years.Up to 40% of

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the subjects with MCI convert to various forms of dementia after 3 years. Many researchers are trying to identify functional markers by PET, MRI, Transcranial Doppler (TCD), Infrared Spectroscopy (NIRS) or biomarkers that may increase the diagnostic specificity allowing to identify dementia in a pre-clinical stage and to anticipate the start of treatment to delay the onset of the disease. NIRS measures the O2 saturation of cerebral cortex microcirculation (TOI) that reflects function and metabolism. Several authors have shown that the reduction of TOI is caused by hypoperfusion of cerebral microcirculation. Objective: To study patients with MCI, at high risk for developing dementia and to identify the markers and the possible pathogenetic mechanisms. Materials and methods: We studied 21 patients with MCI (10M and 11F, mean age 70.2 +- 7.3 s.d.) by an innovative NIRS system,TCD, cranial CT scan, and 10 age matched healthy controls. By NIRS we measured TOI over the frontal, parietal, temporal and occipital cortex. By TCD we examined the mean flow velocity (MFV) and Pulsatily Index (PI) in the middle (MCA) and posterior cerebral artery. Results: in the patients with MCI we found: highly significant reduction of TOI over frontal, temporal and parietal cortex compared with control: Z 3.09, p \0.002 (CI 95%), slightly significant increase of PI of right MCA compared with controls: Z 2.44, p \0.01 (CI 95%), no significant increase of PI of left MCA p \0.1, slight non significant reduction of MFV of bilateral MCA compared with controls p \ 0.3. Conclusions: in patients with MCI the NIRS technique, seems able to identify a functional marker (TOI reduction) suggesting a vascular disorder and hypoperfusion as the primary trigger underlying MCI. Further studies will be needed to assess sensitivity, specificity and predictive value for the conversion in dementia.

O146 Early and late onset Alzheimer’s disease patients have distinct patterns of white-matter damage E. Canu, G.B. Frisoni, F. Agosta, M. Pievani, M. Bonetti, M. Filippi University Hospital San Raffaele (Milan, IT); IRCCS Centro San Giovanni di Dio, Fatebenefratelli (Brescia, IT); Clinical Institute Citta` di Brescia (Brescia, IT) Objectives: Patients with early age-of-onset (EO) Alzheimer’s disease (AD) (before age of 65) show more GM atrophy in the parietal and temporal regions. On the contrary, LOAD show a predominant medial temporal lobe involvement. The pattern of WM loss in LO and EOAD and its relationship with the GM damage has never been investigated and it was aim of this study. In addition, we wished to address whether APOE a˚4 interacts with age of disease onset in determining WM atrophy in AD patients. Methods: Fourteen EOAD and 15 LOAD patients were studied. Patients were matched for dementia severity. Thirty age- and sexmatched HC were also recruited (15 younger and 15 older than 65 years). All participants underwent MRI scan. Statistical Parametric Mapping (SPM5) was used to perform a voxel-based morphometry analysis. Analyses of covariance (ANCOVA) were performed to assess WM differences in EOAD and LOAD, separately, vs. agematched HC. The analyses were replicated on GM tissue in order to perform a posteriori a correlation between WM and GM damage. Full factorial design were assessed in EOAD and LOAD to compare a˚4 carriers and a˚4 non carriers, separately, vs. age-matched HC. Results: Compared to HC, LOAD patients showed WM loss in the parahippocampal regions bilaterally. In EOAD patients compared with age-matched HC, WM loss mapped mainly to the splenium, posterior cingulate bundle, posterior parahippocampal region and parieto-temporal lobe. Differences were significant at p\0.001

S47 uncorrected. The WM damage of the splenium and the parahippocampal regions of both LOAD and EOAD was positive correlated with the GM damage in the posterior cingulate cortex and in the hippocampus bilaterally. Compared with age-matched HC, LOAD a˚4 carriers showed greater atrophy of the parahippocampal WM regions, while no difference was found between LOAD non carriers and HC. In EOAD group, carriers and non carriers showed similar pattern of atrophy compared to HC in the splenium. In addition, EOAD a˚4 carriers showed further clusters of WM atrophy in the parahippoccampal regions. Conclusion: This is the first study investigating the different topography of WM damage in EOAD and LOAD. The different regional distribution of WM atrophy reflects the pattern of cortical loss in EOAD and LOAD. Furthermore, in line with previous studies on GM, our results suggest that a˚4 allele carrier status has also an influence on WM atrophy in the parahippocampal regions, similarly in LOAD and EOAD patients.

O147 White matter damage in early age-of-onset Alzheimer’s disease and its variants R. Migliaccio, F. Agosta, M. Filippi, A. Karydas, G.D. Rabinovici, B.L. Miller, M.L. Gorno-Tempini Memory and Aging Center (San Francisco, US); Scientific Institute San Raffaele (Milan, IT) Objective: To investigate white matter (WM) damage in early age-ofonset Alzheimer’s disease (EO-AD, age \ 65 years) and its variants, such as posterior cortical atrophy (PCA) and logopenic/phonological progressive aphasia (LPA), and compare it to late-onset Alzheimer’s disease (LO-AD, age [ 65 years) patients. Methods: Structural MRI including double spin echo and volumetric magnetization prepared rapid gradient echo (MP-RAGE) sequences were acquired in 40 early onset AD (16 EO-AD, 13 PCA, 10 LPA) and 14 LO-AD patients at presentation, and 72 age-matched controls. Voxel-based morphometry (VBM) was performed using SPM5 software and the DARTEL toolbox. The following sets of linear contrasts were performed to identify regional WM atrophy: (1) all EO patients (EO-AD, PCA, and LPA) vs. young controls; (2) each syndrome vs. age-matched controls; (3) LO-AD vs. old controls. A significance threshold of p\0.05, corrected for multiple comparisons, was accepted. Results: Compared with young controls, all EO patients showed WM atrophy in parietal and lateral temporal regions, bilaterally, and in the splenium of the corpus callosum. When considered separately, EO-AD patients demonstrated WM atrophy in the medial parietal regions bilaterally, right temporal areas, right anterior cingulum, and the posterior part of the corpus callosum; PCA patients showed WM atrophy in the parietal and temporal lobes bilaterally, with right predominance, the posterior cingulum and the splenium of the corpus callosum; and LPA patients showed WM atrophy in left parietal regions. Relative to old controls, LOAD patients showed parahippocampal WM atrophy, with left predominance. Conclusions: WM atrophy was centered on lateral temporal and parietal regions and the posterior corpus callosum was found in EOAD, PCA and LPA. LPA patients showed a more severe parietal damage, in agreement with their isolated language deficit. These findings are consistent with the mostly hemispheric pattern of grey matter atrophy in all forms of EO-AD. Instead, LO-AD showed a more typical pattern of WM damage in the medial temporal regions. The study of WM in AD patients highlights the differences between EO-AD and LO-AD patients, and

contributes to the understanding the clinical profiles and biologic features of atypical forms of AD with an early age-of-onset.

O148 Psychomotor slowing in mild cognitive impairment, Alzheimer’s disease and Lewy body dementia: mechanisms and diagnostic value O. Bailon, M. Roussel, M. Boucart, A. Routier, P. Krystkowiak, O. Godefroy University Hospital of Amiens (Amiens, FR) Background: although psychomotor slowing is very frequent in Alzheimer’s disease (AD) and Lewy body dementia (LBD), its mechanism and diagnostic value have not been examined. Objective: to (1) assess psychomotor speed in patients with mild cognitive impairment (MCI), AD and LBD using a battery of validated reaction time (RT) tests, (2) to determine the underlying mechanisms and (3) to examine whether psychomotor slowing constitutes a useful diagnostic marker. Methods: This study was performed in patients referred for MCI (n=11) and mild dementia (MMSE[ 20) who met the criteria for AD (n=23) or probable LBD (n=18) and matched controls (n=52). Psychomotor speed was assessed with visual inspection time (VIT), digital tapping, simple reaction time (SRT) and choice reaction time (CRT) tests. Results: MCI subjects did not differ from controls. Both dementia groups were impaired but showed different patterns of impairment. In AD, VIT (p=0.0001), tapping (p=0.021), SRT (p=0.0001) and decision time (p=0.0001) were impaired. In LBD, the impairment in VIT (p=0.0001) was very significant and correlated with visual hallucinations (p=0.001), whereas the impairment in SRT (p=0.0001) was related to attentional disorders (p=0.0001). Conclusions: psychomotor slowing of AD is mainly due to slower perceptuomotor and decision processes, whereas attentional processes are unaffected at this early stage. In LBD, psychomotor slowing is mainly due to visual and attention disorders, indicating that subtle visual disorders contribute to hallucinations. Index from SRT test provides a means of assessing attention deficits in LBD. Lastly, VIT and CRT are useful diagnostic markers.

O149 Cerebrospinal fluid biomarkers in patients carrying delCACT mutation in exon 8 of Progranulin gene: report of 10 Italian cases M. Carecchio, C. Fenoglio, L. Benussi, R. Ghidoni, C. Cantoni, M. Serpente, V. Albertini, C. Comi, G. Binetti, F. Monaco, K. Bhatia, N. Bresolin, E. Scarpini, D. Galimberti University College London (London, UK); University of Milan (Milan, IT); IRCCS Centro San Giovanni di Dio, Fatebenefratelli (Brescia, IT); University of Milan (Milan, IT); Amedeo Avogadro University (Novara, IT); Ospedale Maggiore Policlinico (Milan, IT) Objectives: To assess cerebrospinal fluid (CSF) levels of total tau protein (Ttau), tau phosphorylated at threonine 181 (P181 tau) and Bamyloid 1-42 (AB1-42) in Frontotemporal lobar degeneration (FTLD) caused by exon 8 delCACT mutation of Progranulin (GRN) gene. Methods: Ten patients (5 F, 5 M) followed up at Policlinico Hospital (Milan) and at Centro S. Giovanni di Dio-Fatebenefratelli (Brescia), and previously shown to carry GRN delCACT in exon 8 by

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S48 direct DNA sequencing were enrolled in the present study after giving their informed consent for GRN genetic analysis. CSF was obtained during routine diagnostic lumbar punction. Six patients were diagnosed with behavioral variant Frontotemporal dementia (bvFTD), two with Primary progressive aphasia (PPA), one with FTD with motor neuron disorder (FTD-MND) and one with Corticobasal degeneration (CBD). Average age of onset was 59.6 years and average disease duration at the time of lumbar punction was 1.1 years. CSF biomarkers were assessed in duplicate by a standardized enzyme linked immunosorbent assay (ELISA) and absorbances were read at 450nm. Reference values for normal CSF biomarkers were considered according to Sjogren et al. (2001). Results: Median CSF biomarkers values were as follows: Ttau 366 pg/ml (normal value: \300 age 21–50, \450 age 51–70, \500 age 71–90) and AB1-42 was 653.5 pg/ml (normal value [500), both resulting within normal range in 8 out of 10 patients and borderline in 2 of them; median P-181 tau value was 24.5 pg/ml (suggested value \50.4) and resulted normal in all subjects. Conclusion: CSF biomarkers median value was normal in GRN mutation carriers analyzed. This might be related either to en early stage of the disease in which neurodegneration is confined to small cortical areas or to a less severe intensity of neuronal loss in cases of FTLD caused by GRN mutations. Alternatively, soluble tau protein may be sequestered in the brain of these patients reducing the amount detectable in CSF. Our results suggest that normal or borderline CSF biomarkers are consistent with a diagnosis of FTLD caused by GRN mutations. CSF biomarkers assessment needs to be investigated in larger cohorts of patients carrying delCACT in exon 8 and other GRN mutations to be further elucidated.

O150 Dysexecutive syndrome: diagnostic criteria and validation study O. Godefroy, P. Azouvi, P. Robert, M. Roussel, D. Le Gall, T. Meulemans on behalf of the GREFEX study group Objective: to propose new diagnostic criteria of behavioral and cognitive dysexecutive syndromes and to validate them. Methods: 461 patients aged between 16–90 years with severe traumatic brain injury, stroke, mild cognitive impairment, Alzheimer’s disease, multiple sclerosis and Parkinson’s disease were recruited into this prospective cohort study by 21 centers between September 2003 and June 2006. Behavioral and cognitive dysexecutive disorders were examined using the GREFEX battery which includes a specific heteroquestionnaire and 7 cognitive tests. Other cognitive deficit and mood disorders were systematically assessed. We investigated (1) the frequency of behavioral and cognitive dysexecutive disorders in patients suffering from various diseases and a control group and (2) the association of these disorders with loss of autonomy. Results: A dysexecutive syndrome was observed in 60% of patients, it concerned both behavioral and cognitive domains in 26% and was dissociated in 34%. All behavioral and cognitive dysexecutive disorders discriminated (p=0.001, all) patients from controls. The pattern of cognitive syndrome differed (p=0.0001) according to the disease whereas pattern of behavioral disorder did not differ (p[0.3). Finally, behavioral (OR: 4.6, 95CI: 2. 3–9.1; p=0.0001) and cognitive (OR: 3.36, 95CI: 1.7–6.6; p=0.001) dysexecutive syndromes and MMSE score (OR 0.79, 95CI 0.68-0.91; p=0.002) were independent predictors of loss of autonomy. Conclusion: This study provides and validates criteria of dysexecutive syndrome. Behavioral and cognitive are frequently

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dissociated and both contribute to loss of autonomy. Therefore both behavioral and cognitive dysexecutive disorders need to be examined.

__________________________________ Oral session 20 Neuro-oncology O151 Salvage therapy with bevacizumab and fotemustine in recurrent high grade gliomas: an Italian multicentre study E. Trevisan, R. Ruda`, E. Picco, S. Greco Crasto, E. Gaidolfi, M.G. Fabrini, V. Scotti, I. Lolli, M. Caroli, D. Guarneri, R. Soffietti University of Turin (Turin, IT); San Giovanni Battista Hospital (Turin, IT); Institute for Cancer Researche and Treatment (Candiolo, IT); University of Pisa (Pisa, IT); Policlinico (Bari, IT); University of Milan (Milan, IT) Background: Recurrent malignant gliomas have a poor prognosis with low response rates after salvage chemotherapy. Recent evidence indicates that antiangiogenic therapies have an important role in recurrent high grade gliomas. Bevacizumab alone or in combination with irinotecan has been reported to be active with a response rate of 43–57% and with acceptable toxicity. We report the preliminary results with bevacizumab in combination with fotemustine in patients with recurrent high grade gliomas in a multicenter study. Objectives: To assess efficacy and safety in a phase II study of bevacizumab in association with fotemustine in patients with grade 34 gliomas after standard treatment (surgery, radiotherapy and concomitant/adjuvant temozolomide). Methods: from April 2008 to December 2009 we treated 63 patients (22 females and 41 males) with bevacizumab plus fotemustine, with a median age of 55 yrs (range: 19-70) and a median KPS 90 (range: 70-100). Two patients received bevacizumab alone because of persisting myelotoxicity from previous treatments. This regimen was maintained until progression or unacceptable toxicity. We maintain bevacizumab only without fotemustine when persistent myelotoxicity was evident in responding patients. Radiological response was evaluated on T1 weighted images with gadolinium and FLAIR sequences on MRI. Histological diagnosis was glioblastoma in 50 patients and anaplastic gliomas in 13. Results: A significant neurological improvement in more than 50% of patients was seen, with steroid reduction in 60%. The MRI response rate (partial response, major partial response and complete response) was 42% in GBM patients, and 61% in anaplastic gliomas. The median TTP was of 4 months in GBM, and 6 months in anaplastic gliomas. In GBM, the PFS-6 was 27% and in anaplastic gliomas was 46%. Fatal adverse events were infrequent, and were a intatumoral hemorrhage in one patient and pulmonary embolism in another patient. Others side effects were fatigue, leuko-thrombocytopenia, asymptomatic intratumoral bleedings, thrombotic events. Conclusions: Bevacizumab in combination with fotemustine is a promising treatment for recurrent high grade gliomas with acceptable toxicity. The correlation of MGMT status and response in these patients is ongoing.

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O152 Volumetry and dynamic analysis of FET-PET in the presurgical evaluation of gliomas J. Nickel, Y. Hamzavi, G. Stoffels, K.J. Langen, M.C. Sabel, R.J. Seitz University Hospital Du¨sseldorf (Du¨sseldorf, DE); Research Center Ju¨lich (Ju¨lich, DE) Objectives: Amino acid tracers are being widely used with good sensitivity and specifity to outline vital tumor tissue in the presurgical evaluation of gliomas. The predictive potential of O-(2-[18F]fluoroethyl)-L-tyrosine positron emission tomography (FET-PET) regarding the biological grading of gliomas is still under investigation. Also the interdependency and combined use of structural magnetic resonance imaging (MRI) and PET are a matter of discussion. Methods: In 29 patients with gliomas multiple quantitative analyses of MRI-scans (high resolution T1-MRI +/- contrast agent) and the FET-PET data (obtained dynamically after injection of a 200 MBq Bolus of FET as well as statically during the steady state) werde done using the PMOD software (http://www.pmod.com). PET was calculated as mean and maximum tumor to brain ratio (TBR, healthy hemisphere as control), uptake volume (TBR C 1.6 in ml, exact voxel-based volumetry) and kinetic. MRI volume (T1-weighted scans) and volume of contrast agent enhancement were quantified using the same technique. In a sub-population of 18 patients cellular markers of progression in the resected specimen or biopsy were quantified (p53 and Ki67). A multivariate correlation analysis was performed using IBM SPSS Statistics 18 (www. spss.com). Results: Only volumetry and uptake kinetics, but not the TBRanalysis of FET PET significantly correlated with biomarkers of progression (FET volume vs. Ki67, Kendall Tau-b 0.498, p=0.004 / Spearmann-Rho 0.615, p=0.007; kinetic vs. Ki67, Kendall Tau-B 0.498, p=0.014 / Spearmann-Rho 0.588, p=0.13). Higher WHO grades showed a positive correlation with FET-volume and highgrade kinetic (FET volume vs. WHO grade Spearmann-Rho 0.565 / Kendall Tau-b 0.686, each p\0.001; kinetic vs. WHO grade, Kendall Tau-B 0.612, p=0.002 / Spearmann-Rho 0.665, p\0.001). The p53expression and volumetry of MR contrast agent-uptake provided no useful information in this series. Conclusion: Exact volumetric and kinetic analyses of FET-PET improves the presurgical evaluation of gliomas with a better prediction of the WHO grading than MRI analysis. This supports a recommendation for a wider use of amino acid PET and quantitative imaging-analysis in the presurgical assessment of gliomas to facilitate decisions on surgical versus conservative treatment.

O153 Neoplastic meningitis in patients in patients with breast cancer: analysis of 34 cases E. Picco, E. Trevisan, L. Tarenzi, L. Bertero, M. Donadio, R. Soffietti, R. Ruda` University of Turin (Turin, IT) Background: Neoplastic meningitis (NM) is a complication of the CNS that occurs in 6-21% of patients with solid tumors. Breast cancer accounts for 12-50%. The lack of sensitive and specific diagnostic tools represents a difficulty for the diagnosis and treatment of patients with NM. Objective: The aim of the study was to assess the natural history, impact of treatments and outcome of NM in patients with breast cancer.

Materials and methods: We report our experience of 34 patients with NM from breast cancer consecutively seen at our Institution from 2005 to 2009. Diagnosis was based on CSF cytology (pathologically confirmed) or on clinico-radiological data (brain and spine MRI with gadolinium). Results: We collected 38 patients with suspected NM. In 4 patients diagnosis was not confirmed (1 thrombosis of venous sinuses, 1 CSF hypotension, 1 linear contrast enhancement on spinal MRI, 1 cerebral ischemia). In 19/34 (56%) diagnosis was cytologically confirmed. Among 34 patients the most frequent signs/symptoms at the time of diagnosis were headache (47%), radicular pain (9%), dizziness (6%), motor deficits (9%), cranial nerves deficit (20%). Status of systemic disease was advanced in most patients with concomitant systemic and CNS metastasis (85%). Karnofsky performance status at diagnosis was C70 in 14/34 (41%), 50-70 in 11/34 (34%) and B50 in 9/34 (27%). Intrathecal chemotherapy (liposomal cytarabine) alone was administered in 17/34 (50%) patients and in combination with capecitabine (1250mg/m2) in 5/19. Radiation therapy was administered in 6/34 (WBRT in 6/8, focal RT on bulky disease in 2/8), intrathecal chemotherapy in combination with WBRT in 2/8. Because of the advanced status of disease and/or poor KPS 9/34 patients were candidated to supportive care only. Median interval between diagnosis of primary tumor and NM was 34,2 months (range: 0-11,8 years). Median time to neurological progression after treatments was 8 weeks. Median survival calculated from diagnosis of NM was 12 weeks (range 3 weeks – 8 months). Conclusions: The diagnosis of NM is difficult because the disease is the result of different neurological signs and symptoms. Treatment of NM allows an improvement of neurological symptoms. New treatment combinations, such as liposomal cytarabine, could yield better results

O154 Prediction model for small-cell lung cancer in the Lambert-Eaton myasthenic syndrome M.J. Titulaer, P. Maddison, J.K. Sont, P.W. Wirtz, D. Hilton-Jones, R. Klooster, M. Potman, N. Willcox, P.A. Sillevis Smitt, A. Vincent, S.M. van der Maarel, B. Lang, J.J. Verschuuren Leiden University Medical Center (Leiden, NL); Queens Medical Centre (Nottingham, UK); Haga Hospital (The Hague, NL); John Radcliffe Hospital (Oxford, UK); Erasmus Medical Center (Rotterdam, NL) Introduction: In 50% of the patients with the Lambert-Eaton myasthenic syndrome (LEMS) a small cell lung carcinoma (SCLC) can be found. A significant clinical concern is the early detection of these tumors in newly diagnosed LEMS patients. Different factors have been reported to differ between SCLC-LEMS patients and nontumour LEMS patients (NT-LEMS). We propose a model to differentiate SCLC-LEMS from NT-LEMS patients. Methods: We included 107 Dutch LEMS patients (58 with SCLC), diagnosed between 1990 and 2008, from 1998 prospectively. We noted epidemiological data, smoking information, clinical features and collected laboratory and HLA data. Logistic regression was used to determine statistical significance, estimate odds ratios and create a prediction model. A second cohort (n = 112) was collected in the UK (Oxford and Nottingham) to validate the model. Results: Patients with SCLC-LEMS differed from NT-LEMS patients in age of onset, weight loss (at least 5% within 3 months of onset), smoking ever, smoking at diagnosis, ECOG performance score, SOX1-antibodies (all p \ 0.0005). Clinical severity was more prominent in SCLC-LEMS (involvement of arms, proximal and

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S50 distal, and bulbar muscles within 3 months, all p\ 0.0005). A model, using smoking at diagnosis, gender, weight loss, bulbar complaints, ECOG performance score and SOX1 antibodies could predict an SCLC at three months from onset with a high sensitivity and specificity. The area under the curve (AUC) was 90% with clinical features only. Addition of SOX antibodies to the model ameliorated the AUC to 95%. Conclusion: Prediction of SCLC in LEMS is highly reliable within three months from onset, both using clinical features only and even better using a few clinical parameters and one antibody test. This study was partly funded by an ENS fellowship and by the Prinses Beatrix Fonds

O155 Anti-NMDA-receptor encephalitis: analysis of relapses I. Gabilondo, A. Saiz, M. Vinals, F. Villalobos, R. Jadraque, A. Vela, V. Gonzalez, F. Graus Hospital Clinic (Barcelona, ES); Hospital Reina Sofı´a (Cordoba, ES); Hospital Virgen Rocio (Sevilla, ES); Hospital G.U. Alicante (Alicante, ES); Hospital Moncloa (Madrid, ES); Hospital Sant Joan de Deu (Barcelona, ES) Background: Relapses in anti-NMDA-receptor encephalitis occur in 15–25% of cases. The clinical features are not well known. Objectives: To report the clinical profile of patients suffering relapses of anti-NMDAR encephalitis included in a series of 21 Spanish patients. Methods: Relapse was defined by a new psychiatric or neurological syndrome that improved with immunotherapy. We analyzed the following information: age, clinical profile at initial event and each relapse, number of relapses and delay between episodes, total followup, treatment and outcome. Results: We identified 5 (24%) female patients. Median follow-up: 5.5y (5 to 8y). Only one patient had cancer (ovarian teratoma). Median age (years) at the initial event: 19y (8 to30y). Median time from initial event to first relapse: 2.8y (0.5 to8y). Three patients had one relapse. Clinical features at initial event and relapses were identical with typical features (psychiatric symptoms, dyskinesias, speech disorder, seizures, and decreased consciousness). The two patients with [ 1 relapses were older (age 22 and 30y vs 8, 13, and 17y), and the clinical relapses or the initial event were atypical: isolated seizures, pure psychiatric or neurological manifestations. Case reports: Case 1: Female, 30-years old. First event: subacute memory problems, psycosis, and decrease of consciousness requiring intensive care support (ICS). She improved with steroids and immunoglobulin (IVIG) but memory deficits persisted. First and second relapse (30.5 and 31 years): similar to first event with good recovery after immunotherapy. Third episode (32 years): severe depressive psychotic episode treated with steroids, IVIG. Fourth episode (34 years): diplopia and cerebellar ataxia that improved with steroids. Case 2: Female, 22-years old. First event: isolated onset of secondarily generalized partial seizures. Seizures controlled with antiepileptics. First relapse (24 years): Cluster of complex partial seizures, with speech disorder. Remission after ovarian teratoma is discovered and removed. Second relapse (27 years): acute behavioural and attention problems, and status epilepticus requiring ICS. Complete recovery after treatment with steroids and IVG. Teratoma recurrence was ruled out. Conclusions: Relapses of anti-NMDAR encephalitis may occur up to 8 years after the initial event. They may present with isolated seizures or neurological symptoms, or atypical psychosis rather than the full-blown clinical picture of encephalitis.

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O156 Aquaporin-4 expression by thymoma of myasthenia gravis patients K.H. Chan, J.S. Kwan, A.C. Chu, P.W. Ho, J.W. Ho, S.L. Ho The University of Hong Kong (Hong Kong, HK) Background: Neuromyelitis optica (NMO) is a serious idiopathic inflammatory demyelinating disorder characterized by acute transverse myelitis and optic neuritis. A significant proportion of NMO patients are seropositive for NMO-IgG which is autoantibody against aquaporin-4 (AQP4) water channel. Paraneoplastic NMO associated various tumors were recently reported. Aim: We studied the expression of AQP4 by thymoma from patients with and without myasthenia gravis (MG). Methods: Thymoma obtained from thymomectomy in patients with and without MG were studied by immunohistochemistry and western blot. Results: Ten thymoma patients (9 with MG) and two control patients without thymoma or MG were studied. Immunohistochemistry revealed AQP4 immunoreactivity in cell membrane of thymoma cells from all ten thymoma specimens whereas thymic tissues from patients without thymoma or MG were negative for AQP4 immunoreactivity. Western blot revealed that lysates of nine of the ten thymoma specimens reacted with anti-human AQP4 antibody with a band of *30 kDa compatible with the molecular weight of AQP4. Interestingly, immunofluorescence revealed that IgG isolated from 2 NMO patients seropositive for NMO-IgG bound to cell membrane of thymoma cells from all ten thymoma specimens while IgG from healthy control subject did not. Conclusion: Thymoma cells of patients with and without MG express AQP4. NMO-IgG from serum of NMO patients bound to AQP4 expressed on thymoma cell membrane. This study is supported by Seed Fund for Basic Science from the Faculty of Medicine, The University of Hong Kong

__________________________________ Oral session 21 Neuro-ophthalmology O157 Gaze stabilization in humans with chronic loss of vestibular function N. Lehnen, U. Bu¨ttner, K. Jahn, S. Glasauer University Hospital of Munich (Munich, DE) Objectives: Large goal-directed gaze shifts have two parts: (1) a gaze movement toward the target, i.e., a movement of eye-in-head together with head-in-space, and (2) gaze stabilization with gaze being on target. During gaze stabilization, the on-going head movement toward the target is compensated by a counter-rotation of the eyes under the influence of the vestibular-ocular reflex (VOR). Humans with chronic complete loss of vestibular function (vestibular subjects) cannot rely on the VOR but still are, to some extent, able to stabilize gaze. It is still unclear which mechanisms mediate this stabilization; it could be controlled by learned, anticipatory mechanisms, i.e., in a feed-forward way, or by visual or proprioceptive feed-back. Here, we investigate whether gaze stability in vestibular subjects is due to learned anticipatory mechanisms only

S51 (feed-forward control) or whether it relies on proprioceptive feedback. Methods: We increased the head moment of inertia by 330% in five subjects who had undergone complete bilateral vestibulectomy for acoustic neuroma several years prior to the study (vestibular subjects). We compared their gaze shifts with and without increased head inertia to those of ten age-matched healthy controls while they performed horizontal gaze shifts toward briefly flashed targets in darkness (75- and 80-degree target steps). Eye and head movements were recorded with the search-coil technique. Results: Increasing the head moment of inertia leads to head oscillations in both vestibular subjects and, to a lesser extent, healthy controls. When the head moment of inertia is increased in controls, the eyes counter-rotate to compensate for head oscillations. Gaze is stable after it has reached the target. Vestibular subjects, however, displays gaze oscillations along with head oscillations with the increased moment of inertia. The eyes do not compensate for head oscillations. Conclusion: Vestibular subjects cannot compensate for head oscillations provoked by an increase in the head moment of inertia. They show gaze oscillations. This indicates that feed-forward control, rather than proprioceptive feed-back, is the major mechanism for gaze stabilization in subjects with chronic loss of vestibular function. Supported by the BMBF (BCCN Munich 01GQ0440)

O158 Eye movement disorders are different in parkin-linked and idiopathic early-onset Parkinson’s disease B. Machner, C. Klein, A. Sprenger, P. Baumbach, P. Pramstaller, C. Helmchen, W. Heide University Lu¨beck (Lu¨beck, DE); EURAC (Bolzano, IT); General Hospital Celle (Celle, DE) Objectives: Parkin gene mutations are the most common cause of early-onset parkinsonism. Patients with Parkin mutations may be clinically indistinguishable from patients with idiopathic early-onset Parkinson’s disease without Parkin mutations (EOPD). Eye movement disorders have been shown to differentiate parkinsonian syndromes, but have never been systematically studied in Parkin mutation carriers. Methods: Eye movements were recorded in symptomatic (n=9) and asymptomatic Parkin mutation carriers (n=13), idiopathic EOPD patients (n=14) and age-matched control subjects (n=27) during established oculomotor tasks. Results: Both EOPD patients and symptomatic Parkin mutation carriers showed hypometric prosaccades towards visual stimuli, as well as deficits in suppressing reflexive saccades towards unintended targets (antisaccade task). When directing gaze towards memorized target positions, EOPD patients exhibited hypometric saccades, whereas symptomatic Parkin mutation carriers showed normal saccades. In contrast to EOPD patients, the symptomatic Parkin mutation carriers showed impaired tracking of a moving target (reduced smooth pursuit gain). The asymptomatic Parkin mutation carriers did not differ from healthy control subjects in any of the tasks. Conclusions: Although clinically similarly affected, symptomatic Parkin mutation carriers and idiopathic early-onset PD patients differed in several oculomotor tasks. This finding may point to distinct anatomical structures underlying either condition: dysfunctions of cortical areas involved in smooth pursuit (V5, frontal eye field) in Parkin-linked parkinsonism vs. greater impairment of basal ganglia circuits in idiopathic PD.

O159 Increased resting state activity of the visual cortex in patients with Leber’s hereditary optic neuropathy M. Filippi, M.A. Rocca, P. Valsasina, S. Bianchi-Marzoli, M. Petrolini, J. Milesi, A. Falini, G. Comi University Hospital San Raffaele (Milan, IT) Objective: Leber’s hereditary optic neuropathy (LHON) leads to bilateral retinal ganglion cell degeneration and optic nerve atrophy. The assessment of low-frequency (\0.1 Hz) fluctuations in functional magnetic resonance imaging (fMRI) data at rest has demonstrated the presence of high temporal coherence between spatially distinct, functionally-related brain regions, which characterizes the resting state networks (RSN) of the human brain. In this study we investigated abnormalities of RS activity of the visual network in patients with LHON and assessed their correlation with structural damage along the visual pathways, measured using diffusion tensor (DT) tractography, and ophthalmologic impairment, measured with clinical assessment and optic coherence tomography (OCT). Methods: RS fMRI data were acquired from 13 LHON patients and 12 matched healthy controls using a 3T MRI scanner. Independent component analysis (ICA) was used to decompose RS fMRI data into spatially independent maps and time courses using the GIFT software. Forty spatially IC maps were produced, from which the primary visual network was identified. SPM5 was used to assess within- and betweengroups RS activations, as well as spatial correlations with DT tractography measures of optic radiation (OR) damage and clinical variables (p=0.05, corrected for multiple comparisons). Results: Tractography analysis demonstrated abnormal DT MRI measures within the ORs in LHON patients vs. healthy controls (p ranging from \0.001 to 0.002). The visual network was clearly identified in both groups. Compared to controls, LHON patients had a significant increase of RS fluctuations in the occipital cortex (p=0.03), bilaterally, which was significantly correlated with the increase of OR mean and radial diffusivity (r=0.83 and 0.81, respectively) and disease duration (r=0.81). Conclusion: RSN analysis reveals abnormalities of the visual network in LHON patients, which are correlated with structural damage along the visual pathways and disease duration. These abnormalities are likely to reflect a deafferentation of the visual cortex.

O160 Modulating the triggering of saccades by TMS-induced inhibition of the cortical ‘preparatory set activity’ W. Heide, M. Nagel, A. Sprenger, H. Siebner General Hospital Celle (Celle, DE); University Lu¨beck (Lu¨beck, DE); Copenhagen University Hospital Hvidovre (Copenhagen, DK) Background: The generation of saccades is influenced by the level of ‘‘preparatory set activity’’ in cortical oculomotor areas. This preparatory activity can be examined using the gap-paradigm in which a temporal gap is introduced between the disappearance of a central fixation target and the appearance of an eccentric target. Methods: Ten healthy subjects made horizontal pro- or antisaccades in response to lateralized cues after a gap period of 200 ms. Single-pulse transcranial magnetic stimulation (TMS) was applied to the dorsolateral prefrontal cortex (DLPFC), frontal eye field (FEF), or supplementary eye field (SEF) of the right hemisphere 100 or 200 ms after the disappearance of the fixation point. Saccade latencies were measured to probe the disruptive effect of TMS on saccade preparation. In six individuals, we gave realistic sham TMS during the gap period to mimic auditory and somatosensory stimulation without stimulating the cortex.

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S52 Results: TMS to DLPFC, FEF, or SEF increased the latencies of contraversive pro- and antisaccades. This TMS-induced delay of saccade initiation was particularly evident in conditions with a relatively high level of preparatory set activity: The increase in saccade latency was more pronounced at the end of the gap period and when participants prepared for prosaccades rather than antisaccades. Although the ‘‘lesion effect’’ of TMS was stronger with prefrontal TMS, TMS to FEF or SEF also interfered with the initiation of saccades. The delay in saccade onset induced by real TMS was not caused by non-specific effects because sham stimulation shortened the latencies of contra- and ipsiversive anti-saccades, presumably due to intersensory facilitation. Conclusion: Our results are compatible with the view that the ‘‘preparatory set’’ for contraversive saccades is represented in a distributed cortical network, including the contralateral DLPFC, FEF and SEF.

O161 Video measurement of the head impulse test K. Weber, H. MacDougall, L. McGarvie, M. Halmagyi, I. Curthoys University Hospital (Zurich, CH); University of Sydney (Sydney, AU); Royal Prince Albert Hospital (Sydney, AU) Introduction: Clinical testing of semicircular canal function with head impulses (head ‘‘thrusts’’) important in the assessment of patients with vertigo or loss of balance relies on the recognition of the catch-up saccades that the patient generates in order to compensate for the low vestibulo-ocular reflex gain. Quantitative measurement of the vestibulo-ocular reflex gain during impulsive testing until now had to be done with a scleral search coil system – only practical in a research setting. Methods: We have compared the results of impulsive testing using our own novel ultra-light weight goggle based video system with that from simultaneous search coil testing in 8 patients (6 with acute vestibular neuritis, 2 with gentamicin vestibulotoxicity). Results: The vestibulo-ocular reflex gain with the 2 methods was not significantly different. Neither was the ability to recognize covert catch-up saccades that are not detectable by the naked eye but indicate a positive head impulsive test. Conclusions: Video promises to be a safe, accurate and practical means of measuring the vestibulo-ocular reflex. Supported by the NAtinal Helath & Medical Research Council, by the Garnett PAsse & Rodney Williams Memorial Foundation and by GN Otometrics.

O162 Management of idiopathic intracranial hypertension with transverse sinus stenting M. Halmagyi, G. Parker, M. Thurtell, J. Macdonald, R. Ahmed, M. Wilkinson, V. Dunne Royal Prince Alfred Hospital (Sydney, AU) Introduction: Transverse sinus stenosis (TSS), with a pressure gradient, is common in patients with idiopathic intracranial hypertension (IIH). While the role of TSS in IIH pathogenesis remains controversial, modelling studies suggest that stenting of a stenosis with a significant pressure gradient should increase cerebral venous outflow and reduce intracranial pressure, thereby improving symptoms of IIH and reducing papilledema, even when the stenosis is secondary to the intracranial hypertension. Methods: We aimed to further determine if stenting could be helpful in IIH management (Owler BK, Parker G, Halmagyi GM,

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Dunne VG, Grinnell V, McDowell D, Besser M. Pseudotumor cerebri syndrome: venous sinus obstruction and its treatment with stent placement. J Neurosurg. 2003;98:1045–55). Thirty-eight patients, who met diagnostic criteria for IIH and had one or more TSSs with gradient on venography + manometry, were stented. Results: The mean superior saggital sinus pressure was 35mmHg (=476mmH2O) with a mean TSS gradient of 20mmHg. The mean lumbar CSF pressure before stenting was 319mmH2O. Another 7 patients with headache, high lumbar CSF pressure (mean 460mmH2O), and high superior saggital sinus pressure (mean 25mmHg) with a significant gradient (mean=12mmHg) but no papilledema were also stented. Stents were placed using an endovascular approach. Length of follow-up ranged from 6 months to 8 years. The TSS pressure gradient was abolished in all patients immediately following stenting. Most patients reported symptomatic improvement within hours. The papilledema resolved in all patients over weeks and 31/38 with papilledema had a persisting improvement in visual symptoms and visual fields. The mean lumbar CSF pressure after stenting was 205mmH2O (150mmH2O in those without papilledema). In 7 patients symptom relapse was associated with increased lumbar CSF pressure and recurrent stenosis adjacent to the previous stent. In these cases, insertion of another stent again abolished TSS pressure gradient and improved symptoms. Conclusions: Our findings confirm a role for transverse sinus stenting in the management of selected patients with IIH. A randomized controlled study would be required to evaluate transverse sinus stenting in comparison to other treatments.

__________________________________ POSTER SESSIONS Poster session 1 Cerebro vascular disorders: neuro-imaging P163 Acute ischaemic stroke, a neurological emergency— comparison of the methods: CT perfusion versus MRI B. Walter Ludwig-Maximilians-University (Munich, DE) Purpose: Ischemic stroke is correlated with a high rate of disability and death. The early and adequate therapy signifies the basics for the outcome of the individual patient. The detection of ischemic-induced penumbra can principally be assessed with CT perfusion and MRIbased diffusion and perfusion imaging techniques. The purpose of this study is to compare the efficiency of modern CT and MRI- techniques under the special aspects of emergency cases in diagnosing acute cerebral ischemia inside of the given time window. Method: At our department of clinical radiology the faster CT scanner (FLASH and Definition AS+ 128, Siemens) and the modern MRI technique using diffusion-weighted and perfusion imaging (several Magnetoms e.g. 1.5 Ts Avanto and 3 Ts Verio, Siemens) are available in emergency settings of acute ischemia. We investigated 90 patients presenting with acute neurological impairment by the combination of non-enhanced CT, CT angiography, and CT perfusion with colored perfusion maps for cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT) and time to peak (TTP) assessing the time from scan start till conclusive treatment decisions under the conditions of daily routine.

S53 Results: Our used CT program has been evaluated as the faster feasible procedure to gain a comprehensive, non-invasive survey with the possibility to identify territories at risk from infarcted tissue and to detect arterial occlusions. These findings have led to prompt treatment decisions - averagely inside of 20 minutes after CT scan start. A similar efficiency in quickness to prepare the patient (e.g. exclusion of contraindications such as pacemakers or the accurate arrangement of the equipment), to acquire the different sequences including postprocessing would have never been practicable at the same moment by MRI technique. Conclusions: The superiority of normally equivalent techniques can also be characterized by the particular situations of their clinical application. The small time window for thrombolysis demands the quickest possible overview about the portion of potentially salvageable ischemic tissue reachable by modern CT technique. Each hesitation may finally prevent the use of special therapeutic options.

P164 The combination of predictors of ischaemic lesion patterns on diffusion weighted imaging can be key in differentiating acute large artery atherosclerotic and cardioembolic disease D.S. Jung, J.W. Bae, H.J. Jo, K.D. Choi University Hospital of Pusan (Pusan, KR) Objectives: Atherosclerotic involvement of the intracranial vessels occur more frequently in Asian patients than in Westerners. The differentiation between large artery atherosclerosis(LAA) and cardioembolic disease(CE) in acute Middle Cerebral Artery(MCA) ischemic patients may have clinical implications for early management and therapy decision, however differentiation is difficult. There have been few studies addressing the correlation between ischemic lesion topography on DWI and stroke subtypes in patients with only MCA with stenosis or occlusion. Methods: 647 consecutive patients admitted to our Department of Neurology with an acute ischemic stroke were assessed, among them we recruited acute MCA ischemic patients with ipsilateral isolated MCA stenosis or occlusion owing to thrombosis or embolism without Internal Carotid Artery(ICA) stenosis, and they were divided probable LAA group(n = 28) and CE group(n = 12) by TOAST classification. A comparative analysis of radiological patterns between patients with probable LAA group and probable CE group was made. Lesions on DWI of the patients who were included were individually categorized by; location, number, and configuration. Location was further subdivided into whole territorial, branch, pial, internal or external border zone(IBZ, EBZ) and deep or superficial perforator(DP, SP). Single or multiple were numbered as well as configuration by scattered or confluent was noted. MCA stenosis or occlusion on MRA were classified as proximal or distal by the point of bifurcation. Results: IBZ, DP infarcts, proximal M1 were common in the LAA group, while multiple pial, multiple DP, multiple branch, and distal M1 were associated with CE group. However single factor such as pial, branch, and others on DWI did not differ between the two groups statistically, however combination of IBZ, DP and proximal M1 was more common in the LAA group((OR 7.2), while combination of multiple pial, multiple branch, and distal M1 was more common in the CE group(OR 6.9). Conclusion: IBZ, DP lesion are more associated with the LAA group, while multiple with the CE group. Furthermore a combination of variables is more significant than one variable. Our results indicate that specific DWI lesion patterns can be predictors that would help predict presumed subtype classification, however, further

studies are needed because the majority of patients have coexisting etiology. This work was supported for two years by Pusan National University Research Grant

P165 Frequency and haemodynamic status of diffusionnegative stroke C.S. Song, Y. Choi, I.G. Kim, S.H. Kim, C.G. Hong, I.T. Han, J.H. Rha University Hospital of Inha (Incheon, KR) Objectives: Definite diffusion weighted image (DWI) lesion is not always identified despite the clinical setting of acute ischemic stroke. We tried to estimate the frequency and the hemodynamic status of the diffusion negative stroke. Methods: Since January 2007, we prospectively registered acute ischemic stroke within 1 week from the onset. All the patients were evaluated by neurologist and diagnosed as acute ischemic stroke or transient ischemic attack (TIA) until proven otherwise. Brain MRI and including DWI, perfusion weighted image (PWI), and MR angiography (MRA) were performed in all the patients. Patients who received thrombolytic therapy, of hemorrhagic stroke or other stokemimicking conditions were excluded from this study. Results: Until October 2009, 1135 acute ischemic stroke have been registered, with eighty five patients (7.5%) of initially negative DWI finding. Among them, significant stenosis/occlusion of corresponding artery on MRA were found in 21 (24%), including 12 patients (57%) with evidence of perfusion defect on PWI. Among those perfusion defect patients, in 9 patients (75%) neurologic deficit subsided within 24 hours and met the WHO criteria of TIA whereas the neurologic deficit persisted over 24 hours in 3 patients. Among the 9 patients with arterial stenosis/occlusion but no perfusion defect, 1 patient showed neurologic deficit over 24 hours, and in the remaining 8 patients (89%) the neurologic deficits subsided within 24 hours(p\0.05). Sixty four patients without significant stenosis on MRA did not show evidence of perfusion defect, and in most 61 patients (95%) neurologic deficits subsided within 24 hours, but in 3 patients the neurologic deficits persisted over 24 hours (p\0.05). Follow up MRI was taken in cases of aggravated or newly developed neurologic deficits, which were all in the perfusion defect group, and 3 patients showed newly appeared DWI lesion in the territory of perfusion defect. Conclusion: Our data provide the frequency of diffusion negative stroke, and suggests that hemodynamic status is important determinant of the clinical symptom in the DWI negative case. Patients with significant stenosis and perfusion defect are more likely to have symptom longer than 24 hours and subsequently develop acute infarction.

P166 CT-perfusion: from imaging to treatment decisions in acute ischaemic stroke B. Walter Ludwig-Maximilians-University (Munich, DE) Purpose: Stroke continues being the third most important reason for mortality in western countries. The fast availability of adequate treatment can limit or prevent long-term neurological impairments. The present study wants to illustrate the clinical procedures of

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S54 emergency cases for patients with acute ischemia from imaging till the first treatment decisions. Methods: We investigated 67 patients (30 outpatients, 37 inpatients) presenting with variable acute ischemic features by a special CT combination protocol (Siemens FLASH and AS Definition + 128) comprising non-contrast CT, perfusion maps of cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), time to peak (TTP), and CT angiography in 3D. Results: The detection of tissue at risk (penumbra), its size, and the relation to the core area as well as the possible findings of acute vascular occlusions were demonstrated to the present neurologists at the workstation in front of the scanner room. The whole setting incorporating the complete CT protocol, the postprocessing and the final overview by an experienced radiologist could be performed averagely inside of about 20 minutes. 30 patients showed acute ischemic perfusion deficits with potentially salvageable tissue, whereby ten of them immediately received thrombolysis. The other 20 persons had to be treated in conservative way due to different contraindications. The acute symptoms of the remaining 37 patients had been caused by different reasons such as dissections, electrolytic disorders, migraine, high blood pressure etc. Conclusions: The prompt availability of the radiological interpretation enables the quickest possible and adequate treatment procedures such as thrombolysis or - if necessary - therapeutic angiography. The advantages for the clinical outcome of the single patient due to such a close cooperation might be assessed in further trials.

P167 CT-perfusion for monitoring acute vasospasm after subarachnoid haemorrhage B. Walter Ludwig-Maximilians-University (Munich, DE) Purpose: Symptomatic vasospasm is the most common serious complication after aneurismal rupture occurring in about 70% to 90% of patients. Early recognition is essential because the timely use of several therapeutic interventions can impede the occurrence of neurological disabilities. The present study intends to illustrate that dynamic Perfusion CT is an adequate tool for early detection of vasospasm and of possibly associated acute ischemia. Methods: We investigated 23 patients (17 women and 6 men with the age range 29 – 72 years) hospitalized for SAH presenting with acute neurological impairment by dynamic contrast enhanced CT perfusion completed by non-contrast CT and CT angiography (Siemens FLASH or Definition AS+ 128). Perfusion CT monitors the first pass of an iodinated contrast agent through the cerebral vasculature measuring the changes in tissue attenuation. The postprocessing of the data allows the generation of maps of various perfusion parameters including cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time to peak (TTP). Results: Nine patients showed acute vasospasm, three of them with associated acute ischemia and one with manifest infarction. Three further patients presented with an unclear increase of the mean transit time (MTT) and time to peak (TTP) without a pathologic correlation concerning the other parameters. The examinations of additional eleven patients resulted in normal cerebral features. According the radiological findings an adequate therapeutic intervention could immediately be performed.

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Conclusions: Perfusion CT is a fast and effective way of evaluating acute ischemia and may screen patients for early therapeutic vasospasm intervention following aneurismal SAH to prevent the occurrence of neurological impairment.

P168 CT-perfusion unveils subarachnoid haemorrhage pathophysiology: relationship between acute perfusion abnormalities, clinical grade and bleeding severity A. Lagares, M. Cicuendez, M. Amosa, I. Paredes, J. Milla´n, A. Ramos Hospital 12 de Octubre (Madrid, ES) Objectives: To stablish the relationship between different measures of brain perfusion made on dynamic contrast CT reconstructions perfomed as soon as SAH has been diagnosed and the severity of the bleeding determined by the clinical grade and extent of the bleeding or the outcome of the patients. Material and methods: After the diagnosis of SAH by conventional CT a perfusion CT was performed before CT angiography. All imaging studies were performed on a 6-slice spiral CT scanner. All images were analyzed using perfusion software developed by Philips, which produces PCT quantitative data based on temporal changes in signal intensity during the first pass of a bolus of an iodinated contrast agent. Measurements of mean transient time (MTT), time to peak (TTP), cerebral blood volume (CBV) and cerebral blood flow (CBF) in volumes of interest corresponding to territories perfused by the major cerebral arteries were perfomed. Different data regarding severity of the bleeding such as level of consciousness, amount of bleeding in conventional CT were collected. Outcome was assessed by the Glasgow Outcome scale at least six months after the bleeding. For statistical analysis nonparametric correlations between variables were perfomed (Spearman’s Rho). Results: 42 patients have been included in the study since January 2007. In SAH patients there are increasing perfusion abnormalities as the severity of the bleeding increases. The most affected perfusion parameters are TTP and MTT, as they significantly increases with the severity of the bleeding (p\0.01, Spearman’s Rho). When average MTT time is increased over 6,5 seconds there is a 3,2 (CI=1,4–6,8) risk of poor outcome. This value has a positive predictive value of 80% for a poor outcome. Conclusions: SAH causes cerebral blood flow abnormalities even in the acute phase of the illness, consisting mainly in an increase in circulation times (TTP and MTT), which are correlated with the severity of the bleeding. These may be produced by an increase in intracranial pressure, as has been suggested by other authors. Fondo de Investigaciones Sanitarias FIS PI070152 and Fundacio´n Mutua Madrilen˜a Grant 2007/82

P169 White-matter hyperintensities are associated with intracranial atherosclerosis rather than extracranial atherosclerosis J.S. Kim, S.J. Lee, Y.I. Kim, K.S. Lee The Catholic University of Korea (Seoul, KR) Background: There is increasing evidence for an association between white matter hyperintensities (WMH) and large-artery

S55 atherosclerosis. In this study, we sought to evaluate the relationship between intracranial atherosclerosis and WMH. Methods: The study group comprised of 268 patients with acute ischemic stroke, who were classified into three groups according to the location of the stenosis on contrast-enhanced MRA: intracranial, extracranial and non-stenosis. WMH were rated using the semiquantitative method of Scheltens and colleagues. Results: The mean age of the patients (152 men and 116 women) was 67.0±12.4 years. Significantly high WMH score was found in the elderly ([ 70 years), the female, and hypertensive patients, while the total score of WMH was significantly decreased in patients with heart disease, including those with atrial fibrillation, as compared to those without heart disease. The intracranial group had significantly more WMH score in comparison with the other groups; however, there was no significant difference in the WMH score between the extracranial stenosis and the non-stenosis groups. The linear regression analysis showed that age was the factor most strongly associated with the total score of WMH; and the location of stenosis was positively related to WMH, especially in deep white matter. Conclusion: Our data show that intracranial stenosis is associated with WMH, indicating that intracranial stenosis, rather than extracranial stenosis, is likely to cause white matter lesions.

P171 Volumetric analysis of subaracnoid haemorrhage clot: new ways of assessing bleeding severity A. Lagares, L. Jime´nez Rolda´n, J. Ferna´ndez Ale´n, J. Milla´n, A. Ramos Hospital 12 de Octubre (Madrid, ES) Objective: SAH bleeding is assessed with the help of qualitative scales that show moderate interobserver reliability and moderate relation with vasospasm and outcome. New methods have been described in order to quantify the volume of subarachnoid hemorrhage. The objective of this study is to assess the reliability of two different methods for quantifying subarachnoid hemorrhage volume and to establish their relation with different clinical factors, the presence of vasospasm and outcome. Methods: The CTs of 110 patients suffering spontaneous SAH were reviewed. DICOM images were evaluated using ANALYZE 8.1 software running on a personal computer. SAH bleeding volume was estimated using two methods: ROI measurement with semiautomated delineation of the bleeding in each section; and using the Cavalieri principle. Both methods were compared using simple correlations and comparing differences between measurements. SAH bleeding volume was related to different clinical variables, appearance of vasospasm and outcome assessed with GOS by means of univariate and multivariate logistic regression analysis. Results: Both methods obtain very similar results (less than 10% average difference, correlation coefficient 0.95). Bleeding volume correlates with the level of cosciousnees at admission and outcome, although it does not correlate with Fisher grade. There is an increased risk of clinical vasospasm and ischemia in patients with higher bleeding volumes. A total volume of bleeding over 20 cc increases nearly four times the risk of poor outcome after adjusting for confounding factors such as age or WFNS at admission. Conclusion: Volumetric estimation of SAH clot could be helpful in assessing prognosis after SAH and more reliable than classical scales that assess the severity of the bleeding in CT. Fundacio´n Mutua Madrilen˜a Grant 2007/82 and Fondo de Investigaciones Sanitarias FIS 070152

Dementia/Higher function disorders: higher cortical functions P172 Do supine position and deprivation of visual environment influence spatial neglect signs? S. Gassama, A. Deplancke, A. Saj, J. Honore´, M. Rousseaux University of Lille (Lille, FR); University of Geneva (Geneva, CH) Objectives: Studies of spatial neglect have suggested that modulation of gravity information, especially placing the patient in a supine position, allows transient remission of errors in line bisection and subjective straight ahead tasks. Other investigations related to attentional theories suggested improved performance when tasks are performed in the dark, because of the absence of peripheral visual distractors. Our purpose was to examine in the same study the effect of body position (BP) and visual environment (VE) on relatively ecological tests of spatial neglect. Methods: We included patients suffering from a relatively recent (1-3 months) right hemisphere stroke. Twelve were neglect according their pathological performance on clinical paper and pencil tests and six were non neglect. They were compared to 12 matching healthy controls participants in four tasks: line bisection, reading a text, reading numbers and naming animals presented on a paper sheet. These tasks were performed using a computer screen in two positions (sitting and supine) and two conditions of visual environment (light and darkness). Results: The ANOVA showed significant spatial errors or omissions (p\=0.05) in neglect patients compared with non neglect patients and control subjects, but did not reveal any modulation of performance in relation with both BP and VE. Conclusion: Contrary to what has been previously suggested, we did not confirm that neglect signs can be relatively easily improved by placing patients in supine position or reducing the amount of information arising from the environment. In a theoretical perspective, our results do not support the hypothesis that neglect is due to a simple asymmetry in processing gravity and visual information, that could be reduced by supine positioning, nor that of an important deleterious role of peripheral visual information arising from the ipsilesional space on the misorienting of attention.

P173 Post-stroke delay influences consequences of hemianopia on spatial neglect signs A. Saj, J. Honore´, T. Bernati, M. Rousseaux University of Geneva (Geneva, CH); University of Lille (Lille, FR) Objectives: Patients with spatial neglect present severe biases of spatial orientation with translation of subjective-straight-ahead (SSA) representation and counterclockwise deviation of the subjective vertical (SV), resulting in translation errors or contralesional omissions in clinical tests. Most of them also present with hemianopia, but the relative influence of neglect and hemianopia on performance and the possible cumulative effects remain controversial. In addition, most studies have been performed after a few month delay following lesion onset, and partial adaptation of the spatial orientation system to hemianopia could yet have occurred. Here, we analysed the effect of post-stroke delay on the possible additive effects of neglect and hemianopia on the aforementioned neglect signs.

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S56 Methods: All patients suffered a relatively recent right hemisphere stroke demonstrated by MRI or CT scan. Neglect was analyzed by paper and pencil tests and hemianopia by clinical examination in the primary position of gaze and/or Goldmann perimetry. Ten had neglect and hemianopia (N+H+), 6 neglect only (N+H-), 3 hemianopia only (N-H+) and the 12 other had no visual difficulties (N-H-). For SSA, participants had to adjust a bar, movable in translation, straight ahead of the navel. In SV experiment, they had to adjust a luminous rod to the vertical. The three clinical tests were line bisection, bell cancellation and scene drawing. Tasks were administered two times with a 30–60 day delay. Results: At first examination, neglect patients showed rightward SSA translation, counter-clockwise SV deviation, and pathological performance in clinical tests, with more definite impairment when hemianoptic. Importantly, the errors decreased from the first to the second session in patients who were hemianoptic (N+H+; N-H+), but remain stable in those who were only neglect (N+H-) or had no visual difficulties (N-H-). And at that time, patient performance was no more aggravated by hemianopia. Conclusion: Hemianopia strongly modulated SSA, SV and clinical tests errors at first examination, but this disappeared at the second session. This finding emphasizes the importance of the time delay since stroke onset, which can explain previous discrepancies. Furthermore, hemianopia consequences are clearly adaptable and their reduction is a key factor of patient improvement.

P174 Delirium recognition—Use of the Confusion Assessment Method M. Grigaitis, M. Plueger Barrow Neurological Institute (Phoenix, US) Objective: Delirium is a common condition in the older hospitalized adult, defined as a mental disorder of acute onset with a fluctuating course, characterized by disturbances in consciousness, attention, memory, thought, perception and behavior. Delirium is associated with functional decline, increased hospital stay, and increased mortality. By the year 2020 53% of the population in the United States (US) will be older than 65 years. Current estimates indicate 55% of all surgical procedures in the US are performed on people 65 years and older. Despite the significance of this condition, clinicians recognize less than half the cases of delirium among older patients in the hospital. This raises the question; if delirium were identified early in the course of post operative care could treatment begin earlier thereby decreasing the untoward outcomes? Given the fluctuating nature of delirium symptoms the bedside nurse is best suited to assess for delirium. The purpose of this project was to evaluate the use of an educational intervention coupled with the use of a standardized delirium assessment tool to answer the question: In post operative neurosurgical patients over age 50, does the use of a standardized assessment tool for delirium affect nurses’ recognition of delirium? Methods: Nursing knowledge of delirium was measured using the Delirium Knowledge Questionnaire administered to 44 practicing registered nurses followed by an educational intervention consisting of a video presentation and printed materials regarding the Confusion Assessment Method (CAM) developed by the Hartford Institute for Geriatric Nursing. Upon validation on the use of the CAM each nurse was to assess each neurosurgical post operative patient over the age of

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50 each shift for 4 weeks, followed by a post intervention knowledge questionnaire. Results: Of the 44 RNs that participated in the project 37 completed both the pre and post intervention questionnaires. 89% reported they utilized the CAM to assess their patients during the project period and 62% indicated its use positively affected their patient assessment. A paired samples T test was used to analyze the delirium knowledge scores comparing the pre and post intervention scores, t(36) = -7.2, p= 0.001, 95% CI = -4.7 to -2.6. Conclusion: The use of the CAM coupled with an education component clearly is effective in increasing nursing awareness and recognition of delirium.

P175 Gesture apraxia in patients with Alzheimer’s disease and Lewy body disease M. Rousseaux, J. Renier, M.A. Mackowiak University of Lille (Lille, FR) Objectives: Gesture apraxia (GA) is a classical consequence of Alzheimer disease (AD). Authors suggested more severe impairment in producing non significant/significant gestures, pantomimes on verbal command/by manipulation of the object and global conceptual (recognition and production) difficulties. However, these dissociations are discussed, and the cognitive mechanisms of GA remain unclear. In addition, little is known about consequences of other dementias. Here, we addressed GA in patients with AD or Lewy body disease (LBD). Methods: We included 31 AD and 7 LBD patients (NINCDSADRDA and McKeith criteria). Dementia was classified as mildmoderate or moderately severe using the Mattis Dementia Rating Scale. The battery is composed of two parts: 1. Simple gestures: imitation of finger and hand configurations, discrimination of meaningful/meaningless gestures, symbolic gestures (recognition, production on verbal command and imitation) and pantomimes (recognition, production on verbal command, imitation and with the object), 2. General knowledge and complex gestures: matching functional objects, recognition of objects by their function, production of complex sequential gestures and knowledge of action sequences. Patients were compared with 38 matching control subjects. ?A3B2 twb=.25w?>Results: AD patients showed difficulties (p\0.01) in each subtest of simple gesture assessment, except discrimination of meaningful/meaningless gestures, and recognition and imitation of symbolic gestures. Conversely, general knowledge was relatively preserved, with seldom impairment in recognition of objects by their function. Patients with mild-moderate dementia were only impaired in producing symbolic gestures on verbal command. Analysis of dissociations suggested that most patients had parallel impairment of the conceptual and production systems, and that selective impairment of the production system was more frequent than that of conceptual system. LBD patients showed modest difficulties, and only disorders of imitation of finger configurations reached significance. Correlations with the MDRS score were frequent, especially for pantomimes and general knowledge. Conclusion: AD patients show definite GA since the moderately severe stage of dementia, and LBD patients are relatively preserved. The intrinsic spatial complexity of gestures (pantomimes) is a key factor of recognition disorders. GA relies more on production than conceptual difficulties.

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P176 Comparative study of the neuropsychological characteristics in Lewy body dementia and Alzheimer’s disease C. Charro Gajate, E. Die´guez Perdiguero, J. Gonzalez Fernandez, M. Gon˜i Imizcoz General Hospital Yagu¨e (Burgos, ES) Introduction: In comparison with Alzheimer’s Disease (AD) little is known about the neuropsychological deficits in Lewy Body dementia (LB) and the neuropsychological markers that support the diagnosis of LB are not known with precision. Although the results between studies have been contradictory, it seems that this disease can have a particular pattern of neuropsychological deficits. Objective: The objective of the present study was to analize the neuropsychological factors as diferential factors between BL and AD, that will allow precise diagnosis. Methods: We analyzed the neuropsychological assessments from patients with a diagnosis of probable AD (n= 11) and probable BL (n= 11) paired them by age, and by their global cognitive deficit, which was measured with the Mini Mental State Examination (MMSE). The different neuropsychological tasks assessed the performance in different cognitive domains: auditory span, working memory, semantic memory, visospatial/visocontruction ability and episodic memory. Results: The patients with the diagnosis of LB showed more affectation in visoconstruction, semantic and fonetic verbal fluency, working memory and auditory span than the patients from the AD group, meanwhile the last group mentioned scored significantly less than the group of patients with LB in the delayed recognition task. Conclusion: It seems that evidence exists in favor of the pattern of neuropsychological affectation is different in both kinds of diseases and this seems to be related to the associated neuropathology. Financed by Fundacio´n Caja Burgos

P177 Early onset dementia: characteristics in a large cohort from academic memory clinics C. Picard, F. Pasquier, O. Martinaud, D. Hannequin, O. Godefroy University Hospital of Amiens (Amiens, FR); University Hospital of Lille (Lille, FR); University Hospital of Rouen (Rouen, FR) Objectives: To describe the characteristics of early-onset dementia in a large cohort from three memory clinics. Methods: We assessed all patients with dementia referred to the Academic Memory Clinics at Amiens, Lille and Rouen University Medical Centers between January 2005 and December 2007. Patients aged \ 65 at the time of symptom onset were included in the earlyonset group (EOD), whereas older subjects were included in the lateonset group (LOD). Results: 3473 patients (including 1932 women) were included and 811 (23.4%) were classified as EOD. The gender ratio was 1.12 whereas women were overrepresented in LOD (p=0.001). EOD patients were more frequently (p=0.001) living at home (87.3%). They had a lower educational level than the general population (p=0.0001) but were more educated than patients with LOD (p=0.001). The Mini Mental State Examination did not differ (p=0.3) between EOD (18.6 ±7.6) and LOD (18.9±6). The most common causes of EOD were Alzheimer’s (22.3%) and vascular (15.9%) diseases and four pathologies that were significantly more frequent (p=0.001) than in the late-onset group: frontotemporal dementia (9.7%), alcohol-related dementia (9.4%), traumatic brain injury (3.8%) and Huntington’s disease (3%).

Conclusions: EOD is characterized by specific features and different causes although Alzheimer’s and vascular dementias remain the main causes of dementia in patients younger than 65 years.

P178 Relationship of serum calcitonin gene-related peptide levels and Mini-Mental State Examination in patients with cognitive dysfunctions V. Papantoniou, A. Tsaroucha, T. Karianos, A. Fothiadaki, A. Archontaki, P. Valsamaki, A. Rizoulis, N. Sifakis, G. Gerostergios, A. Stipsanelli, A. Papadimitriou Alexandra University Hospital (Athens, GR); University Hospital of Thessaly (Larisa, GR); Hospital of Tripoli (Tripoli, GR) Aim: To assess the variation of CGRP neuroptetide expression between patients with different status of cognitive impairment and in healthy normal individuals in relation to age. Materials and methods: 11 patients (mean age ± sd :79.5±19.2) were submitted to mini mental state exam (MMSE). Serum CGRP levels were measured with RIA method and compared (t-test) with normal controls (group c1, n=5) matched for age (mean age ± sd :72±15) and younger normal volunteers (group c2, n=5) (mean age ± sd :31.8±12) in order to evaluate change in CGRP expression with ageing. CGRP expression was correlated (linear regression analysis) with MMSE. Results: Mini mental state exam evaluation for patients with cognitive dysfunction was (mean score ± sd) 14±7.2 (range 12–24). CGRP in patients, group c1 and group c2 was (mean value ± sd) 190±46.76, 128.8±24 and 89.7±33 respectively. CGRP levels in patients with dementia were significantly higher as compared to group c1 and c2 (p=0.009 and p=0.0008 respectively). Linear regression analysis revealed a significant coefficient of correlation between CGRP serum value and MMSE score in patients group (r=0.854, p\0.0001). Conclusion: Serum CGRP is over expressed in patients with cognitive diseases. Its correlation with MMSE shows a decrease of CGRP along with the severity of the disease. CGRP seems to increase with age in the normal healthy population.

P179 The Korean Addenbrooke’s Cognitive Examination revised for differential diagnosis of Alzheimer’s disease and subcortical ischaemic vascular dementia Y.T. Kwak, S.H. Suk, W.K. Kim Hyoja Geriatric Hospital (Sanghadong, KR); Sanbon Hospital of Wonkwang University (Kunpo shi, KR); Hallym University College of Medicine (Kangdong gu, KR) Background: Sensitive, specific neuropsychological screening tests, such as the Addenbrooke’s Cognitive Examination Revised (ACE-R), are essential for dementia diagnosis. We aimed to validate the use of the Korean version of ACE-R (K-ACER) to differentiate Alzheimer’s disease (AD) from subcortical ischemic vascular dementia (SIVD). Methods: Standard tests for dementia screening were applied to 156 subjects (84 controls, 30 AD, 42 SIVD), and total and subdomain scores on the K-ACER, as well as the sub-domain ratio (VLOM) were compared. Results: The reliability of the K-ACER was very good (a coefficient 0.84), and cut-off score for dementia was determined (cut-off value 78, sensitivity 0.93, specificity 0.95). The likelihood ratio for dementia was

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S58 calculated as between 78 and 82. At a cut-off of 78, the likelihood of dementia was 18.6:1. Although a comparison of K-ACER scores between AD and SIVD patients revealed significant differences in verbal fluency, language domain and VLOM ratio, sensitivity and specificity for differential diagnosis between AD and SVID proved less accurate. Conclusions: The K-ACER is a rapid, sensitive and specific dementia screening test. Though sub-domains of items may be useful for differentiating between AD and SIVD, sensitivity and specificity is less accurate than dementia screening itself.

P180 Verbal fluency and psychomotor speed in early Parkinson’s disease: is there a link? G. Hipp, N. Diederich, M. Vaillant, V. Pieri Central Hospital of Luxembourg (Luxembourg, LU) Objective: To investigate the relationship between PMS and VF in PD patients at an early stage. Reduction of psychomotor speed (PMS) and verbal fluency (VF) have been reported in Parkinson’s disease (PD). At the early disease stage it is unresolved if VF reduction indicates an initiation deficit, an ongoing cognitive deficit, or if it’s mainly due to PMS reduction. Methods: We prospectively recruited 31 non-demented patients with early PD, defined as\3 years of disease duration, and compared with 50 non-demented healthy controls. PMS was tested with the Trail Making Test A (TMTA), semantic and phonemicVF by asking subjects to name animals respectively words beginning with ‘‘P’’ within 2 minutes. The Mini Mental State Examination (MMSE) and the Frontal Assessment Battery (FAB) were performed. PD patients were tested on medication. Statistical analysis used ANOVA, KHI2 and Pearson’s correlation coefficients. Results: Gender distribution and age were similar in both groups (p[0.05). PD patients were slower than controls at the TMTA test (47.8±15.9 versus 37±11; p=0.0005). They produced fewer words in both VF tasks than controls (semanticVF: 29.1±7.7 versus 34.9±8; p=0.002. phonemicVF: 14.3±6.3 versus 18.8±8.5; p=0.01). A correlation between TMTA and the VF tasks was present only in PD patients, being higher for semanticVF (r=-0.67, p\0.0001) than for phonemicVF (r=-0.50, p=0.004). Conclusion: In early PD, VF performance is strongly linked to PMS reduction, suggesting that it echoes the reduced speed of the information treatment rather than an ongoing initiation deficit. Interestingly, this dependency is stronger for semantic than phonemicVF.

P181 Cognitive disturbances in chronic kidney disease: cardiovascular risk factors and mood disorders as underestimated confounders O. Todica, A. Schwanitz, M. Dalis, N. Wolters, M. Volsek, A. Kribben, H. Bruck, D.M. Hermann University Hospital Essen (Essen, DE) Objectives: Cognitive and memory deficits are common findings in patients with chronic kidney disease (CKD). Previous studies have shown that the most often affected domains are verbal memory and cognitive flexibility. Most of these studies compare patients with CKD or patients with end-stage renal disease (ESRD) with healthy subjects. There is strong evidence for associations between CKD and ESRD with cardiovascular risk factors and diseases. The precise link between these risk factors, associated mood disturbances and cognition remains vague.

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Methods: 28 Patients with CKD (61 ± 13 years) were prospectively compared with two separate control groups: with a sample of 29 patients with cardiovascular diseases without CKD (63 ± 11 years) and with a sample of 10 healthy participants (49 ± 5 years). All participants were assessed with a neuropsychological test battery comprising tests for memory, information processing, cognitive flexibility and visuospatial abilities. Depression and anxiety were assessed with Hospital Anxiety and Depression Scale (German version). Results: Our preliminary analysis in this ongoing study show that CKD patients had a significantly worse performance in tests for information processing speed, cognitive flexibility and spatial working memory in comparison with healthy participants. In contrast, there was no difference in cognitive performance of CKD patients and patients with cardiovascular diseases and normal kidney function. Interestingly, we found a significant negative relation between cardiovascular risk factors and performance in neuropsychological tests. Patients with CKD showed higher scores for depression and anxiety; the depression scores were negatively associated with the spatial working memory performance. Conclusions: Although impaired kidney function is associated with deficits in specific cognitive domains, cardiovascular risk factors might influence cognition independent from CKD based on our study. In addition, depression is likely to represent a confounder for neuropsychological deficits at least in certain cognitive domains.

P182 Anton’s syndrome and racial hygiene D. Kondziella University Hospital (Copenhagen, DK) Anton’s syndrome is arguably the most striking form of anosognosia. Patients with this syndrome behave as if they could see despite their obvious blindness. Although best known for the description of asomatoagnosia and visual anosognosia, Gabriel Anton (1858–1933) made significant other contributions to the clinical neurosciences. These include pioneer works in neurosurgery, neuropsychology and child psychiatry. Yet it has not been recognized in the English-language literature that Anton also was a dedicated advocate of eugenics and racial hygiene. This poster provides a case of Anton syndrome and puts the works of Gabriel Anton into their historic context.

P183 Klu¨ver–Bucy syndrome following cardiac arrest: a case report R.S. Scalco, L.C. Marrone, N. Posenato, M.R. Fighera, A.L. Palmini, A.G. Almeida, J.C. da Costa Pontifical Catholic University of Rio Grande do Sul (Porto Alegre, BR) Objectives: Bilateral lesions in the anterior temporal lobe result in a neurobehavioral condition termed Klu¨ver–Bucy syndrome (KBS). It is characterized by prominent oral tendencies, hypermetamorphosis, emotional blunting, visual and auditory agnosia and hypersexuality. We present a rare case of KBS following recovery of consciousness after cardiac arrest. It is the first such case report ever. Methods: An unique KBS case report. Results: A 52-year-old previously healthy man was transferred to Sa˜o Lucas Hospital (SLH) for a neurological evaluation in 2009. He was admitted at Esteio Hospital a month before for treatment of acute heart attack causing cardiac arrest. After circulatory support was provided, patient was transferred to an Intensive Care Unit (ICU) for mechanical ventilation and cardiologic treatment. After 13 days of

S59 coma he woke up. He got very aggressive since that day. First neurological evaluation in SLH revealed that he was easily irritable but expressed no sad or happy emotions under appropriate circumstances. He was speaking just in Italian dialect and family found his speech incomprehensible. Portuguese speech was confuse and incoherent. Additionally, he began exhibiting global amnesia. Over the ensuing days, the patient was reported to have outbursts of irritation with nurses, doctors and family. He also presented prominent oral tendencies, hypermetamorphosis, hypersexuality, and visual and auditory agnosia. He used vulgar words and made sexual comments all the time. Psychologic evaluation ruled out depression and obsessivecompulsive disorder. Laboratorial analysis of cerebrospinal fluid and blood test were normal. Medical imaging tests showed anterior bitemporal lobes abnormalities. It was first prescribed Carbamazepine and Trazodone without success. A couple of days after treatment he developed rhabdomyolysis and acute renal failure. The myopathy resolved following the proper treatment and Carbamazepine withdrawal. Quetiapine is not helpping as well. He is supposed to return no Neurological clinic on February of 2010. Conclusion: The case reported above describes a probable anoxicischemic encephalopathy affecting bilateral temporal lobes. The intimate association between KBS and temporal lobe damage has been widely reported. However, this is the first one following cardiac arrest ever described. It shows the importance of neurological and radiological evaluation for diagnosing underlying causes of behavior alterations.

Pain and headache: megrim P184 Crosscultural analysis of symptoms and predisposing factors in migraine F.J. Carod-Artal, D. Ezpeleta, M.L. Martı´n-Barriga, A.L. Guerrero Virgen de la Luz Hospital (Cuenca, ES); Gregorio Maran˜o´n University General Hospital (Madrid, ES); University Hospital (Valladolid, ES) Objectives: To assess knowledge and recognition of symptoms and precipitating factors between two populations of migraneurs in Europe and South-America. Methods: Cross-cultural analysis was performed in three Neurology Outpatient Clinics from Spain and one from Brazil. Migrain patients were prospectively recruited during 2009. Migraine was diagnosed according to current IHS criteria. Patients answered a questionnaire about migraine symptoms and predisposing factors. Results: 292 patients (mean age 34.6 years; 80% females; 52% Spanish) were included. Brazilian patients were significantly younger (33.1 vs 35.9 years; p=0.03). Mean number of migraine attacks during the last month was higher in Brazilian patients (7.3 vs. 3.8; p\0.001). A family history of migraine was also more common in Brazilian patients (79.4% vs. 64.3%; p=0.004). Regarding vascular risk factors, prevalence of hypertension (15.6% vs. 5.3%; p=0.006) and hypercholesterolemia (14.9% vs. 6%; p=0.02) was significantly higher in Brazilian migraineurs, whereas tobacco use was higher in Spanish patients (9.2 % vs. 22 %; p=0.002). The use of contraceptives in women was similar in both samples (23.7 % vs. 26.1 %). Gastrointestinal symptoms were referred more frequently by the Brazilian population (nausea 90.8% vs. 66.9%, vomiting 68.8% vs 22.6%; p\0.0001) whereas photophobia, phonophobia and headache aggravation during physical activity had similar frequency in both populations. The 37.5% of patients (Brazilian: 41.3 %; Spanish: 34 %) fulfilled criteria of migraine with aura. Visual aura was the most

common type (31.9 % vs. 27.8 %) followed by sensory aura (7.1 % vs 11.5 %). Brazilian patients identified a higher number of migraine attack predisposing factors (79.4% vs. 66.2%; p=0.04). Main predisposing factors in Brazilian and Spanish patients were, respectively: food intake (30.5% vs 12.6%; p=0.0002), sleep disturbances (56.7 % vs 28.5%; p\0.0001), smells (52.5 % vs. 9.3 %, p\0.0001), stress (73.1% vs. 46.4%; p\0.0001), and catamenial period in females (55.6% vs. 38.1%; p=0.02). Conclusion: Differences regarding symptoms and predisposing factors of migraine and their recognition between European and South-American patients exist. It may be explained by a greater severity of migraine in our Brazilian series, but also on an ethnic and cross-cultural basis. Further studies are needed to assess other crosscultural differences about migraine in other cultural settings.

P185 Stress and migraine-related dizziness G. Lee Dankook University (Cheon-An, KR) Objectives: Migraine-related dizziness(MRD) refers to a disorder in which vestibular symptoms are an integral part of migraine symptomatology.The purpose of this study was to quantitatively assess the magnitude of subclinical balance dysfunction in migraine patients and to better define the pathophysiology of MRD. Methods: Thirty-three patients with acute MRD were enrolled. Their scores on the measures of balance were compared with untreated age and sex matched migrainous patients without dizziness. The questionnaires for stress amount were asked to both groups. All the subjects underwent balance measurements that included vestibular evoked myogenic potential(VEMP) testing. The spectral frequency analysis of body sway while standing upright was investigated. Sensory organization tests were done by computerized dynamic posturography. Results: There was a significant increment in the level of stress at MRD group. MRD patients had reduced VEMP amplitudes compared to the controls. MRD group’s center-of-pressure sway showed a significant increase in spectral power at high frequencies. Computerized dynamic posturography showed decreased vestibular ratio in the patients with MRD. Conclusion: These results suggest that stress may induce abnormal vestibulo-collic reflex and disequilibrium in MRD people. The pathogenesis of MRD is likely related to both peripheral and central vestibular structure disturbances.

P186 Procalcitonin levels in migraine patients H. Turan, B. Horasanli, M. Ugur, H. Arslan Baskent University (Konya, TR); Baskent University (Ankara, TR) Objectives: Migraine is a risk factor for ischemic stroke. Sterile vascular inflammation may develop during migraine attacks. Our goal is to investigate procalcitonin (PCT) levels in migraine patients which are important markers for infection and sepsis, but can also be found at elevated levels in various cases of inflammation. Methods: There were eighty adult migraine patients participating in our study. Patients were initially separated into two main groups; attack period and period between attacks (Group 1 consists of 34 patients who had migraines during the attack period, Group 2 consists of 46 patients during the period in between attacks). After this, the patients were further divided into 4 subgroups based on their aura status (Group 1a. Migraine without aura, 27 patients during attack

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S60 period, group 1b. Migraine with aura, 7 patients during attack period, group 2a. Migraine without aura, 40 patients during the period in between attacks, group 2b. Migraine with aura, 6 patients during the period in between attacks). PCT measurement was made using B.R.A.H.M.S sensitive Procalcitonin Kryptor kit in the Kryptor immunoassay machine which uses immunoflourescence TRACE (Time Resolved Amplified Cryptate Emission) technology(BrahmsDiagnostica, Henningsdorf, Germany). Results: Average PCT levels in patients during attack periods were found to be higher than the average PCT levels of patients during the period in between attacks. These elevated levels were determined to be statistically significant (p\0.01). Serum PCT levels in the patients with migraine without aura during the attack period were significantly higher than those of patients during the period in between attacks (p\0.01). Conclusions: Based on the significantly high levels of PCT, our results support the idea that sterile inflammation plays a role in migraine pathogenesis. Further studies are necessary to understand whether PCT is a marker for ischemic stroke risk in patients who go through frequent migraine attacks.

P187 Vestibular evoked myogenic potential in patients with migraine R. Abolfazli, M. Moallemi, F. Haji Abolhasan, J. Fatahi, S. Jalaie Tehran University of Medical Science (Tehran, IR) Background: Migraine is a common primary headache with complicated nature. Vertigo and dizziness are frequent symptoms in this disease. Motion sensitivity occurs in two-thirds of patients with migraine. Clinical experiences and different evaluations, recognize associations of migraine and vestibular disorders. However, even in the absence of vestibular symptoms, neurotological tests may be abnormal interictally, suggesting subclinical vestibular dysfunction in migraine. A relatively new test in field of vestibular assessments known as a ‘‘vestibular evoked myogenic potential’’ (VEMP), assess otolith function in particular the saccule and the functional integrity of inferior vestibular nerve. Objective: To evaluate neural pathway of VEMP in migraine patients. Methods: In this cross-sectional study, 25 cases of migraine (22 female and 3 male) who were diagnosed according to the criteria of IHS-1988 participated. All patients received a detailed history-taking, pure-tone audiometery and tympanometry. Other neurologic problems ruled out by appropriate investigations such as MRI and physical examinations. control group consisted of 26 healthy subjects (18 female and 8male), without neurootological symptoms and personal or family history of migraine or other recurrent primary headaches. The short tone burst (95 dB nHL, 500 Hz) was presented to ears. VEMP was recorded with surface electromyography over the tonically contracted ipsilateral sternocleidomastoid muscle. Result: Response was present in all subjects as a biphasic waveform. Mean of amplitude and p13 latency values in migraine patients differed significantly from the normal group. Mean of the p13–n23 amplitudes and p13 latencies of the migraine patients were 133.98 (SE ±15.88) and 16.70 (SE ± 0.37) for the right side and 143.57 (SE ±15.05) and 17.07 (SE ± 0.48) for the left side, whereas the averaged amplitudes of the healthy controls showed a mean of 204.84 (SE ±12.83) and 15.43 (SE ± 0.16) on the right and of 211.14 (SE ± 12.30) and 15.81(SE ± 0.19) on the left, respectively. Although there was no statistical difference between two groups in other parameters of VEMP.

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Conclusion: The obsereved abnormalities in VEMP response probably are due to changes in functional structure of active components of VEMP subsequent to migraine.

P188 Morphologic characteristics of the circle of Willis in patients with migraine E.R. Lebedeva, S.A. Kolotvinova, N.R. Kobzeva, Y.S. Shibkova The Urals State Medical Academy (Yekaterinburg, RU) Objectives: An incomplete circle of Willis (CW) and other abnormalities of CW may predispose to cerebral hypoperfusion which can be one of the factors leading to white matter abnormalities in patients with migraine. This study assessed the relationship between the morphologic characteristics of the CW and migraine. Methods: The study included 150 patients with migraine (age 18– 56, 12 men and 138 women, 21 patients with migraine with aura and 129 without aura) and 119 patients of controls without migraine who had no history of cerebral ischemia or infarcts on MRI (age 18–62, 40 men, 79 women). All patients underwent 3-dimensional time of flight magnetic resonance angiography of the CW. According to the vessel size seen on 3D TOF MR angiograms, the component vessels consisting of CW were regarded as normal, hypoplastic, or absent. The anterior part of the CW (APCW) was considered complete when the anterior communicating artery (ACoA) as well as the A1 segments of the anterior cerebral artery (ACA) were present on visual examination, incomplete when any of these vessels was missing and indeterminate when we observed a hypoplastic A1 segment of ACA. The posterior part of the circle of Willis (PPCW) was considered complete when both posterior (PCoA) and the P1 segments of the posterior cerebral artery (PCA) were present on visual examination, incomplete when one of these vessels was missing and indeterminate when we observed hypoplastic PCoA or P1 segment of PCA. Migraines were diagnosed by International Headache Society criteria. Results: We found the following morphologic characteristics of the CW in patients with migraine: complete APCW - 137, incomplete APCW - 0, indeterminate APCW -13, complete PPCW - 101, incomplete PPCW - 4, indeterminate PPCW - 45; hypoplasia (n=36) or aplasia of the vertebral artery (n=6), duplication of ACA (n=3) or of A1 segment (n=3), hypoplasia of inferior (n=3) or superior cerebellar artery (n=2). Among these characteristics, only incomplete and indeterminate patterns of posterior CW were significantly more common in migraineurs than in the control group (33% vs 19%; P= 0.01; odds ratio 2.0; 95% CI: 1.1–3.5). No difference was found between migraineurs with and without aura. Conclusion: Our results showed that an incomplete and indeterminate configuration of the posterior CW were associated with migraine.

P189 Neurophysiological features of episodic and chronic migraine A. Sergeev, A. Abramova, J. Azimova, G. Tabeeva Sechenov Moscow Medical Academy (Moscow, RU) Objectives: The aim of this study was to estimate the psychophysiological characteristic of episodic and chronic migraine at the various functional statuses of brain. Methods: We performed trial in 27 patients aged 20-55, 10 episodic migraine patients, 8 chronic migraine patients and 9 controls. The neuropsychological profile had been made according to the

S61 attention test (Munsterberg’s test), the visual perception test, the Beck Depression Scale, the Spielberger’s test, and assessments of the sleep disorders. To test the ERP habituation, four consecutive blocks were recorded P300 potentials, before and after 24-hour sleep deprivation. Results: Complaints of cognitive and emotionally personal disorders changes were reported by 76,5%. Patient population with chronic migraine felt decrease of capacity for work, problems in concentration, perception and remembering information complexity, heightened anxiety and depressed mood, also they were easily tired. The visual perception and attention level at the background for migraine (5,2+1,9 - Munsterberg’s test; 11,0+1,9 visual perception) was lower compared to normal controls (4,0+1,2 - Munsterberg’s test; 5,0+1,7 visual perception) to a greater extent due to chronic migraine patients. The increase of visual perception and attention level for normal controls and episodic migraine patients was established after 24-hour sleep deprivation. At the same time visual perception and attention level was reduced for chronic migraine patients after 24-hour sleep deprivation compared to background status. P300 latent periods in first and second series were increased for control group after 24-hour sleep deprivation, but in third and forth series pronounced dynamics to the decrease of P300 latency with decrease of N2\P3 amplitudes was registered. The increase of P300 latency and decrease of N2\P3 amplitude was reported after sleep deprivation compared to background. Also latency reduction and increase of amplitude in response at the verbal stimulus ‘‘Pain’’ was reported. Conclusion: The P300 study of episodic and chronic migraine patients pointed at the reduction of perceptual speed, information processing and transfer between different brain parts factors, it is more pronounced for chronic migraine.

P190 Assessment the effectiveness of omega 3 on migraine headache severity in migraineurs A. Saberi, K. Esmaeelzadeh, A.R. Ghayeghran, A. Heidarzadeh Gilan University of Medical Sciences (Rasht, IR) Introduction: One of the mechanisms of migraine pain is neurogenic inflammation caused by induction of prostaglandins (PGs) and leukotrienes(LTs) cascade and polyunsaturated fatty acid omega 3 have antiinflammatory and so analgesic effect by modifying their production. Objective: determining the effect of omega-3 on the severity of migraine headache. Materials and methods: In this randomized double blind clinical trial study 198 migraineurs referred to the clinic of neurology in poursina hospital in Rasht, Iran from January to September 2009 were selected according to IHS criteria. 97 patients (case group) was given 2 pearls of omega3 (2gr) and the other 99 patients (control group) 2 pearls of glycerol for 3 months. Headache severity was graded according to MIDAS before and after treatment.The analysis was performed in each group by sign test and comparing the changes of headache severity between 2 groups by repeated measure ANOVA variance analysis and by SPSS 15. Results: 97 patients in case group (27 male & 70 female) with mean age of 26.51±7.01 years and 99 patients in control group (28 male & 71 female) with mean age of 24.85±6.21 years participated in this study. This 2groups were adjusted for age (P=0.081) and sex (P =1.000). The reduction in headache severity in case group was 35.1% that was statistically significant (P=0.001) and in control group; 20.2% that wasn’t statistically significant (P=0.154).The changes in headache severity had statistically significant difference in these 2 groups. (P =0.048)

Conclusion: Omega 3 is effective on reduction of migraine headache severity.

P191 Spreading depression: the effects of anti-epileptic drugs used in migraine prophylaxis J.B. Mascarenhas de Moraes Federal University of Rio de Janeiro (Rio de Janeiro, BR) In this study, we analize the effects of antiepileptic drugs, also used in migrain prophylaxis, on the spreading depression (SD) in isolated retina of chick0 (Gallus gallus domesicus). We studied five drugs with proven effect on the modulation of GABAergic transmission: Topiramate, Valproate semisodium, Gabapentin, Lamotrigine and Levetiracetam. Chicks retinas were kept at 30–31C in superfusion chamber, with a flow of 1,0–1,8 ml/min. of a Ringer’s reference solution, and the reaction was evoked by mechanical or chemical stimuli, every 15 minutes.Using this model, we first measured the speed (mm/min.), the amplitude (mV), the threshold (activity of KCl-) and the absolute refractory period (sec) of the SD, with and without the drugs. Subsequently, the speed and amplitude parameters were analized in an in vivo model, also with and without drugs under study. In addition, the GABAtransaminase enzyme activity was determined, with and without drugs. All drugs, particularly Topiramate, reduced the speed and amplitude in a dose-dependent and reversive manner in vitro as well as in vivo. All the drugs also reversibly increased the SD threshold for the SD after stimulation with KCl- in specific concentrations. All the tested drugs increased reversisibly tha absolute refractory period. Topiramate was considered the most effective drug in terms of the proposed parameters Levetiracetam, in spite of its sui generis mechanisms of action, was the less effective drug. The enzyme GABA-transaminase displayed slightly decreased activity, in the presence of Topiramate, Valproate semisodium and Gabapentin. These results reinforce the notion that SD is a subjacent and relevant factor for the triggering of migraine.

P192 CPAP therapy in patients with obstructive sleep apnoea and migraine U. Kallweit, H. Hidalgo, P.S. Sa´ndor University Hospital Zurich (Zurich, CH); Kamillus-Klinik (Asbach, Background and objectives: Associations between sleep disorders and headache are diverse in nature. Obstructive sleep apnea syndrome (OSAS) is a frequent complaint in the general population (2-5%). OSAS patients are at higher risk for vascular events. Activation of inflammatory pathways is caused by intermittent hypoxia and there is increasing evidence that inflammatory processes play an important role in the vascular pathophysiology of OSAS. Some inflammatory markers associated with vascular risk have been reported as elevated in patients with OSAS. Migraine physiopathology is not fully understood, but neurogenic inflammation seems to play a key-role. There is little known on OSAS, continuous positive airway pressure (CPAP) therapy and migraine. Methods: We prospectively studied migraine characteristics in a series of 73 consecutive patients suffering from obstructive sleep apnea syndrome before and after a one-year treatment with CPAP. Video-polysomnography data before and at follow-up was analyzed. Results: Six patients (five were men) fulfilled diagnostic criteria for migraine (migraine with aura (n=3), migraine (n=2) and chronic migraine (n=1)) according to International Headache Society criteria (ICHD-II). Mean attack frequency was 7.2 per month. No patient received migraine prophylaxis. Mean age was 46.7 (range 39-57),

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S62 mean BMI was 29 (± 7 SD); mean apnea-hypopnea-index was 31.8 (± 18.1 SD). For OSAS, all patients were treated with CPAP therapy. At follow-up at one year, all patients described significant improvement of their migraine (five patients had been headache free for the last 3 months, the patient with chronic migraine described a decrease of headache days from daily headache before treatment to a frequency two per month during the last three months). Discussion and conclusion: Migraine significantly improved in our group of migraine patients also suffering from OSAS under CPAP therapy. These findings indicate that in predisposed individuals, hypoxia might be a trigger not only for phenotypic tension headache in the mornings, but also headache fulfilling migraine criteria. This might be explained in the context of the role of inflammation in both, migraine and OSAS. Our findings need to be confirmed in larger studies.

P193 Late-onset galactorrhea and menometrorrhagia/ menorrhagia with venlafaxine use in migraine: a case report M.S. Berilgen Firat University (Elazig, TR) Venlafaxine is a serotonin and norepinephrine reuptake inhibitor (SNRI). At the same time, especially in high doses, it is also an inhibitor of dopamine reuptake. This drug is used for the indications of major depressive disorder, generalized anxiety disorder and social anxiety disorder. Also, in recent studies, its effectiveness in migraine prophylaxis has been reported. In the period of use, together with the frequent side effects such as dizziness, dry mouth, appetite loss, nausea, sleeplessness and drowsiness, rare side effects such as galactorrhea and menorrhagia can occur. For a 36-year-old woman who was having 5-6 migraine attacks per month, Effexor (venlafaxine hydrochloride) was started as prophylaxis at a dose of 75 mg/day. In the 12th month of the drug’s use, galactorrhea began to be seen. In the days following this, menstrual irregularity became apparent. On further follow-up this was determined to be menometrorrhagia. In the patient’s gynecologic, endocrinologic and breast examinations no pathology was evident. From the lack of pathology in the patient, the onset of galactorrhea and menometrorrhagia was attributed to side effects of the drug. Within four weeks after the drug was stopped, these symptoms disappeared. Although cases of galactorrhea and menorrhagia related to venlafaxine use have been reported in the literature, the patient reported here is the first in which both galactorrhea and menometrorrhagia occurred together.

Preclinical neurology P194 Protective effects of pergolide in a 6-hydroxydopamine model of Parkinson’s disease A. Ciobica, L. Hritcu, V. Artenie, M. Padurariu Alexandru Ioan Cuza University (Iasi, RO); Gr.T. Popa UniversitySocola Hospital (Iasi, RO) Objectives: One of the most widely used animal models of PD involve injecting of 6-OHDA directly into the SN, in order to induce selective neurodegeneration of dopamine nerve terminals. We previously demonstrated that 6-OHDA-induced lesion of SN results in memory deficits and increase brain oxidative stress. Some authors speculated that dopaminergic drugs may exert brain antioxidant

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activity which could explain some of their protective actions. The aim o the present study was to examine the effects of pergolide, a mixed D1/D2 agonist, on behavioral deficits and brain oxidative stress induced by 6-OHDA in a rat model of PD. Methods: Specific right-unilateral lesions of the SN were produced with 6-OHDA. Two weeks after operation, all surviving animals showing no evident neurological abnormalities were admitted to drug treatment. Pergolide was injected intraperitoneally at the dose of 0,3 mg/kg/day for consecutive 10 days. Radial 8-arm maze and Y maze tasks were used for memory assessment. We also assessed the levels of some enzymatic antioxidant defences like superoxide dismutase (SOD) and glutathione peroxidase (GPX), as well as lipid oxidation makers like MDA (malondialdehyde), from the temporal lobe, using chemiluminometric and spectrophotometric methods. Results: Administration of pergolide resulted in a significant facilitation of short-term memory, explored by Y-maze task, as indicated by a increase of spontaneous alternation percentage. This effect could not be attributed to increased motor activity, since the number of arm entries was not significantly changed. Also, pergolide induced a significant decrease in the number of working and reference memory errors, explored in the radial arm maze, suggesting significant positive effects on spatial memory. We also observed an increase in the specific activity of SOD and GPX, in temporal lobe of pergolide-treated rats, compared to control group. Moreover, Pearson’s correlation coefficient and regression analysis revealed a significant positive correlation between spontaneous alternation in Y maze and SOD specific activity. Conclusions: Our data suggest that pergolide may counteract both behavioral and biochemical changes induced by 6-OHDA in a rat model of PD. Our study also suggests that these positive behavioral responses could be correlated with some antioxidant actions of pergolide. This could be useful for future investigations and clinical applications of dopaminergic drugs. This research was supported by the National Council of Scientific Research and University Education (Grant TD CNCSIS no. 464), Romania.

P195 Nicotine attenuates memory impairment and oxidative stress in 6-hydroxydopamine model of Parkinson’s disease A. Ciobica, L. Hritcu, V. Artenie, M. Padurariu, W. Bild Alexandru Ioan Cuza University (Iasi, RO); Gr.T. Popa UniversitySocola Hospital (Iasi, RO); Romanian Academy (Iasi, RO) Objectives: Studies have shown that over 50% of people with PD experience some form of cognitive impairment. Several potential neuroprotective compounds have been proposed in treatment of PD symptoms, including nicotine. In the present study a 6-hydroxydopamine (6-OHDA) rodent model of Parkinson’s disease was used to investigate the effects of nicotine treatment on memory processes and oxidative stress after neurotoxin administration. Methods: 6-OHDA (2lg/ll) was right-unilateral injected into the ventral tegmental area (VTA) or the substantia nigra (SN) of adult male Wistar rats. Nicotine (0.3mg/kg) was injected 4 consecutive days in 6-OHDA-lesioned rats, two weeks after the rats recovered from the neurosurgery. Y maze and shuttle-box (active avoidance) tasks were used for memory assessment. We also assessed the levels of some enzymatic antioxidant defences like superoxide dismutase (SOD) and glutathione peroxidase (GPX), as well as lipid oxidation makers like MDA (malondialdehyde), from the temporal lobe, using chemiluminometric and spectrophotometric methods. Results: Nicotine improves memory impairment in 6-OHDAtreated rats, evidenced by a decrease of crossing latency in the shuttle-

S63 box task and an increase of spontaneous alternation in Y maze task. In addition, nicotine increased antioxidant enzymes activities in the temporal lobe cortex of animals treated with 6-OHDA, the brain region most susceptible to oxidative stress, suggesting antioxidant effects. Conclusions: Taken together, our data suggest that nicotine (0,3 mg/kg) may counteract both behavioural and biochemical changes induced by 6-OHDA in a rat model of PD. Our study also suggests that these positive behavioural responses could be correlated with some antioxidant actions of nicotine. This could be useful for future investigations and possible clinical applications of nicotine. This research was supported by the National Council of Scientific Research and University Education (Grant TD CNCSIS no. 464), Romania.

P196 Aged and MPTP monkeys show comparable signs of Parkinson’s disease P.J. Hurley, J.D. Elsworth, M.C. Whiittaker, R.H. Roth Yale University (New Haven, US); St. Kitts Biomedical Research Foundation (St. Kitts, KN) Objectives: Parkinson’s Disease (PD) and the natural aging process share a number of biochemical mechanisms which result in nigrostriatal dopamine depletion, including microglial activation, mitochondrial DNA deletions, subtelomeric methylation, decreased VEGF, Nurr1, and estrogen, and increased a-synuclein. The present study aims to determine the extent that natural aging resembles parkinsonism induced by the neurotoxin 1-methyl-4-phenyl-1,2,3,6tetrahydropyridine (MPTP) in monkeys. Methods: Ten aged Chlorocebus sabaeus (St. Kitts monkeys, mean age 24.5 ± 0.29) were compared with 10 young adult monkeys, (mean age 6.5 ± 0.15). The groups were observed by trained observers, blind as to age and without knowledge of the hypotheses. The Parkinson’s factor score, which correlates highly with post mortem striatal dopamine (DA) concentrations, was used. The effects were compared with other control groups: 15 aged monkeys that had previously been given MPTP, and 10 young adult monkeys that had previously been given MPTP. The response of aged monkeys to DA replacement strategies is a key test of how similar aged parkinsonian monkeys are to human PD. Thus the behavioral effects of L-Dopa and DA agonists (apomorphine, dihydrexidine, and pergolide) were assessed in aged and young adult MPTP-treated monkeys. DA concentrations were measured in 3 aged and 4 young adult MPTP-treated monkeys, in addition to untreated controls. Results: The aged animals had higher scores on the Parkinson’s factor score (p\0.0001) compared with the young adults, with nearly all of the component scores showing significance [tremor (p\0.0002), eating problems (p\0.0001), delayed initiation of movement (p\0.0001), and poverty of movement (p\0.0001).] An arousal factor was decreased in the aged monkeys, confirming another behavioral change previously associated with DA (p\0.02). DA concentrations were 76% lower in the aged monkeys in the ventral putamen (p\0.001), with greater reductions in putamen than in caudate. LDopa and DA-agonists had differential behavioral effects in the 2 models. Conclusions: Aged monkeys show a similar profile of parkinsonism to that seen after administration of the neurotoxin, MPTP, to young adult monkeys. The pattern of greater DA depletion in putamen vs caudate in aged monkeys is the same as in human PD and contrasts with the greater depletion in caudate seen after MPTP. Some aged monkeys of this species reflect many facets of PD. Supported by Axion Research Foundation, St. Kitts Biomedical Research Foundation, Michael J. Fox Foundation

P197 Effect of dietary zinc supplementation in triple transgenic AD mice C. Corona, S.L. Sensi University G. d’Annunzio (Chieti, IT) Objectives: Several lines of evidence indicate that metal ion dyshomeostasis can play a role in the progression of Alzheimer’s disease. (AD) For instance, perturbation of Zn2+ brain homeostasis has been shown to exacerbate AD pathological features. Zn2+ is also a potent modulator of mitochondrial function (reviewed in Sensi et al., Nat. Rev. Neurosci., 2009) and energy deficiency as well as mitochondrial dysfunctions are well characterized events associated with AD. In this study we explored the role of Zn2+ supplementation in the progression of AD-like pathology in an animal AD model. Methods: To investigate the effect of dietary Zn2+ supplementation in a transgenic animal model of AD, the 3xTg-AD mouse, that by expressing mutant APP, PS1, and s shows an age-dependent intraneuronal accumulation Ab as well as features of tau pathology, we treated male 3xTG-AD mice with water containing 30 ppm of Zn2+ for 11–13 months starting in mice at 1 month of age. Mice were tested for cognitive decline using both hippocampal- and cortexdependent behavioral tasks and sacrificed to asses Ab and s pathology as well as mitochondrial respiratory deficits. Results: We find that Zn2+ supplementation in 3xTg-AD mice greatly delays memory deficits and strongly reduces both Ab and s pathology in the hippocampus. Finally we also find that Zn2+ supplementation prevents age-dependent mitochondrial deficits that are observed in the cortex and hippocampus of untreated 3xTg-AD mice. Conclusions: Our data support the hypothesis that Zn2+ deficiency could be a risk factor for AD and restoring the brain cation levels may be beneficial in the treatment of AD.

P198 Alterations of brain and cerebellum proteomes in 3xTg-AD mice D. Ciavardelli, S.L. Sensi University G. d’Annunzio (Chieti, IT) Objectives: Triple-transgenic Alzheimer (3xTg-AD) mouse express mutant PS1M146V, APPswe, and tauP301L transgenes and progressively develop plaques and neurofibrillary tangles with a temporaland region-specific profile that resembles the neuropathological progression of Alzheimer’s disease (AD). The main aim of this study was to evaluate changes in the protein changes underlying different stages of the disease progression in this AD model. Methods: In this study, we employed proteomic approaches, such as two-dimensional gel electrophoresis (2D-E) and mass spectrometry (MS) to investigate the alterations in protein expression occurring in the brain and cerebellum of 14-month old female 3xTg-AD mice. Presenilin-1 knock-in (PS1KI) mice do not develop cognitive decline and were used as controls. Finally, employing the Ingenuity Pathway Analysis (IPA) we evaluated novel networks and molecular pathways involved in this AD model. Results: In 3xTg-AD brains, we identified several differentially expressed spots and their analysis showed a significant down-regulation of synaptic proteins associated with neurotransmitter synthesis, storage and release as well as a set of proteins that are associated with cytoskeleton assembly and energy metabolism. Interestingly, in the cerebellum, a structure not affected by AD, we found an up-regulation of proteins associated with carbohydrate metabolism and protein catabolism. Conclusion: Our proteomic study in the brain and cerebellum of 3xTg-AD mice show an interesting divergence of effects between these two CNS regions. In the brain, we observe a significant down-

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S64 regulation of synaptic, cytoskeletal, and mitochondrial proteins, suggesting that synaptic and mitochondrial dysfunction are playing a key role in the later stage of the AD-like pathology observed in this region. In contrast, in the cerebellum we find an up-regulation of proteins that are involved in energy metabolism, clearance of misfolded protein, and detoxification. These findings are particularly intriguing as they may shed new light on endogenous mechanisms set in motion by the cerebellum to counteract the pathogenic actions of A-b and p-tau and offer novel targets for therapeutic intervention.

P199 Age-related modulation of the gene expression profile in the hippocampus of triple transgenic AD and control mice V. Gatta, T. Caporale, L. Stuppia, S.L. Sensi University G. D’Annunzio (Chieti, IT) Objectives: Alzheimer’s disease is a multifactorial neurological condition and the genetic alterations involved in its development are not completely understood. In this study, using a microarray approach we investigated the age-related gene expression profile in the hippocampus of AD transgenic and control mice. Methods: A global gene expression profile in hippocampi obtained from 3xTgAD (expressing mutant human APP, PS1, and tau), PS1KI (expressing human mutant PS1), and WT mice at 3 and 12 months of age (m.o.a) was studied by employing a Mouse OneArrayTM Whole Genome DNA microarray that contained 31,802 oligonucleotides. Hierarchical clustering analysis was performed by using Cluster 3.0 and Tree View software. Data were then analyzed with Ingenuity Pathways Analysis (IPA) software in order to classify them on the basis of their biological functions and disclose functional networks and/or pathways. Results: When comparing 3xTg-AD and PS1KI mice to WT mice, hierarchical clustering revealed the presence of 453 up-regulated and 265 down-regulated transcripts, respectively. IPA analysis of the up-regulated genes revealed that these are involved in functional areas related to cell to cell signaling interaction, nervous system development and function, neurological diseases, as well as cell death. IPA analysis of the down-regulated genes indicates functions related to organ development, cellular growth and proliferation, gene expression, and lipid metabolism. Analysis of the up-regulated genes showed pathways linked to GABA neurotransmission and mitochondrial dysfunction while down-regulated genes appear to be involved in pathways associated with calcium and CREB-dependent intracellular signaling. Conclusion: In this study, we find that key AD-related genes such as mutant APP, PS1, and tau modulate the expression of genes that are relevant for inhibitory neurotransmission, energy production, intracellular signalling, and homeostasis of calcium. These findings may help to unravel the genetic determinants of both AD progression and/or neuroprotection.

P200 Effect of adrenalectomy on nucleus Meynert neurons in amyloid-b 25-35 peptide-induced model of Alzheimer’s disease K. Simonyan, V. Mnatsakanyan, H. Stepanyan, V. Chavushyan, I. Meliksetyan, Z. Avetisyan, H. Mnatsakanyan Institution of Physiology Orbeli (Yerevan, AM) Objectives: The disorders of hormonal homeostasis play a significant role in the pathogenesis of Alzheimer’s disease (AD). Acute

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corticosterone treatment has been shown previously to decrease the number of new neurons in the adult dentate gyrus. By contrast, removal of endogenous corticosterone by adrenalectomy significantly increased the number of new granule neurons. Together, these studies indicate that the stress-induced decrease in neurogenesis in the dentate is modulated by glucocorticoid levels. This work sought to determine effects of adrenalectomy (AEC) in a rat model of AD. Methods: Complex electrophysiological analysis and histochemical study by detection of Ca2+-dependent acid phosphatase activity were performed on: 1) intact animals; 2) Ab 25–35 bilateral intracerebroventricular injected animals and 3) adrenalectomy (AEC) + Ab 25–35 injected rats. Electrophysiological studies by extracellular recording of Nucleus Meynert (NM) single-neuronal spike activity under high-frequency (tetanic) stimulation (HFS) of hippocampal CA1 field have been performed on 20–28 weeks after Ab injection. Results: In electrophysiological study variability of post stimulus excitatory and inhibitory tetanic (TP, TD) and posttetanic (PTP, PTD) potentiation and depression by programmed analysis were performed. In NM neurons of intact rats the number of excitatory and inhibitory responses caused by hippocampal HFS are equal: TP and TD effects were characteristic during HFS. In Ab 25–35 group the inhibitory responses are dominating and the effects were as follows: TD+PTD (64/205 – 31.25%) and TD+PTP (59/205 – 28.8%). In this group the areactive neurons were recorded 1.6 times more often than in norm. In AEC+Ab group the excitatory responses were three times less than inhibitory effects, and didn’t contain TP (but contain only PTP). The number of areative neurons (26 / 295 – 8.8%) were equal to the number of those in norm (17/200 – 8.5%). AEC resulted in optimal restoration of electrophysiological parameters. Histochemical analysis showed that in contrast with neurodegeneration existed in Ab 25-35 group and the functional metabolism in AEC + Ab group are close to the norm. Conclusion: Our data show high sensitivity of NM and hippocampal neurons in response to Ab 25-35 and AEC. Progressing of AD is prevented by deficit of adrenal gland hormones.

P201 Neuroprotective function of cellular prion protein in a mouse model of amyotrophic lateral sclerosis P. Steinacker, A. Hawlik, S. Lehnert, O. Jahn, S. Meier, E. Go¨rz, K. Braunstein, M. Krzovska, B. Schwalensto¨cker, S. Jesse, C. Pro¨pper, T. Bo¨ckers, A.C. Ludolph, M. Otto University of Ulm (Ulm, DE); Max Planck Institute for Experimental Medicine (Go¨ttingen, DE) Objectives: The cellular prion protein has anti-apoptotic and antioxidative properties and a neuroprotective role under acute stress like in a cerebral ischemia model has been demonstrated. In our study we analyzed the role of the cellular prion protein under chronic neurodegenerative conditions using the example of an amyotrophic lateral sclerosis (ALS) model. Methods: By crossbreeding we generated mice with or without prion protein that express human Cu/Zn-superoxide dismutase 1 with a G93A mutation and develop disease resembling amyotrophic lateral sclerosis in humans. The mice were characterized and compared for disease progression and survival time, for histopathological changes like motoneuron degeneration and vacuolization and for signaling events in spinal cord tissue homogenates. Results: Prion protein deficiency leads to an earlier onset of the disease and shorter survival times of ALS model mice. The decline of motorical properties by means of muscle strength and the ability to balance on a rotor occurred earlier and this was paralleled by reduced numbers of healthy motoneurons in the spinal cord of double

S65 transgenic mice. In a proteomic approach glial fibrillary acidic protein was identified to be down-regulated and calpain-mediated collapsin response mediator protein-2 as well as creatine kinase to be up-regulated. Extracellular signal-regulated kinase 2 is activated at disease onset specifically in the double transgenic mice, but not in the ALS mice with prion protein. There was also an increase in levels of phophorylated Akt and NF-kB and a tendency for reduced Bcl-2 in the ALS model mice, but without a detectable dependency on prion protein expression. Conclusion: We propose that the cellular prion protein has a beneficial role in the SOD1G93A ALS mouse model by influencing neuronal and/or glial factors involved in anti-oxidative defence, rather than anti-apoptotic signaling. This work was supported by the Landesstiftung Baden-Wu¨rttemberg (P-LS-Prot/42) and the European Commission (cNeupro, Anteprion).

P202 Investigating neurodegenerative disorder systems using USPIO-nanoparticles with (SECARS) microscopy L.H. Machtoub Innsbruck Medical University (Innsbruck, AT) Objectives: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease, pathologically characterized by loss of motor neurons. The mechanism underlying motor neuron degeneration remains incompletely understood. In this study, we investigated a novel application of Surface-Enhanced Raman Scattering and Coherent Anti-Stokes Raman Scattering (SECARS) microscopy for imaging intravenously injected ultra small paramagnetic iron oxide (USPIO) nanoparticles in transgenic amyotrophic lateral sclerosis experimental model. Methods: Experiments were performed on transgenic amyotrophic lateral sclerosis rat model, expressing multiple copies of mutated (G93A) human SOD-1 gene (hSOD-1G93A), magnetically labelled with antibodies tagged with ultra small paramagnetic iron oxide nanoparticles (USPIO). Brain tissues, taken from ALS and wild type (WT) rat models, were investigated by ex vivo SECARS, and immunohistochemistry. Results: Marked intensity enhancements have been observed in specific pathological regions of the ALS brain in compared with WT. The results obtained from immunohistochemistry correlated SECARS enhancements to selective association of lipids to up-taken USPIO which shows high accumulation in the brainstem and midbrain region. Conclusion: The results presented show the promising potential of SECARS microscopy in investigating neurodegenerative disorders in experimental systems using USPIO particles as molecular nanoprobes. Acknowledgement: Thanks to Prof. P. R. Andjus and D. Bataveljic, University of Belgrade, for providing the ALS model.

P203 Melatonin interacts with hyperbaric oxygen on superoxide dismutase expression in rat brain cortex tissue S. Oter, M. Ozler, K. Simsek, T. Topal, S. Sadir, H. Yaman, R. Ogur, A. Korkmaz Gulhane Military Medical Academy (Ankara, TR) Objective: The oxygen toxicity risk of hyperbaric oxygen (HBO) is a known matter. Usually, patients undergoing HBO therapy are recommended to use antioxidants in order to prevent against oxidative stress and related unwanted effects. Antioxidant vitamins E and C

often fail to offer such a complete prevention (1, 2), but melatonin (MEL), a potent antioxidant and multifaceted biomolecule mainly secreted by the pineal gland, has proven successful in protecting against molecular damage resulting from HBO exposure (3, 4). Interestingly, both HBO and MEL have the ability to stimulate activities of antioxidant enzymes. In the present study we tested the effects of MEL and/or HBO on the transcription of cupper/zincsuperoxide dismutase (Cu/Zn-SOD) in the brain cortex tissue of rats. Methods: Forty-eight Sprague-Dawley rats were divided into control, HBO, MEL and HBO+MEL groups; HBO exposure was carried out at a single dose of 3 atm for 2 h; MEL (10 mg/kg) was injected intraperitoneally 1 h before HBO was introduced. Immediately after the 2 h exposure brain tissues of the rats were harvested; malondialdehyde (MDA) and protein carbonyl (PCO) levels, the activity of catalase, glutathione peroxidase and Cu/Zn-SOD and mRNA levels for Cu/Zn-SOD were estimated. In addition, the reduced/oxidized glutathione (GSH/GSSG) ratio was determined. Results: As predicted, HBO increased oxidative stress markers; MDA and PCO levels were found to be elevated and the GSH/ GSSG ratio was reduced. MEL significantly reversed these changes. Additionally, both HBO and MEL increased the transcription rate of Cu/Zn-SOD mRNA; HBO was found to be more effective in this regard. An interesting finding was that MEL increased the SOD mRNA transcription itself, but limited the increasing effect of HBO. Conclusion: These findings confirm the stimulatory effects of HBO as well as MEL on the activity of the antioxidant enzyme, SOD. Further experimentation is needed to explain the unexpected finding of limited Cu/Zn-SOD mRNA expression with combined treatment. References: (1) Bader et al, Annals of Nutrition and Metabolism 2006; 50:173. (2) Bader et al, British Journal of Nutrition 2007; 98:826. (3) Dundar et al, Clinical and Experimental Pharmacology and Physiology 2005; 32:926. (4) Mollaoglu et al, Journal of Pineal Research 2007; 42:50. This study was supported by the ‘‘Scientific & Technological Research Council of Turkey’’ with the grant Nr. 105S060.

P204 The transplantation of genetically modified haematopoietic stem cells improves central and peripheral motor function in a mouse model of Krabbe disease D. Ungaro, I. Visigalli, S. Ungari, L. De Toni Franceschini, S. Amadio, C. Butera, A. Biffi, G. Comi, U. Del Carro Scientific Institute San Raffaele (Milan, IT) Introduction: Globoid cell leukodystrophy (GLD) or Krabbe disease is a lysosomal storage disorder due to the inherited deficiency of galactocerebrosidase (GALC) activity. The enzymatic defect results in the storage of undegraded metabolites in the nervous systems, leading to progressive dysmyelination and early death of the affected patients. In previous works it has been demonstrated that transplantation of hematopoietic stem cells (HSC) genetically corrected by means of a lentiviral vector (LV) can correct disease manifestations in murine models of neurodegenerative lysosomal diseases. Aim of the study: We performed a neurophysiological study on GLD mice transplanted with HSC transduced with LV encoding the functional GALC gene and to investigated whether this therapy could prevent the development of motor conduction impairments. Methods: The sciatic nerve motor conduction velocity (MCV) and Motor evoked potentials (MEP) by transcranial electric stimulation (TES) were performed to obtain respectively peripheral and central

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S66 nervous system functional parameters. An unpaired Student’s t test was performed for statistical evaluation of the data. Results: The F wave latency, the motor conduction velocity and MEPs latency showed a significant improvement in treated GLD mice at comparison with untreated affected controls (respectively F wave: 18,1 millisec vs 15,65 millisec p= 0,02; MCV: 3,5 m/sec vs 10,8 m/ sec p= 0,001 MEPs latency 8,4 millisec vs 5,10 millisec p=0,01). Central parameters (cMEP and CCT) were recordable at the 35 postnatal days in all the treated mice and in only 2 of 6 untreated mice(respectively cMEP latency:17,35 vs 13,55 millisec p=0,001; CCT 10,25 vs 8,45 millisec p=0,02). Conclusion: The transplantation of gene-corrected HSC by reestablishing the defective enzymatic activity in the hematopoietic system of GLD mice allows preventing the development of the central and peripheral motor conduction impairment typical of the disease.

P205 Downregulation of oxido-inflammatory cascade in alcoholic neuropathic pain by epigallocatechin-3-gallate V. Tiwari, A. Kuhad, K. Chopra Puanjab University (Chandigarh, IN) Introduction: Alcoholic neuropathy is one of the devastating complications of long term alcohol consumption which involves decreased nociceptive threshold characterized by spontaneous burning pain, hyperalgesia and allodynia. Alcoholic neuropathy has been associated with behavioral alterations, increase in oxidative-nitrosative stress and pro-inflammatory cytokines. Aim: The present study was designed to explore the protective effect of epigallocatechin-3-gallate against alcoholic neuropathy in rats. Materials and methods: Ethanol (10g/kg,35%v/v) was administered for 10 weeks by oral gavage and neuropathic pain was assessed by using vonFrey hair test, randall sellitto and tail immersion test. EGCG was also administered for the same duration daily 1 hr before the ethanol administration by oral route. Markers of inflammation such as TNF-a, IL-1b and TGF-b were also assessed in sciatic nerve of ethanol treated rats by using ELISA. Results: Chronic alcohol (35%) treated rats developed neuropathy after 6 weeks, which was evident from decreased tail flick latency (thermal hyperalgesia), paw withdrawal threshold in Randall-Sellito test (mechanical hyperalgesia) and von-Frey hair test (mechanical allodynia) along with enhanced in oxidative-nitrosative stress and inflammatory mediators (TNF-a, IL-1b and TGF-b1 levels). Coadministration of epigallocatechin-3-gallate significantly and dosedependently prevented behavioral, biochemical and molecular changes associated with alcoholic neuropathy. Conclusion: In conclusion, the current findings suggest the neuroprotective potential of epigallocatechin-3-gallate in attenuating the behavioral and biochemical alterations associated with alcoholic neuropathy through modulation of oxido-inflammatory cascade.

P206 Effect of dopaminergic D1/D5-receptor blockade within the nucleus accumbens on the hippocampal long-term potentiation in the dentate gyrus in vivo H. Tabassum, J. Frey Leibnitz Institute for Neurobiology (Magdeburg, DE) Hippocampal long-term potentiation (LTP) is a long-lasting increase in synaptic efficacy after brief high-frequency stimulation of afferent

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fibers and is considered to be a cellular model of learning and memory. It has been shown that stimulation of modulatory brain structures and regions like the prefrontal cortex, ventral tegmental area, locus coeruleus, basolateral amygdala can influence hippocampal LTP. However, less is known of the role and the effects of the nucleus accumbens (NAc) on hippocampal LTP. The NAc is the central component of the basal ganglia that is positioned to integrate signals arising from corticolimbic areas and to translate them into motor behaviour and learning. Electrical stimulation of the NAc core and shell region has been shown to modulate LTP in the dentate gyrus, although there is no direct connection from the NAc to the hippocampus. It has been shown by others that hippocampal LTP in the dentate gyrus can be regulated by the dopaminergic system (Manahan-Vaughan lab). We were now interested to study if the dopaminergic system within the NAc affects LTP in the dentate gyrus in freely moving animals. Thus, we have applied a specific D1/D5 dopamine receptor blocker, SCH23390, into the NAc and studied its possible effect on control potentials as well as on LTP in the dentate gyrus in freely moving rats. Interstingly, treated animals show a depression in baseline transmission in the dentate gyrus, just caused by D1/D5-blockade within the NAc. Furthermore, these animals were characterized by a reduced LTP after weak tetanic stimulation of the perforant path when compared with controls. As there is no direct dopaminergic connection between NAc and dentate gyrus, the effects must be based on indirect mechanisms, most likely also involving glutamatergic and/or GABAergic pathways. This work was supported by the DFG, SFB 779 B4 to JUF.

P207 Induction of long-term synaptic plasticity events and its impact to occlude further depression in CA1 hippocampal neurons S. Parvez, B. Ramachandran, J. Frey Leibniz Institute for Neurobiology (Magdeburg, DE) Synaptic plasticity has often been argued to play an important role in learning and memory. The hippocampus is one of the major experimental systems for studies of synaptic plasticity in the context of putative information storage mechanisms in the brain. Our lab has successfully shown that during the maintenance of early long-term potentiation (E-LTP) the further induction of longer lasting LTP is precluded. However, if early-LTP was transformed into late long-term potentiation (L-LTP), the same synapses further allowed LTP induction again, thus the induction of LTP was not precluded anymore. We wanted to investigate whether hippocampal LTP or longterm depression (LTD) also prevents the establishment of LTD in the same synaptic input. Our results now show that the prior induction of LTP or LTD occludes LTD in apical dendrites of CA1 neurons in hippocampal slices in vitro during the early phase of LTP or LTD. However, LTD can be again induced after the establishment and maintenance of LTP or LTD, which takes around 4 h. It seems that the neuronal network preserves the capacity for short-term depression immediately after potentiation but for the onset of additional LTD in the same synaptic input a time window of 4 h is critical. Our results demonstrate that, once LTD or LTP has been established, hippocampal neurons do not lose their capacity for the induction of additional LTD during the late phase of the initial synaptic plasticity event. S.P. was supported by a fellowship from the Alexander von Humboldt Foundation

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P208 Effect of notch signaling on differentiation of rat marrow mesenchymal stem cells into neurons induced by fasudil hydrochloride Z. Eryi, W. Liudong, W. Quanqing, L. Jingjing, J. Yonglin, J. Linjun, G. Wenjuan, J. Yanjie

3. The expression of caveoolin-1 were increased persistently correspenting with time and there are the highest expression after 6d of induction, besides, there was significant difference between before induction and after 6d of induction. Conclusion: Lipid raft, which careolin-1 is marking protein could have important role in regulating MSCc differentiate into neurons.

Zhengzhou University (Zhengzhou, CN) Objective: To investigate the effect of notch signaling on differentiation of rat bone marrow mesenchymal stem cells into neurons induced by fasudil hydrochloride. Methods: The experiments were divided into non-transfected group, transfected group (transfected with Rn-Notch1-siRNA), positive control group (transfected with Rn-MAPK-1 Control siRNA) and negative control group (transfected with Negative Control siRNA). Fasudil hydrochloride induces MSCs differentiating into neurons. The fluorescence expressed by transfected MSCs were observed under inverted fluorescence microscope. The expression of notch1 mRNA, Hes1 mRNA and MAPK1 mRNA in MSCs was detected by RT-PCR. The expression of Notch1 protein, NSE, neurofilament M (NF-M) and glial fibrillary acidic protein (GFAP) was detected by immunocytochemical method. The viability of MSCs was detected by MTT. Results: 1.The fluorescence of MSCs was mostly displayed after transfection of 72 hour and the efficiency of transfection was up to 91.3%±4.2%. Meanwhile, the notch1 mRNA and Hes1 mRNA expressed by MSCs of transfected group was significantly decreased (P\0.05) and MTT displayed that the viability of MSCs was also significantly reduced (P\0.05). 2. Fasudil hydrochloride can induce MSCs differentiate into neurons and the best efficiency of induction was observed in the transfected group.There was higher expression of NSE and neurofilament-M (NF-M) than the other group (P\0.05). Conclusion: There may be notch1 signaling and Rho/Rho GTPase signaling synergy on differentiation of rat bone marrow stromal cell into neurons induced by fasudil hydrochloride and they jointly promoted the differentiation of MSCs into neurons.

P209 Effect of caveolin-1 on differentiation of rat bone marrow mesenchymal stem cells into neurons W. Liudong, Z. Eryi, J. Yonglin, G. Wenjuan, J. Yanjie

Extrapyramidal disorders: movment disorders P210 Tremor in patients with diabetic polyneuropathy T. Tomaszewski, M. Rudzinska, K. Banaszkiewicz, M. Dec, M. Wojcik, S. Bukowczan, M. Michalski, A. Wasielewska, A. Zajaczkowska, A. Szczudlik Jagiellonian University Medical College (Cracow, PL) Objectives: Tremor can be observed in a significant portion of patients with diabetic polyneuropathy. Peripheral nervous system involvement and tremor in diabetes mellitus may share the patomechanism, however the cause of tremor in neuropathy is not clear. The aim of the study was to analyze the relationship between nerve conduction and tremor occurrence, frequency and amplitude in patients with diabetic polyneuropathy. Material and methods: 35 patients with diabetic polyneuropathy were included. Their mean age was 64.9 ± 14.5 years and mean disease duration was 8.0 ± 7.6 years. Neurological and electrophysiological examinations of tremor in the upper limbs as well as nerve conduction study were performed at all patients. Electrophysiological examination of tremor was done using triaxial accelerometry. Nerve conduction study was performed on ulnar and median nerves. Results: In the clinical examination tremor was observed in 48.6 % of patients. Mean frequency of tremor was 7.6 Hz. Mean nerve conduction velocity was 48.8 m/s, and it was significantly lower at patients with tremor (43.0 m/s), as compared to those without tremor (56.1 m/s, p=0.006). There was no correlation between conduction velocity and tremor frequency or amplitude. Conclusion: Low conduction velocity is related to higher tremor occurrence but not with tremor frequency or amplitude.

Zhengzhou University (Zhengzhou, CN) Objective: To investigate the role of caveolin-1in bone marrow mesenchymal stem cells(MSCs) differentiating into neurons. Methods: The experiments were divided into non-transfected group, tranfected group (tranfected with Rn-caveolin-1 siRNA), positive control group (transfected with Rn-MAPK-1 control siRNA) and negative control group (transfected with Negative control siRNA). MSCs was induced to differentiate into neurons by b-ME.The fluorescence expressed by transfected MSCs were observed under inverted fluorescence microscope.The expression of caveolin-1 and MAPK-1mRNA was detected by RT-PCR.The neural cell specific marker NSE, NF-M, GFAP were detected by immunocytochemistry stain technique.The survival ratio of MSCs was detected by MTT. Results: 1. The fluorescence of MSCs was mostly displayed after tranfection of 72 hour and the efficiency of transfection was up to (81.5± 2.8) %. Meanwhile, the caveolin-1mRNA expressed by MSCs of transfected group was decreased (P\0.05). MTT displayed that the survival ratio of MSCs of transfected group hadn’t significant difference than other groups. B-ME induced MSCs into neural cell.The differetiation efficiency of MSCs transfected had the best effect and the expression of Nestin, NF-M were increased significantly comparing with the other groups (P\0.01).

P211 Rivastigmine-induced dystonia: case report P. Alonso-Bejar, F. Garcia-Carrizo Hospital del Tajo (Aranjuez, ES) Objectives/background: drug-induced dystonia is a relative wellkown phenomenom. Some of these cases are causing by drugs that interfere with dopamine metabolism by blockage of dopamine receptors in Central Nervous System areas vulnerable to the generation of dystonic syndroms, like the putamen and the caudate nucleus. We present a case of dystonia related to Rivastigmine treatment. Methods/case: a 69 years old women presented with a 5 years history of a moderate Alzheimer’s disease. Her father had had unspecified dementia (begining at seventh decade). Memantine and Galantamine treatmets disrupted by gastrointestinal and behavioral side-effects. Treated with sitagliptin, metformin, atorvastatin, omeprazol, carvedilol, furosemide, enalapril and espironolactone because of her other pathologies (hypertension, diabetes, dyslipidemia); clonazepam at low doses (0.5mg per day) was used like hypnotic drug. Transdermal rivastigmine was iniciated at usual dosage (4.6 mg per day). Few days later a cervical dystonia in anterocolli was observed.

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S68 Screening for metabolis disturbances was negative (blood analysis). Gradual recovery ad integrum was observed with Rivastigmine disruption, without specific treatment needed. Results/discussion: Due to the colinomimetic effect, Rivastigmine can induced extrapiramidal side-effects; bradykinesia, dyskinesia and tremor have been described very often. Another case of dystonia related with rivastigmine treatment was described in the literature. However, in that case the patient was taking neuroleptic drugs simultaneously, drugs with well-known extrapiramidal side-effects. Our patient was treated with drugs without extrapiramidal side-effects described. Conclusion: Dystonia can be a side-effect related with rivastigmine treatment. As an acute extrapiramidal effect, recovery can be expected with drug disruption.

P212 Erdheim-Chester disease manifested as chorea and neuropsychological disorder R. Felgueiras, M. Pires, J. Pereira, L. Xavier, A. Tuna Hospital Santo Anto´nio (Porto, PT) Objective: We present a patient with Erdheim-Chester disease, a rare non-Langerhans histiocytosis of unknown aetiology, manifested by chronic neuropsychological symptoms and asymmetric chorea. Methods: Description of a clinical case. Results: Male, 51 years old, with previews unexplained hypertension since his youth. In the last three years he presented bilateral frontal chronic headaches associated with depressive symptoms. He got insidiously worse and his family and friends reported in the last year inappropriate behaviour (apathy, indifference and jargon). Three years later the neurological examination showed an asymmetric generalized chorea and the neuropsychological evaluation confirmed deficits in attention, psychomotor performance, language and executive functions. Brain MRI revealed an extra-axial enhancing lesion with mass effect upon the right frontal lobe; a diffuse pachymeningeal thickness; a left optic nerve sheath solid meningeal enhancement lesion and a left subthalamic nucleus lesion with T2 hyperintensity. The cerebrospinal fluid study identified a mononuclear pleocytosis (104 leucocytes/lL; 72 monocytes/lL) with elevated protein levels (0.97 mg/dl) and normal glucose. The frontal meningeal lesion was biopsied and we observed histiocytes with CD68 positive and S100 negative immunophenotype. Thoracic and abdominal CT-scan revealed similar bilateral infiltrating lesions in peri-renal tissue. Full-body bone scintigraphy with 99mTCHDP unmasked typical intense fixation in the craniofacial bones and in the distal extremities of long bones. Laboratory tests excluded lupus, antiphospholipid antibody syndrome, thyroid disorder and HIV infection. The genetic test for Huntington disease was negative. The patient started oral corticosteroids and after 3 months of follow up, his neurological condition was similar. Conclusion: This is a peculiar case of an Erdheim-Chester disease with unusual neurological involvement. The chronic neuropsychological and extrapyramidal presentation could be justified by the frontal, subthalamic and pachymeningeal reported lesions.

P213 Gait disorder in a patient with Wilson’s disease 18 years after onset of disease F. Brugger, A. Felbecker, G. Ka¨gi, S. Ha¨gele-Link, B. Tettenborn Kantonsspital St. Gallen (St. Gallen, CH) Objective: Wilson’s disease is an autosomal recessive inherited disorder of copper metabolism leading to an excessive accumulation of

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copper in and outside the liver. A broad spectrum of neurological symptoms comprising dystonia, parkinsonian features, cerebellar and bulbar signs is very common and can severely impact the patient’s quality of life. Even though gait disorder is a quite prominent neurological sign in Wilson’s disease, the features of the gait abnormalities have not been described in detail in the literature. We describe the gait abnormalities in a patient who has been suffering from clinical signs of Wilson’s disease for 18 years and has been treated with different anticopper agents since the first diagnosis in 1992. Methods: This 51-year-old male patient was diagnosed with Wilson’s disease at the age of 33 after a 2 years lasting history of severe arm and head tremor resulting in a significant impairment of his working ability. Irritable and aggressive behavior was present at time of disease onset and worsened in the first years after the diagnosis. He reported a marked progression of symptoms after changing the treatment from D-penicillamin to zinc sulfate in the late 1990s. Even though D-penicillamine was reintroduced, since this time walking remained impaired and the patient has been bound to a walking frame to overcome his gait disorder in a suitable manner. Recent urine analysis showed that copper was effectively eliminated under D-penicillamine. Results: On the neurological examination the patient revealed a complex gait disorder comprising features of severe (gait-specific) dystonia, gait apraxia and freezing of gait (FOG), respectively. While walking sidewards along the wall he used a simple cue to improve his gait impairment. Otherwise no significant impairment of leg motility or marked dystonic features could be observed when he was in a sitting or lying position. Some frontal signs were positive in this patient, pyramidal signs, however, were missing. Conclusion: This is an illustrative case showing a particular pattern of gait abnormalities with a combination of FOG and dystonia. While dystonia is well known in patients with Wilson’s disease FOG is unusual and could reflect the involvement of different neuroanatomical structures beyond the basal ganglia pathology.

P214 Valproic acid-related Pisa syndrome R. Manso ´ vila, ES) Hospital Nuestra Sen˜ora de Sonsoles (A Objectives: Pisa syndrome (pleurothotonus) is an uncommon type of truncal dystonia manifested by persistent lateral flexion of the trunk. The development of Pisa syndrome is most commonly associated with prolonged treatment with antipsychotics; however, it has also been reported, although less frequently, in patients who are receiving other medications (cholinesterase inhibitors, antiemetics, tricyclic antidepressants, selective serotonin reuptake inhibitors, lithium carbonate and tiapride), in those not receiving medication (idiopathic Pisa syndrome) and in those with neurodegenerative disorders. Here, we present the case of a patient with frontotemporal dementia who developed Pisa syndrome secondary to valproic acid treatment. Methods: A 73 year-old woman with frontotemporal dementia had experienced a behavioural deterioration consisting of disinhibition and emotional blunting in the last month. Her medications were trazodone (100 mg/day), clonazepam (0.25 mg, twice a day) and mirtazapine (15 mg a day). Because of progression of the psychiatric symptoms, valproic acid (250 mg, twice a day) was added according to the psychiatrist’s instructions. From about 10 days after starting medication, she developed flexion of the trunk to the right. She showed no other signs or symptoms suggestive of an extrapiramidal syndrome.

S69 Results: Laboratory values were normal. A brain scan revealed cortical atrophy. Pisa syndrome was suspected, and then, valproic acid was discontinued. Approximately 2 weeks after reducing the dose, abnormal postures gradually improved, and after 1 month, flexion of the trunk resolved. Conclusion: We report a case of Pisa syndrome in which pleurothotonus occurred after treatment with valproic acid and improved after discontinuation of this medication. To our knowledge two previous cases of valproic acid-related Pisa syndrome have been described, but those patients were also taking other drugs which can cause Pisa syndrome (olanzapine, paroxetine and rivastigmine in one case and risperidone in the other). Risk factors for this syndrome include combined pharmacological treatment, old age, female gender, and the presence of an organic brain disorder, all of which were present in our patient. Although treatment with anticholinergic agents has been proposed, definitive therapy remains the discontinuation of the offending agent.

P215 Pisa syndrome and Parkinson disease H. D’Onofrio, H. Videla, J. Maegli, A. Caride, J.M. Duarte, M. Talarico, A. Bertotti Deutsches Hospital (Buenos Aires, AR) Objective: To report Pisa Syndrome (PS)in two patients never exposed to drugs usually related to this syndrome, who fulfilled the clinical criteria for Parkinson disease diagnosis(PD). One of them was suffering typical signs of Parkinson disease when Pisa Syndrome appeared and the other one started a Pisa Syndrome and then developed a typical Parkinson disease. Background: Pisa Syndrome is an axial dystonia expressed by a lateral lean associated to a slight rotation of the trunk, maintained while sitting, standing, or walking. The dystonia can be corrected by passive mobilization of the trunk. PS has been described in patients receiving classic or atypical neuroleptic, or using cholinesterase inhibitor or psychotropics. It was reported in MSA of Parkinsonian predominance and in Alzheimer disease as well, but PS is rarely found during an ongoing clinical PD or as an initial sign of PD. Method/results: Two patients (1F-1M) were assessed between 20052009. The F patient (69 years old) was first time evaluated because of resting tremor of the right hand and bradykinesia. She underwent to lab, brain MRI, Transcranial EchoDoppler (TCE) and autonomic tests. Then she started a L-Dopa plus decarboxylase inhibitor, (low doses 300 mg/ d) improving bradykinesia and resting tremor. 2 years later the family reported a persistent right lateral lean of the trunk. Motor symptoms were unchanged and either lowering or raising L-dopa dosage did not modify the trunk dystonia. EMG, vertebral spine X-Ray and MRI were non contributory. The follow up showed a good motor control with LDopa 400 mg/d and CoQ10 60 mg/d. The M patient(64 years old) asked our opinion because of a six months evolution of a lateral deviation of the trunk. No other associated clinical sign was found. Lab and brain/spine MRI were normal as well, but TCE showed a differential echogenicity at S.Nigra brainstem level. During a 3 years follow up an expressionless face and a hand resting tremor developed. Autonomic tests were found normal. L-Dopa plus decarboxylase inhibitor (400 mg/d) improved motor signs but trunk dystonia remained unchanged. Conclusion: Pisa Syndrome appearing as an initial clinical sign of PD or during the clinical course of Parkinson Disease is unusual but PD must be included in the diagnosis workup of these patients, specially when no prior exposure to neuroleptic, psychotropic or cholinesterase inhibitor are reported, and differential diagnosis with MSA has to be addressed.

P216 The relation between depression and other symptoms of Huntington’s disease K. Banaszkiewicz, M. Banach-Go´rnicka, M. Bielanska, E. Bojanowska, D. Nieweglowska, M. Rudzinska, A. Szczudlik Jagiellonian University Medical College (Cracow, PL) Objectives: Huntington disease (HD) is a progressive neurodegenerative disorder which is manifested by several behavioral disturbances, depression, involuntary movements and cognitive disturbances. The prevalence of depression varies from 33% to 69% in HD however it rarely presents as a major depression. Despite a shared pathological basis of all signs of HD, it seems that depression and other HD symptoms come up independently from each other. Depression may also be a consequence of the patients’ disability. The aim of our study was to assess the relation between depressive symptoms and motor signs, cognitive and behavioral disturbances, apathy and disability in HD patients. Methods: 27 patients (11 female, mean age 40.3 years) suffering from Huntington disease were included. To assess depressive symptoms Beck Depression Inventory (BDI) was used. To quantify motor signs and cognitive disturbances the Unified Huntington Disease Rating Scale (UHDRS) was administered. Lille Apathy Rating Scale (LARS), Buss-Perry Aggression Questionnaire and Irritability Questionnaire were used to evaluate apathy, aggression and irritability respectively. Disability was assessed using Total Functional Capacity Scale (TFC). Results: Mean BDI was 14.8 ± 13.2. There were significant correlations between BDI and cognitive disturbances on UHDRS cognitive scale (R=-0.41) and between BDI and LARS (R=0.46). No significant correlations were found between BDI and motor part of UHDRS, severity of irritability or aggression. BDI correlated also with TFC (R=-0.40) and the duration of disease (R=0.47), but not with CAG repeat number. Conclusion: The study shows that severity of depressive symptoms in Huntington disease is associated with cognitive disturbances, apathy and disability, while it seems to be not related to movement disturbances, irritability or aggression.

P217 Different patterns of hypothalamic dysfunction in Huntington’s disease, according to growth hormone response to arginine test E. Salvatore, C. Rinaldi, T. Tucci, L. Di Maio, C. Di Somma, S. Savastano, G. Lombardi, A. Filla, A. Colao, G. De Michele Federico II University (Naples, IT); IRCCS Fondazione SDN (Naples, IT) Objectives: Hypothalamic dysfunction has been recently shown in Huntington’s disease (HD), an autosomal neurodegenerative dominant disorder characterized by motor, cognitive, and psychiatric disturbances. Aim of the study was to evaluate hypothalamic involvement in HD patients, in particular if the growth hormone (GH) response to arginine infusion may be an in vivo biomarker of the degree of hypothalamic dysfunction. Methods: We investigated 17 consecutive patients seen at our HD Clinics, and 17 age, sex, and body mass index (BMI) matched healthy controls. Clinical assessment of patients was performed using the Unified Huntington’s Disease Rating Scale (UHDRS) motor section and the Total Function Capacity (TFC). Metabolic

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S70 and endocrine investigations included total, LDL and HDL cholesterol, basal insulin, GH, insulin-like growth factor 1 (IGF-1), Standard Deviation Score IGF-1(SDS IGF-1), and the GH response to arginine stimulation. Results: HD patients showed lower plasma IGF-1 and SDS IGF-1 levels and higher baseline GH in comparison to control subjects. The arginine test induced a normal GH peak in 9 patients (53%), whereas the response was absent in the remaining 8 (47%). We did not find any differences in age, sex distribution, CAG triplet repeats, phenotype at onset, disease duration and stage, UHDRS motor score, and previous exposition to neuroleptics among patients with normal GH and those with absent response. However, the latter patients showed higher LDL cholesterol and insulin levels and lower HDL cholesterol level. Conclusion: According to a different GH response to arginine, we could identify two subgroups of patients, with distinct metabolic profile. It should be clarified if these two subgroups of patients correspond to different patterns of neurodegeneration or to different disease stages.

P218 Acute reversible parkinsonism in a diabetic uremic patient H. Nzwalo, F. Sa´, C. Capela, F. Ferreira, C. Bası´lio Faro Hospital (Faro, PT); Central Lisbon Hospital (Lisbon, PT) Background: The syndrome of acute bilateral basal ganglia lesions in diabetic uremic patients is rare. It affects mostly Asian people, and there is only one report in Europe. Typically, patients present with acute reversible parkinsonism or dyskinesia. They all express reversible basal ganglia lesions, hyperintense on T2-weighted and hypointense on T1-weighted images on Brain Magnetic Resonance (B.MRI). Dialysis intensification and/or treatment with dopaminergic agonist apparently has good results. We present a case of this syndrome, in all aspects similar to previous reported. Case presentation:A 62-year-old, Caucasian man, with hypertension and diabetic nephropathy in dialysis for three years, presented with two week history of gradual onset of slurred speech, fatigue, gait disturbance and decrease spontaneity. He had no antecedent of hypotension, electrolytic disturbance and use of any drug, aside from Metformin, Losartan, Nifedipine and Erithropoeitin. On general examination, he was stable with normal cardiopulmonary sounds and no edema. Neurological examination revealed dysarthria, bradykinesia, generalized muscular rigidity, and gait disturbance. There was no resting tremor. The Blood Urea Nitrogen (60 mg/dl) and serum creatinine level (3.3 mg/dl) where within the regular values, and glycated haemoglobin was 6.8%. Electrolyte levels were within normal limits. His B.MRI revealed bilateral and symmetrical involvement of the lenticular nuclei, with hypointense signal on T1 and hiperintense on T2. He started treatment with Ropinirole initially and L-Dopa subsequently and haemodialysis was intensified. His clinical condition improved after the second week, and at the end of third week he was assinptomatic. B.MRI at control was normal. Conclusion:The pathophysiology of this syndrome remains in discussion. Many factors acting sinergically, like uremic neurotoxicity, diabetes associated microvascular changes, deregulation of local glucose metabolism and cerebrovascular blood flow, could at some critical physiological point cause damage to the basal ganglia in susceptible patients.

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P219 Mitochondrial myopathy with parkinsonism in two brothers: a case report A. Koksal, H. Ertem, F. Aysal, Y. Altunkaynak, S. Baybas Bakirkoy Research and Training Hospital for Psychiatry, Neurology and Neurosurgery (Istanbul, TR) Objectives: Mitochondrial myopathies(MM) are a group of neuromuscular disorders that result from defects in the function of the mitochondria.The primary defect in MM results from mutations in important genes that determine the structure of proteins that function in the mitochondria.MM can be caused by defects in nuclear and mitochondrial DNA.People affected with one of these disorders usually have weakness,exercise intolerance,heart failure,central nervous system abnormalities like dementia,stroke-like symptoms,deafness,blindness,seizures,anemia,endocrinopathy,heavy eyelids, and vomiting.Any multi-system progressive disorder should lead a physician to suspect a mitochondrial disorder.Diagnosis can be particularly difficult if there is only one symptom.Diagnosis can be confirmed by laboratory studies,muscle biopsy and molecular genetic evaluation. Methods: We report two brothers aged 51 and 43, who had myopathy,ataxia,polyneuropathy and extrapyramidal features and diagnosed MM with clinical examination,electrophysiologic studies and muscle biopsy. Results: For the patient aged 51, the central nervous system deficiency had started with ataxia and myopathy and after then parkinsonian features especially hand tremor at rest added.For the other brother the parkinsonian features had started earlier than myopathy.In laboratory evaluations it’s determined that brother aged 51 had type 2 DM and the other had mild increase of blood serum lactate and pyruvate levels and he had hearing loss either.Electromyographic studies confirmed a motor-sensorial polyneuropathy and myogenic signs.Cerebral and cerebellar atrophies were determined in cranial MRimagination.Neurological examination of both revealed cerebellar dysarthria,weakness of extraocular muscles,bilateral horizontal and vertical gaze paralysis,weakness of distal muscles,decreased deep tendon reflexes.The extrapyramidal motor system symptoms like tremor,bradykinesia,rigidity and adynamia caused by myopathy were common.Also the brother aged 43 had dysmetria and dysdiadochokinesia.Dopamine agonist drugs and coenzyme q10 were used for treatment.This treatment had beneficial effect on patients’ ability to perform daily life activities,their health-related quality of life. Conclusion: The aim of this report was to remind clinicians of atypical presentation of familial Parkinson’s disease and considering mitochondrial myopathy for the differential diagnosis.

P220 A case of painless arm and moving fingers K.S. Yum, Y.D. Kim Konyang University Hospital (Daejeon, KR) Objectives: Painful limbs/moving extremities syndrome (PLME) is defined as the association of pain in at least one limb and slow involuntary, writhing and wriggling movement of flexion/extension and/or abduction/adduction of at least one finger or toe. PLME is a syndrome with many variants. Painless forms were rarely reported. Especially, painless arm with moving fingers was reported only one case. Methods: We report a case of painless arm and moving fingers that we observed.

S71 Results: An 18-year-old right handed female was referred to neurology department for involuntary movements of the left third finger for 3 months. She was a university student who studies architecture. She had no history of medical disease or trauma of hand or arm. The family history did not show any diseases. Her symptoms were developed abruptly, and lasted without improvement or aggravation. She did not complain pain or paresthesia on her hand or fingers. Involuntary movements were absent during sleep or voluntary movement of hand. The patient’s general medical examination was normal. Neurologic examination revealed abductionadduction of the fourth left finger at a frequency of 3 to 5 Hz. The patient could not stop the movement, nor would contralateral action either reduce or increase it. Tactile stimulation of the left hand did not reduce involuntary movement. Motor and sensory examinations and tests of cerebellar function were normal. Deep tendon reflex, Hoffmann and Tromner sings were normal on her arm. Laboratory data of routine hematological, blood chemistry, serologic tests include ceruloplasmin, serum copper and thyroid function test were normal. DYT 1 gene was negative. Magnetic resonance image of her brain and cervical spine were normal. Nerve conduction study of extrimities and somatosensory evoked potential of her arm were normal. electromyography showed spontaneous 100-200 msec bursts of 400-500 mV multiple motor unit potentials on left second, third and fourth dorsal interosseous muscles. We prescribed Clonazepam, amitryptilline and baclofen. But her symptoms did not response any drugs. Conclusion: Painful arm and moving finger (PAMF) is a rare variant of PLME. Etiology of PLME is not certain. Treatment of PLME has not been confirmed yet. Our case has different clinical features from other cases. Unlike other PLME, our case has no evidence of neuropathy, infection or metabolic abnormality.

P221 A shaking grandfather and a grandson with the fragile x-syndrome F.M. van der Toorn, A. Schreuder Atrium Medical Centre Parkstad (Heerlen, NL) Background: The fragile-X tremor/ataxia syndrome (FXTAS) is a progressive neurological syndrome, including intention tremor, gait ataxia and mild parkinsonism. Other features are memory deficits, sometimes declining to dementia, psychiatric symptoms, like anxiety, depression and dysautonomia. FXTAS develops in a subgroup of older male carriers of an expansion in the fragile-X-mental retardation 1 gene (FMR1 gene). The full mutation is an expansion of a CGG repeat in the FMR1 gene to over 200; normal chromosomes have fewer than 54 repeats. The maternal grandfathers of patients may carry a premutation in the 55 to 200 range. Pathologically, there are characteristic eosinophilic intranuclear inclusions in neurons and astrocytes. Case report: An 84-year-old man presented with a 6-year history of slowly progressive action and intention tremor. He had difficulty walking and complained of memory deficits. His grandson had been diagnosed with fragile-X syndrome (mental retardation). Physical examination revealed moderate cognitive dysfunction, marked action and intention tremor of arms and legs, rigidity and dysmetria in all limbs, stooped posture with gait ataxia and axial instability. Magnetic Resonance Imaging (MRI)of the brain showed generalized atrophy and enhancement of T2 signal intensity in the middle cerebellar peduncles. A CGG-repeat of 80 sequences in the FMR1 gene confirmed the diagnosis of fragile-X tremor/ataxia premutation syndrome.

Due to his gait disturbances, patient fell frequently and developed an acute subdural hematoma with a hemiparesis. After surgery he recovered but became wheelchair-bound eventually. Conclusion: Progressive neurological symptoms like ataxia and tremor in grandfathers of boys or men with the fragile-X syndrome should prompt suspicion of FXTAS. In patients with idiopathic ataxia and tremor or multiple system atrophy phenotype, it may also be worthwhile looking for the premutation, especially if there is a family history of mental retardation. Many of these patients have been described to have a characteristic T2 hyperintensity in the middle cerebellar peduncles, like our patient did.

P222 Idiopathic Parkinson’s disease and proximal myotonic myopathy—A case report of a 71-year-old woman L. Klingelho¨fer, A. Storch, H. Reichmann, M. Wolz Dresden University of Technology (Dresden, DE) Objectives: The rare association of parkinsonism and proximal myotonic myopathy (PROMM) is already known and has been described as ‘‘Parkinsonism-Myotonic-Myopathy-Complex’’ in six cases. All published patients suffered from progressively severe parkinsonism accompanied by missing levodopa response or loss of initial L-Dopa sensitivity and development of secondary symptoms such as dementia. Case report: A 71 year old woman developed proximal muscle weakness and increased blood levels of creatine kinase at the age of 51. Seven years later a bilateral hypakusis was diagnosed and again nine years later a bilateral cataract was operated. At the age of 62 she developed a tremor of the left leg, a right sided bradykinesia with worsening of the fine motor skills as well as a hypomimia and a smaller and slurred handwriting. Parkinson’s disease was diagnosed and confirmed by levodopa challenge test and 18-F-Dopa-PET. Based on a worsening of proximal muscle weakness and myotonic discharges in EMG, genetic analysis with expansion of the CCTG repeats of the ZNF9 gene confirmed the suspected diagnosis of a PROMM. We observed a slow progress of the parkinsonian syndrom with ongoing L-Dopa response and without development of any atypical signs or secondary symptoms over the following five years of the disease. MRI of the brain showed only sporadic subcortical white matter lesions on T2-weighted images most likely according to microangiopathy. The Mini-Mental-Status-Scale and the Parkinson Neuropsychometric Demetia Assessment showed standard values related to age. Conclusion: This is a case report of a patient with PROMM and idiopathic Parkinson’s disease - both confirmed by specific diagnostic methods (18-F-Dopa-PET and molecular genetic analysis). In contrast to the six published cases we report the first case of a PROMM patient with mild typical progression of parkinsonism and consistent levodopa-response without any atypical signs or secondary diseases. In conclusion we interpret parkinsonism as idiopathic and not as a cerebral feature of PROMM.

P223 Paroxysmal kinesigenic dyskinesia and central pontine lesions D. Pothalil, C.-A. Sibille, M.P. Rutgers, M. Gille Clinique Sainte-Elisabeth (Brussels, BE) Background: Paroxysmal kinesigenic dyskinesia (PKD) consists of brief episodes of choreic/dystonic movements triggered by sudden movements and responsive to antiepileptic drugs. PKD is often familial with an autosomal dominant inheritance. A locus in the pericentromeric region of the chromosome 16 has been mapped. PKD

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S72 is considered as a sodium channelopathy with deficits in cortical, brainstem, and spinal inhibitory circuits due to disordered basal ganglia modulation of cortical motor output. We report a case of lateonset PKD associated with central pontine lesions. Case report: A healthy 63-year-old woman presented with paroxystic kinesigenic choreic movements of the left leg for 3 months, responsive to low dose of carbamazepine. She did not have any familial history. Interictal neurological examination was normal. Complete blood tests, electroencephalography, evoked potentials, and interictal 99-mTc-HMPAO single photon emission computed tomography were unremarkable. Brain magnetic resonance imaging (MRI) revealed central pontine lacunar lesions without any basal ganglia involvement. Discussion: Our patient presented with a sporadic late-onset PKD. Although the majority of cases of PKD are idiopathic, they have been many reports of symptomatic PKD in various etiologic conditions, such as head trauma, multiple sclerosis, perinatal hypoxic encephalopathy, hypoparathyroidism, hyperthyroidism, progressive supranuclear palsy, thalamic infarct, hypoglycaemia, and diabete mellitus. Our patient did not fill any of these conditions. However, her brain MRI revealed central pontine lacunar lesions. Rare cases of PKD and delayed dystonia have been reported in osmotic myelinolysis without extra-pontine lesions. In these cases, as in our patient, the movement disorder could be due to a disruption of basal ganglionic connections by the pontine lesions.

P224 The study of transcranial magnetic stimulation on congenital mirror movement M. Yu¨cel, O. Demir, O. O¨z, O¨. Karadas, B. O¨ztu¨rk, Y. Kutukc¸u, Z. Odabasi

in the early stage of the disease. Recently, regional apparent diffusion coefficients (rADC) map of MRI has been reported useful in the differential diagnosis of patients with MSA-P vs. PD. MSA-P patients have significantly higher putaminal rADC intensity. We investigated the putaminal abnormality of MSA-P patients by the conventional diffusion-weighted images (DWI) of MRI and follow up the serial MRI change. In addition, we also investigated the three dimensional DWI and visualize the localization of the putaminal abnormality. Methods: MSA-P patients were studied. Clinical diagnosis of MSA-P was made by two neurologists according to the established consensus criteria. 58 year-old woman had difficulty to move her left foot from 2 years ago. 72-year old man felt right hand clumsiness from 4 years ago. 61-old-woman had a clumsiness of the left hand form 3 years ago. 75 year-old woman felt gait disturbance form 2 years ago. All patients were examined with MRI. Informed consent was obtained from all patients. MRI was performed using 1.5T MRI system (Achieva; Philips Medical System). DWI images were obtained from 6-mm thickness, 1.5-mm inter-slice gap. Three patients also had DWI images which were obtained by 2-mm thickness, 0.2mm inter-slice gap. Results: There were slight low intensity lesions of the putamen in T2WI of MRI in all patients. But the DWI change was seen more clearly. We investigated the putaminal abnormality which was spread from the dorsolateral to the ventral. In the three dimensional image, the dorsolateral change of the putamen is prominent. The laterality of the DWI change corresponded to the degree of the symptom. Conclusion: The low intensity lesion of putamen in MSA-P patients is likely to reflect ongoing neuronal degeneration and astrogliosis. We think that conventional DWI detects these changes in MSA-P patients, and the change of DWI can be detected more sensitively than that of T2WI. We can also demonstrate the serial MRI change of the putaminal abnormality in MSA-P patients.

Gulhane Military Medical Academy (Ankara, TR) Introduction: Mirror movements (MM) are synkinesias occurring in the opposite side during the intentional use of a limb. They are occasionally present in children, but persistence after age 10 is abnormal. This phenomenon has been well recognised in early childhood and in a variety of hereditary and acquired disorders. Although no unifying theory accounting for its mechanism is entirely accepted, MM in such neurological disorders as X linked Kallmann’s and childhood hemiparesis have been postulated to occur as a result of abnormal transcallosal inhibitory connections, relative overactivity of the ipsilateral motor cortex, failure of corticospinal tract decussation, or a combination of the above. Case Presentation: A 21-year-old man was admitted to our hospital with involuntary movements that accompany voluntary activity in homologous muscles on the opposite side of his body. His neurological examination was in normal ranges except bilateral mirror movements. Brain MRI showed callosal hypogenesis. In the study of transcranial magnetic stimulation, Motor evoked potential responses were obtained from the bilateral APB muscles with cortical stimulation. Conclusion: TMS may help us to understand the etiopathogenesis of mirror movements.

P225 Diffusion-weighted imaging in Parkinson variant of multiple system atrophy Y. Aburakawa, Y. Suzuki, K. Kuroda, T. Kimura, O. Yahara National Hospital Organization Douhoku Hospital (Asahikawa, JP) Objectives: Clinical differentiation of the Parkinson variant of multiple system atrophy (MSA-P) from Parkinson’s disease (PD) is difficult

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P226 An anterior spinal artery syndrome due to violent neck movements. A rare complication of Gilles de la Tourette’s syndrome D. Manoli, V. Zouvelou, M. Rentzos, T. Zampelis, G. Vlachos, I. Evdokimidis National and Kapodistrian University of Athens (Athens, GR) Introduction: Tourette’s syndrome presents with a broad spectrum of involuntary movement, vocal and behavioral disorders. In these patients, severe motor tics involving the neck may be responsible for the development of serious spine disease. Case: We report a 20-year-old man who experienced tics and vocalization since the age of 7 years. His tics were complex and were characterized by repetitive violent twisting and extending movements of the head, eye blinking, jumping as well as sniffing and snorting. They fluctuated until the age of 19, despite the received pharmacological treatment (neuroleptic drugs, benzodiazepines). At age 17, he developed progressive weakness of upper extremities. Clinical examination, three years later, showed bilateral asymmetric wasting and weakness of the hand muscles (left[right) and hyporeflexia of the upper limbs. No numbness, constipation or urinary problems were noticed. Electromyography showed evidence of denervation in the C5-C6, C6-C7, C7-C8 myotomes. Magnetic resonance imaging of the cervical spine revealed anterior ischemic myelopathy concerning mostly anterior horn cells, more severe in C6. Conclusion: It is generally known that motor tics can produce disabling myelopathy, an association rare but previously reported. This report puts special emphasy on the fact that our patient presented with exclusive upper limbs weakness, similar to spinal atrophy syndrome.

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Multiple sclerosis: clinical aspects P227 Chronic cerebro-spinal venous insuficiency in multiple sclerosis—Old theory, new question marks? O. Dolezal, A. Lopez Soriano, E. Havrdova Charles University (Prague, CZ); University Hospital Germans Trias i Pujol (Barcelona, ES) Objectives: According to recent publications where the role of chronic cerebro spinal venous insuficiency (CCSVI) in MS ethiology was mentioned, we tried in our study to evaluate the quality of venous drainage in normal controls. We also followed one subject for the 3 day period, studying intrapersonal time variation of venous drainage. Acording to this evaluation we tried to formulate our opinion about possible intravascular intervention. Methods: We examined 10 non MS subjects. Mean age of subjects was 30.3 yrs. The patients were negative according to chronic venous insuficiency in lower extremities. We were respecting criteria proposed by Zamboni 2009, we did not include transcranial examination. In the second phase we followed one subject (normal control) for the period of 3 consecutive days. We used Toshiba Nemio ultrasound machine. For evaluation of CCSVI we used venous hemodynamic severity score (VHSS) proposed by Zamboni et. al 2009. Results: Four normal controls from our group had at least one point in venous hemodynamics severity score (VHSS) and one subject fullfill two criteria of CCSVI (negative cross-sectional area of jugular vein in supine position and non detectable flow in one major vein). Subject followed for three consecutive days showed day to day variation especially in jugular and vertebral diameter in supine and in upright position as well (range 4x3 mm to 10 x 4 mm in left jugular and 3.5 x 1.4mm to 6.8 x 2.3 mm in right jugular vein in upright, and 1.8 mm to 3.8 mm of anterior- posterior diameter in upright position of vertebral vein on the left side). Conclusions: In our group we found one false positive patient according to CCSVI criteria and four borderline cases. We found significant day to day variation of ultrasound findings in major neck veins in our one case study. Regarding to extremely small amount of patients we can not make relevant conclusions but presence of signs of CCSVI in normal subjects and variation of venous drainage intrapersonally is interesting. It opens new serious questions about ethiological link of CCSVI and MS and indication of intravascular intervention, because percutaneous transluminal angioplasty (PTA) does not seem to be optimal procedure in potential venous insufficiency.

interferons, measured by multiple sclerosis functional composite (MSFC). Method: 99 patents (67 female), who had been treated with any interferon, were included in the study. Most of them had relapsing remitting course. Mean age was 34.4; mean disease duration was 8.02 years. 49 of patients had been treated with interferon b 1b, 40 of them with subcutaneous interferon b 1a, and 10 of them with intramuscular interferon b. Mean duration of interferon treatment was 43.32 months. Patients were clinically evaluated by expanded disability status scale (EDSS), 9 hole peg test (HPT) and Timed 25 Foot Walk Test (TWT). Cognitive evaluation was made by paced auditory serial addition test (PASAT), and auditory consonant trial (ACT). Results: 9 out of 99 patients had Nabs against interferons. MSFC score was significantly better in NAb- patients (p=0.008). Both 9-HPT (p=0.009) and TWT (p=0.005) were significantly worse in Nab+ patients comparing with Nab- patients. There were neither cognitive tests (PASAT and ACT) nor EDSS or attack rate differences between two groups. Conclusions: The present study is the first one evaluating the effects of NAbs with MSFC. It is also unique determining effects on cognition. Our results suggested that there is at least moderate negative clinical impact of NAbs even at 18 months. It does not seem to be cognitive impairment in NAb+ patients. Follow up results help us further conclusions on both clinical and cognitive impact of NAbs.

P229 Could the type of presentation of clinically isolated syndrome be an indication to start early treatment? M. Clerico, E. Versino, G. Contessa, S. De Mercanti, L. Durelli University of Turin (Orbassano, IT) Objectives: To indicate different levels of evidence for the efficacy of early treatment of clinically isolated syndrome (CIS) stratified by different types of presentation. Methods: We found published data on types of presentation only for CHAMPS trial. We performed subgroup analyses (per protocol; sensitivity analyses) on the bases of different presentations (optic neuritis, brainstem/cerebellar, spinal cord).We further obtained row data from the pharmaceutical companies (monofocal patients stratified by type of presentations) for ETOMS and BENEFIT trial. We performed a logistic regression comparing the efficacy of IFN treatment in the different types of presentations. Results: The analyses performed on CHAMPS comparing IFN vs placebo in preventing conversion to CDMS showed that 1)

P228 Do neutralizing antibodies affect interferon b treatment based on multiple sclerosis functional composite? Preliminary results D. Kaya, S. Ozakbas, S. Tufan, E. Idiman for the Neuroimmunology Study Group of the Dokuz Eylul University Objectives: During the treatment of multiple sclerosis (MS) with interferon-b, both binding antibodies (BAbs) and neutralizing antibodies (NAbs) against the drugs have been reported. But there is considerable controversy with respect to the clinical impact of Nabs. The aims of the present study were to detect the BAbs, and Nabs in patients with MS treating with interferon b for at least 18 months, and to determine the impact of the antibodies against clinical effects of

2) 3)

for optic neuritis no statistically significant difference in treated group compared to placebo group in all the analyses but the ‘‘best case scenario (p=0.02), for brainstem/cerebellar no statistically significant difference, in patients whose onset was spinal syndromes in ‘‘per protocol’’ (p=0.02) and in ‘‘best case scenario’’ analysis (p=0.02) the difference between the risk of conversion in IFN- compared to that in placebo-treated patients was statistically significant.

The logistic regression performed on ETOMS and BENEFIT trial showed an efficacy of IFN in preventing conversion to CDMS more evident ([ 30%) for brainstem/cerebellar onset compared to other sites of presentation, however not statistically significant. Conclusion: The most relevant data is the one from the logistic regression, it seems that the major effect of IFN b treatment in CIS is for brainstem/cerebellar onset compared to the others. We will extend our analysis including stratified data on monofocal patients from CHAMPS study as soon we will obtain them from the pharmaceutical company.

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P230 Temporal and spacial characteristics of gait in multiple sclerosis across levels of disability J. Preiningerova Lı´zrova´, M. Rothbard, M. Alvi, S. Henry Charles University (Prague, CZ); Yale University (New Haven, US) Objectives: The goals of this study were to evaluate temporal and spacial gait parameters in multiple sclerosis patients at different levels of disability (EDSS 0–6.5) and to identify variables that will best describe changes in gait to serve as outcome measures in interventional studies in different disability groups. Methods: Subjects were evaluated on the GAITRite electronic walkway for characteristics of self selected and fast walks. EDSS was used to categorize MS subjects by level of disability. The MS group included 47 women and 30 men, ranging in age from 19–72 years (mean 44). Length of disease ranged from 1 to 37 years (mean 12.3), with 84.4% of subjects being diagnosed with RRMS and 10% with SPMS. The control group included 12 women and 15 men, ranging in age from 22–67 years (mean 39). Results: For the controls and MS subjects in all disability groups except the bilateral assistance group, cadence, stride length, mean normalized velocity, and percent of gait cycle spent in double support were significantly different between self-selected and fast walking speeds. Mean normalized velocity was significantly lower than controls for MS subjects with minimal and moderate disability at the fast walking speed. Subjects with bilateral assistance exhibited loss of ability to improve parameters when asked to increase speed from self selected to fast walking speed. Groups with EDSS 0-6.0 spent a significantly greater percentage of the gait cycle in double support compared to controls at the fast walking speed, but not at the selfselected walking speed, making the fast walk test more sensitive to abnormalities of gait. There were no significant differences between groups at either walking speed for cycle time differential or base width. Conclusion: Mean normalized velocity and double support time at fast walking speed, as well as change in gait parameters between self selected and fast walking speeds are sensitive to abnormalities of gait in patients with MS even in groups with minimal disability on EDSS. Our next step is to validate this data in a larger sample and then evaluate behavior of these parameters in longitudinal follow up, its congruency with relapse, and correlation with other measures of disability.

P231 Depression, disability and cognitive impairment in multiple sclerosis: a cross-sectional italian study F. Mattioli, F. Bellomi, C. Stampatori, R. Capra Citizens Hospitals Brescia (Brescia, IT) Objective: Disability, cognitive impairment, fatigue and depression are interacting Multiple Sclerosis (MS) features, whose relation is still unclear. The aim of this study is to evaluate, in a sample of Multiple Sclerosis patients, the prevalence of depression, its predicting factors and relation with cognitive impairment, fatigue and disability. Methods: 225 MS italian patients and 166 age and sex matched healthy subjects were assessed for depression with the Beck Depression Inventory- FS (BDI-FS). Depressed patients where further investigated for the presence of neuropsychological impairment. Results: Depression was significantly more frequent and severe in patients than in controls. EDSS score was the only factor predicting depression (3.5 = threshold EDSS score for depression) in patients. Neuropsychological impairment was not correlated with depression, whereas fatigue was found to be significantly correlated with

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attention, executive function and memory test scores, as well as with BDI-FS score in patients. Conclusion: Depression is not correlated with cognitive impairment in MS, whereas EDSS and fatigue are predictive of the occurrence of depression. Fatigue can induce attention, memory and executive functions deficits in patients.

P232 The effect of age on disability development in multiple sclerosis A. Scalfari, A. Neuhaus, M. Daumer, G. Ebers, P.A. Muraro Imperial College (London, UK); Sylvia Lawry Centre (Munich, DE); Oxford University (Oxford, UK) Objectives: Acute attacks and unremitting disability in multiple sclerosis (MS) are probably driven by different mechanisms. Age has often been indicated as a possible factor influencing the accumulation of disability. We investigated the effect of age on disease evolution. Methods: The London Ontario database, which was recently updated to 28 years of follow up, is one of the largest natural history data collections on MS currently available. We assessed the disease course of 1023 patients attaining sustained disability levels on the Disability Status Score (DSS) scale: DSS 3 (moderate disability), DSS 6 (use of an aid for walking), DSS 8 (being wheelchair bound) and DSS 10 (dying from MS). Patients were stratified according to the initial disease course and compared. Kaplan Meier analysis was used in order to estimate the time from disease onset and from birth (subject age) to disability milestones; we then assessed the influence of type of initial disease course and of age at disease onset on the outcomes. Results: At the end of follow-up most patients (52.2%) were affected by secondary progressive (SP) MS, 26.6% were still in the relapsing remitting phase (RR MS) and 21.2 % had a primary progressive course (PP MS). The PP MS group had a much older mean age at onset (38.6 Vs 28.5 years) compared to the relapsing onset group (RR/SP MS); the risk of having a progressive initial disease course increased with age at onset (HR 1.10, p \ 0.001). Survival analysis confirmed the worse outcome in the PP MS patients attaining disability levels from disease onset in a shorter time compared to relapsing onset patients. An older age at onset correlated to a faster disease progression in the RR/SP group only; no effect was observed in PP patients. In the total population mean ages at disability levels were 41.6 years for DSS 3, 49.0 years for DSS 6, 58.7 years for DSS 8 and 75.3 years for DSS 10. Survival analysis from birth showed no effect of the type of initial disease course on ages at disability levels; no statistically significant differences were observed between the relapsing onset and the progressive onset groups for any of the endpoints analyzed. Conclusions: Accumulation of disability in Multiple Sclerosis appears to be, at least to some extent, an age-related process and not affected by the initial disease course, be it RR or PP. Altered ageing mechanisms could play a role in the disease evolution.

P233 Familial effects on the age of onset, initial symptoms and clinical courses of multiple sclerosis M. Eraksoy, G. Akman-Demir, Z. Yapici, T. Gunduz, M. Kurtuncu on behalf of the Turkish Multiple Sclerosis Genetic Study Group (TMSGSG) Accumulated data have showed that both genetic and environmental factor(s) influence the susceptibility, development and evolution of multiple sclerosis.

S75 Our cohort was consist of 4193 patients with multiple sclerosis at January 2010.We studied 319 patients with multiple sclerosis came from 147 multiplex families and compared the findings age and gender matched sporadic patients. According to preliminary results, mean age at onset of multiple sclerosis gradually decreased in the familial patients with multiple sclerosis, but initial symptoms, clinical courses MRI findings, oligoclonal bands in CSF and response to disease modifying treatments(DMDs)were heterogen. This study was unable to reveal remarkable environmental factor(s) in this cohort. The preliminary results demonstrated that age at onset of multiple sclerosis decreases from older to younger generations in familial multiple sclerosis, but there was no significant concordance for initial symptoms,clinical course, laboratory findings, and response to DMDs.In coclusion, this results suggest that genetic factors might be play an important role than environmental factors.

P234 Gender differences in sexual dysfunction among a Multiple Sclerosis population S. Haggiag, G. Ricci, G. Bolla, E. Quartuccio, O. Picconi, M. Fele, C. Gasperini, S. Galgani San Camillo-Forlanini Hospital (Rome, IT); Opera S.R.L. CRO (Genoa, IT) Objective: To evaluate the different impact of neurological, physical, psychological and urological disabilities on sexual dysfunction between women and men with MS. Background: Patients with MS frequently experience difficulties in their sexual life. Multiple factors, besides the damage to the nervous system pathways, may differently contribute to sexual dysfunction in women and men. Design/methods: 122 RRMS patients, 78 women and 44 men, were assessed by the Female Sex Function Index (FSFI) and the International Index of Erectile Function (IIEF) questionnaires, respectively. All the patients underwent the following urinary assessments: postvoid residual urine volume (PVR), maximum urinary flow rate (Qmax) and sphincter EMG (s-EMG). Other evaluations included: Beck Depression Inventory (BDI), Rosenberg Self-Esteem Scale (RSE), Fatigue Impact Scale, Fatigue Severity Scale, SF-36 Health Survey. Results: The mean age was 45.5 (SD 9.6) years, the mean disease duration was 13.0 (SD 9.0) years, and a median EDSS of 2.1 (SD 1.4). The mean FSFI score was 18.32 (SD 11.65) and the mean IIEF score was 45.91 (SD 26.02). By multiple regression analysis women BDI score was negatively associated to FSFI score (-1,4; p=0,001). In men a negative association between abnormal PVR values and IIEF score (-0.2; p=0.029), and a positive association between RSE score and IIEF score (2.9; p=0.006) were found. In women a negative association was found between BDI score and Orgasm (-0,2; p=0,021), BDI score and Satisfaction (-0,2; p=0,006) BDI score and Desire (-0.1; p=0,037); and a positive association between FSFI-pain score and Desire (0,1; p=0,012). Whilst in men abnormal PVR values were negatively associated to Orgasm (-0.02; p=0.0043), and a positive association between Qmax rates and Desire (2.6; p=0,009) was shown. Conclusions/relevance: Sexual dysfunction in women is shown to be mainly associated to depression, whilst in men is mainly associated with abnormal urinary function. Our data suggest a genderspecific approach to diagnosis and management of sexual disturbances in MS.

P235 Stressful events and relapses in MS patients: a controlled study R. Tanasescu, M. Ticmeanu, D. Luca, L. Dumitrescu, I. Cojocaru, A. Oprisan, C. Baicus Colentina Hospital (Bucharest, RO); University of Medicine and Pharmacy Carol Davila (Bucharest, RO) Background: Multiple Sclerosis is an inflammatory disease with multifactorial profile. Factors that can precipitate the clinical onset of the disease are still debated. Among them, stressful life events and infections have been associated with relapses in multiple sclerosis. Anxiety has also been reported to influence other diseases of unpredictable course. Methods: We studied the presence of self-reported stressful situations as possible precipitating factors contributing to relapses in a cohort of 91 patients aged between 17–36 year old (mean age 26, sex ratio 2/1 with a female predominance), followed prospectively in a 12-months case-control study. They were compared to 80 patients matched for age, sex, and degree of disability, who did not experience clinical exacerbations during the same period. Data on severity and MS course, social and medical information were collected. Every patient completed a specific questionnaire including infectious, traumatic, stressful factors, the social status anterior, concomitant and following MS relapse. Only potential risk factors occurring in the three months preceding the interview were considered. Statistical analysis was performed, Chi-square and Fisher exact tests were used to observe association between categorical variables (Graphpad Instat 3). Results: Relapses were preceded in 66% of cases by a severe stressful situation; in 28% of cases by an infection, and in a third by high temperature exposure. 29% of patients reported more than one factor preceding the relapse. The stressful events as sole preceding factor were encountered in 54% of patients. However, the difference between the relapsing patients and the control group was not statistically significant for the self reported stressful events. Discussion: Psychological stress in MS patients may play an important role on the course of the disease, in addition to episodes of infection. Nevertheless, it was shown that most relapses in patients with declared disease are not preceded by the conditions commonly considered as risk factors. In our study group, even stressful situations were the most frequently reported by patients as preceding relapses, their presence was not significantly linked with disease clinical activity. Since it was already suggested that psychological stress may play a role in the development of MS, further study in the same population is advocated also by trying to quantify the psychological stress.

P236 Physician and patient perspectives in multiple sclerosis: results from the MS Choices Survey A. Rin˜o´n, E. Verdun, M. Buch, D. Holley Merck Serono S.A. (Geneva, CH); GfK NOP Healthcare (London, UK) Objectives: Treatment with disease modifying drugs (DMDs) can delay the progression of multiple sclerosis (MS) and reduce relapse frequency. However treatment effects may be compromized if patients do not adhere to therapy. The level of patient adherence to MS therapies has yet to be accurately measured and poor adherence is likely to be multifactorial. Therefore it is important to have a better understanding of the views of both physician and patients on MS

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S76 therapies. The Global MS Choices Survey investigated patient and physician perspectives regarding key aspects of MS diagnosis, treatment adherence and disease management. Methods: This survey was conducted in 7 countries (UK, Spain, Italy, Germany, France, Canada and Australia), and involved patients with MS (MS diagnosis for C 1 year; age 18–60 years; current treatment with a DMD) and physicians (neurologist for 3–30 years; treating C 15 patients with MS per average month; C 60% of their clinical consultations occupied by patients with MS). Separate questionnaires were used for physicians and patients, each containing approximately 30 questions and taking 15–20 minutes to complete. Results: Questionnaires were completed by 331 patients and 280 neurologists. Several differences were observed between the responses of patients and physicians to specific questions, particularly those relating to treatment adherence. Overall, the proportion of patients reporting taking a treatment break (31%) was almost twice that estimated by neurologists (on average 17%). In addition, 19% of patients reported discontinuing their treatment altogether, compared to on average 14% of patients estimated by neurologists. The reasons cited for poor adherence also differed between the patients and neurologists in the study. For example, more physicians cited side-effects as the main reason for poor patient adherence (226/277, 82%), compared with 42% of responding patients (48/ 113). Conclusion: The MS Choices Survey indicates that neurologists may underestimate the scale of poor adherence to DMDs, which could impact on the assessment of treatment efficacy and result in inappropriate treatment escalation. Further, disparities were identified between patient and neurologist responses regarding the underlying reasons for poor adherence. Improvements in the dialogue between patients and neurologists may increase adherence to DMDs and ultimately lead to better treatment outcomes. Study supported by Merck Serono S.A.–Geneva, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany.

P237 Contemporary trends in survival in multiple sclerosis in the US: study design and rationale G. Cutter, S. Reshef, H. Golub, D. Kaufman, A. Brueckner, R. Preblick, V. Knappertz University of Alabama (Birmingham, US); Bayer HealthCare Pharmaceuticals Inc. (Montville, US); Care-Safe LLC (Newton, US); Slone Epidemiology Center (Boston, US); Bayer Schering Pharma AG (Elbonfeld, DE); Bayer HealthCare Pharmaceuticals Inc. (Wayne, US) Objective: Multiple sclerosis (MS) leads to an established survival disadvantage. However, the details by which this is mediated and the magnitude of the effect in the era of disease-modifying therapy have been insufficiently characterized. This study attempts to assess the current survival challenge in MS utilizing payer data sources, an MS disease-specific cohort, and concurrent control populations. Methods: US national insurance claims data and a US-based MSregistry, NARCOMS, will be utilized in the Survival in Multiple Sclerosis in the United States (SIMS-US) study to assess mortality in patients with MS. All identified MS patients will be queried in the National Death Index and Social Security Administration Death Master File to obtain vital status and cause of death. Patients with MS will be identified by an algorithm specifying ICD-9 340 diagnostic codes, at least one prescription for disease-modifying treatment, and a minimum dwell time within the database. Patient identification will

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be validated through a records review of a representative sample. Non-MS comparison groups will be matched for age in the year MS was first identified in the claims database, gender, and geographic area of residence. Results: Over 40,000 MS subjects will be identified from the claims data, in addition to over 34,000 NARCOMS participants. Survival curves from birth, all-cause and cause-specific mortalities, and proportional mortality rates will be compared between MS and non-MS cohorts. Survival curves from the date of MS diagnosis will be generated within NARCOMS and compared with life span curves and will be presented. Conclusions: SIMS-US is a retrospective study of survival patterns and survival in US patients with MS. SIMS-US will seek to further understand the natural history of MS survival in multiple US cohorts and explore the viability of deriving mortality outcomes from claims databases. Study supported by: Bayer HealthCare Pharmaceuticals, Inc. Montville, NJ, USA

P238 MS-related in-hospital mortality: principal diagnoses associated with death F. Ernst, J. Pocoski, G. Cutter, D. Kaufman, H. Golub, V. Knappertz Premier, Inc. (Charlotte, US); Bayer HealthCare Pharmaceuticals, Inc. (Wayne, US); University of Alabama (Birmingham, US); Slone Epidemiology Center (Boston, US); Care-Safe LLC (Newton, US); Bayer HealthCare Pharmaceuticals, Inc (Montville, US) Objective: To examine mortality-related diagnoses among patients with multiple sclerosis (MS) who died in-hospital compared with patients with diabetes mellitus (DM) and general hospitalized patients (GHP). Methods: Patients who died between January 1, 2007–December 31, 2008 were identified in the U.S. hospital-based Premier PerspectiveTM Database. Patients with principal or secondary ICD-9 codes for MS (code 340) were included in the MS cohort. Comparator groups included patients with a DM ICD-9 code (code 250 and all subcodes) and adult patients with any ICD-9 code (GHP). The single principal ICD-9 diagnosis code for each hospitalization was examined, with some analyses of the hospitalization during which the patient died and other analyses of hospitalizations during which the patient did not die. Analyses conducted thus far have been descriptive in nature, with no statistical comparisons between cohorts. Results: Total unique patients identified in each cohort were 64,436 patients with MS, 2,812,810 patients with DM, and 6,854,350 GHP. For deceased patients with MS, the five most frequent ICD-9 diagnosis categories (frequency) were septicemia (28.6%), other lung diseases (7.7%), cardiac dysrhythmias (5.9%), MS (5.1%), and pneumonitis (4.8%). The corresponding categories for deceased patients with DM were septicemia (16.5%), other lung diseases (9.6%), cardiac dysrhythmias (6.6%), acute myocardial infarct (6.3%), and heart failure (5.2%); and for deceased GHP, septicemia (15.8%), other lung diseases (8.9%), acute myocardial infarction (5.2%), heart failure (4.3%), and pneumonia (organism unspecified) (3.7%). The preponderance of septicemia was observed in nearly all age-groups for all three cohorts. Conclusions: Septicemia was the principal diagnosis for mortality in patients with MS; it was nearly twice as frequent as in patients with DM and GHP. Study supported by: Bayer HealthCare Pharmaceuticals, Inc. Montville, NJ, USA

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P239 The clinical features of late-onset multiple sclerosis in Greek patients E. Andreadou, E. Katirtzoglou, M.E. Evangelopoulos, G. Koutsis, E. Oikonomou, A. Dimitriou, K. Kilidireas, D. Vassilopoulos

EDSS \6 and EDSS score C6 at ten years. Conclusion: The median time from symptom onset to progress to EDSS score 6 was 22 years for Chinese RRMS patients. This study is supported from research funding from Bayer Health care

Athens National University (Athens, GR)

P241 The prevalence and type of pain in multiple sclerosis J. Savic, S. Grgic, I. Marjanovic, D. Kisic Tepavcevic, T. Pekmezovic, J. Drulovic

Objectives: To investigate the clinical characteristics, MRI and CSF findings of multiple sclerosis (MS) patients with disease onset after the age of 50 (late-onset MS, LOMS); to compare them to those with onset between 18-40 years (usual onset MS, UOMS). Methods: The MS center at the Neurology Department, University of Athens acts as a primary, secondary and tertiary referral center for MS patients in Greece. During a period of 5.2 years from 2004 to 2009, the initial symptomatology, course and severity of MS in 1,055 consecutive patients were recorded. MRI and CSF data were collected. Results: Sixty-nine patients with LOMS and 778 with UOMS were identified. In the LOMS group, 50.7% had primary progressive MS compared to 5.9% in the UOMS group (p\0.001). Initial symptomatology was significantly different between LOMS and UOMS (p 0.009), with long tract dysfunction more common and optic neuritis/ brainstem dysfunction less common in LOMS compared to UOMS. Mean EDSS score was 3.4 ± 1.8 for LOMS and 2.27 ± 2.08 for UOMS patients (p\0.001). The mean MS Severity Score (MSSS) score was 6.8 ± 2.4 for LOMS and 3.1 ± 2.7 for UOMS patients (p\0.001). Gadolinium-enhanced lesions were less frequently found in LOMS than in UOMS patients (27.3% vs. 50% p= 0.004). No significant differences were observed in gender distribution or presence of oligoclonal bands between the two groups. Conclusion: Primary progressive course, higher EDSS and MSSS score are significantly more frequent in LOMS compared to UOMS patients. The distribution of initial symptomatology is also different between the two groups.

P240 Clinical outcome of of Chinese relapsing remitting Multiple Sclerosis patients K.H. Chan, C. Tse, S.L. Ho, P.W. Ho, J.W. Ho

Clinical Centre of Serbia (Belgrade, RS); Clinical Centre of Banja Luka (Banja Luka, RS); University of Belgrade (Belgrade, RS) Objectives: Pain is a frequent symptom in multiple sclerosis (MS), although its prevalence vary in different studies from 29% to 86%. We analysed the prevalence and type of the different painful syndromes (dysesthetic pain, trigeminal neuralgia, Lhermitte’s sign, musculosceletal pain and headache) that affect patients with MS. Methods: In a cross-sectional study, the authors assessed pain in patients with MS using a symptom-oriented approach. A semistructured questionnaire was administered during a face-to-face interview with 272 consecutive multiple sclerosis (MS) outpatients followed-up over a 3-month period, at the Department of multiple sclerosis, Institute of Neurology, Clinical Center of Serbia, Belgrade, and Clinic of Neurology, Clinical Centre of Banja Luka. Results: The mean age of the patients was 38.5 years, and female/ male ratio was 2.5. The mean disease duration was 8.2 years and the median Expanded Disability Status Scale was 3.0. Most of the patients were affected by the relapsing-remitting form of the disease (80.1%), while the remaining 19.9% suffered from secondary progressive MS and primary progressive MS. Lifetime prevalence at the date of examination of at least one type of neuropathic pain was 70.2% in MS patients, while the actual prevalence was 44.5%. Pain and frequencies included dysesthetic pain 46.4 %, Lhermitte’s sign 19.5 %, musculosceletal (painful tonic spasms, low back pain) in 27.6%, headache in 33.1%. Conclusion: These findings present preliminary data of our ongoing study which suggest high prevalence of pain in our MS sample. Our results underline the necessity of pain evaluation in MS patients for a more specific and individualized treatment.

The University of Hong Kong (Hong Kong, HK) A significant proportion of relapsing remitting multiple sclerosis (RRMS) patients develop irreversible deterioration, secondary progressive disease (SPMS) with accumulating neurological disability. Reported outcome and prognostic factors are inconsistent and information from Chinese is limited. Aim: study the clinical outcome of Chinese RRMS patients with duration C10 years. Method: RRMS patients with MRI abnormalities fulfilling Barkhof’s criteria for dissemination in time and space followed up in our hospital is studied retrospectively. Results: 61 RRMS patients were studied. Their mean symptom onset age was 26.5 years (range 12-50), mean duration after symptom onset was 20.3 years (range 10-33); 48 (79%) were female. At 10 years, 30% patients had EDSS score B2, 34% EDSS 2.5–3.5, 20% EDSS 4.0–5.5 and 16% EDSS C6, and 20% developed SPMS. At latest follow-up (mean duration 20.3 years), 15% patients had EDSS B2, 20% EDSS 2.5–3.5, 19% EDSS 4.0–5.5 and 46% EDSS C6.0, and 59% developed SPMS. The median time from symptom onset to EDSS 6 was 22 years. The mean duration from symptom onset to SPMS was 13.2 (range 7–20) years. No differences were detected in demographic characteristics, presenting neurological features, relapse frequency, neuroradiological findings and disease modifying therapies between patients with

P242 Clinical factors determining MS-related quality of life A. Gruszczak, K. Pocinska, H. Bartosik-Psujek Clinical Hospital (Lublin, PL) Objectives: Objective factors and subjective opinions are important in estimation of patient’s state because they consist on the quality of life. As subjective factors of quality of life in MS we can classify: fatigue, pain, vision problems, bladder and bowel problems, sexual satisfaction, perceived cognitive deficits and mental health. Patients with similar clinical symptoms may differ in functioning because the correlations between objective rates of disease and patients filings are not always significant. Aim: The aim of the study is to measure and analyze the influence of subjective clinical factors on the MS related quality of life. Methods: 122 inpatients with clinically definite MS, according to McDonald criteria, were investigated. To measure the quality of life the MS-specific HRQOL instrument, Multiple Sclerosis Quality of Life Inventory (MSQLI), was used. It consists of a generic measure, the Health Status Questionnaire (SF-36) and nine symptom-specific

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S78 measures. The functional impairment was estimated using Expanded Disability Status Scale (EDSS). Results: The physical component score (PCS) significantly correlated with fatigue (R=-0,39, p=0,000007), pain (R=-0,41, p=0,000002), bladder (R=-0,34, p=0,0001), bowel (R=-0,27, p=0,002) and vision problems (R=-0,2, p=0,02). Whereas the mental component scores (MCS) significantly correlated with fatigue (R=0,6, p=0,0000001), pain (R=-0,56, p=0,0000001), bowel problems (R=-,023, p=0,01), vision problems (R=-0,34, p=0,00009), perceived cognitive deficits (R=-0,31, p=0,0004) and mental health (R=0,69, p=0,0000001). In regression model as independent determinants of quality of life in physical domain remain: fatigue, pain and mental health. Whereas as determinants of quality of life in psychical domain remain: fatigue, cognitive functioning and mental health. Conclusions: Symptoms such as: fatigue, pain, mental functioning, perceived cognitive deficits worsen the quality of life of patients with MS, so complex therapy, which contains treatment of symptoms connected with both physical and psychical functioning, is important.

P243 Fatigue in menstrual cycle: comparison of premenstrual period and ovulation phase in patients with multiple sclerosis Y. Guven Yorgun, S. Ozakbas, E. Idiman Dokuz Eylul University (Izmir, TR) Objectives: During the course of multiple sclerosis (MS) 50-80% of patients complain of fatigue, and the prevalence of fatigue has been shown as higher than many typical MS symptoms. It has not been found to correlate closely with either demographic features or disability. It, sometimes, may be a transient phenomenon. Premenstrual symptom worsening has been shown in retrospective analysis in MS patients. The aims of the present study were to determine the relationship between fatigue and menstrual cycle periods and to investigate symptom severity as perceived by patients in premenstrual period. Method: 27 relapsing remitting ms patients included in the study. Mean age was 34.02, mean disease duration was 7.6 years. Patients were given; modified fatigue impact scale (MFIS), which provided an assessment of the effects of fatigue in terms of physical, cognitive, and psychosocial functioning. Fatigue severity scale (FSS), which is designed to differentiate fatigue from clinical depression, since both share some of the same symptoms, and Beck depression scale (BDS). Patients’ perception about fatigue was measured by visual analog scale (VAS). All scales were administered in premenstrual period and ovulation phase for 2 consecutive cycles. Fatigue scores compared between two periods, and correlations with depression scale and demographic features were detected. Results: There was no difference in the periods in terms of FSS, but patients were significantly more fatigued in premenstrual period on the basis of MFIS (p=0.023). The most prominent difference was detected on cognitive fatigue scores of MFIS (p=0.008). Physical score of MFIS was also significantly impaired in the premenstrual period compared to ovulation period (p=0.046). Patients’ perception of fatigue significantly declined in the premenstrual period (p=0.03). There was no difference in social score of MFIS. Fatigue severity scale had moderate negative correlation with MFIS (r= -0.369, p=0.043). Conclusions: Our results suggested that there is a clear, possibly, transient fatigue in the premenstrual period, and MFIS seems to be more sensitive to demonstrate fatigue change, at least, to detect menstrual cycle changes in patients with MS.

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P244 The study of circadian rhythms disorder and its relationship with chronic fatigue in multiple sclerosis and comparison with control group M. Najafi, S. Haghighi, M. Etemadifar, A. Maghzi, F. Najafi, M. Akbari Alzahra University Hospital (Isfahan, IR) Objectives: The aim of this study is to determine the frequency of circadian rhythm disorders in MS patients in compare with control group and ascertain its association with chronic fatigability. Methods: The study was case-control and held on 2009 in MS Clinic in Azahra Hospital on 120 MS patients and 60 people as control group. The questionnaires of Pittsburgh Sleep Quality Index (PSQI), FSS and EDSS was given to patients and for assessing the circadian rhythm disorders, the PSQI questionnaire was given to control group too. All the findings was analyzed in SPSS software. Results: The amount of circadian rhythm disorders in MS patients was significantly higher than control group (P=0.002). In this manner, these kind of circadian rhythm disorders in patients with severe fatigue was significantly higher than patients with mild fatigue (P\0.05). Conclusion: This study showed that the rate of CRDs in MS patients with severe and mild fatigue was higher than control group and also there was relationship between Circadian Rhythm Disorders and chronic fatigability.

P245 Sexual dysfunction in patients with multiple sclerosis: an exploratory hospital-based study R.S. Calabro`, L. De Santi, E. Palella, S. Passari, E. Sessa, P. Bramanti IRCCS Centro Neurolesi ‘‘Bonino-Pulejo’’ (Messina, IT) Objectives: Sexual dysfunction (SD) is a common and unfortunately an overlooked symptom of Multiple Sclerosis (MS), severely impacting on patient quality of life. Its prevalence ranges between 40% and 80% in women and between 50 and 90% in men. Sensory genital dysfunction and erectile dysfunction are the most frequently reported SD in women and men, respectively. MS can directly affect neurophysiological process of sexual function but physical disability, other comorbidities and psychosocial status can further complicate the disorder. This study was aimed at investigating the prevalence of SD in a hospital cohort of MS patients. Methods: Eighty-seven consecutive outpatients, aged between 18 and 60 years (54 females and 33 males) and regularly followed in our hospital, were enrolled in the study. Eighty-one MS patients showed a relapsing-remitting clinical course while 6 had a secondary progressive course. All the patients were asked to fill a specific questionnaire, created by a team of skilled neurologists and sexologists, to explore patient sexual life and the relation between sexuality and MS. Physical disability was assessed through the Expanded Dysability Status Scale (EDSS). Results: Sixty-one % of patients changed the way they viewed themselves with a reduction of self-esteem after the diagnosis of MS. The onset of MS determined a lower frequency of sexual intercourses compared to that before (p \ 0.0001). 69% of patients complained at least a SD (decreased libido, erectile dysfunction, premature or retarded ejaculation, painful penetration) and in 22% the disorder was reported as frequent. 42% of patients complained a reduced libido, the most frequent SD, in the year before the observation. Libido showed a significantly negative correlation with disability expressed by the EDSS (r = -0.32, p = 0.005) but not with disease duration (p = 0.1).

S79 Conclusion: The diagnosis of MS itself determines the reduction of self-esteem and of the interest in engaging sexual intercourse with decreased libido. According to previous studies, our results show a high prevalence of SD in patients with MS with a correlation with physical disability but not with disease duration. Since preventive strategies and treatments might manage SD, it is necessary to increase the focus on sexual aspects when counseling MS patients.

P246 Social support in patients with multiple sclerosis K. Naumiuk-Sojczuk, S. Sojczuk, A. Nasilowska-Barud, H. Bartosik-Psujek, Z. Stelmasiak Clinical Hospital (Lublin, PL) Multiple sclerosis is a chronic, inflammatory, demyelinating disease of the central nervous system, in which a multifocal, disseminated damage (demyelization and axons degradation) of the nervous tissue occurs. The main feature of the disease is the presence of disseminated demyelinating foci (e.g. plaques) which cause various neurological symptoms. Multiple sclerosis is a life-long disease, the degree of symptoms intensification and their dynamics are varied. The aim of the study was evaluation and analysis social support obtained from the family, friends and health service by the investigated MS patients. The study included 120 patients hospitalized in the Clinic of Neurology of the Public Clinical Hospital nr 4 in Lublin. The investigated group included 75 women (62, 50%) and 45 men (37, 50%). The following scientific methods were employed: Own Construction Questionnaire, Tardy’s Social Support Scale in the authorized translation of K. Kmiecik-Baran. The investigated MS patients obtained most evaluation support from their family members. Friends, colleagues, health service provided the investigated MS patients with the most instrumental and evaluation support. The investigated MS patients obtained the least emotional support from all support groups (family, friends, health service). Both men and women obtained on average the most evaluation support from their families and health service. Whereas they obtained least emotional support from all social groups providing social support. Study results provide new data concerning the influence of the somatic disease on psychological functioning of people. They may be useful in broader recognition of problems encountered by patients with multiple sclerosis.

P247 Social and economic burden in multiple sclerosis patients J. Kruja, J. Naska, I. Zekja, S. Mijo, S. Grabova, A. Kuqo University Hospital Centre Mother Theresa (Tirana, AL) Objectives: A number of studies have suggested that multiple sclerosis affects negatively the social impairment, daily activities, sexual relationships ecc. Social and economic exclusion play an important role to the patient’s life trajectory. The aim of this study was to examine the impact of MS to the social and economic exclusion particularly in the following domains: social functions and roles, economic constrain, marital status, family relationships and education. Methods: A randomized control trial of patients (n=100) with a definite diagnosis of MS completed validated questionnaire of Multiple Sclerosis Quality of Life Inventory (MSQLI), MSSS - Form with a particular attention to the positive social interaction. It was also estimated by an individual interview the social and economic frame,

level of education and additional lifestyle features. This survey was conducted from November 2008 to December 2009 in Hospital Centre ‘‘Mother Teresa’’ Service of Neurology, Tirana, Albania. The indicators used in this study are interpreted by harmonizing qualitative and quantitative narrative analyses. Results: Over 29% of total interviewed patients (mean age 38) are classified with severe social problematic and 49% (mean age 36) are estimated with moderate social problematic to which correspond moderate levels of disability of 4,6 and 3 points, assessed by Expanded Disability Status Scale (EDSS). Further data analyzing permit a detailed assessment and the association between neurological impairment and social - economic difficulties, emphasizing social alteration during patient’s disease course. Female patients reported elevated social isolation features measured in 75% by total. Eleven percent of subjects interviewed and also evaluated with severe social problematic are divorced meanwhile the low education level (4 – 8 years of basic education) is represented by 39 % of total sample. Conclusion: Multiple sclerosis reduces opportunities and appropriate choices of patients determining the lack of social and economic inclusion. Accomplishment of social functions and roles is associated with the scale of disease disability.

P248 Epistasis among HLA-DRB1 alleles in a Spanish cohort with multiple sclerosis L. Romero-Pinel, J. Pujal, S. Martı´nez-Ye´lamos, L. Gubieras, E. Matas, L. Bau, M. Torrabadella, C. Azqueta, T. Arbizu University Hospital of Bellvitge (L’Hospitalet de Llobregat, ES); Cord Blood and Tissue Bank (Barcelona, ES) Background and objective: Multiple sclerosis (MS) has been consistently associated with the HLA-DR2 haplotype and particularly with the HLA-DRB1*15 allele. Epistatic interactions among both parental alleles in the DRB1 loci have been demonstrated to modify the risk susceptibility. This study investigated the frequencies of the different genotypes of HLA-DRB1, their impact on MS susceptibility and their correlation with the clinical severity in a Spanish population. Methods: A genotype was considered as the combination of the two parental alleles of DRB1. We compared the frequencies of the genotypes in a sporadic MS population (n=380) and an unrelated healthy control cohort (n=1088). Patients were registered using the European Database for Multiple Sclerosis (EDMUS) and followed up on a six-monthly basis. All the patients selected for this study fulfilled the McDonald criteria for Multiple Sclerosis. The mean age at onset was 29.55 years (SD 9.97), the 64.5% were female, the mean disease duration was 11.7 years (SD 8.15, range 0.13–45.2) and median Extended Disability Status Scale (EDSS) score was 2 (range 0–8.5). The clinical course was relapsing remiting (RR) in 332 patients, secondary progressive (SP) in 31 patients and primary progressive (PP) in 17 patients. We correlated the different genotypes with the age at onset, sex distribution, symptoms at onset, course of the disease and progression severity by means of the time to reach the progressive phase and an EDSS of 3 and 6. The statistical methods performed were Pearson chi-square test, t-Student test, Kaplan Meier survival analysis (log rank) and Cox logistic regression as appropriate. Results: We found 81 different genotypes. There were four different genotypes which predisposed to MS. Three of them contained the DRB1*15 allele (DRB1*03/15, DRB1*04/15, DRB1*08/15) and the fourth was homozygote for the DRB1*03 allele. The highest odds-

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S80 ratio was found with the genotype DRB1*08/15 (OR=3.88, 95% CI=1.83–8.26, p\0.01), followed by the DRB1*03/03 (OR=3.15, 95% CI=1.93–5.14, p\0.01), the DRB1*03/15 (OR=2.72, 95% CI=1.88–3.94, p\0.01)) and the DRB1*04/15 (OR=2.54, 95% CI=1.64–3.98, p\0.01). The DRB1*01/04 and the DRB1*15/15 genotypes where associated with a shorter time to reach an EDSS of 6. Conclusions: Our results show the importance of epistatic interactions among the HLA-DRB1 alleles, modifying the risk for multiple sclerosis as well as the clinical severity.

P249 Concomitant central and peripheral inflammatory demyelinating disease: report of four patients E. Andreadou, A. Moustris, V. Pappas, A. Areovimata, M.E. Evangelopoulos, G. Koutsis, K. Kilidireas, D. Vassilopoulos Athens National University (Athens, GR) Inflammatory demyelinating diseases are a heterogeneous group of disorders that may affect the central or peripheral nervous system. Rare forms of concomitant central and peripheral demyelination, sometimes fulfilling the criteria for multiple sclerosis (MS) and/or chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) have been reported in the literature. Objectives: We screened 1055 consecutive patients, followed up at the Unit of Demyelinating Diseases of the Neurology Department, University of Athens, during the period 2004–2009. We reviewed clinical features, MRI and cerebrospinal fluid data to identify patients with demyelinating disease possibly involving both the central and peripheral nervous system, not attributable to other causes. Results: Four patients with this combination of clinical involvement were found. The first patient had an episode of acute transverse myelitis at 12 and multiple demyelinating lesions on spinal MRI, the second one presented at the age of 18 with belt distribution of dysaesthesia in the chest area and demyelinating lesions on brain and spinal MRI and the third one presented at the age of 19 with an episode of transverse myelitis and multiple demyelinating lesions on spinal MRI. All three patients, the following years developed a disease indistinguishable from relapsing CIDP. Finally, the fourth patient presented at the age of 20 with left hemihypaesthesia followed by retrobulbar neuritis and had multiple demyelinating lesions on brain and spinal MRI. All patients had a high CSF protein level without pleocytosis and without oligoclonal bands, abolished deep tendon reflexes and electrophysiological data compatible with a sensorimotor demyelinating polyneuropathy. Conclusions: Simultaneous central and peripheral demyelination is an ill-defined entity that can occur on rare occasions. Although some features appear to be similar among this entity and the common demyelinating diseases (MS and CIDP), its etiology remains elusive and treatment trials are lacking.

P250 Primary progressive multiple sclerosis switching to a relapsing-remitting form, following a fulminant episode M. Tu¨tu¨ncu¨, O. Delikan, F. O¨zer, S. Saip, A. Siva Istanbul University (Istanbul, TR); Haseki Hospital (Istanbul, TR) Background and goals: Primary Progressive Multiple Sclerosis (PPMS), switching to a relapsing remitting form is unexpected,

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since they are distinct disorders. We report the clinical and radiological features of a patient with PPMS, who experienced an unexpected fulminant episode and then clinically switched to RRMS. Method: Case report of a PPMS patient who had developed a clinical picture consistent with severe acute encephalopathy followed by a relapsing-remitting course. Result: A 29-year-old male with a past history of gradual gait difficulty and weakness in the legs with bladder dysfunction since September 2000, showed progressive spastic paraparesis and decreased vibration sense in the lower extremities on examination, had only a few lesions consistent with MS on his consecutive magnetic resonance images (MRI) without much change over years.He was diagnosed and followed as PPMS. He was relatively stable at EDSS 7 for the last 2 years and had no new MRI activity until April 2007, when he developed severe headache, upper extremity weakness, confusion, agitation and meningismus. His serology and blood tests were negative. The CSF had shown oligoclonal bands and high IgG level. Cranial MRI showed bi-hemispheric multiple large enhancing demyelinating-inflammatory lesions of the same age, suggestive of fulminant MS. He was treated with high-dose methylprednisolone for 10 days and made a gradual recovery over four months and was back to his baseline. His acute MRI lesions improved and he was back to his earlier EDSS score of 7 and remained stable. However, on March 2009, he developed diplopia, dysarthria and slurred speech, and an MRI done at this time showed multiple gadolinium enhancing new lesions, consistent with RRMS! Conclusion: We are not aware of earlier reports of PPMS switching to RRMS following a fulminant episode, all seen in the same patient. Both disorders are considered as clinically and immunopathogenetically distinct disorders and are not expected to occur in the same individual. This case may be an illustrative example for the concept that idiopathic demyelinating disorders may overlap in the same individual.

P251 Persistent hiccups induced by high-dose methylprednisolone in optic neuritis G. Genc, S. Bek, T. Kasikci, G. Koc, S. Demirkaya, Z. Odabasi Gulhane Medical Faculty (Ankara, TR) Introduction: We report a case of optic neuritis who developed persistent hiccups associated with high-dose intravenous methylprednisolone (IVMP) therapy. Case report: A 50 year-old man was admitted to our hospital for right optic neuritis and applied 1 g/day IVMP therapy for 3 days. Hiccups began 24 hours after the initial injection and became persistent. Neurological examination was normal except right optic neuritis. Brain and cervical magnetic resonance imaging (MRI), MR angiography, thorax tomography were all normal. Persistent hiccups were controlled by oral chlorpromazine 25 mg/day within 3 days and treatment was terminated at the fifth day of the treatment. Conclusion: The mechanism of the hiccups associated with IVMP is unclear. In animal studies, glucocorticoids reduced the threshold of synaptic transmission in the midbrain by increasing the amplitude of peripherally stimulated evoked potentials in the midbrain, and regulated the metabolism of neurotransmitters in rat brain. We suggest that persistent hiccups were induced by high-dose IVMP therapy because of the lack of known causes and the temporal relation between IVMP administration and the occurence of hiccups. Eventually, hiccups may develop due to high-dose IVMP therapy and several treatment options are available.

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Neuro-rehabilitation P252 Effects of night sleep on motor cortical excitability following finger-tapping task H.Y. Jung, H.J. Lee, J.J. Lee, T.H. Kim Inha University Hospital (Incheon, KR) Objectives: We wanted to investigate whether night sleep could affect the motor cortical excitability following a finger tapping task by using transcranial magnetic stimulation. Methods: Eight healthy volunteers were enrolled to investigate the effect of day wake or night sleep on the motor cortical excitability following finger tapping. The subjects were trained on a finger tapping task at 9:00 am or at 9:00 pm and they were retested for the same task 12 hours later after either sleeping or being awake, respectively. The finger tapping task was performed by the index finger of the nondominant hand with the patient in the sitting position, and it was guided with the same PC words training programs. These two phases were a counterbalanced crossover design. Whether or not there were changes of cortical motor excitability was examined with transcranial magnetic stimulation (TMS) and electromyography(EMG), and these procedures consisted of the resting motor threshold (rMT), the paired pulse tests (ICI & ICF), the recruitment curves (RC), the compound muscle action potentials (CMAP), the F waves recorded at the right first dorsal interossei (FDI) and also the differences of the hand performance levels. The data was assessed by comparing the changes of cortical excitability between day wake and night sleep after equivalent amounts of training. Results: The results showed that for the night of sleep cases, the finger performance level, the ICI and the RC with 140% of the rMT were significantly changed (p\0.05), but the ICF and the RC with 120% of the rMT were not changed between the pre- and post-task training (p[0.05). For the day wake cases, there were significantly changes in the finger performance level and the RC with 140% of the rMT (p\0.05), but the ICI, ICF and RC with 120% of the rMT were not changed between the pre- and post-task training (p[0.05). Conclusion: The above findings suggest that between day wake and night sleep, there were some different changes of cortical excitability after the same finger task training and presumably, night sleep might have additional effects on cortical motor excitability via GABA dependent synaptic enhancement.

P253 Is action slowing a determinant of disability in stroke patients? O. Godefroy, S. Spagnolo, M. Roussel, M. Boucart University Hospital (Amiens, FR); University Hospital (Lille, FR) Objective: To determine mechanisms, determinants and prognostic value of action slowing. Methods: Thirty six stroke patients not presenting any clinical motor deficit of the preferred hand (mean post-stroke delay: 11 months) were compared to matched controls on Finger Tapping test (motor speed), Visual Inspection time test (visual perceptual speed) and Simple and Choice Reaction Time tests. Results: Patients were slower on all tests except Choice Reaction Time: Visual Inspection (p=0.003), Finger Tapping test (p=0.001), Simple Reaction Time (p=0.002) tests were impaired including performance measured with the ipsilesional hand. This pattern and

the uniform lengthening across the entire Reaction Time distribution both suggest that psychomotor slowing was due to slowing of perceptual and motor processes. The main determinant of action slowing was lesion location: (1) Visual Inspection time: right inferior parietal lobulus (OR: 18; 95CI: 2.9–108); (2) Finger Tapping: left frontal middle gyrus (OR: 18; 95%CIs: 2.9–108) and lenticular nucleus (OR: 59; 95%CIs: 1.9–1775); (3) SRT: right lenticular nucleus (OR: 110; 95%CIs: 8-1490) and posterior fossa (OR: 55; 95%CIs: 3.4–890). Finally poor outcome depended on tapping frequency measured with the contralesional index (OR: 0.1; 95%CI: 0.02-0.5; p=0.0005) and impairment on the Token test (OR: 151; 95%CI: 2.24-1136; p=0.02). Conclusions: This study shows that stroke-related action slowing is mainly due to slowing of perceptual and motor processes. Action is slowing was related to lesion of large network. Finally tapping frequency is an independent predictor of outcome. This supports that action slowing is an important consequence of stroke and that it is a promising prognosis indice.

P254 The diagnostic of hand function disorders after spine cord injury I. Morozov, S. Belousov Nizhny Novgorod Research Institute of Traum and Orth (Nizhny Novgorod, RU) Objectives: The aim of study is to reveal the hand motor function disorders after spine cord injury. We use the original biomechanical method for examination. Methods: We have evaluated 60 patients with cervical spinal cord injuries. 54 males and 6 females in the age from 16 to 57 y.o. were involved. The neurological level and degree of injury were established and tested according to the American Spinal Injury Association classification as following: type A - 34.8% patients, type B - 28.3%, type C - 21%, type D - 13% and 2.9 % patients with type E injury. The analyzer of pressure «F-Scan» was used for visualization and quantitative analyze of distribution of the loading on the various zones of the hand. This technique has been accepted for assessment of weight-bearing of the foot during the walking. With the use of this technique we examined the characteristics and degree of pressure distribution on the various hand zones during the forced grip. Sensor elements connected with computer are applied on 65 mm diameter cylinder. ‘F-Scan’ records loading distribution on the palm, II-V fingers, thumb and thenar when the patient grip cylinder with maximal force. Results: It was revealed that spine cord injury on C4-5 level leads to redistribution of the loading on thumb and palm, C5-C6 - to increasing of the loading on II-V fingers, in C7 level injuries the loading on thenar appears and distribution of the loading approximates to normal. We have determined that in type A (ASIA) injuries two from all other various hand zones are kept uninvolved; distribution of the loading between two ‘working’ zones is equal or significant predominance of one of the zone occurs. The loading on thumb is considerably more that normal in type B and C injures. Major distinction between these groups and type C injuries is appearance of loading on thenar. In type D injury loading distribution approximates to normal. Conclusion: Thus we resume that spine cord injury results in loading redistribution on the various hand zones according to the level and degree of injury. Loading redistribution and appearance of new loaded hand zones during the dynamic control of the patients are favorable criteria of hand function restoration.

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P255 Aphasia and life quality in stroke patients—an exploratory study of SS-QOL in patients with aphasia C. Magalha˜es, S. Pires-Barata, S. Moita, L. Rebocho, M.H. Teixeira da Silva Hospital do Espirito Santo EPE (E´vora, PT) Purpose: The quality of life in patients with aphasia is not well documented due to the fact that they are frequently excluded from the life quality studies. The aim of this study is to analyse the life quality among stroke patients with aphasia when compared to stroke patients without aphasia. Methods: Twenty stroke patients (10 with aphasia: Motor Transcortical, Anomic and Conduction Aphasia and 10 without aphasia) were evaluated with SS-QOL. The inclusion criteria’s for the study were: first stroke, 3 to 18 months from the vascular event, aphasia without comprehension deficit, independent walking and being on rehabilitation. Results: Our sample of 20 patients, age 71±11, 12 were men. Ischemic stroke was found in 17 patients, 12 in the left hemisphere and 8 had a time of evolution of [3–6 months]. The time of evolution was discrepant between the two groups, most of the non aphasic had a shorter time, when considering the aphasic group. The life quality was altered on both groups, although the patients with aphasia revealed better quality of life. The motor transcortical aphasia patients revealed worst life quality when compared to the other aphasia subtypes and to the patients without aphasia. Discussion: The evaluation of the quality of life in patients with aphasia is possible. Significant differences in quality of life were observed in both groups and in the aphasia subtypes. The size of the sample might contribute to the lack of association between other variables. More research is needed to better understand the quality of life in stroke patient with aphasia in order to provide a better therapeutic intervention.

P256 Increase of neuropsychological aspects on specific revalidation H. Brissart, M. Leroy, C. Baumann, C. Vachon, M. Debouverie Central Hospital (Nancy, FR); EPNSF (Fresnes, FR); University of Nancy (Nancy, FR) Background: Actually, most of researches have focused on cognitive rehabilitation interventions for persons with Multiple Sclerosis (MS). Methods and designs of these studies have been widely criticized (O’Brien and al., 2008). Objective: We elaborated upon and evaluated the efficiency of a revalidation program applied to MS patients. It proposes various exercises according to recent remediation theories, in order to both stimulate impaired cognitive functions and develop new abilities to compensate for these cognitive discrepancies. Design/Methods: We administered PROCOG-SEP during 10 sessions each lasting 2 hours, every two weeks, to 39 patients suffering from MS: 21 females, 7 males, with a remittent form [EDSS: 3,14 (r:1,5)]. Group control is composed of 10 MS patients: 9 females, 1 male. No statistical differences were observed concerning EDSS, disease duration or level of education with experimental group. PROCOG-SEP stimulated lexical access, verbal and non verbal episodic, semantic and working memory and executive functions, developed associative memory and favored social interaction and a

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final exercise included all stimulated functions. Data was collected using BCcogSEP performances and included a psycho-clinical interview to complete each cognitive evaluation. Results: Wilcoxon statistical analysis has shown improvements before and after PROCOG-SEP on BCcogSEP subtests such as visuospatial memory (p = 0,004) and verbal fluency (p = 0.04) for the experimental group. Conclusions: These results confirm the data observed in a preliminary study (Brissart et al, 2009). For the first time, to our knowledge, we presented a program that manages cognitive deficits caused by MS. These results allow us to believe in the possibility of improving not only cognition but also the quality of life of patients with MS.

P257 Preliminary data on bladder dysfunction and treatment in a group of neurological patients F. Locatelli, G. Selvaggio, F. Allera, S. Galbiati, F. Formica, V. Torri Clerici, P. Avantaggiato, E. Beretta, A. Bardoni, G. Poggi, S. Strazzer IRCCS E. Medea (Lecco, IT); Childrens’ Hospital V. Buzzi (Milan, IT) Objectives: Neurological bladder disorders are not only common after spinal cord lesions but also following different cerebral lesions. The aim of our study is to evaluate the occurrence of neurological bladder dysfunctions in a group of heterogeneous neurological patients, especially focusing on patients affected by cerebral lesions. Methods: We collected clinical-instrumental data regarding patients evaluated at our neurological bladder dysfunction department from 2006 to 2009: sex, age, aetiology, symptoms, laboratory exams, urinary tract and bladder scans, urodynamic exams when requested. Results: So far we have evaluated 63 patients, the majority of whom are in paediatric and juvenile age. Regarding aetiologies, 66.7% of them are affected by a wide variety of cerebral lesions, mainly traumatic injury, tumour, cerebral palsy, cerebrovascular event, anoxia. 28.6% patients have spinal cord pathologies. 4.7% of them are probably affected by primary enuresis. Symptoms like straining, dysuria, increased urine voiding frequency, incontinence, urgency, retention and enuresis were referred. Infections or negative exams were found at urinalysis and urine culture. At urinary tract and bladder scans gravel, nephrolithiasis, hydronephrosis or a negative exam were detected. The urodynamic exam revealed detrusor areflexia or detrusor hyperreflexia, particularly in spinal cord lesions, whereas mixed alterations of bladder function or negative exam were found in cerebral lesions. The therapies we proposed for neurogenic bladder due to spinal cord lesions are mostly anticholinergic drugs and/or daily intermittent catheterisms, together with antibiotics (when necessary). When neurogenic bladder is of cerebral origin, our treatments and indications are extremely varied: anticholinergic drugs, intermittent catheterisms, antibiotics, hydration, prevention or treatment of nephrolithiasis, pelvic rehabilitation, a-lythic drugs, desmopressin, spontaneous voiding stimulation. Conclusions: Ours is a miscellaneous group of patients with different bladder and urinary tract dysfunction of neurological cause. Patients with spinal cord lesions present with a homogeneity of clinical features, hence the different diagnostic exams and treatment options. Conversely, patients with cerebral injuries present with highly variable patterns of symptoms and characteristics which presuppose individual therapeutic approaches and responses to therapies, sometimes without beneficial effects.

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P258 Post-stroke pain management R.E. Popescu, R. Constantinescu, A.S. Nica University Emergency Hospital (Bucharest, RO); National Institute of Rehabilitation (Bucharest, RO); University of Medicine and Pharmacy (Bucharest, RO) Objectives: The aim of the study is to present an evaluation algorithm and following of the nociceptive and neuropathic pain in hemiplegic patients, after a right ischemic stroke, included in a complex neurorehabilitation program. Methods: The study included 17 patients with the following criteria: age up to 65 years old, overweight, no cardiovascular complications, hospitalized in Neurology and Medical Rehabilitation Departments. We noticed pain topography: head and neck region, shoulder, hip and knee joints. Also we noticed as type of pain: central, peripheral and mixed. The clinical evaluation of these patients has been made using visual and analogical scale (VAS) and neuropathic pain scale. The rehabilitation program, up to 3 weeks, had the objective to improve the functional locomotor parameters in connection with the dynamics of pain, applying a complex rehabilitation treatment including physical-kinetic program and medication. We followed two categories of patients, first receiving only drugs and second, combined physical therapy and drug therapy. We followed the pain in dynamics and the reassessment of the functional locomotor aspects after the improvement of pain. Results: The study pursued the correlation between the pain and the initially functional level, also the functional and clinical dynamics of the hemiplegic patients from the studied groups, under different complex treatment, in order to notice the benefits and the limits of the both therapeutically offers. The results had been pursued biostatistically and we noticed that the average of the improving pain, after 3 weeks of treatment, pursued by VAS, was bigger to the patients treated with combined therapy, 50%, than 40% treated only with medication, without a remarkable difference. We have marked the pain score after a week since the beginning of treatment and we have noticed that the average of improving pain was meaningful bigger in the patients with the combined therapy 25% in comparison with 10% in patients treated only with drug therapy. Conclusions: Concerning simptomatology, the evolution was prolonged in the patients treated only with medication. The combined therapy produced the decrease of intensity of pain, more rapidly, that determined a better application of the rehabilitation program with the primary objective being the independence of the patient over his problems and better reaction to daily solicitations.

P259 The Nociception Coma Scale: a sensitive scale to assess nociception in disorders of consciousness C. Chatelle, A. Vanhaudenhuyse, S. Majerus, D. Ledoux, M. Boly, O. Gosseries, M.-A. Bruno, P. Boveroux, A. Demertzi, G. Moonen, S. Laureys, C. Schnakers on behalf of the Coma Science Group Objectives: Assessing behavioral responses to nociception is difficult in severely brain-injured patients recovering from coma. Recently, we proposed a new scale developed to assess nociception in vegetative (VS) and minimally conscious (MCS) coma survivors, the Nociception Coma Scale (NCS). In this study, we explored its ability to assess specific behavioural responses linked to nociception. Methods: By using the NCS, we assessed the behavioral responses of 25 postcomatose patients (11 VS and 14 MCS; age range 15-82 years; 10 of traumatic etiology; 11 acute) during a baseline and following noxious (pressure applied to the fingernail) and tactile (tap on the shoulder) stimulations.

Results: Differences in the NCS total scores were tested with mixed repeated measures analyses of variance on condition (baseline, tactile, nociceptive) as within-subject factors, and the level of consciousness (LOC), etiology and time since the onset as between-subject factor. Results showed a main effect of condition (F= 49,665; p\0.001). By using post-hoc analyses, we found a significant differences between NCS total scores in baseline and nociceptive condition (t=-7.256; p \0.001) and, more interestingly, between tactile and nociceptive condition (t=-8.413; p\0.001); NCS total scores being higher for the nociceptive condition. Moreover, we found an interaction between condition and LOC (F=5,905; p=0.001). Post-hoc analyses confirmed a significant difference between MCS and VS patients, specifically, for the nociceptive stimulation; MCS patients showing higher scores than VS in response to nociceptive stimulation and not to the tactile one. Conclusion: Our results show that the NCS constitutes a sensitive clinical tool for specifically assessing nociception in severely braininjured patients. This scale constitutes the first step to a better understanding and management of pain in patients recovering from coma. This study was supported by the Fonds National de la Recherche Scientifique (FNRS)

P260 Assessing the psychological impact of the management of severely brain-damaged patients among Belgian families C. Schnakers, O. Gosseries, D. Ledoux, S. Majerus, M. Boly, A. Vanhaudenhuyse, M.-A. Bruno, A. Demertzi, P. Boveroux, G. Moonen, S. Laureys Cyclotron Research Center (Lie`ge, BE); University Hospital (Lie`ge, BE) Objectives: The objective of our study was to evaluate needs such as medical information, involvement in care as well as emotional, social, instrumental and professional supports in relatives of severely braininjured patients recovering from coma. Method: The Family Needs Questionnaire (French or Flemish version) was sent to the legal surrogate of patients being at home or hospitalized in one of the 37 centres (i.e., neuro-rehabilitation centres and nursing homes) involved in the Belgian federal network for the care of vegetative and minimally conscious patients. Results: We collected 98 questionnaires. The majority of the participants considered the medical information, the involvement in care, the social and emotional supports as important to very important. Few participants were entirely satisfied for the following needs: medical information (29%), social (23%) and emotional (9%) supports. Moreover, 22% of the participants presented severe anxiety whereas 16% often felt depressed. Conclusions: The evaluation and the satisfaction of the needs of patients’ relatives are particularly important in order to maintain a good relationship with the medical staff and, hence, to optimize the care of patients recovering from coma.

P261 Burnout in caregivers managing patients recovering from coma: a Belgian study O. Gosseries, D. Ledoux, S. Majerus, M.-A. Bruno, A. Vanhaudenhuyse, M. Boly, A. Demertzi, P. Boveroux, G. Moonen, S. Laureys, C. Schnakers Cyclotron Research Center (Lie`ge, BE); University Hospital (Lie`ge, BE) Objective: Our objective was to assess the presence of burnout among caregivers working in neuro-rehabilitation centers or nursing homes and managing severely brain-injured patients recovering from coma.

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S84 Method: The Maslach Burnout Inventory (French or Flemish version) was sent to 37 centres involved in the Belgian federal network for the care of vegetative and minimally conscious patients. The following demographic data were also collected: the age, the gender, the profession (i.e., physician, nurse, physiotherapist, speech therapist, occupational therapist, psychologist and social worker), the expertise in the field (i.e., less than 4 years, between 4 and 9 years or more than 9 years), the amount of time spent with the patients (i.e., hours per week) and the working place (i.e., neuro-rehabilitation center or nursing home). Results: Our results show that 18% of the 509 participants presented a moderate to severe burnout. More specifically, the majority of these participants presented an emotional exhaustion (68%) and a depersonalization (50%). According to univariate analyses, the profession (i.e., nurse), the working place (i.e., nursing home), the amount of time spent with the patients and the age were significantly associated with the presence of burnout. Nevertheless, according to our multivariate analysis, the profession (i.e., nurse) was the strongest variable associated with the presence of burnout. Conclusions: According to our study, a significant percentage of caregivers, and particularly of nurses, taking care of vegetative and minimally conscious patients presented a burnout. The prevention of burnout among caregivers is crucial as it often leads to a poor patients’ care.

could be correctly communicated via facilitated communication. In all cases FC was frequently used for [6 months previous to testing. In conclusion, despite the demonstrated usefulness of FC in one of the 3 presented cases, the use of FC in acute acquired brain injury should prompt controlled blinded verification of the facilitator prior to its clinical use. Funded by the Belgian National Funds for Scientific Research and European Commission FP7 DECODER project

__________________________________ Poster session 2 Cerebrovascular disorders: vascular disorders/haemorrages P263 Transcranial ultrasound is useful in guiding treatment of cerebral vasospasm in aneurysmal subarachnoid haemorrhage F. Perren, B. Schatlo, M. Kotowski, P. Bijlenga, V. Pereira-Mendes, Y. Gasche, K. Schaller University Hospital of Geneva (Geneva, CH)

P262 Facilitated communication in severe traumatic brain injury M.-A. Bruno, C. Schnakers, A. Vanhaudenhuyse, G. Moonen, S. Laureys Coma Science Group (Lie`ge, BE) Facilitated communication (FC) describes the process by which a disabled person is physically assisted by another person (i.e., ‘facilitator’) to communicate using a communication board, modified typewriter or computer. The vast majority of controlled experimental studies have shown its invalidity in children with severe developmental disabilities such as profound mental retardation or autism. Nevertheless, proponents of FC propose the technique in communicatively impaired or non-communicative patients with acquired acute brain injury despite the lack of any controlled studies in this setting. We here assessed the efficacy of FC in 3 patients with chronic disorders of consciousness following coma. Following auditory (or visual) presentation of a word (or picture) to the patient in the absence of the facilitator, the latter reentered the room and was requested to assist the patient to communicate the presented word or picture. Patient and facilitator were requested to confirm the given answer. Prior and following the experiment participants confirmed agreement with the employed methodology. Patients’ level of consciousness and motor communication were repeatedly assessed using the Coma Recovery Scale Revised (CRSR). Patient 1 was a 47 y-old male studied 26 years after an acute traumatic brain injury (CRS-R total score of 11). Patient 2 was a 37 yold male studied 25 years after TBI (CRS-R total score of 10). In both patients none of the presented words could be correctly communicated via FC. Patient 3 was a 46 y-old male studied 11 years after TBI. CRS-R testing showed eye opening without stimulation, visual pursuit, oral reflexive movements, localization to noxious stimulation, reproducible movement to command and accurate communication using thumb movements. In this patient all of the presented words

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Objective: The ability of transcranial ultrasound to predict or detect angiographic and clinical vasospasm after subarachnoid hemorrhage (SAH) is under continuous debate. We evaluated whether transcranial ultrasound based treatment decisions influence outcome in a prospective cohort. Methods: Consecutive non-randomized patients suffering from acute SAH due to ruptured intracranial aneurysms as diagnosed with computed tomography angiography (CTA) / digital subtraction angiography (DSA) were systematically monitored using transcranial ultrasound (Doppler/color-coded duplex ultrasound) from baseline (day 1) every 24-48 hours over 15-21 days. Vasospasm onset and severity were recorded and assessed using the Lindegaard index (present if [3). Therapy onset and clinical outcome were compared. Clinical outcome was measured at discharge and at 6 weeks using the NIH Stroke Scale. Results: 46 SAH patients (32 women, 10 men, mean age 53.5 years) were included. 24 patients (24/46) had a neurological deficit at admission. Endovascular treatment of the ruptured aneurysms was performed in 28 patients, the remaining 18 were clipped. 33/46 had a transcranial ultrasound-based diagnosis of vasospasm. 27/33 patients underwent DSA/CTA which confirmed this finding. Temporary neurological worsening (at least 4 points on NIHSS) occurred in 34/ 46 patients (in 30 with vasospasm). In the 30 patients with vasospasm, focal neurological worsening occurred after the detection of vasospasm on transcranial ultrasound. In 18/30 of them therapy was started immediately after transcranial ultrasound/DSA diagnosis of vasospasm. 14 of 18 patients recovered completely and 4 had a focal neurological deficit at discharge and after 6 weeks. In 12/30 patients, therapy onset was initiated after clinical symptoms developed and only 2 of them recovered completely. In these patients, the deficits remained at discharge and after 6 weeks (Fisher Exact p\0.02; 2tailed). Conclusion: Within the limitations of a small cohort, the use of transcranial ultrasound may stipulate early treatment of vasospasm prior to clinical manifestation. Therefore, it may contribute to a better outcome in patients with aneurysmal SAH.

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P264 Cognitive impairment and dementia following cerebral haemorrhage P.Y. Garcia, J.M. Bugnicourt, S. Canaple, C. Lamy, M. Roussel, O. Godefroy University Hospital of Amiens (Amiens, FR) Background and purpose: The objective of this study was to determine the frequency of cognitive impairment and dementia in a transversal study of a cohort of patients hospitalized for spontaneous intracerebral hemorrhage. Methods: We analyzed 183 consecutives cases of spontaneous intracerebral hemorrhage from 2002 to 2006 in a single academic center. The survivors were contacted to be assessed by a neuropsychological battery in order to determinate their cognitive status at 3 years of follow up. Results: Seventy-eight patients were assessed 40 months poststroke. Thirty patients have been examined without a comprehensive neuropsychological battery Their cognitive and disability assessment was based on IQCode and Instrumental Activities of Daily Living, 40% had significant impairment reaching criteria of dementia. In the 48 patients examined with the neuropsychological battery, cognitive impairment was observed in 37 patients reaching dementia criteria in 6. Conclusion: This transversal study performed in a single center showed that the prevalence of dementia is 22% 3 years following a spontaneous cerebral hemorrhage.

Pathogenic subtypes of stroke in the group of SHT I were: 36% atherothrombotic, 55.5% cardioembolic and 8.5% hemodynamic; in the group of IS 27.6% - atherothrombotic, 68.9% cardioembolic and 3.5% hemodynamic. Comparing groups of IS and SHT I by BP A we do not have any significant differences: 153.39 ± 22.37 mm. rt. st. and 151.38 ± 28.12 (p[0.05). Also as for PTI: 86.95 ± 18.41% and 81.37 ± 14.12% (p[0.05). The lethality in SHT I was 27.3%, in IS – 25%, in SHT H – 28.6%, in HS – 36.4%, no significant differences. In the case of deaths SHT developed later (on 4th day nearby). For survived patients NIHSS B in group SHT I was 10.05 ± 5.07, in group IS – 8.5 ± 4.34, statistically insignificant difference (p[0.05). Conclusion: SHT I develops in a large size strokes regardless of the pathogenic subtype and does not worsen outcome of the stroke. Differences of BP level and PTI in SHT I and IS groups were not exposed in this investigation.

P266 Spontaneous cervico-cerebral artery dissections: clinical features and outcome at six months R. Fernandez, S. Gil, A. Garcia, F. Diaz, P. Va´zquez, J. Villanueva, A. Gil General University Hospital Gregorio Maran˜o´n (Madrid, ES) Objectives:

P265 Spontaneous haemorrhagic transformation of the ischaemic stroke: risk factors, influence on the outcome A. Kudakova, I. Kalenova Clinical Hospital 1 of the Administrative Offices of the President (Moscow, RU) Objective: To explore risk factors of spontaneous hemorrhagic transformation (SHT) of the ischemic stroke (IS) and its influence on the outcome, compare SHT with IS and hemorrhagic stroke (HS). Methods: 81 patients with stroke (47 women and 34 men, age from 40 to 92 (mean 68.9 ± 12.88)) were examined in the acute period of stroke (A) and on 30th day (B), both with the help of computer tomography or magnetic resonance imaging of the head (CT or MRI) (to investigate middle size of stroke injury (S)), NIH stroke scale (NIHSS), Barthel index (BI), prothrombin index (PTI), blood pressure measurement (BP). Patients were divided into 4 groups: 1. SHT on the type of impregnation (SHT I): 33 patients, 18 women and 15 men, mean age 67.36 ± 14.69, NIHSS A 12.75 ± 6.23, BS A 23.78 ± 35.06, S 60.41 ± 18.13 mm. 2. SHT on the type of hematoma (SHT H): 7 patients, 4 women and 3 men, mean age 70.7 ± 13.3, NIHSS A 13 ± 4.58, BS A 7.14 ± 18.89, S 56.71 ± 30 mm. 3. IS: 30 patients, 19 women and 11 men, mean age 71.04 ± 10.5, NIHSS A 11.36 ± 4.3, BS A 26.3 ± 35.4, S 57 ± 24.2 mm. 4. HS: 11 patients, 6 women and 5 men, mean age 66.45 ± 13.34, NIHSS A 8.81 ± 4.53, BS A 32.7 ± 45.62, S 26.9 ± 12.5 mm. For the group IS, chosen patients were those with large stroke injury size and high neurological decline, so that differences in groups SHT I and IS were statistically insignificant (p[0.05). Results: SHT was symptomatic in 27.5% of all cases of SHT; 24.24 % of cases of SHT I and 42.8% of cases of SHT H.

– To describe the clinical characteristics of patients with spontaneous cervico-cerebral artery dissection (SCAD) – To know about the clinical outcome at six months: recurrences and functional status, measured by modified Rankin score. – To collect information regarding permeability/recanalization of the vessel lumen at six months. – To identify factors that may influence the prognosis. Methods: Review of patients with diagnosis of SCAD recorded in our institution database between 1999 and 2008. Results: We identified 28 patients with SCAD, 10 women and 18 men; mean age: 42.5 years (28 to 72). 10.7% of patients had a previous history of high blood pressure, 7.1% had diabetes mellitus, 10.7 % hypercholesterolemia, 43% were current smokers and 25% had a previous history of migraine. Clinical manifestations: 71.4% of our patients suffered an ischemic stroke, 21.4% a TIA, 60.7% presented headache, Horner syndrome was observed in 14.7%; a precipitating factor was identified in 32.1% of cases. We collected 37 dissections (21 in internal carotid artery, 1 in common carotid artery, 1 in external carotid artery and 14 in vertebral arteries), 8 arteries were occluded. Multiple artery dissection was observed in 6 patients. Treatment: 17.8% patients were treated with antiplatelet therapy, 75% received anticoagulants, endovascular treatment was performed in 14.3% and thrombolysis in 7.1%. At 6 months follow up, 9.5% suffered a stroke/TIA recurrence, one patient died, good outcome (defined as modified Rankin Scale score of 0 to 2) was observed in 85% of patients. Complete or partial lumen recanalization was detected in 70.8%, in 20.8% permeability remained unchanged, and 8.3% developed an occlusion. Spontaneous complete or partial recanalization occurred in 87.5% of non occlusive SCAD and in 38% of occluded arteries (p=0.02). The different treatment options did not influence recurrence or recanalization rates. Conclusions: Clinical prognosis of patients with SCAD is favorable. Recanalization rate is high except for occluded arteries. The different treatment options do not seem to modify the outcome.

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P267 Vascular cognitive impairment and depression: relationship to metabolic syndrome O. Kopchak Central Hospital of Ministry of Internal Affairs (Kiev, UA) Objectives: Vascular cognitive impairment (VCI) indicates cognitive impairment that is caused by vascular risk factors in patients with cerebrovascular disease. The aim of the study was to establish association between metabolic syndrome, vascular cognitive impairment and depression. Methods: There were 136 patients with VCI (64 men and 72 women mean age 59±10,8 years) enrolled into the study. Diagnostic evaluation included medical history, physical and neurological examination, magnetic resonance imaging of the brain. Cognitive function was assessed by Mini-Mental State Examination (MMSE). Depression was measured by Beck‘s Depression Inventory (BDI) and Hamilton‘s scale. Metabolic syndrome was characterized by the following criteria: waist circumference [94 cm for men and [80 cm for women plus two or more of the following: fasting plasma glucose[5,6 mmol/l or previously diagnosed type 2 diabetes; systolic blood pressure [130 mmHg, diastolic blood pressure[85 mmHg, antihypertensive medication; plasma triglycerides [1,7 mmol/l; and plasma HDL cholesterol \1,03 mmol/l for men and \1,29 mmol/l for women. Depending on the presence of metabolic syndrome all patients with VCI were devided into two groups: with metabolic syndrome (group A) and without it (group B). Results: Among patients of the A group light cognitive decline was found in 26 individuals (MMSE score -26,4±1,3), mild cognitive decline in 38 patients (MMSE score -25,6±1,2), light dementia in 4 patients (MMSE score -21,2±3,2). Among patients of the B group 45 individuals had light cognitive decline (MMSE score -26,8±1,1), 23 patients had mild cognitive decline (MMSE score -24,7±1,4). According to BDI depression was found in 48 patients of the A group and in 42 patients of the B group. Significant association was found between severity of depression and cognitive decline in patients of the A group (r=0,24, p\0,1). Participants with the metabolic syndrome were more likely to have moderate to severe depression (10 vs. 6,9%, p=0,069). Conclusion: Cognitive impairment was more significant in patients with the metabolic syndrome. Our data show an association between the metabolic syndrome, cognitive decline and depression in patients with VCI. We conclude that control and treatment of metabolic syndrome will possibly prevent development and progression of cognitive decline and ameliorate depression in patients with VCI.

P268 Relationship between markers of endothelial damage and intima-media thickness in asymptomatic subjects P. Wipfler, H. Bernhard, B. Leschnik, G. Pilz, J. Kraus, W. Muntean Paracelsus Medical University (Salzburg, AT); Medical University Graz (Graz, AT) Introduction: Von Willebrand factor (VWF), tissue factor pathway inhibitor (TFPI) and Plasminogen activator inhibitor (PAI-1) are considered reliable markers of endothelial damage. Carotid Intima media thickness (IMT) is an established marker of subclinical atherosclerosis, and is also an independent risk factor for myocardial infarction and stroke. Here we investigate the relationship between these markers of endothelial damage and IMT. Methods: Plasma levels of VWF, TFPI and PAI-1 were measured in 149 subjects (60.5% women) free of clinically overt atherosclerotic disease. All subjects underwent ultrasonography of the common carotid arteries. For our study we grouped the healthy subjects into 3 age groups (younger than 45 years, 45 to 60 years and older than 60 years).

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Results: We found a significant positive correlation between VWF and IMT (p=0.007) in the age group older than 60 years. A weakly significant positive correlation between TFPI and IMT (p=0.08) was again only seen in the age group older than 60 years. A significant correlation between VWF (p=0.028) and IMT was also found by multiple linear regression analysis after adjusting for age, gender, blood pressure, smoker and low density cholesterol (LDL). There was no significant correlation between VWF or TFPI and IMT in the age groups younger than 60 years. We found also no correlation between PAI-1 and IMT in none of age groups. Discussion: In adults older than 60 years and without clinically overt atherosclerotic disease, VWF and TFPI were significantly associated with carotid IMT. This findings might indicate a relationship between VWF and TFPI and the development of atherosclerosis in older cohorts. It is therefore tempting to speculate that endothelial damage is more important for development of atherosclerosis in subjects older than 60 years than in younger subjects.

P269 Haemodynamic stability during carotid artery stenting under general anesthesia in elderly patients with a highgrade carotid artery stenosis C.B. Cho, H.K. Park, H.K. Rha Saint Mary’s Hospital (Seoul, KR) Purpose of study: During carotid artery stenting (CAS) under local anesthesia, hemodynamic instability (hypotension, bradycardia etc.) has been reported to occur. Hemodynamic instability during CAS under local anesthesia, especially in elderly patients,may be a risk factor for complications. We evaluate the hemodynamic stability during CAS under general anesthesia in elderly patients with a high grade carotid artery stenosis. Methods: A total of 15 patients CAS procedures were performed under general anesthesia using sevoflurane and nitrous oxide in oxygen in patients aged 65 years or older between November 2007 and February 2009. All CAS procedures were performed for high grade stenoses ([70% in NASCET criteria). Nine procedures were performed for symptomatic stenoses. Degree of systolic blood pressure change, hypotension, and bradycardia during CAS were assessed. Results: The mean age of patients was 69 ¡’ 3.2 years old. The mean degrees of stenosis before and after CAS was 75.8±7.5 %and 25.9±9.8%, respectively. No hypotension (SBP \ 80 mmHg) occurred during procedures, and transient bradycardia (HR\50/min) occurred in 1 (0.6%) during procedures. The mean systolic blood pressure change was 35±11.9 mmHg. No procedure was complicated with stroke during and after CAS. Conclusion: General anesthesia using sevoflurane and nitrous oxide in oxygen depressed baroreceptor reflex sensitivity, induced hemodynamic stability during CAS, and may decrease the rate of occurrence of complications in elderly patients with a high-grade carotid artery stenosis.

P270 Asymptomatic intracranial stenosis and cognitive impairment S. Pires-Barata, S. Mateus, V. Po´s-de-Mina, L. Fe´lix, F. Ferreira, C. Santos, S. Lourenc¸o, I. Mendes, L. Rebocho, M.H. Teixeira da Silva Hospital do Espirito Santo EPE (E´vora, PT) Purpose: Few studies have specifically addressed the association between asymptomatic intracranial stenosis and cognitive impairment.

S87 The purpose of this study was to determine the role of asymptomatic intracranial stenosis in the development of cognitive impairment. Methods: Between October 2006 and October 2007, 1944 patients performed head CT scan and Transcranial Doppler. Forty eight patients fulfil the inclusion criteria for the study (age B71 years, good bilateral window, pathology in the CT scan and neuropsychological evaluation). From those, 6 were excluded for having bilateral stenosis, 4 for occlusions, 2 hipoplasias, 18 for others pathologies. Seventeen patients were included, with first ischemic stroke and contralateral stenosis considering stroke lateralization. Results: From the 17 patients (12 men), age ranged from 48 to 71 years, 66% had anterior circulation stroke, 33% were lacunars and 56% on the left hemisphere. Right hemisphere intracranial stenosis were found in 46% of the patients and 31% were in the middle cerebral artery (MCA). 25% showed light right stenosis (30 to 50%) and 20% moderate right stenosis (51 to 99%). From 3 patients with moderate right MCA stenosis, one presented speech disorders and two showed impairment in the ability to criticize. Two patients with moderate posterior cerebral artery (PCA) stenosis presented deficits in sustained attention and in planning and sequencing. Two patients with moderate left MCA stenosis meet dementia criteria. Discussion: Associations were verified between the presence of intracranial stenosis and the development of cognitive impairment, considering the reduced dimension and sample bias. The lesion after stroke may justify part of the deficits found. But in all patients with contralateral stenosis cognitive impairment was also found. This may be due to functional deficit by hemodynamic compromise. Considering the presented limitations, more research is needed to understand the mechanisms that might lead to this impairment processes.

P271 Biochemical and functional endothelial dysfunction in migraineurs M. Saadatnia, S.H. Javanmard, A. Sonbolestan, K. Heshmat University of Medical Science (Isfahan, IR) Background: Migraine has been proposed as a risk factor for cerebrovascular events. Some studies showed patients with migraine had an underlying systemic vasomotion abnormality. There are some controversies in nitrate-mediated vasodilatory response and metabolites concentrations in acute and interictal period of migraineurs. The aim of this study was to evaluate functional and biochemical endothelial function in migraineurs and healthy subjects in interictal period. Materials and methods: Twenty four migraineurs without aura and 15 age and sex matched healthy subjects were enrolled in this study between July 2008 and June 2009. Flow-mediated dilatation (FMD) by means of brachial artery ultrasonography, blood determinations of fasting nitrites (NO(2)) and C reactive protein (CRP) were measured in all patients and control subjects. Results: Flow-mediated dilatation of patients with migraine was significantly lower than that of control subjects (6.23±5.63 Vs 13.24±3.54, respectively, P= 0.000). Concentration of nitrites (NO(2)) also was lower in migraineurs (4.14±2.21 vs 7.02±3.14, respectively, p=0.006). However, there was no significant difference in concentration of CRP between two groups (2.02±1.16 vs. 3.36±4.32, respectively, p=0.258). Conclusion: We have shown that migraineurs have decreased functional and biochemical dilation markers (endothelium dependent function and nitrites (NO(2)) concentration) whereas there is no difference in concentration of inflammatory biochemical markers like (CRP).

P272 The incidence of carotid arteries stenosis and intracranial arteries stenosis in patients with severe coronary artery disease P. Luchowski, J. Wojczal, M. Kozlowicz, J. Stazka, K. Buraczynska, A. Szczepanska-Szerej, R. Krupinski, A. Wolski, Z. Stelmasiak Medical University (Lublin, PL) Objective: To evaluate the frequency of stenosis of extracranial arteries (carotid- ICA and vertebral- VA) and intracranial arteries (anterior cerebral artery-ACA, middle cerebral artery-MCA, posterior cerebral artery-PCA, intracranial part of vertebral artery-iVA and basal artery-BA) in patients with known coronary arteries disease confirmed with normal coronarography. Methods: 123 patients (71% male, mean age = 66.0) waiting for conorary artery bypass grafting (CABG) were enrolled for extracranial Doppler duplex sonography, trancranial color-coded duplex sonography (TCCS) and transcranial doppler (TCD) examination. The degree of stenosis in the extracranial segment of ICA and VA was classified as normal, \50%, 50–69%, 70–99% or occlusion. The degree of stenosis in the intracranial segments of the iICA and iVA as well as the stenosis of the ACA, MCA, PCA and BA were classified as normal or \50% or C50% stenosis and occlusion. Results: Fifteen percent of patients were found to have advanced ICA disease ([ 50% stenosis), 7% had severe stenosis ([ 70% stenosis) and 4% had complete occlusion (one patient had bilateral ICA occlusion). Two patients had extracranial VA occlusion and one patient had VA stenosis in extracranial segment of this artery. With use of TCCS and TCD we have found two patients wiht MCA stenosis over 50%, two patients with PCA occlusion, three patients with iVA occlusion, one patient with BA stenosis of more than 50% and one patient with iICA stenosis of more than 50%. In total, 7% of patients had severe stenosis or occlusion within intracranial arteries. Conclusion: A sizeable proportion of patients undergoing CABG surgery were found to have coexistant extracranial and intracranial artery disease. Since stroke is a well known serious complication of CABG, preoperative evaluation of the cerebral arteries to identify patients at increased risk of stroke after CABG seems very important. Thus, based on this study we recommend cerebral artery evaluation, particularly in patients with peripheral vascular disease.

P273 Haemodynamic instability after elective carotid stenting: frequency and risk factors D. Popescu, M.O. Romanitan, O. Bajenaru, F. Antochi Bucharest University Emergency Hospital (Bucharest, RO) Objectives: To investigate the frequency and risk factors for hemodynamic instability (hypotension and/or bradycardia) in response to elective carotid stenting and their association with neurological complications. Carotid artery stenting implies instrumentation of the carotid bulb where the baroreceptors are placed and therefore baroceptor’s dysfunction may provoke hemodynamic instability. Methods: The study started in the Neurology Clinic of the Emergency University Hospital, Bucharest as a retrospective analysis of the charts of 130 patients (110 men with mean age of 55 years) who underwent elective carotid artery stenting with cerebral protection for high-grade ([70%) symptomatic internal carotid

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S88 artery stenosis. By hemodynamic instability one can understand the drop in systolic blood pressure of more than 30mmHG and bradycardia. Results: 20% of patients had a drop in systolic blood pressure beyond 30 mmHg and/or bradycardia despite an adequate fluid balance. We did’t use atropine as premedication before carotid stenting. There was no need for aggressive resuscitation (dopamine) and none of the patients with bradycardia needed pacemaker support. Neurological complications (transient ischemic attack, minor stroke, major stroke) occurred in 9% of patients and were not significantly associated with hemodynamic instability. Extensive carotid artery manipulation, a long stenosis situated at the bifurcation and the prior use of b-blockers were associated with an increased adjusted risk for hypotension or bradycardia. Conclusion: Hemodynamic instability due to hypotension and bradycardia in response to carotid artery stenting occurs in a relatively low proportion of patients. Patients who had an long (over 6 mm) stenosis situated near the common carotid artery’s bifurcation and therefore underwent extensive carotid manipulation or those who were on b-blockers were at high risk for hypotension or bradycardia. The preadministrations of intravenous fluids didn’t prevent the periprocedural hypotensive response.

P274 Health-related quality of life after radiosurgery for cerebral arteriovenous malformations presented with seizure S.Y. Yang DongGuk University College of Medicine (Gyeonggi-do, KR) Objectives: Until recently, the effectiveness of radiosurgery in arteriovenous malformation (AVM) presented with seizure has been measured only in terms of seizure frequency, which is not sufficient in estimating the usefulness of radiosurgery. To evaluate the success of radiosurgery, health-related quality of life (HRQOL) and employment status should not be neglected. The objective of this study was to evaluate HRQOL and employment status after radiosurgery in AVM patients presented with seizure. Methods: Between 1997 and 2006, 86 consecutive AVM patients presented with seizure who underwent radiosurgery were assessed by serial imaging tests, clinical evaluations including employment status, and a HRQOL survey. A HRQOL questionnaire was developed as a retrospective screening tool to assess the present estimation and the patient’s self-rated relative changes (trend values) in HRQOL after radiosurgery. These results were correlated with Engel Seizure Frequency Scoring System. Results: Follow-ups ranged from 12.8 to 124.8 months (mean, 62.4). Seventy-eight patients who answered the HRQOL questionnaire described their trend values after radiosurgery as ‘improvement’ in 70, ‘no change’ in 4, and ‘aggravation’ in 4. The mean trend values and the mean HRQOL scores in patients who experienced seizurefree, medication-free, or AVM obliteration were significantly better than in patients who did not (all P values\0.05). Although a higher proportion of patients described their activity in workplace as getting better at last follow-up, as compared with their preradiosurgical activity, employment status differences were not significant (P=0.395). Conclusion: Radiosurgery could improve in both HRQOL and employment status, especially in patients with seizure-free, medication-free, or AVM obliteration.

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P275 Characteristics of cerebrovenous thrombosis in Saudi population treated at a medical centre, Riyadh S. Kojan, I. Al Thubaiti, M. Al Zahrani, A. Al Khathaami, M. Al Jumah King Abdulaziz Medical City (Riyadh, SA) Cerebrovenous thrombosis (CVT) is a rare disorder. Predisposing factors are identified in majority of cases. Previous data from Saudi Arabia identified Behcet’s disease as most common predisposing factor. Anticoagulation is the standard treatment; however, direct thrombolytic therapy is believed to be safe and effective in selected cases. Objectives: To evaluate the characteristics, symptoms and signs, involved venous sinuses, etiologies and prognosis of CVT in Saudi patients treated at KAMC from 1998 to 2008. Methods: Retrospective, chart review study. CVT Patients older than 14 years were included. Results: 49 patients identified. Age from 15 to 66 years (mean 37.5) with female predominance (73%). Main symptoms were headache (88%), weakness (52%), nausea and vomiting (50%), seizures (39%), and impaired level of consciousness (LOC) (48%). Main signs were papilledema (40%), weakness (39%), and impaired LOC (35%). Few patients (6%) had normal exam. When head CT scan was done, venous infarction was found in 62% (81% of which with hemorrhagic transformation). Other findings included thrombosed vein or sinus and empty delta sign (15%). Diagnosis was confirmed by MR or CT venography. Transverse, followed by superior sagittal, sinuses were most commonly affected. Etiology was unknown in 27%. Main predisposing factors were hypercoagulopathy (45%) i.e. protein S deficiency (18%), antiphospholipid antibody syndrome (18%), protein C deficiency, factor V Leiden and Prothombin 20210 mutation (2% each). All patients were treated with intravenous heparin infusion (PTT target 1.5-2.5 baseline) or subcutaneous LMW heparin with excellent response in all but 1 patient who was comatose and had subarachnoid hemorrhage. Who received local thrombolytic therapy. Anticoagulation with Warfarin or LMW heparin was continued for minimal 6 months. Those who were considered to have high risk of recurrence, longer treatment applied. Prognosis was very good with complete or almost complete recovery in essentially all patients. 1patients died due to malignancy. Conclusion: CVT is not uncommon and etiology is identified in more than 2/3 of patients. Coagulopathy disorders were most common predisposing factors in our Saudi population; however, our data is in concordant with the previous data as none of our patients had Behcet’s disease. The transverse sinuses were most commonly affected. Standard anticoagulation, and rarely direct thrombolytic, therapy was associated with excellent outcome.

P276 Bilateral carotid-cavernous sinus fistulas with spontaneous resolution A.-F. Corbu Emergency University Hospital of Bucharest (Bucharest, RO) We report a case of a 74-year-old woman who presents for decreased vision, diplopia, red eyes, right hemicrania and facial pain in the distribution of the first division of right trigeminal nerve. The onset of symptoms is a month before, during a flare hypertensive. At first,

S89 symptoms appeared on the right side, than on the left, and aggravated until presenting to the hospital. She had a minor trauma 5 month ago, she had fallen on her left shoulder, no other significant pathology. Physical examination reveals: BP 130/85mmHg, proptosis of both eyes, more on the right eye, bilateral chemosis, bilateral sixth nerve palsy, on the right side more than on the left side. Ophthalmologic examination reveals: conjunctival arterializations and chemosis, dilation of retinal veins, optic disc swelling, elevated intraocular pressure, and angle closure glaucoma. We present the sonography, MR angiography, cerebral arteriographies and her clinical evolution. The first arteriography reveals a Barrow type B (dural) indirect carotid-cavernous fistula with bilateral fistulas of the cavernous sinus and the communication between sinuses, with blood flow from the left one to the right one. The second arteriography showed both sinuses thrombosed, the right more than the left one and the communication significantly diminished. Between those two the patient develops atrial fibrillation which is converted to sinusal rithm (with amiodarone), starts the anticoagulant therapy, first intravenous with low molecular weight fractioned heparin, continued oral, with acenocumarol. Without any endovascular treatment the symptomatology was partially resolved, she remained with sixth right nerve paresis and mild chemosis, on antihypertensive, anticoagulant and antiglaucoma treatement. Bilateral carotid-cavernous fistulas is very rare, it may undergo spontaneous resolution. To our knowledge this is the first reported case of bilateral indirect (dural) carotid- cavernous fistulas in the literature describing such a phenomenon.

P277 Seizure outcome after radiosurgery for cerebral arteriovenous malformations S.Y. Yang DongGuk University College of Medicine (Gyeonggi-do, KR) Objectives: The analysis of seizure outcome is extremely complex in patients with arteriovenous malformations (AVMs) because of the inadequate and secondary target of most studies and is rarely properly reported with the Engel outcome scale. This rarity of data supporting the therapeutic usefulness of radiosurgery precludes making recommendations for AVM patients presented with seizures. We aimed to determine the effect of radiosurgery on seizure outcome in patients with an epileptogenic nonhaemorrhagic AVM. Methods: Between 1997 and 2006, 86 consecutive unruptured AVM patients who presented with seizures underwent radiosurgery and were assessed by serial imaging tests and clinical evaluations between 1 and 10 years after radiosurgery. Pre- and post-radiosurgical seizure frequencies were compared using the Engel Seizure Frequency Scoring System. Seizure-free and off-medication were defined as seizure frequency scores of 0–2 and score 0, respectively. Results: Mean follow-up was 62.4 months (range, 12.8–124.8). Seizure frequencies significantly decreased for the first 4 years after radiosurgery (all P values \0.05), remaining unchanged from 4-year to 10-year. AVM obliteration was an independent prognostic factor for seizure-free and off-medication. At last follow-up, 74.4% (64/86) of the patients achieved seizure-free and 47.7% (41/86) were offmedication: the rates of seizure-free and off-medication were 93.3% (42/45) and 77.8% (35/45) in patients with obliteration, while 53.7% (22/41) and 14.6% (6/41) in those without obliteration, respectively (all P values \0.001). Conclusion: Radiosurgery may improve seizure outcome in unruptured AVM patients presented with seizures, especially in patients with obliteration.

P278 Vascular malformations of the spinal cord—a treatable cause for paraparesis M.O. Romanitan, R. Nechifor, B. Dorobat, D. Popescu, O. Bajenaru, A. Roceanu, F. Antochi Emergency University Hospital (Bucharest, RO) Objectives: Spinal cord vascular malformations (arterial and venous) represent a reversible cause of myelopathy. It has been shown that spinal dural arteriovenous malformations (SDAVMs) present with a progressive paraparesis, principally in men aged 60 years and over. They are usually dorsolumbar in situation and do not produce pathognomonic clinical features. Since the condition is probably underdiagnosed and may be quite a common cause of progressive leg weakness in elderly people the aim of our study was to show that the surgical treatment is relatively simple, safe, and if carried out at an early stage can lead to dramatic neurological recovery. Methods: We report 15 cases of paraparesis due to SDAVMs hospitalized in the Neurology Clinic of the Emergency Hospital, Bucharest, during a period of one year (October 2008-November 2009). The mean age of the patients was 62.5 years and the simptomatology consisted in progressive paraparesis in all patients. The diagnose was made after MRI, CT scan and spinal angiography were performed. In order to treat the venous hypertension and to prevent devastating bleeding endovascular obliteration of the fistula or nidus with acrylate was applied. Results: The neurological improvement of the simptomatology was noticed at 6 weeks after the intervention. No periprocedural complications were reported. The follow-up included both neurological exam and spinal angiography. Conclusion: The treatment of spinal cord malformations is being expanded with the use of interventional neuroradiology. With further improvements in spinal angiography and endovascular techniques, these lesions may be embolized either as a primary treatment or as a complement to open microsurgical techniques. The objective is the creation of a new hemodynamic equilibrium between the lesion and the spinal cord to decrease the risk of hemorrhage and prevent the progression of the spinal cord ischemia. Although it is a rare disease, clinicians should be aware of SDAVMs as a frequently misdiagnosed and progressively disabling neurologic condition that can be cured.

Clinical neurophysiology P279 Cross-talk between the right brain and the heart: the multiscale entropy of electroencephalogram correlates negatively to the multiscale entropy of RR interval tachogram P.F. Lin Tainan Hospital (Tainan, TW) Objectives: The brain and the heart are the two most important organs in humans. Close connections between them have been suggested according to many studies of neuroanatomical and pharmacological methods. A lately proposed neurovisceral integration model has indicated an inhibitory role on the right prefrontal cortex in the central autonomic network. We used multiscale entropy (MSE) analysis to examine the complexity hidden in different scales of our electroencephalography (EEG) and electrocardiography (ECG) data.

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S90 Methods: A sample of old people (N=87, 58 dementia, 29 normal), without a history of previous stroke, cancer, heart, or other major systemic diseases, aged 65 years and older, from a geriatric outpatient-clinic participated in this study. Clips of two-hour RR interval (RRI) files from a 24- hour EKG and clips of 40-second-clean resting EEG data were obtained for each subject and processed by MSE. Mini-mental status examination (MMSE) and other neuropsychological tests were performed. All the data were collected before exposure to acetylcholinesterase inhibitors. Results: After adjusting age and gender, statistically significant negative correlations were shown between the MSE of EEG and the MSE of RRI in many channels of the brain (F2, F4, F8, T4, C4, P4, O2, Fz, Pz, F3, O1, P3). MSEs of RRI are positively correlated to ratios of low-to-high frequency spectra power (LF/HF) of linear heart rate variability (HRV) analysis. The MSE of EEG is higher in cognitively normal than demented subjects. Conclusion: The central autonomic control to the heart seems lateralized in the right brain. Brains of better cognitive functions (higher MSEs of EEGs) may associate proportionally with relative higher parasympathetic drive to the heart (lower MSEs of RRIs and lower LF/HF ratios).

P280 Frontal intermittent rhythmic delta activity: a prospective study E.A. Accolla, A.O. Rossetti, P.W. Kaplan University Hospital of the Canton of Vaud (Lausanne, CH); John Hopkins Bayview Medical Centre (Baltimore, US) Objectives: Although known since several decades, the electroencephalographic (EEG) pattern of Frontal Intermittent Rhythmic Delta Activity (FIRDA) has been mainly studied in selected populations and/ or retrospectively. We undertook this analysis to identify clinical and neuroradiological FIRDA correlates overcoming those limitations. Methods: in this cohort study, we prospectively assessed all EEG recorded over 3 months in adults and children for the presence of FIRDA, defined as a predominantly frontal delta activity (1–4 Hz, lasting at least 2 seconds, and preserved reactivity to stimulation). The FIRDA group was compared with a randomly selected control group of patients without FIRDA, identified among EEG of the same period. Demographical, clinical, laboratory and radiological data were collected. For each subject, we assessed the presence of a structural lesion, and of encephalopathy (anoxic, infectious, epileptic, toxic, and metabolic). Comparisons were performed using uni-and multivariate analyses. Results: FIRDA was noted in 36/559 (6%) EEGs; the control group comprised 80 subjects. Univariate analysis showed a significant inverse relationship between FIRDA and epilepsy, and a direct correlation with older age, inpatient status, renal impairment, structural brain lesions and encephalopathy. Only the latter two were independently associated with the occurrence of FIRDA; etiologies were however unspecific. Asymmetric FIRDA was associated with an underlying (mostly ispilateral) brain lesion, but isolated symmetric FIRDA could occur in otherwise healthy subjects during hyperventilation. Conclusions: In this prospective study, FIRDA was clearly more prevalent than previously described. Unless recorded solely during hyperventilation, FIRDA seems to represent an unspecific abnormal EEG finding associated with a wide range of structural lesions and encephalopathic conditions. Of note, and opposite to previous descriptions, FIRDA does not appear particularly related to hydrocephaly, deep midline brain lesions, or leucoencephalopathy. FIRDA asymmetry should suggest the presence of an underlying brain lesion.

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P281 Cortical evoked potentials in paediatric cerebral malaria M. Bhanushali, T. Taylor, M. Molyneux, E. Mwandira, M. Sapuwa, G. Birbeck Michigan State University (East Lansing, US); Liverpool School of Tropical Medicine (Liverpool, UK); Queen Elizabeth Hospital (Blantyre, MW) Objective: To evaluate whether somatosensory evoked potentials (SSEP) and auditory evoked potentials (AEP) obtained during acute cerebral malaria (CM) predict adverse neurologic outcomes in CM survivors. Background: Pediatric CM, characterized by unarousable coma, parasitemia and no other evident coma etiology, is a frequently fatal, diffuse encephalopathy. Cortical evoked potentials (EP) may offer prognostic value into neurologic outcomes in survivors. Methods: As part of a prospective cohort study of CM survivors, SSEPs and AEPs were obtained during the CM coma. Results: EPs were obtained in 25 pediatric CM survivors during their acute infection. The study population was characterized by mean age of 4.2 years (median 2.8; IQR 2.3–5.8) and 12 were male (48.0%). The average time from admission to recovery with a Blantyre Coma Score of 5 was 20.4 hours (median 10.5; IQR 6.0–25.5), and 12 (48.0%) experienced seizures acutely. During follow-up, 7 (28.0%) of survivors had at least one adverse neurologic outcome including epilepsy, behavioral disorders and/or gross neurodisabilities characterized by language regression, motor or sensory deficits or ataxia. Only a single subject had absent EPs during the acute CM infection and this child had a good neurologic outcome. Conclusions: Among pediatric CM survivors, cortical EPs are generally intact and do not predict adverse neurologic outcomes. Further study is needed to determine if cortical EPs predict mortality in acute CM.

P282 NMO spectrum disorder and optic neuritis: are VEPs useful? L. Straffi, M. Radaelli, M. Bianco, J.J. Gonzalez-Rosa, L. Moiola, D. Dalla Libera, M. Rodegher, V. Martinelli, G. Comi, L. Leocani University Hospital San Raffaele (Milan, IT) Objectives: the aim of our study was to investigate whether the presence of IgG-NMO antibody is associated with a different pattern of response at visual evoked potentials (VEPs) in patients affected by neuromyelites optica spectrum of disorders (NMOsd) with optic neuritis (ON). Methods: we retrospectively studied clinical, immunological and neurophysiological data from 28 patients affected by NMOsd who presented at least one optic neuritis (16 patients bilateral and 12 unilateral). All the patients underwent IgG-NMO antibody testing and pattern-reversal checkerboard VEPs at check-size 15’. Bilateral ON was present in 6/11 (55%) Ig-NMO positive patients and 10/17 (59%) IgG-NMO negative patients. Latency and presence of VEPs response over the affected and unaffected eyes were determined. Results: All non affected eyes had a measurable VEP response. No significant effect of the presence of IgG-NMO was found concerning VEPs latencies in non affected eye. Concerning eyes previously affected by NO, the presence of IgG-NMO was significantly associated with a higher frequency of absence of VEPs (70% vs 36%; p= 0.02 Fischer). In eyes with presence of cortical VEP responses (5 from IgG-NMO positive and 17 from IgG-NMO negative patients), no significant latency differences were found according to the presence of IgG-NMO. Conclusions: Our main result was a more frequent absence of visual evoked responses after optic neuritis in the presence of NMO

S91 antibodies in patients with NMOsd. This finding suggests a pathological process characterized by a more frequent and severe axonal involvement associated with the presence of NMO antibodies. If validated by future studies, these results may suggest a possible usefulness of VEPs in the differential diagnosis of NMO.

P283 Diagnostic and prognostic role of pattern reversal visual evoked potentials in the course of multiple sclerosis N. Tevzadze, M. Janelidze, R. Shakarishvili S. Khechinashvili University Hospital (Tbilisi, GE); P. Sarajishvili Institute of Neurology (Tbilisi, GE) Objectives: Multiple Sclerosis (MS) is an chronic inflammatory neurodegenerative disease in which axonal loss remains clinically silent for many years and irreversible neurological disability develops when a threshold of axonal loss is reached and compensatory of CNS resources are exhausted. The aim of this study is to reveal diagnostic role of Pattern Reversal Visual Evoked Potentials (PRVEP) as a sensitive measure in detecting subclinical abnormalities of visual function and the monitoring course of MS. Methods: 42 patients with MS, age ranging from 18–55 years, were participating in this follow-up study. The degree of disability was graded using the Kurtzke Expanded Disability Status Scale (EDSS). All patients had cranial MRI with 17 patients also having spinal MRI and all patients had demyelinating plaques consistent with MS. PRVEP was evaluated for P100 latency, amplitude and waveform morphology, all patients (with and without history of optic neuritis) underwent full neuro-ophtalmologic examination. Results: PRVEP showed abnormal results in 100 % patients with history of optic neuritis and in 65% without history of optic neuritis. Neuro-ophtalmologic examination was correlated with PRVEP. Increased latency correlated with progressive course of disease and with EDSS, deterioration changes in follow-up was shown in 11 patients (6 was related with clinical progression, 5 without other clinical symptoms may be associated with further episodes of subacute demyelination). Remyelination changes of PRVEP during follow-up was shown in 7 cases following corticosteroids treatment, showing some improving in amplitude and latencies measures over the time, but no one case indicate complete normalization. Conclusions: PRVEP is objective, reproductible, sensitive, continuous measure test of the anterior pathways function of the visual system and we suggest that PRVEP can provide not only diagnostic, but also prognostic information during MS progression and monitoring functional improvement of the primary visual pathways as well as progressive deterioration.

P284 Visual analysis reliability of electroencephalogram in anoxic-ischaemic patients by neurophysiologists J. Ribeiro, R. Rego, D. Alves, J.A. Mendes-Ribeiro, P. Grebe, M. Dinis-Ribeiro Centre for Research in Health Technologies and Information Systems (Porto, PT); Pedro Hispano Hospital (Matosinhos, PT); Sa˜o Joa˜o Hospital (Porto, PT); Sa˜o Sebastia˜o Hospital (Santa Maria da Feira, PT) Objectives: Electroencephalogram (EEG) is a sensitive indicator of brain dysfunction severity (5)(6) in stuporous and comatose patients. Hockaday (8), Synek (9) and Young (3) are the most used EEG classification systems (EEG CS). A reliable grading system is a major concern as it will provide a uniform classification of cerebral

dysfunction and the consistency and accuracy needed to use this system in clinical ground (3), improving and standardising clinical research and an adequate care of patients. The aim of this study is to assess visual analysis reliability of electroencephalograms in stuporous and comatose patients following cardiopulmonary arrest by neurophysiologists. Methods: Reliability was estimated using weighted Cohen’s kappa coefficient (wKc) and proportion of agreement (Pa). A total of 56 EEG tracings (42 patients), from two different hospitals, constituted the sample. Three invited observers (rater A, B and C) classified all 56 EEG tracings, in a blind fashion, using Hockaday, Synek and Young’s EEG CS. Results: Concerning reliability analysis of rater A vs. B vs. C, strength of agreement shows a tendency to decrease from Hockaday (wK=0.0.65) to Synek (wK=0.61) and to Young’s EEG classification system (wK=0.55). The highest agreement of all rater combinations was obtained regarding Young’s EEG classification system and rater A vs. B (substantial agreement of 0.77). Good agreement was achieved for rater A vs. B considering Young’s EEG classification system and hospital A (wK=0.85). This was also the highest achieved value among all rater combinations and sub-group analysis. The lowest strength of agreement, for each hospital, was achieved by rater A vs. C when using Synek’s EEG classification system for Hospital A (wK=0.27) and for Hospital B when using Young EEG classification system A (wK=0.31). Considering a Kc of 0.7 is commonly used as a threshold of ‘‘sufficient reliability’’ (7), neither one of the studied EEG CS achieved the desirable agreement when considering all three raters. Conclusion: EEG CS optimization is desirable in order to provide the needed confidence to physicians to integrate one or several of these CS consistently into clinical practice. This study also intends to provide relevant information concerning these CS limitations and advantages in order to assist further research in the development of a truly reliable EEG CS and further inclusion into a predictive model that integrates both clinical and neurophysiologic measures.

P285 Effects of muscles cortical map integration on the selectivity of their voluntary activation E. Coppi, R. Chieffo, F. Spagnolo, L. Straffi, J.J. Gonzalez-Rosa, A. Inuggi, G. Comi, L. Leocani University Hospital San Raffaele (Milan, IT) Objectives: to evaluate the relationship between cortical map overlap of different muscles at transcranial magnetic stimulation (TMS) and their selective voluntary activation. Methods: we studied a group of 30 right-handed healthy volunteers (14 younger, aged 25.5±1.8; 16 older, aged 61.3±5) by TMS. We performed TMS cortical mapping at 15% above resting motor threshold of 3 hand muscles: abductor pollicis brevis (APB), abductor digiti minimi (ADM) and extensor carpi radialis (ECR). The degree of their cortical overlap and ADM coactivation during a simple motor task performed with ipsilateral APB were measured. Motor performance was evaluated using the Nine Hole Peg Test (NHPT). Results: We found a correlation between degree of overlap (DO) and NHPT in both hands. Subjects with a greater DO were faster in NHPT execution considering dominant and non dominant side (Spearman r=0.4, p=0.03 in the dominant hemisphere; r=0.5, p=0.004 in the non-dominant). Greater DO also correlated with less coactivation of ipsilateral ADM in the non-dominant site only (r=0.5, p=0.005). All these correlation did not remain significant when performing partial correlation adjusting for age. Conclusions: In our findings, hand dominance and hand performance are associated to a higher degree of overlap within the hand

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S92 muscle representation over both hemispheres, possibly resulting from simultaneous integrated activation during skilled movements. The correlation between DO and hand muscles coactivation, found in nondominant side only, is probably related to a more reduced efficacy of intracortical inhibitory circuits; these effects are related to aging.

P286 Repetitive transcranial magnetic stimulation treatment on hereditary spino-cerebellar degeneration Y. Nakamura, I. Yamada, H. Sakamoto Sakai Hospital (Osaka, JP) Objectives: Patients with spinocerebellar degeneration (SCD) are severely disturbed in gait and routine daily activity due to cerebellar ataxia as the disease progresses. Repetitive transcranial magnetic stimulation (rTMS) has recently been used as a therapeutic tool for treating neuropsychatric disorders. It is known the different effects of cortical excitability or inhibition among central nervous systems by different stimulation sites, stimulation frequencies and stimulation intensities of rTMS. The different clinical manifestations among SCDs may suggest that the study is needed for suitable stimulation methods considering the impairment and lesions of CNS. Subjects: Patients with SCA3 and patients with SCA6 or 16qADSCD were enrolled. All patients were evaluated with an International Cooperative Ataxia Rating Score (ICARS) before and after treatment. Eleven patients with SCA3 enrolled (one female, ten males; mean age:44 years old; mean disease duration: 6.5 years; mean International Cooperative ataxia rating score (ICARS) was 40. Fourteen patients with SCA6 and 16q-ADSCD enrolled (7 females, 7 males; mean age:60.4 years old; mean disease duration: 8 years; mean International Cooperative ataxia rating score (ICARS) was 41.6. The target of stimulation position for rTMS was cerebellum itself in case of SCA3 and was motor cortex for pure cerebellar form (SCA6 and 16q-ADSCD). A stimulation frequency of 1 Hz for cerebellar rTMS was used. Three hundred stimuli per a day were administered on five consecutive days for two weeks. In case of pure cerebellar form, 1000 stimuli at 5Hz per a day were done for 2 weeks. rTMS treatment was repeated at a interval of a half year and lasted for two years. Results: In SCA3, mean ICARS after rTMS was significantly improved from 46 points to 35 points. There was less progression of the disease or keeping ADL in six patients with SCA3 at a half year interval of cerebellar rTMS for two years. And also patients with pure cerebellar form showed significant improvement after motor cortical rTMS at a5Hz (from mean ICARS of 41.6 before treatment to 31.9 points after treatment). Conclusion: In this study, two different patterns of rTMS were done: one is cerebellar rTMS at 1Hz for SCA3 and other was motor cortex rTMS at a 5Hz for pure cerebellar forms of SCA6 and 16qADSCD. Both patient groups showed significant improvement after rTMS. rTMS for SCD can modify the disease progression and so the more study must be needed.

P287 Activity dependent conduction block in chronic inflammatory demyelinating polyneuropathy D.C. Straver, L.H. van den Berg, R.M. van den Berg-Vos, H. Franssen University Medical Centre (Utrecht, NL); St Lucas Andreas Hospital (Amsterdam, NL) Objective: Previous studies suggested that activity dependent CB contributes to weakness in CIDP. However, these studies investigated only

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one nerve segment per patient, employed cervical magnetic stimulation which may be submaximal, included nerves with marked axon loss which precludes assessment of CB, and lacked criteria for activity dependent CB. Obtaining more reliable evidence for activity dependent CB is important because it may be treated pharmacologically. Methods: We investigated 22 nerve segments in 18 CIDP patients, employed supramaximal electric stimulation, excluded nerves with marked axon loss, and adopted criteria for activity dependent CB. Each nerve was tested before and immediately after 60 seconds of maximal voluntary contraction (MVC) of the relevant muscle. Per segment we determined segmental area ratio (area proximal CMAP / area distal CMAP), presence of CB, and CMAP duration prolongation. Per nerve we calculated total area ratio (area CMAP at Erb’s point / area most distal CMAP). Results: MVC induced increases in CMAP duration prolongation and mean distal and proximal CMAP area; MVC did not induce changes in mean area ratios, number of segments with CB, or activity dependent CB according to our criteria, except for one segment. This indicates that MVC induced temporal dispersion of nerve action potentials but not CB. Conclusion: Activity dependent CB is uncommon in CIDP. This work was supported by a grant from the Prinses Beatrix Fonds.

P288 Can we get more information from sensory nerve action potential? The ratio of amplitude to rise time B. Isak, K. Uluc, A. Sun, G. Sunter, T. Tanridag, O. Us University Hospital (Marmara, TR) Objective: To evaluate a composite parameter (i.e., the ratio of amplitude to rise time) of sensory nerve action potential in patients with distal symmetric polyneuropathy due to diabetes. Methods: Eighty two patients with diabetes and thirty-four controls were evaluated by routine nerve conduction studies (NCS) with additional parameters i.e., rise time and the ratio of amplitude to rise time (A/RT). The patient group was divided into three subgroups according to NCS; normal, moderately affected and severely affected. Results: Reduction in the A/RT ratio was more informative than the rise time, amplitude, latency and the velocity of the SNAP. Sural nerve was very sensitive (70.8% for left and 62.5% for right sural nerves) and specific (100%) when the limit was accepted as ‘‘1’’ for A/RT. Conclusions: Evaluating the A/RT of the SNAP would help the clinician to get clues about the possible existence and the severity of the polyneuropathy and shorten the NCS by avoiding the evaluation of uncommon nerves.

P289 Preservation of motor neuron excitability during the cutaneous silent period in amyotrophic lateral sclerosis W.K. Kim, Y.T. Kwak Kangdong Sacred Heart Hospital (Seoul, KR); Hyoja Geriatric Hospital (Yongin, KR) Objective: Electrical stimulation of a cutaneous nerve can transiently suppress electromyographic (EMG) activity in a voluntarily contracting muscle. This period of electrical silence, known as the cutaneous silent period (CSP), is usually evoked in upper limb muscles by stimulating cutaneous nerves in the digits. To determine motor neuron excitability in the patients with ALS, we examined Fwaves in the abductor pollicis brevis (APB) muscle generated in response to antidromic stimuli during the CSP.

S93 Methods: Five patients with ALS (5 males; 43–68 years old) and 13 healthy subjects (6 males and 7 females; 34–70 years old) were studied. Result: The latencies of the onset and endpoint of the CSP in the normal subjects were 84.3±10.9 and 122.4±9.7 ms (mean ±1 SD), respectively. These latencies were within the normal limits determined in earlier studies. In the patients with ALS, the onset was 103.9±4.2 ms and the endpoint was 137.6±2.1 ms, showing that the CSP was delayed. F-waves in the APB muscle were recorded with and without conditioned cutaneous nerve stimulation to produce CSPs in the patients with ALS. Of the 5 patients, F-waves were seen in four in the control condition. No F-waves were seen in one patient with marked APB muscle atrophy. Three out of the 4 patients generated Fwaves in the test condition. The latencies of the F-waves in the test and control conditions were similar. Conclusion: Although additional data is needed to fully understand the CSP, the preservation of F-waves during the CSP appears to support the hypothesis that the motor neurons remain excitable in ALS patients.

P290 Lacking of facilitation in botulism: serial neurophysiological studies of intramuscular botulinum—a toxin in humans A. Petrucci, L. Lispi S. Camillo Hospital (Rome, IT) Introduction: The marked facilitation occurring with high frequency stimulation and with maximum voluntary contraction is the most distinctive electrodiagnostic feature of the presynaptic abnormalities of the neuromuscular junction (nmj), of which the Lambert Eaton Myasthenic Syndrome (LEMS) is the best known. The botulinum toxins interfer with nmj, blocking the release of vesicles containing acetylcholine. A facilitation has been reported in some muscles in case of botulism by some Authors, however to a lesser degree respect of LEMS. We observed three patients affected by iatrogenic botulism in which the right diagnosis was delayed because of the repetitive nerve stimulation (RNS) tests were normal. Objective: To investigate the effects of the RNS tests in botulism, looking for the presence of facilitation at high rates of stimulation, by means of a simple and easily reproducible experimental model. Materials and Methods: Ten subjects referring our botulinum toxin therapy ambulatory for blepharospasm and hemifacial spasm were inoculated with 15 IU botulin toxin type A – Botox in extensor brevis digitorum (EDB) muscle. Stimulation of the peroneal nerve at ankle was applied, recording the muscle action potential (cMAP) according to the following protocol: baseline; after 10 sec of voluntary maximum contraction; 3 sec at 3 Hz RNS; 7 sec at 20 Hz RNS. The stimulation was delivered either on the injected or on the controlateral EDB muscle, at time 0 (inoculation), time 1 (after 2 weeks), time 2 (after 4 weeks), time 3 (after 3 months). Results: cMAP was significantly low in amplitude at the injected side at times 1 and 2; a partial recovery occurred at time 3. A significant facilitation was observed in anyone patient, neither after maximum voluntary contraction or at 20 Hz RNS. Absence of significant decremental response at 3 Hz and 20 Hz RNS was recorded in all subjects. Conclusions: Our study demonstrates the absence of facilitation in botulinun toxin type A injected muscles; moreover, it confirms the blocking of the nmj operated by this toxin, picturing its chro-

nological outline. It is crucial to be aware of the effects of the botulinum toxin on the nmj in order to avoid dangerous mistake in the patients care.

P291 Diagnostic yield of electromyography in inpatient referrals in a busy tertiary hospital—Singapore experience K. Verma, K. Prasad, L. Tay National Neurosicence Institute (Singapore, SG) Objectives: 1) To study inpatient referral patterns for electrodiagnostic studies. 2) Diagnostic Yield of the tests performed. Methods: EMG records for the initial 6 months in 2009 were reviewed for the consecutive inpatients referred to our busy EMG clinic, catering to a tertiary care public hospital with bed strength of 1200 in Singapore. The records were reviewed by two electromyographers independently for the referring diagnosis and the study results. The interpretation was categorized as. A) Conclusive- confirms the referring diagnosis, B) Indeterminate- indicates some features of referring diagnosis C) Normal, D) New Diagnosis (able to explain a referring diagnosis but as a different localisation. E) Additional Diagnosis (incidental, underlying). Results: There were 180 inpatient referrals over a six month period in 2009. Majority (85%) of the patients were referred from the medical disciplines with neurology accounting for 48%. The Study was conclusive in 42%, normal in 38% and indeterminate in 10% cases. New diagnosis which was conclusive was noted in 10%. Peripheral Neuropathy & Entrapment neuropathy were the most common referral accounting for 40% of all cases. The referrals for myasthenia gravis (ocular) and Myopathy had lower diagnostic yield of 50%. ICU referrals accounted a mere 6 for respiratory failure and critical illness neuropathy. Entrapment neuropathy was the most common additional diagnosis noted with carpal tunnel syndrome in 14 cases. Conclusion: The study shows inpatient EMG referrals in a large public hospital were varied with most coming from medical disciplines suggesting a possible more comprehensive evaluation by them. The referring diagnosis was confirmed in 52%of cases with 10%showing a new diagnosis which was clinically relevant. It remains a challenge as 40%of the studies were either normal or indeterminate; we were unable to ascertain if this number was possibly due to over referrals. The study concludes a utility of electrodiagnosis in the evaluation and management of inpatients.

P292 Impaired sacculocollic reflex in vascular inner ear damage S. Kim, S.H. Park, J.S. Kim Seoul National University College of Medicine (Seongnam-si, KR); Seoul National University Bundang Hospital (Seongnam-si, KR) Objectives: The aim of this study was to determine saccular dysfunction by measuring vestibular-evoked myogenic potentials (VEMP) in vascular inner ear damage due to infarction in the territory of anterior inferior cerebellar artery (AICA). Methods: We recorded VEMP in 12 patients with AICA infarction documented on MRI. VEMP was induced by a short tone burst and recorded in the contracting sternocleidomastoids muscle. Patients also underwent audiometry, bithermal caloric tests, fundus photography,

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S94 and measurement of the subjective visual vertical (SVV) tilt. Normative data of VEMP were obtained from 47 healthy volunteers. Results: Eight patients (67%) showed abnormal VEMP, unilateral in six and bilateral in two. The VEMP abnormalities included absent responses in three, decreased p13-n23 amplitude in five, and delayed p13/n23 responses in three. VEMP was abnormal mostly in the side of MRI lesions. However, one patient showed decreased amplitude in the contralesional side and two with unilateral lesion exhibited bilateral VEMP abnormalities. In contrast, one patient with bilateral lesions involving the middle cerebellar peduncles had unilateral VEMP abnormality. Abnormal VEMP was found mostly in the side of canal paresis. However, the proportion of canal paresis, hearing loss, ocular tilt reaction, SVV tilt, and MRI lesions did not differ between the abnormal and normal VEMP groups. Conclusion: The abnormal VEMP in our patients with AICA territory infarctions indicates impaired sacculocollic reflex in vascular inner ear damage. The associations and dissociations of the audiovestibular dysfunction suggest differential involvements of the labyrinthine structures in AICA infarction.

P293 A new scalp waveform is discovered (N6) that is vestibular in origin after using air-conducted sound stimuli E. Papathanasiou, A. Lemesiou, S. Hadjiloizou, P. Myrianthopoulou, M. Pantzaris, S. Papacostas Cyprus Institute of Neurology and Genetics (Nicosia, CY); Cyprus Paediatric Neurology Institute (Nicosia, CY) Objective: The saccule, a vestibular organ, is now known to be able to be stimulated with sound. Specifically, high intensity clicks or moderate intensity tone stimuli can be used. This allows one to obtain vestibular evoked potentials reliably using a reproducible, short duration and high rise time stimulus. Neurogenic vestibular evoked potentials that are recorded from the scalp have so far been recorded in the form of N3 (click air-conducted), N5 (tone air-conducted), and P10 (bone-conducted stimulus) waveforms. The purpose of this study is to find other vestibular waveforms obtained with air-conducted sound. Methods: The experiments were organized into four parts: (A) Topographical scalp mapping and using the hypothesis that candidate vestibular waveforms are those that appear at the scalp surface with moderate intensity tone stimuli (saccule and cochlear stimulation, around 120 dB nHL) but do not appear at moderate intensity click stimuli (cochlear stimulation only, around 70 dB nHL), (B) determining the consistency in appearance of candidate vestibular waveforms in normal volunteers, (C) further characteristics such as their (i) relationship to vestibular evoked myogenic potentials (VEMP), (ii) sensitivity to 5 kHz tone, (iii) threshold of activation, and (D) recording of the new vestibular waveforms in a case of hearing loss. Results: A montage was discovered, O2-P3 and O1-P4 with left and right ear stimulation respectively that yielded a negative wave at 6 msec after stimulus onset and was labeled N6. It is not a VEMP, disappears with 5 kHz tone stimuli, has a high threshold of stimulation and is present in a case of hearing loss. This waveform has not been reported before. Conclusion: A new vestibular waveform is discovered that probably originates at or near the midbrain based on its latency.

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Significance: Together with the previously mentioned waves, lesions along the vestibular pathway can now be localized further.

P294 The analysis of sudomotor skin responses and RR interval in patients with different degrees of glucose tolerance P. Schestatsky, G. Ghisleni, S. Piccoli Garcia, A.C. Menezes Xavier, J. Zampieri, E.P. Calgaro Rocha, A. Locatelli Smith, C. Sebastiani, F. Gerchman Hospital of Porto Alegre (Porto Alegre, BR) Objectives: Subclinical autonomic dysfunction is a very common finding in patients with diabetes. However, few studies have assessed autonomic function in patients with prediabetes (impaired fasting glucose and/or impaired glucose tolerance). The aim of our study was to examine the prevalence of autonomic alterations in patients with prediabetes using sympathetic skin responses (SSR) and RR interval analysis. Methods: We selected 5 controls, 5 patients with prediabetes and 5 patients with diabetes according to universally accepted criteria. We excluded patients with clinical symptoms of neuropathy, including autonomic complaints. We recorded the SSR from palms (p-SSR) and soles (s-SSR) induced by electrical stimuli and RR intervals through electrodes in the chest during rest, deep breathing and orthostasis maneuvers. Results: Both p-SSRs and s-SSRs were similar between groups. However, although within normal values, the variation of RR interval in response to different maneuvers were significantly lower in patients with prediabetes and diabetes when compared to controls (ANOVA; p=0.01). Conclusion: Patients with diabetes and prediabetes without signs and symptoms of neuropathy have different cardiac autonomic responses in comparison with controls. This could bring new information on the patophysiology, diagnosis and prognosis of neuropathy associated with impaired glucose tolerance.

P295 Cold sensation after experiencing heat pain. Differences between healthy subjects and patients with peripheral sensory neuropathy C.D. Castillo Herna´ndez, J. Casanova-Molla`, J. Verger, J. Valls-Sole´ Hospital Clinic of Barcelona (Barcelona, ES) Introduction: Cold is sensed by activation of various subsets of sensory receptors responding to temperature decrease. It is possible to perceive cold with temperature decrement even if the absolute values are still above heat threshold (paradoxical cold, PC). We characterized PC in healthy subjects during quantitative sensory testing, and examined the utility of such method in the assessment of patients with sensory polyneuropathy (SPN). Methods: In 21 healthy subjects and 33 patients with SPN, we assessed warm and heat pain sensation using a modified method of limits. A thermode was attached to either the ventral forearm or lateral leg. Subjects reported their sensation using a bidirectional

S95 electronic-VAS system from a neutral position. Thermode temperature changed from 32C to 47C and back at a rate of 0.5 C/s. Results: PC was reported by 95.2% of healthy subjects while the temperature descended, beginning at a median temperature of 34.4C (ranging from 33.2 to 35.1C) and lasting for a median of 17.3 s (range 12.7-21.4 s). In contrast, most SPN patients (82%) reported no cold sensation but, instead, 70% marked a prolonged warm-hot sensation. Statistical analyses showed that patients had a significantly reduced percentage of trials with PC sensation (p\0.01), which was of longer duration than in healthy subjects. Conclusions: Perception of cold sensation after experiencing heat pain is abnormally reduced in patients with SPN. This might be an early sign of skin receptor dysfunction that can be added to the classical findings in quantitative thermal sensory testing of patients with peripheral neuropathy.

P296 A diagnostic tool to evaluate path integration ability in humans R.M. Schwarzkopf, I. Pulido Valedolivas, M. Wutte, A. Zwergal, S. Glasauer, K. Jahn University Hospital of Munich (Munich, DE); Autonomous University of Madrid (Madrid, ES); Ludwig-Maximilians University (Munich, DE) Objectives: Without landmarks, navigation is based on information about self-velocity, which is transformed to position or orientation by a process called path integration (PI). Using PI, one can estimate the own position without visual or acoustic clues by integrating small increments of movement onto a continually updated representation of direction and distance from a starting point. Respective deficits can derive from damages of cerebral areas involved in spatial navigation, particularly structures of the temporal lobe, most notably the hippocampus and the entorhinal cortex, but also the parietal cortex. In this study, our aim was to establish a simple diagnostic tool to evaluate PI in patients with suspected deficits in spatial navigation. Methods: To evaluate the efficiency of the test-battery, we tested 16 healthy subjects (20-65 years, 9 male, 7 female, 15 right handed, 1 bimanual) using three simple tests, which are considered to measure different aspects of PI and spatial memory: 1. Goal-directed walking task (GT), in which participants attempted to walk to a previously seen target. 2. Homing task (HT), in which subjects attempted to return to a starting point after being guided blindfolded a certain linear distance. 3. Homing-vector task (HVT), in which subjects were asked to complete the third side of a previously guided triangle. Subjects were blindfolded and wore earphones. Tasks were randomized and performed in a corridor of the University Hospital. To measure the subjects’ three dimensional position, a Light Emitting Diode (LED)-camera tracking system was used. Raw data were analyzed by using Matlab 7.0 software. Results focused on the correlation of required/walked distance for GT, HT, HVT and the correlation of required/walked angle (HVT). Results: The analysis of data from healthy subjects showed that all tasks can be performed with high accuracy and reliability, the HVT being the most demanding test. Test results showed a low variability between runs (5 repetitions for each of 3 different distances in GT and HT). Conclusion: Our data show, that this test-battery reveals results comparable to the PI performance found in previous studies. The new test-battery is a reliable diagnostic tool and can now be used for the systematic investigation of PI ability in patients with spatial memory deficits. PI so far was not tested routinely in patients and we expect new insights in the brain structures involved in human spatial orientation.

Pain and headache P297 Gender distribution of allodynia in different types of headache C. Lovati, P. Bertora, C. Mariani L.Sacco Hospital (Milan, IT) Background: Migraine-related allodynia has been found prevalent among women with respect to men, but the frequency of allodynia complaint in women and men in migraine subgroups and in other kinds of headache is not known. Male/Female difference may be due to hormonal status as well as to gender-related characteristics of central nervous system. Objective: To assess the gender distribution of allodynia among patients with different kinds of headache. METHODS: 438 patients (91 men, 347 women) were evaluated. Diagnoses were as follows: migraine without aura (MO), 138 women, 35 men; migraine with aura (MA), 82 women, 14 men; episodic tension type headache (ETTH), 27 women, 20 men; chronic migraine without aura (ChMO), 60 women, 8 men; chronic migraine with aura (ChMA), 28 women, 6 men; chronic tension-type headache (CTTH), 12 women, 8 men. Presence of cutaneous allodynia was investigated by semistructured interview. Statistical analysis was performed by v2 test. Results: Allodynia was more frequent among female migraineurs, with respect to male migraine patients (respectively 189 out of 308 61,3% vs. 19 out of 63 – 30,1%, p\ 0,01). Allodynia was complained by 14 out of 39 women with tension-type headache (35,9%) and by 7 out of 28 tension-type men (25%), without a statistical difference (p=0,28). The difference in allodynia complaint found comparing men and women with migraine was present also considering separately episodic forms (126 out of 220 women -57,3% - vs. 12 out of 49 men -24,5%- were allodynic, p\0,01) and chronic types (63 out of 88 women -71,6% - vs. 7 out of 14 men -50% - were allodynic, p=0,05). Gender-related prevalence of allodynia in different diagnostic groups was as follows: MO women 64/138 (46%), men 9/35 (25,7%); MA women 62/82 (75,6%), men 3/14 (21,4%); ChMO women 39/60 (65%), men 4/8 (50%); ChMA women 24/28 (85,7%), men 3/6 (50%); ETTH women 10/27 (37%), men 4/20 (20%); CTTH women 4/12 (33,3%), men 3/8 (37,5%). Conclusions: Allodynia shows a female predominance in migraine, in both chronic and episodic forms, with or without aura, but not in tension-type headache. This results may reinforce the hypothesis that allodynia in these two different primary headaches has dissimilar pathophysiology.

P298 Demographic and nosological characteristics of first thousand headaches in an outpatient neurology headache registry A.L. Guerrero, E. Rojo, M.L. Pen˜as, S. Herrero, E. Cortijo, P. Mulero, M.J. Neri, L. Bautista, B. Gonza´lez, R. Ferna´ndez University Hospital (Valladolid, ES) Objectives: Headache is a common cause of medical attention requirement both in primary and neurology ambulatory assistance. International Classification of Headache Disorders, II Edition (ICHDII) allows defining and codifying headache in a reproducible and precise form. The aim of this study is to analyze incidence and

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S96 characteristics of different headaches in a monographic outpatient office. Methods: On January 2008 a monographic headache consultation office was settled in a general tertiary hospital. Patients were sent from primary care (by means of a standard or high resolution derivation), and from other neurology or other specialities offices. All the patients’ headaches attended were prospectively codified according to ICHD-II criteria. In every case we considered patient age and sex, time of evolution of each headache, ancillary test needed, and previous symptomatic or preventative therapies. Results: On January 2010 registry included 1000 headaches corresponding to 682 patients. Ratio female/male 2.46 and age of 43.19 ± 17.1 years (range: 14-94). 33.2% of the patients were derived from Primary care, 24.8% came from other neurology offices and 6.1% from other specialities, mainly neurosurgery. Among the 1000 headaches, 51.4% were included in ICHD-II Group 1 (Migraine), 16% in Group 2 (Tension-type), 2.6% in Group 3 (trigeminal autonomic cephalalgias), 6.9% in Group 4 (Other primary headaches) and 3.4% in Group 13 (Cranial Neuralgias). 8.5% of migraines corresponded to chronic migraine and 15.5% to migraine-related medication overuse headache. Regarding secondary headaches, 1.1% of all cases were included in Group 5 (Headaches attributed to trauma) and 8.3% in Group 8 (Headaches attributed to a substance or its withdrawal). Only 3.4% of patients corresponded to Group 14 (unspecified or not elsewhere classified headaches), including 11 cases of recently described epicrania fugax and 14 trochleodynias. 5.2% of headaches were included in ICHD-II appendix, including 24 nummular headaches. Conclusion: Data of our registry show characteristics of patients attended in a monographic headache outpatient office in a general tertiary hospital comparable to those previously described in such a type of office. Migraine is the most frequent diagnosis. Most headaches can be codified according to ICHD-II criteria.

P299 Nosological characteristics and therapeutic results in a series of 30 patients with nummular headache E. Cortijo, A.L. Guerrero, S. Herrero, M.L. Pen˜as, E. Rojo, P. Mulero, R. Ferna´ndez University Hospital (Valladolid, ES) Objectives: Nummular headache (NH) is defined, according to the Appendix of the International Classification of Headache Disorders II Edition (ICHD-II) as a head pain of mild to moderate intensity felt in a small, well circumscribed, rounded or elliptical area typically 2-6 cm in diameter. More than 100 cases of NH have been reported from different countries. Temporal pattern is remitting or chronic, and pain exacerbations of variable duration have been described. Regarding theraphy, first series authors stated that specific treatment is seldom necessary in NH, but, further experiences have shown that this entity can be difficult to treat. Analgesics, non-steroidal anti-inflammatory, antidepressants, anaesthetic blocks, topiramate and gabapentin, have been used without clear benefit. Methods: We reviewed all patients with NH diagnosed in accordance with ICHD-II criteria, attended in a monographic headache outpatient office in a tertiary hospital during a two year period (January 2008 – January 2010). In each patient we considered demographic and nosological characteristics, as well as temporal pattern, presence of exacerbations, relief provided with symptomatic treatment, and requirement of preventive therapies. Results: 30 patients (18 females, 12 males) out of 725 attended in the mentioned clinic during inclusion period (4.1 %) were diagnosed of NH. Mean age at onset 49.218.1 years (range: 21–79). Two

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of the patients presented a bifocal NH and we, so, analyzed pain characteristics in 32 areas. 28 ± (87.5%) were rounded and 4 (12.5%) elliptical. Mean diameter 4.7 ± 1.1 (range: 2–6) and more frequent locations were occipital (10 areas, 31.3%), parietal (8, 25%) and frontal (6, 18.8%). Mean intensity of pain was 5.2 ± 1.8 (range: 1–8) on a ten-point visual analogical scale. Regarding temporal profile, in 18 areas (56.3%) was chronic, in 5 (15.6%) episodic and undetermined due to a time from onset under 1 year in 9 (28.1%) locations. In 16 areas (50%) pain exacerbations were described, lasting from 3 seconds to 15 minutes. Regarding therapy 21 (70%) patients did not improved with symptomatic drugs, and at least one preventative was prescribed in 24 (80%) patients without consistent effectiveness. Conclusion: Nummular headache is not an uncommon diagnosis in an outpatient headache office. In our tertiary hospital series, basal pain intensity is moderate and symptomatic drugs commonly provide no relief. So, patients frequently need a preventive therphy.

P300 Incidence and influence on submission of primary stabbing headache in an outpatient headache clinic M.L. Pen˜as, A.L. Guerrero, E. Cortijo, E. Rojo, S. Herrero, P. Mulero, R. Ferna´ndez University Hospital (Valladolid, ES) Objectives: According to the International Classification of Headache Disorders, second edition (ICHD-II), primary stabbing headache (PSH), is a head pain, occurring as brief, sharp, jabbing stabs or series of stabs, predominantly felt in the distribution of the first division of the trigeminal nerve, not attributed to other disorders, ruled out by appropriate investigations. Population studies have shown that PSH is a common headache. However most people suffer attacks of low frequency or intensity and seldom visit the doctor. There are few clinic based studies of PSH, and its real influence as a primary cause for referral to ambulatory neurological or to a monographic headache outpatient office is to be determined. We pretend to investigate the burden of PSH as the main complaint in an outpatient headache clinic. Methods: We reviewed all patients with PSH diagnosed in accordance with ICHD-II criteria, attended in a monographic headache outpatient office in a tertiary hospital during a two year period (January 2008 – January 2010). In each patient we considered demographic and nosological characteristics. Patients were derived from primary care, or from other neurology or other specialities offices. We considered in each case if PSH was the main cause of submission. Results: 36 patients (26 females, 10 males) out of 725 attended in the mentioned clinic during inclusion period (5 %) were diagnosed of PSH. Mean age at onset 28 ± 17.8 years (range: 10–72). Mean time from onset of symptoms to diagnosis of 1.6 ± 9.1 years. 24 patients fulfilled ICHD-II criteria for other headaches (14 of them migraine with or without aura, 6 tension-type headache, 2 hemicrania continua, 1 primary cough headache and 1 primary exertional headache). 77.7 % of patients were submitted from primary care, 5.6% came from other neurology offices, and 16.7% from other specialities, mainly neurosurgery. In 14 patients (39%) PSH was the main reason for submission, its intensity or frequency in 5 (35.7%) and fear of malignancy in 9 (74.3%). Only 2 patients of those with other associated headaches were submitted due to PSH. Conclusion: PSH is not an uncommon diagnosis in an outpatient headache office. However, and according to our data, it is not frequent as the main cause of submission to a headache clinic.

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P301 Allodynia phenomenon in idiopathic intracranial headache patients E. Ekizoglu, B. Baykan Istanbul University (Istanbul, TR) Objectives: Allodynia, described as perception of pain resulting from a nonnoxious stimulus to normal skin is frequently associated with migraine and other primary headaches. However, its presence in idiopathic intracranial hypertension (IIH) cases, as a secondary headache disorder has not been investigated yet. Our aim was to study allodynia and related headache features seen in IIH. Methods: We included IIH patients fulfilling the modified Dandy’s diagnostic criteria, followed up by our headache outpatient clinics for two years. Their headache features, lumber puncture and other laboratory findings were retrospectively investigated from their files. They were also interviewed by telephone in case of any missing data. Allodynia was assessed using the validated 12 item allodynia symptom checklist (ASC-12). Results: 20 IIH patients aged 40±13 years (19 women) were included. Allodynia was detected in 10 patients being moderate in 4 and mild in 6 patients. Only 2 had migraine diagnosis previously. Furthermore, 8/10 fulfilled migraine diagnosis except the exclusion of a headache etiology according to International Headache Society-2004 criteria. On the other hand, 7/10 patients with non migrainous headaches (2 with previous tension type) did not report allodynic symptoms (p=0.002). Only 2 patients with previous migraine and one exceptional patient with migrainous features were non-allodynic. CSF pressure did not correlate with the severity of allodynia. Conclusion: Allodynia is accepted as a result of central sensitisation in primary headaches. Interestingly however, if IIH leads to a migraine-like headache, it seems to trigger the same mechanisms in pain pathways and cause allodynia phenomenon.

P302 Pregabalin and Radicular Pain Study (PARPS): preliminary results in an Asian population Y.L. Lo, P.W.T. Cheong, J.M. George, S. Fook-Chong National Neuroscience Institute (Singapore, SG); Singapore General Hospital (Singapore, SG) Objectives: Pain from cervical spondylosis (CS) may result from degenerative spinal canal stenosis (cervical spondylotic myelopathy (CSM)) or lateral recesses compromise, leading to nerve root compression (cervical spondylotic radiculopathy (CSR)). Pregabalin was shown to be effective in randomised, placebocontrolled trials for post-herpetic neuralgia and diabetic neuropathy. In this study, we evaluate its efficacy in CS with undelying CSR or CSM in a prospective, open label trial comprising Asian patients. Methods: Patients with CS and CSR or CSM (clinical, MRI, or electrophysiological evidence) presenting with neuropathic pain were recruited. We excluded patients with diabetes, underlying neurological disease or were previously on antiepileptics. Pregabalin 75 mg bd was administered for 4 weeks, after which diosage was increased to 150 mg bd for another 4 weeks if the visual anologue scale (VAS) was not reduced by 50%. In addition, we monitored the Short Form McGill Pain Questionnaire (SFMPQ) at baseline, 4 weeks and 8 weeks. Results: We recruited 47 patients, of which 22 completed the trial. Of the 25 who withdrew, 12 (48 %) were for somnolence. 12 patients’ (52%) dosages remained at 75 mg and 11 patient’s (48%) dosages were escalated to 150 mg bd.

There were significantly reducing trends from baseline for VAS (ANOVA, F(1, 20), F = 23.6, p\0.0005), SFMPQ (sensory) (F(1, 21) = 9.4), p = 0.006) and SFMPQ (affective) (F(1, 20) = 8.8, p = 0.008). For VAS, there was significant reduction at 4 weeks (p = 0.001) and 8 weeks (p \ 0.0005) compared to baseline. For SFMPQ (sensory), there was significant reduction at 4 weeks (p = 0.01) and 8 weeks (p = 0.006) in scores compared to baselines. For SFMPQ (affective), there was significant reduction at 4 weeks (p = 0.04) and 8 weeks (p = 0.008) in scores compared to baseline. Conclusion: Pregabalin is efficacious in alleviation of pain symptoms related to CSR, evaluated by quantitative severity and other experiential scales. However, somnolence is a major side effect leading to high dropout rates, even at the lowest dose. The findings suggest the need for further studies of efficacy at lower dosages, particularly in the Asian population. This study is supported by a grant from Pfizer PL.

P303 TNF-a in CRPS and ‘normal’ trauma—significant differences between tissue and serum H.H. Kra¨mer, T. Eberle, I. Wagner, N. U¨ceyler, F. Zipp, C. Sommer, F. Birklein University Medicine (Mainz, DE); University of Wu¨rzburg (Wu¨rzburg, DE) Objective: Posttraumatic TNF-a signaling may be responsible for pain and hyperalgesia in complex regional pain syndromes (CRPS). In order to specify the role of TNF-a we investigated tissue (skin) and serum concentrations in three different patient groups: patients with osteoarthritis (non-trauma, planned surgery), with acute trauma undergoing surgery, and with CRPS I. Methods: Thirty patients (10 in each group) were recruited. Mean CRPS duration was 7.2 months (range 1.4 to 21 months). Skin punch biopsies were taken at the beginning of the surgery in osteoarthritis (non-trauma) and trauma patients and from the affected side in CRPS patients. Blood samples were taken before the respective procedures. Skin and serum TNF-a levels were quantified by ELISA. Results: Compared to patients with osteoarthritis, skin TNF-a was significantly elevated in CRPS (p \ 0.001) and trauma patients (p\0.04). Skin TNF-a in CRPS was higher than in acute trauma (p \ 0.02). In contrast, serum TNF-a values were the same in osteoarthritis and CRPS, and lower in trauma patients (p \ 0.03). Conclusion: Our results indicate a local but not a systemic increase of TNF-a in CRPS. This increase persists for months after limb trauma and offers the opportunity for targeted treatment.

P304 Serial polysomnography in hypnic headache shows no association with REM sleep M. Obermann, D. Holle, T. Wessendorf, S. Zaremba, C. Gaul, H.C. Diener, Z. Katsarava University of Duisburg-Essen (Essen, DE) Objective: To identify associations of REM sleep with the occurrence of headache in patients with hypnic headache. Background: Hypnic headache is a rare primary headache disorder exclusively related to sleep. Patients wake up every night with typical headache lasting between 15 min and several hours. Early case reports and small case series suspected a strong association with REM sleep, as it was observed, that patients always woke up in REM sleep.

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S98 However, recent polysomnographic investigations reported patients with headache onset in Non-REM sleep. Design/methods: We performed polysomnography in 6 patients with hypnic headache according to the diagnostic criteria of the International Headache Society (ICHD-II) in four consecutive nights. An independent, experienced sleep medicine specialist blinded to the diagnosis evaluated a total of 22 nights where typical headache occurred. Results: We found no association of the occurrence of headache in patients with hypnic headache with a particular sleep phase. Headache onset was arbitrarily distributed to REM and Non-REM sleep. Two patients had two headache attacks in one night and had one attack in REM and the other one in Non-REM sleep. Headache occurred most often in sleep phase 2, which also is the most likely finding as this is the most common sleep phase. One patient had obstructive sleep apnoea syndrome where headache resolved after CPAP mask therapy. Conclusion/relevance: The occurrence of hypnic headache attacks is not associated with a particular sleep phase, neither REM nor NonREM sleep. The underlying pathophysiology remains uncertain, but is obviously not dependent on REM sleep.

P305 HURT index in primary care: reliability and impact on headache management and patients’ satisfaction M. Al Jumah, A. Al Khathaami, S. Kojan, H. Tamim, A. Al Oayed, T. Steiner, R. Lipton King Abdulaziz Medical City (Riyadh, SA); Imperial College (London, UK); Montefiore Medical Center (New York, US) Introduction: The Headache Under-Response to Treatment (HURT) index is an outcome measure developed in collaboration with WHO as an aid to headache management, particularly in primary care. Objectives: To assess test-retest reliability of the Arabic version of HURT, and evaluate its implementation in primary care. Methods: Prospective, controlled study conducted in two stages. First, 40 adult Arabic-speaking patients attending primary care complaining of headache completed HURT at their initial and followup visits 4-6 weeks apart. Test re-test reliability was evaluated by intra-class correlation coefficient analysis. Second, 223 such patients were enrolled at four primary-care centres: two introduced HURT in 68 patients (intervention arm) and two continued their regular practice (control arm). After 3 months, all centres applied the Patients’ Satisfaction Scale and Doctors’ Satisfaction Scale. Results: For questions 1–4 of HURT, statistically significant correlation coefficients ranged from 0.66 to 0.78. These questions required recall of past events, and were subject to real changes, if any occurred, in the frequency of these events over the test-retest period. For questions 5-8, with responses expressing beliefs or perceptions at the time of testing, correlation coefficients were much higher (0.90 to 0.93). Use of HURT was associated with improvement of headache measured as the total of the differences between responses at initial and follow-up visits, which was statistically significant. There was a trend towards greater patientsatisfaction in the intervention arm and a slight opposite trend in doctor-satisfaction. One explanation of this disparity is that HURT was working as it should – improving care (perceived by patients) whilst revealing deficiencies in care, and need for improvement, to the physicians. Conclusion: The Arabic version of HURT is a reliable measure in primary care and its use may improve care for the headache patient. More studies are planned.

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P306 Short-term corticosteroid therapy in medication overuse headache, prednisolon versus dexametason M. Togha, S. Razeghi Jahromi, N. Beladimoghadam, A. Shah University of Medical Sciences (Tehran, IR); Shefa Neuroscience Research Centre (Tehran, IR); Beheshti University of Medical Sciences (Tehran, IR) Objectives: Medication over use headache (MOH) is a severe frequent headache due to long term repeated analgesic, ergot preivative or triptan use. Discontinuation of responsible drug is a main part of treatment. Improvement of headache usually achieves after treat with eight weeks. Different modality of treatment suggested for this type of headache during discontinuation of responsible drugs. We conducted this study to compare the efficacy and complications of dexamethasone and prednisolone. Methods: Sixty migrainers, 50 female and 10 male with mean age of 35.6±1.83 years, with MOH were enrolled. They randomly assigned to two groups. Twenty eight were put on dexamethasone (10 milligram daily) and 32 on prednisolone (50 milligram daily) therapies. Both of drugs were tapered after the first week and discontinued at the end of fourth week. Repeated measures of analysis of variances were used to evaluate the effect of these drugs on severity and frequency of headache during 6 weeks. The data were adjusted for age and previous drug dose. Results: Ibuprofen, acetaminophen, ergotamine C, diclofenac were most commonly used. The longest and shortest duration of analgesic drugs consumption were 84 and 4 months respectively. Patients on prednisolone showed 72.5% and 91.4% improvement in severity and frequency of headache in first week compared to baseline. In patients on dexamethasone therapy, significant improvement in severity of headache was noted after week three (76.43%). However the frequency of headache was decreased by 40.81% in first week of treatment. No serious side effect was noted, although injection of dexamethasone was unpleasant for most of the patients. Conclusion: Short term Prednisolone could be a safe oral therapy which is more potent than dexamethasone in treating MOH.

P307 Comparison of the analgesic effects of injections with botulinum toxin A, lidocain, or saline in the treatment of greater occipital neuralgia M.W. Seo, K.J. Kim Jeonbuk National University Hospital (Jeonju, KR) Backgrounds: Greater occipital neuralgia (GON) is a distinct type of headache characterized by piercing, throbbing, or electric-shock-like chronic pain in the upper neck, behind the ears, and usually on one side of the head. Results have demonstrated that while a significant number of severe GON patients respond well to local anesthetic occipital nerve blocks, substantial, long-term pain relief is usually not achieved. Several studies have demonstrated an analgesic effect of botulinum toxin-A (BTX-A), outlasting the duration of its effects as a muscle relaxant. Clinically, BTX-A has been successfully used to treat several different types of headaches, including tension-type headaches, cervicogenic headaches, migraines, nummular headaches, and chronic daily headaches. Furthermore it has been suggested that BTX-A is effective against varied neuralgic pain. In the current study, we hypothesized that BTX-A would provide more prolonged pain relief as compared to local lidocaine or placebo injections.

S99 Objectives: This prospective study was proposed to compare the analgesic effect of BTX-A to those of lidocaine and saline injections in severe GON. Methods: Thirty-six patients with GON (20 females, 16 males) were enrolled in the present study. All were randomly assigned to three groups: lidocaine injection(n = 12), BTX-A injection(n = 12), or saline injection(n =12). Further, they all satisfied the International Classification Headache Disorders Criteria for GON. Subsequently, the greater occipital nerve was identified at its point of entry to the scalp, along the superior nuchal line midway between the mastoid process and occipital protuberance. The point at which maximal tenderness was elicited was used as the injection site. Approximatley 1.5 ml of two percent lidocaine, 30 units of BTX-A, or 1.5 ml of physiological saline were injected separately. Results: VAS was significantly decreased in groups receiving the lidocaine or BTX-A injections; however, it did not significantly change in the physiological saline injection group. In terms of VAS scores at one month post treatment, the BTX-A group exhibited better values than those for both the lidocaine and saline groups (p\0.016). Conclusions: The present study demonstrated that BTX-A injection may exhibit a higher efficacy and more stable occipital blocks as compared to lidocaine or saline injections in the treatment of GON.

P308 Pain threshold and tolerance in major depression disorder S. Zambito Marsala, F. Fabris, M. Gioulis, G. Defazio, C. Marchini, M. Tinazzi Hospital San Martino (Belluno, IT); University of Bari (Bari, IT); University of Verona (Verona, IT) Objective: To assess pain threshold and tolerance in patients with major depression disorder. Background: Pain and depression may be closely related. Sometimes, depression causes unexplained physical symptoms, such as back pain or headaches. Moreover depression may impair the subjective response to pain and suffering. Conversely, chronic pain is an emotional condition as well as a physical sensation, it can change mood and behaviour. Studies show that pain and depression share common mechanisms. Brain pathways that handle the reception of pain signals, including the seat of emotions in the limbic region, use some of the same neurotransmitters involved in the regulation of mood, especially serotonin and norepinephrine. In fact the more common antidepressant drugs may influence mood as well as pain. Patients and methods: 25 patients with a recent diagnosis of major depressive disorder, drug naive for any specific antidepressant therapy, were selected. 20 patients referred pain mainly with muscular or arthralgic features to one body part or headache present at the time of the study, developing at/after the onset of depression state. In all patients, pain threshold and tolerance were assessed, using electrical stimulation delivered to the little finger and big toe. Both right and left hand and foot were tested separately in each patient. Results were compared with those obtained in 25 agedmatched controls. Results: Pain threshold and pain tolerance were significantly lower in patients for both right and left hand and foot than in normal subjects. Conclusion: These results extend previous data indicating that the processing of nociceptive inputs and probably the consciousness of pain is altered in major depression disorder.

P309 Sympathetic skin responses evoked by jaw clenching in patients with bruxism P. Schestatsky, L. Vidor, B. Genari, R. Schestatsky, W. Caumo Hospital of Porto Alegre (Porto Alegre, BR) Objectives: The sympathetic skin response (SSR) is a simple and noninvasive method of autonomic assessment that reflects a synchronized activity of the sweat glands. Autonomic disturbances and excessive jaw clenching possibly contribute to the generation of temporomandibular joint dysfunction (TJD). The aim of our study was to examine the possible association between jaw clenching-evoked SSR responses (jc-SSR) and bruxism, a high-risk condition for TJD. Methods: In 8 patients with bruxism and 8 healthy volunteers, we recorded the SSR from the palm of the hand induced by either electrical (e-SSR) and jaw clenching (jc-SSR) stimuli of variable intensities and durations. Electrical shocks of 30 mA in the median nerve and phasic contractions of both masseter and temporal muscles were performed. We measured the latency, duration, amplitude and waveform of the e-SSRs and jc-SSRs in patients with bruxism without facial pain complaints and normal controls. Results: All variables from e-SSRs were similar between groups. However, the latency of jc-SSR was significantly longer in patients with bruxism in comparison with controls (3.2 ±01s vs1.32±0.4s; p\0.01). The amplitude, duration and waveform of jc-SSR were similar between groups. Conclusion: Patients with bruxism have abnormal sudomotor responses induced by jaw clenching, but not by electrical stimuli, suggesting a specific autonomic dysfunction that might predispose to TJD. Our results underscore the possibilities of physiological studies using the jc-SSR in clinical practice, especially in the assessment of autonomic function in patients facial pain conditions.

P310 A SUNCT case with response to steroid treatment O¨. Karadas, H. Akgu¨n, B. O¨ztu¨rk, O. O¨z, U¨. Ulas, Z. Odabasi Gulhane Military Medical Academy (Ankara, TR) Short-lasting unilateral neuralgiform headaches (SUNCT) is chacarterized with conjunctival injection and tearing. It is usually seen in 5th decades and male dominancy is prominent. Attacks last for 5-240 seconds and their frequency varies 1-30 hourly. We present a SUNCT diagnosed case treated with steroid. 30 year old male patient was admitted to our clinic with pain described as right periorbital localized stabbing and throbbing in quality and moderate to severe in intensity. he was suffering from attacks 25-30 times daily. Systemic and neurological examinations were normal in the attack free period. Gabapentin, indometazin and carbamazepine treatments were inefficacious in his history. Methyprednisolone 48 mg/d PO administarted after other differential diagnoses were evaluated. On second day of the treatment, his complaints reduced significantly. Attack frequency and intensity, especially autonomic symptoms were decreased in three month follow-up. attacks were rarely seen after steroid treatment (1–2 weekly). SUNCT is one of the most rarely seen primary headache types. Several attack and preventive therapies were used to treat SUNCT. A spesific drug of choice is not reported in the guidelines. We think that it is important to share these cases to find the best beneficial agent or therapy.

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P311 Indifference to pain: a case report T. Kasikci, S. Bek, G. Koc, U¨. Ulas, Z. Odabasi Gulhane Medical Faculty (Ankara, TR) Introduction: ‘Indifference to pain’ is the absence of an appropriate nocifensive response to painful stimuli, despite apparently normal sensory-discriminative capabilities for pain. We present a case having indifference to pain. Case report: A 21-year old man was admitted to our hospital with the complaints of not feeling pain since his childhood. His medical and family history were unremarkable. Perception of the other sensory modalities was normal. Neurological examination was normal except loss of pain/temperature sensation. Despite the sensory stimuli developed hyperemia in the skin, he did not show any reaction. Also there were traumatic scars in lower limbs. He exhibited no evidence of an abnormality of the routine biochemical tests, nerve conduction studies, somatosensory evoked potentials, tilt testing, blink reflexes, sympathetic skin response, R-R interval and brain MRI. After electrophysiologic and imaging studies, he was diagnosed as ‘indifference to pain’. Conclusion: Our case is different from the other cases reported in the literature because of the normal neurologic examination and neurophysiologic tests. We couldn’t establish the cause of indifference to pain. We consider that further reports to explain the underlying nociceptive neurophysiology are needed.

P312 A case of hemicrania continua transformed to chronic paroxysmal hemicrania K.I. Mu¨ller, S. Bekkelund University Hospital of North Norway (Tromsø, NO) Objective: Transition from one primary unilateral headache to another is infrequently reported in the literature. We present a patient with hemicrania continua (HC) who, after a period of remission, evolved to chronic paroxysmal hemicrania (CPH). Method: Observational case report. Results: A 55–year–old woman presented with a 15-year history of left-sided headache. The headache was constant with periods of mild exacerbations associated with ipsilateral lacrimation and rhinorrhea. Initially, the headache was treated as migraine without success. Over-the-counter pain relievers, nonsteroid antiflogistics, triptans, and physiotherapy failed to relieve the symptoms, until she went into remission for about one year after introducing Rofecoxib 25 mg one time daily. The headache fulfilled the international headache society criteria (IHC) for HC. When Rofecoxib was discontinued her strictly left sided headache reappeared, but in a different pattern. Now she had frequent daily severe attacks lasting on average 15 minutes, accompanied by ipsilateral lacrimation, rhinorrhea and ptosis. Due to disabling headache she was hospitalized. On admission the clinical and neurological examination and brain MRI were normal. She responded promptly to Indomethacin, and was completely headache free with a dose of 50 mg three times daily. The headache fulfilled the criteria for CPH. Conclusion: CPH evolving from HC as demonstrated in this case, support the assumption that these two primary headaches share common pathophysiological mechanisms.

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P313 Unusual presentation of complex regional pain syndrome type 1 A. Al Tahan, K. Al Majed, R. Al Hammad King Saud University (Riyadh, SA) Objectives: To describe in detail a very rare presentation of Complex regional pain syndrome type1 (CRPS1). Methods: A thorough review was done of the different clinical features, investigations and therapeutic measures that were utilized in a 22 years old Saudi woman affected over 3 years by recurrent attacks of CRPS involving in turn all limbs. Results: Symptoms started early 2006 with sever spontaneous pain and tactile allodynia involving the right upper limb, associated with skin redness, swelling, and dryness with weakness. These recovered well after sympathectomy but recurred to involve in turn the left upper limb and later both lower limbs which were treated by a series of cervical and lumbar, both surgical and chemical sympathectomy. On 10/2008 CRPS recurred in the right arm which relapsed after multiple stellate ganglia block, a trial of electro-convulsive treatments and abated on intrathecal pump of Morphea and Baclofen. Apart from significant psychosocial stress no clear risk or precipitating factor was noted. Up to our knowledge only three similar cases of CRPS involving all limbs, were reported in literature. Conclusion: This case report besides describing a very rare presentation of CRPS1, it serves as an example of the difficulty encountered in the management of this syndrome.

Child neurology P314 Autoimmune activations in patients with MPS III: novel biomarkers for diagnosis and therapeutic intervention? R. Al-Dahhak, S. Killedar, C. Rankin, J. DiRosario, Y.L. Wu, C.Y. Yu, B. Zhou, D. McCarty, H. Fu Nationwide Children’s Hospital (Columbus, US) Mucopolysaccharidosis (MPS) III are a group of lysosomal storage diseases with severe neurological manifestation. While the primary pathology is known to be the lysosomal storage of heparan sulfates, detailed mechanisms of neuropathology of MPS III are unclear. Using a mouse model, we showed that a robust immune activation, especially a profound neuroinflammatory response, contributes to the neuropathology and disease progression of MPS IIIB. In this study, we tested peripheral blood samples from patients with MPS IIIB (n=8) and IIIA (n=1), to assess their immune status, which is currently unclear. White blood cell differential showed higher lymphocyte ratio in majority tested MPS III patients than healthy control children. Leukocytes from all tested patients exhibited significant increase in 3H-thymidine-incorporation when stimulated with an anti-human-CD3 or anti-CD40/IL4 antibodies, suggesting the activation of T-cells and B-cells. Complement deposition assays by flow cytometry for red blood cell C4d showed increased levels of C4d deposition on RBC and reticulocytes in most of tested patients, indicating an ongoing activation of complement classical pathway. In addition, anti-nuclear-antibodies were detected in 5 patients. Together, for the first time, these data demonstrate a heightened chronic autoimmunity in patients with MPS III, involving both cellular and

S101 humoral immune activation. This phenomenon offers a window for identifying novel biomarkers and therapeutic targets of MPS III.

P315 Influenza A-associated encephalitis/encephalopathy with transient diffusion MRI abnormalities finally resulting in diffuse cerebral atrophy V. Torri Clerici, F. Locatelli, S. Galbiati, F. Formica, P. Avantaggiato, E. Beretta, A. Bardoni, G. Poggi, S. Strazzer IRCCS E. Medea (Lecco, IT) Objectives: We report the case of one patient with influenza-associated encephalitis/encephalopathy (IAEE) who presented with severe Central Nervous System (CNS) manifestations finally resulting in severe motor and cognitive impairments. Methods: We reviewed the case retrospectively, including the clinical, laboratory and radiological data. We also reviewed the literature. Results: Our patient, male, aged six years, was admitted to another hospital with two generalized tonic seizures as initial neurological symptom, and subsequent postictal mental state, following 1-day prodromal illness consisting of high fever reaching 39C (102.2F), and mild cough. He showed dystonic movements, drug-resistant fever, and endocranial hypertension treated by cerebrospinal fluid (CSF) derivation. Intravenous (IV) lorazepam, ceftriaxone, acyclovir and corticosteroids were administered. The CSF analysis was normal. Polymerase chain reactions (PCRs) and serologies for common neurotropic viruses were negative in blood and CSF. Serological tests for systemic autoimmunity were negative. Real-time PCR from nasopharyngeal swab samples revealed influenza A. Oseltamivir was initiated. The initial EEG showed generalized continuous polymorphic delta slowing, without epileptogenic focus, consistent with a severe encephalopathy. The Magnetic Resonance Imaging (MRI) at day one was normal. The MRI at day two revealed cerebral edema. The diffusion-weighted MRI (DWI) at day three revealed subcortical white matter lesions. The MRI performed at day twenty did not evidence the diffusion abnormality but revealed initial cerebral atrophy. The last MRI at two months revealed diffuse mild grey matter atrophy, sparing the temporal regions. The neurological impairment evolved to multiple deficits: tetraparesis, dyskinesia characterized by intense bursts of extrapyramidal movements (orofacial dyskinesia, choreiform and dystonic episodes), severe cognitive and visual impairments. Conclusions: Influenza A is associated with a high incidence of febrile seizures. Most of these cases have a favorable neurological prognosis, as reported in the literature. However, ours was a severe case of influenza A-associated encephalopathy which resulted in severe neurological sequelae. In our opinion, it is important for clinicians to inform the parents about the possible secondary neurological progression of influenza A-associated encephalitis. Further studies will be necessary to make this determination.

P316 Epilepsia partialis continua: a paediatric hospital experience Coimbra, Portugal F. Palavra, C. Diogo, C. Costa, M. Vasconcelos, O. Gonc¸alves, I. Fineza, C. Robalo Central Hospital of Coimbra (Coimbra, PT); Children’s Hospital D. Pedro (Aveiro, PT); Children’s Hospital of Coimbra (Coimbra, PT) Introduction: Epilepsia Partialis Continua (EPC) has been considered an equivalent of status epilepticus. It may have different etiologies and the prognosis ultimately depends on it.

Objectives: To characterize the population of patients diagnosed with EPC who attend the Epilepsy Consultation at Coimbra’s Pediatric Hospital (CPH). Methods: We conducted a retrospective study, consulting the clinical files of patients diagnosed with EPC identified through the computerized database of CPH since 2001. We collected demographic and clinical data, concerning functional evolution of the patients. Results: We studied 12 patients, 10 males, aged in the range 10.5±5.7 years. In about half of the cases, there was a previous history of epilepsy, with onset at the age of 3.6±2.1 years. EPC settled by 6.0±3.3 years and had a duration of 1.4±1.3 years. Treatment was performed with 3.3±1.0 anti-epileptic drugs, associated with human immunoglobulin in two thirds of the cases. The EEG showed abnormal elements in all cases and cranial MRI revealed alterations in 83% of patients. Among the most common etiologies, we mention Rasmussen’s Disease (RD) in 41.7% of cases, followed by sequelae of encephalitis and malformations of cortical development. One third of patients underwent surgery. The functional evolution was considered unfavorable in 75.0% of patients. All cases of RD had an unfavorable functional evolution, although the difference was not statistically significant, comparing them with the other patients (p=0.205). Conclusion: EPC is a rare entity, with multiple etiologies. The diagnosis is sometimes complex, it has poor response to anti-epileptic therapy and the prognosis is generally unfavorable.

P317 Long-term open salbutamol trial in spinal muscular atrophy A. Prufer de Queiroz Campos Araujo The Federal University of Rio de Janeiro (Rio de Janeiro, BR) Objectives: Spinal Muscular Atrophy (SMA) is one of the most common neuromuscular disorders in children. Albuterol/salbutamol, a b 2-adrenoceptor agonist, has been shown to improve muscle strength in SMA patients in a pilot trial, and to increase survival motor neuron gene 2 transcript levels in fibroblast cell lines. The aim of this study was to verify the tolerability and clinical response of salbutamol in children and adolescents affected by SMA. Methods: The children and adolescents with confirmed SMA diagnosis (presence of deletion) followed at a University Hospital, were invited for a prospective open trial with salbutamol. They were classified as SMA type I, II or III according to their best motor ability, evaluated according to the modified Hammersmith functional score, 10 minute walking test (when able to), vital capacity, daily time on non-invasive ventilation, heart rate, number of respiratory events. This is an Institutional Review Board approved study and consent was given by all those included. The salbutamol dosage was 1 mg three times a day and if this was tolerated, with no increase in more than 10 % of pulse rate, dosage was increased to 2 mg three times a day. Assessments were at baseline and at 3, 6 and 12 months of therapy. Results: Twenty eight patients (3 type I, 16 type II, 9 type III) took part of this study. Their age ranged from 1 to 20 years, they were followed up to one year. Their overall outcome was favorable and showing stability of their assessment. None had decrease of motor or respiratory function. Seven had an increase in at least one measure (up to 14 points in HMFS, up to 5% in vital capacity). Tolerability was excellent, no changes in heart rate or adverse effects were observed. Patients, family members and health professionals referred subjective improvement and were keen to continue on treatment after the 12 month trial. Conclusion: While no curative treatment is available, salbutamol seems to be a safe option to induce improvement in motor and respiratory function.

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P318 Patterns of continuous performance test errors in children with attention deficit/hyperactivity disorder and pervasive developmental disorder Y. Tsushima, T. Hirasawa, S. Sanada, M. Yanagihara, S. Ohno, M. Oka, Y. Ohtsuka, T. Ogino Hyogo University of Teacher Education (Kato, JP); Okayama University (Oakayama, JP); Ohno Paediatric Clinic (Oakayama, JP); Chugokugakuen University (Oakayama, JP) Objective: Continuous performance test (CPT) was originally developed in 1956 by Rosvold to detect and evaluate brain damage in both children and adults. This study attempts to assess attention function and response control in children with attention deficit hyperactivity disorder (AD/HD) and pervasive developmental disorder (PDD) without comorbid AD/HD using a CPT. Among the various versions of the CPT available, we used the Kiddie CPT (K-CPT; Conners, 2001) modified for younger children with reduced task duration. Methods: The K-CPT was administered to children with AD/HD (N=16), children with PDD (N=9), and typically developing children (N=25) from 7–11 years of age. All clinical participants were drug free at the time of examination and had minimum Full Scale IQ of 80 or above assessed by the WISC-IV. Performances were examined using 6 measures: omission error, commission error, mean hit reaction time, hit reaction time standard error, detectability, and response style. Statistical analyses were conducted to examine differences in performance among the three groups by analyses of covariance or analyses of variance. Results: In comparison with the typically developing group, the AD/HD group showed significantly more commission errors (p\ 0.001), lower detectability (p\ 0.05) and higher hit reaction time standard error (p\ 0.01), while the PDD group showed no significant differences. There were no significant group differences on omission error, hit reaction time and response style. Conclusions: AD/HD and PDD groups showed different profiles of sustained attention and response control performances. These findings suggest inadequate selective attention, sustained attention as well as inhibitory control function in AD/HD. The sample size of children with AD/HD and PDD is, however, not large enough for an assertive interpretation.

P319 Salmonella meningoencephalitis: a report of a case M.J. Gil, M.T. Fernandez, C. Isart, B. Martinez

EEG was performed which shows no alteration. At 15 days of start of table MRI performed skull shows multiple nodular deposits in supratentorial periventricular white matter, suggesting involvement of encephalitis (secondary microabscesses) and marked with irregular uptake in paquimeninges.During the days after the child remains afebrile and without episodes comitial, Treatment with Cefotaxime and maintaining a dose of Phenytoin. Last MRI skull made no alterations. Conclusion: Salmonella meningitis is a rare extraintestinal complication that usually affects children under one year old, with a peak incidence of 2 to 4 weeks. CNS involvement by Salmonella is an important complication that must be recognized and treated early. Should be included in the differential diagnosis of any child with focal seizures and Salmonella gastroenteritis.

P320 Neuronal ceroid lipofuscinosis type 2 (CLN2), JanskyBielschowsky in Oman R. Koul, A. Alfutaisi, A. Alakhyat Sultan Qaboos University (Muscat, OM) Objectives: Diagnosis of Neuronal Ceroid Lipofuscinosis (NCL) type 2, (CLN2) in children with neurodegenerative disease. Methods: All children with neurodegenerative diseases were investigated for the underlying causes. The diagnosis of NCL type 2 (CLN2) was made on clinical findings, histological features and genetic studies. Twenty children with this disease were diagnosed. The treatment was symptomatic. Results: Nine families with twenty children were seen. There were 16 male (80%) and 4 female children. Most of the patients, 18 of 20 (90. %), were CLN2 type,and 2 patients were the atypical type. Six children were seen in 1 extended family. One of these children had genetic study and found to have homozygous for a c.1525, C -[ T (codon 509 mutation in exon 12 of the CLN2 gene. Most children (90 %) had onset with myoclonic seizures except in 1 family. The majority had onset between ages 1 to 4 years. Neuroregression and microcephaly were noted in all. Cortical and cerebellar atrophy was seen in all. Ophthalmological examination was abnormal in all. Only six of the 20 are living and all are under ten years age. Conclusion: CLN2 type was the most common form of neuronal ceroid lipofuscinosis in this part of the Arab world. There was male predominance of 80.0%. Previously a report of eleven children was published in J Child Neurology Volume 22 Number 5, May 2007 555–559

Hospital de Getafe (Madrid, ES) Objectives: Salmonella meningitis is a rare entity. Because of high mortality is necessary to provide immediate treatment. Material and methods: Case report. Results: Male child of 8 months of age without medical history of interest entered by a of fever, up to 40 , catarrhal symptoms and diarrheal stools for some 3 days, unresponsive to previous treatment with amoxicillin. Once in the emergency department he has an episode of decreased level of consciousness with tonic - clonic seizure lasting 1 minute. Additional tests are performed: full analysis, routine urinalysis, skull and chest x-ray CT. The results of CSF are objectified signs consistent with acute bacterial meningitis, and treatment starting with Cefotaxime, Vancomycin and Dexamethasone and phenytoin. As for the results of CSF culture positive samples for analysis Salmonella. At this time the treatment is removed with Vancomycin and Dexamethasone and maintained with Cefotaxime.

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P321 Ultrasound method for complex diagnostics of hypoxicischaemic lesion of central nervous system in newborns M. Sigatullina Tashkent Pediatric Medical Institute (Tashkent, UZ) Research objective: Complex evaluation of damage of Central Nervous System (CNS) in full-term newborn children with hypoxicischemic encephalopathy (HIE). Methods: 106 full-term newborns with transferred chronic fetal hypoxia have been examined. The complex neurological research and Doppler ultrasound assessment of cerebral blood flow were conducted. 55 children have been included into the first group with lower degree of HIE, second group was comprised by 45 children with

S103 average degree of HIE and the third group – 6 children with serious hypoxic lesion of CNS. Results: Ultrasound measurement results showed the brain ischemic signs (50% of cases), ventriculomegaly (38% of cases) (Group 1), and intraventricular hemorrhages of 1-th and 2-th degrees (20% of cases) (Group 2). Examination of 3-rd group children showed periventricular hemorrhage with presence of cystic changes. Dilatation of a subarachnoid space was found as well. 2nd group children examination showed hyperechoic changes of periventricular zones. Intraventricular hemorrhages of II-III degree for 2-nd and 3-rd groups were accompanied by syndrome of cerebral depression, a muscular dystonia, clonic seizures, disturbance of blood circulation and breathing. According to Doppler ultrasound assessment of cerebral blood flow of all newborns (n=106), the cerebral blood flow has been considerably increasing during the first 30 min after birth. The index of resistance (IR) in a Arteria Cerebri Anterior (ACA) was 0,72 ±0,01, in Arteria Cerebri Media (ACM) - 0,75± 0,03, Arteria Basilaris – (AB) - 0,62±0,01. For 30% of children from 2-nd group IR raised within 2 hours after birth in ACA up to 0,77 +0,01, in ACM - up to 0,76± 0,01, in AB - 0,78±0,01, and at the end of day 3 normalization of parameters of IR was noticed for this group of children (IR (ACA)- 0,71±0,01; IR (ACM) - 0,72 ± 0,01, IR (AB) -0,75±0,01). For 15% of children from 3-rd group increasing of IR in ACM and BA with relative normalization of a cerebral blood flow was noticed only on a seventh day. Conclusion: The compensatory increase of cerebral blood flow in main arteries of brains was found in children with severe degree of hypoxic central nervous system damage. Results were confirmed by Doppler ultrasound assessments.

P322 Autoimmune myasthenia gravis: the youngest patient diagnosed in Serbia A. Potic, V. Milic Rasic, J. Jancic Medical Faculty University of Belgrade (Belgrade, RS) Objective: To draw attention to the possibility of autoimmune myasthenia gravis (MG) among very young paediatric patients- a group more characteristic for congenital MG syndromes. Methods: We report the youngest patient diagnosed in Serbia with autoimmune MG. The disease commenced at the age of three years when the girl presented with unilateral ptosis and sporadic diplopia appearing after physical exhaustion during the afternoon and evening. Apart from ocular signs, the girl presented with no other signs of weakness and fatigability. The perinatal period and developmental milestones went uneventful, with no data pointing to a possible earlier disorder appearance. The family history was negative for any of the autoimmune disorders. Neurological examination confirmed isolated ocular weakness and fatigability (unilateral ptosis and ophthalmoparesis) -Osserman type I MG. The neostigmine test was positive, a characteristic decremental response was documented on the repetitive stimulation study, while positive anti- AChR (acetylcholine receptor) -antibodies were found in serum. The mediastinal MRI (magnetic resonance imaging) showed normal findings for the age. Results: Within a period of seven months a complete clinical remission was accomplished with prednisone therapy (an alternateday dose of 2 mg/kg) and supportive pyridostigmine therapy. Thymectomy was not performed. Conclusion: The usual onset of childhood autoimmune MG is after ten years of age and the earlier disease onset often raises a suspicion of a congenital myasthenic syndrome. We herewith describe that an autoimmune MG should not be overlooked despite the patient’s age.

P323 The false belief task in 5-year-old children: delay in theory of mind development T. Go Doshisha University (Kizugawa-shi, JP) Objectives: The false belief task has often been used as a test of theory of mind (TOM). TOM is considered a critical precursor to advanced human social-cognitive skills. Studies in the 1980s and the 1990s reported that children were usually able to pass the false belief task after the age of 5, whereas most children with autism spectrum disorders (ASD) were unable to do so. Recent studies have indicated an increase in the number of children diagnosed with ASD. TOM developmental might be delayed in normal children as well as children with ASD. To investigate this possibility, the false belief task was studied on 5-year-old children in the community. Methods: ‘‘Smarties’’ task was used as the false belief task. It was performed as one of routine medical checkups for all 5-year-old children in a rural Japanese town with a population of around 13000. About 50-60 % of 5-year-old children in the town took the routine medical checkups. Results: A total of 101 children, 53 boys and 48 girls, was performed the task. Fifteen children (14.9%), 7 boys and 8 girls, passed the task. Forty children (39.6%), 23 boys and 17 girls, failed to pass it. Six children (5.9%), 3 boys and 3 girls, said •gI don•ft know•h. Forty children (39.6%), 20 boys and 20 girls, did not answer. Conclusion: The present study indicates that the current pass rate of the false belief task is much lower in normally-developing children than previous studies. TOM developmental seems to be delayed in normal children at present.

P324 Identification of a novel de novo mutation in the SCN4A gene in a patient with paramyotonia congenita J.B. Kim Konyang University Hospital (Daejeon, KR) Objectives: Paramyotonia congenital (PMC) is a rare autosomaldominant neuromuscular disorder where muscles are difficult to relax following contraction. Repetition of movements makes the muscle stiffness become progressively worse whereas classical myotonia is alleviated by exercise. Mutations in the SCN4A gene, which encodes a skeletal muscle voltage-gated sodium channel, have been reported to be responsible for this disorder. We report a novel de novo mutation in the SCN4A gene in a 12-year-old boy with PMC. Patient and Methods: A 12-yr-old boy was admitted to our hospital with complaints of periodic paralysis that first developed when he was around one year of age. The patient described cold-induced stiffness and often subsequent transient weakness. At admission, there were no abnormal findings on radiologic examination, electrocardiography or laboratory testing, except increased serum creatine kinase at 620U/L (normal, 32-294). PMC was confirmed by electromyography, with demonstration of cold-induced myotonia and membrane depolarization. Mutation screening was carried out by direct sequencing the entire coding region of the SCN4A gene. Results: Mutational analysis revealed a heterozygous c.2386C[G substitution in the SCN4A gene, leading to a Leu796Val mutation in the protein sequence. The parents were clinically unaffected and did not show a mutation in the SCN4A gene. A de novo Leu796Val mutation has not been previously reported. We confirmed its absence in 200 unaffected and unrelated Korean individuals, i.e. 400 chromosomes. The patient showed a marked improvement of the paralytic symptoms with prophylactic administration of acetazolamide. Conclusion: Our findings have implications for the diagnosis and genetic counseling of an isolated member of a family with the

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S104 phenotypic features of PMC. These results also suggest that de novo mutations in the SCN4A gene may occur more frequently than might previously have been anticipated.

Peripheral neuropathy P325 Charcot-Marie-Tooth disease and ascorbic acid trials: results of the CMT-TRIAAL and CMT-TRAUK D. Pareyson, M. Reilly, N. Rizzuto, G. Fabrizi, L. Santoro, A. Quattrone, G. Vita, L. Padua, F. Gemignani, F. Visioli, M. Laura`, D. Radice, D. Calabrese, A. Schenone, A. Solari for the CMT-TRIAAL and CMT-TRAUK Groups Objective: There is no drug therapy for Charcot-Marie-Tooth neuropathy type 1A (CMT1A) associated with the duplication of the peripheral myelin protein 22 (PMP22)gene. Ascorbic acid (AA) proved effective for transgenic mice overexpressing PMP22, a model of the human disease. Two recent trials of AA showed no benefit in adults and children, but were underpowered, lasted only one-year, and some encouraging post-hoc analyses left unsolved the question of AA efficacy. The CMT-TRIAAL (CMT-TRial Italian with Ascorbic Acid Long term; EudraCT no: 2006000032-27) and the CMT-TRAUK (CMT-TRial with Ascorbic acid United Kingdom; ISRCTN61074476) are phase III randomized, double blind, placebo-controlled parallel trials of ascorbic acid in CMT1A involving 271 symptomatic adults from eight Italian and one UK centers, based on a shared protocol/analysis. Methods: Treatment consisted in two-year oral AA (1,500 mg/day) or placebo. Efficacy endpoints were changes in CMT Neuropathy Score (CMTNS, primary endpoint); distal maximum voluntary isometric contraction; 10-meter timed walking; 9-hole-peg test; Overall Neuropathy Limitations Scale (ONLS); visual analogue scales (VAS) for pain and fatigue; health-related quality of life (SF-36); and electrophysiology. Assessments were performed at baseline and every six months thereafter. Results: AA treatment was well tolerated. Almost 89% of patients (n =240) completed the study, and only 19 patients dropped out for adverse events (nine in the AA group). There was no difference between AA-treated and placebo groups at any time for all outcome measures. Mean CMTNS was 14.7 ± 4.9 vs 13.9 ± 4.3 at baseline and 14.7 ± 5.4 vs 14.3 ± 4.5 after two years (AA vs placebo group). Mean worsening from baseline value after two years was 0.2 ± 2.8 in AA and 0.3 ± 2.6 in placebo group: much less than in previous reports, based on partly retrospective data or short-term follow-up. Conclusions: This trial showed no clinical efficacy of AA over a two-year period in the largest series of CMT1A patients ever studied. Disease progression was slower than expected in the placebo group. CMT-TRIAAL was granted by Telethon-Italy (GUP05007) and partially by the Agenzia Italiana del Farmaco (AIFA; FARM53APAH); CMT-TRAUK was funded by the Muscular Dystrophy Campaign, UK.

P326 Nerve conduction studies in Charcot-Marie-Tooth disease type 1A : data from ascorbic acid trials (CMTTRIAAL and CMT-TRAUK) C. Marchesi, L. Santoro, F. Manganelli, C. Pisciotta, L. Padua, V. Scaioli, M. Reilly, A. Solari, D. Pareyson for the CMT-TRIAAL and CMT-TRAUK Groups Objective: Charcot-Marie-Tooth disease type 1A (CMT1A), the most common CMT form, is associated with Peripheral Myelin Protein 22

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gene duplication. Typically nerve conduction slowing is dramatic and diffuse in sensory and motor nerves, reflecting the widespread Schwann cell derangement. The CMT-TRIAAL (CMT-TRial Italian with Ascorbic Acid Long term) and the CMT-TRAUK (CMT-TRial with Ascorbic acid United Kingdom) are phase III randomized, double blind, placebocontrolled parallel trials of ascorbic acid involving 271 CMT1A symptomatic adults from eight Italian and one UK centers. We report the electrophysiological data of the basal assessment of the trial population. Methods: Two hundred and sixty-nine patients (aged 18-70 years) underwent electrophysiological examination including assessment of motor nerve conduction velocities (MCV), distal latencies (DL), compound muscle action potentials (CMAPs) of the ulnar, median and peroneal nerve (non-dominant side; registration from I dorsal interosseous muscle for the ulnar nerve, from extensor digitorum brevis - EBD - or, when no M-response was recordable, tibialis anterior muscles for the peroneal nerve). Sensory action potential (SAP) amplitude and sensory conduction velocity (SCV) of the ulnar nerve (non-dominant side) were recorded. A series of clinical outcome measures were also evaluated: CMT Neuropathy Score (CMTNS); distal maximum voluntary isometric contraction; 10-meter timed walking; 9-hole-peg test; Overall Neuropathy Limitations Scale; VAS for pain and fatigue; health-related quality of life (SF-36). Results: We obtained the following values (Mean ± SD). Ulnar nerve: MCV 19.8 ± 4.8 m/s, DL 7.7 ± 1.8 ms, distal CMAP 3.3 ± 2.0 mV; median nerve: MCV 21.1 ± 5.1 m/s, DL 10.1 ± 2.2 ms, distal CMAP 3.2 ± 2.2 mV; peroneal nerve (EBD): MCV 19.9 ± 5.0 m/s, DL 10.9 ± 3.2 ms, distal CMAP 0.25 ± 0.65 mV (no response = 194 pts); peroneal nerve (Tibialis anterior): CMAP = 1.3 ± 1.4 mV. Ulnar nerve SCV = 20.2 ± 5.0 m/s. No SAP response could be recorded in the vast majority of patients (n = 215), irrespectively of age. Conclusions: In this very large CMT1A population nerve conduction studies confirmed the dramatic and diffuse slowing in conduction. Interpretation of our findings and their association with demographic and clinical characteristics is underway. CMT-TRIAAL was granted by Telethon (GUP05007) and Agenzia Italiana del Farmaco (FARM53APAH); CMT-TRAUK was funded by the Muscular Dystrophy Campaign, UK.

P327 Chronic idiopathic axonal polyneuropathy is associated with the metabolic syndrome N.A. Visser, N.C. Notermans, Y.T. van der Schouw, J.H. Wokke, L.H. van den Berg, A.F. Vrancken University Medical Centre Utrecht (Utrecht, NL) Objectives: In approximately 25% of patients presenting with polyneuropathy, no cause can be found despite extensive evaluations and these patients may be diagnosed with ‘chronic idiopathic axonal polyneuropathy’ (CIAP). Impaired glucose tolerance, hypertension, dyslipidaemia, and obesity have been suggested to be associated with CIAP, although the evidence has not been consistent. We investigated the association between CIAP and the metabolic syndrome (MetS), defined as the presence of at least three of the NCEP ATP III MetS criteria: elevated fasting glucose, elevated hypertriglycerides, reduced HDL-cholesterol level, elevated blood pressure, central obesity. Methods: A prospective study was started in January 2009 at the UMC Utrecht, the Netherlands. Blood pressure, fasting glucose, triglycerides, HDL-cholesterol, and waist-circumference were determined in patients with CIAP. The findings were compared to those in control subjects from an existing population based Dutch cohort. Based on the proportion of patients and control subjects that met the MetS criteria, the odds ratio (OR) with 95% confidence interval (95% CI) was calculated.

S105 Results: 63% of 109 patients with CIAP (mean age 64.5 yrs) met the MetS criteria compared to 36% of 452 sex matched control subjects (mean age 60.5 years; p\0.05), yielding OR 3.1 (95% CI 2.0 to 4.7; p\0.001). 38% of 327 sex and age matched control subjects met the MetS criteria, yielding OR 2.8 (95% CI 1.8 to 4.4; p \ 0.001). Conclusion: Patients diagnosed with CIAP significantly more often meet NCEP ATP III criteria for the MetS compared to population derived sex and age matched control subjects. This finding strongly suggests that the MetS could be a factor in the etiology of CIAP. This study was funded by the Prinses Beatrix Foundation, grant number WAR 07-24

P328 Effect of ascorbic acid in CMT1A disease: a Czech multicentre, randomized, double-blind, placebocontrolled trial R. Mazanec, P. Vondracek, M. Havlova, A. Kobesova, J. Haberlova, J. Bo¨hm, L. Novakova, E. Vyhnalkova, P. Seeman, M. Bojar

innervation and mitochondria enzymatic function. Methods: We performed a distal leg skin biopsy before and after 30-days treatment with linezolid. The intraepidermal nerve fiber density (IENFd) was quantified using bright-light histochemistry with the panaxonal marker PGP 9.5. For the analysis of mitochondria, we double-labelled skin sections with immunofluorescent staining of complex IV and PGP 9.5. Images of co-localization of mitochondria in axons were obtained and quantified using a confocal microscope. We also measured mitochondrial function on plasmatic lymphocytes by spectrophotometry through enzymatic measurement of COX activity. Results: None of the patients referred sensory complaints. There were no changes in the IENFd (mean 6.6/mm before vs. 8.8/mm after treatment) but axonal swelling and fragmented fibers were significantly increased after treatment. The mitochondrial immunoreactivity was reduced after treatment compared with pretreatment situation (5.23% vs. 7.11%, paired t-test p \0.005). Mitochondrial plasmatic function significantly decreased 61% after treatment (p\0.001). Conclusion: The presence of morphological abnormalities with preserved IENFd is indicative of incipient axonal damage in small sensory fibers. The mitochondrial disfunction due to linezolid toxicity may be involved in axonal impairment and provide new clues to understand small fiber neuropathy.

Charles University (Prague, CZ); Masaryk University (Brno, CZ) Background: Charcot-Marie-Tooth disease type 1A (CMT1A) is the most common hereditary neuropathy characterized by distal muscle atrophy and sensory impairment. No causative treatment is currently available. The experimental trial in a transgenic mouse model of CMT1A has shown, that ascorbic acid can reduce demyelination of peripheral nerves and improve muscle function. We evaluated the safety and efficacy of ascorbic acid in CMT1A adult patients. Methods: 24-months, randomized, double blind, placebo-controlled efficacy trial was performed from November 2007 to December 2009. We randomized 60 CMT1A patients with genetically proven PMP22 gene duplication into two groups – ascorbic acid group receiving 1.5 g active substance per day and placebo group. All investigators were blinded to treatment and separated into treating and evaluating investigators. The primary outcome measures were the CMT neuropathy score (CMTNS) at 24 months, dynamometry, 9 peg hole test, 10 meters walk and electrophysiology. This study is registered with the EUDRA CT No 2006-007025-31. Results: 51 patients finished the trial; 27 treated with ascorbic acid and 24 in placebo group. Median change in CMTNS from baseline to 24-months was 0.8 points for the placebo group and 0.5 points for the ascorbic acid group. There were no statistically significant differences in efficacy and frequency of side effects between the groups. Conclusion: Ascorbic acid at the dose of 1.5 g per day was safe and well tolerated in CMT11A adult patients over 24 months period. However, our data show no significant differences in CMTNS outcome between the groups. Supported by IGA grant MH CR NR/9517-3.

P329 Subclinical small fibre neuropathy related to long treatment with linezolid: the possible implication of mitochondrial failure J. Casanova-Molla, M. Morales, G. Garrabou, C. More´n, M. Nicola`s, F. Cardellach, A. Soriano, J. Valls-Sole´ Hospital Clinic of Barcelona (Barcelona, ES) Introduction: Long lasting treatments with the antibiotic linezolid can cause toxicity(hyperlactatemia, anemia and sensory neuropathy) that is attributed to blocking of mitochondrial protein synthesis.We aimed at characterizing the mitochondrial toxicity of linezolid on skin

P330 Efficacy and safety of subcutaneous immunoglobulin, Vivaglobin, in patients with multifocal motor neuropathy S. Misbah, G. Comi, R. Fazio, I. Andresen, A. Baumann, J. Burton, M. Sturzenegger John Radcliffe Hospital (Oxford, UK); University Vita-Salute San Raffaele (Milan, IT); CSL Behring AG (Berne, CH); Neurology Practice (Langenthal, CH); University Hospital Berne (Berne, CH) Objectives: Multifocal motor neuropathy (MMN) is characterized by progressive, asymmetric, lower motor neuron weakness and muscle atrophy, caused by partial conduction blocks in motor but not sensory nerves. High-dose intravenous immunoglobulin (IVIG) treatment has been the only available therapy, to which approximately 80% of patients respond. Subcutaneous immunoglobulin (SCIG) home therapy is an effective and well-tolerated alternative offering flexibility to patients. The objective of this open-label multicentre Phase II study was to assess the efficacy, safety and convenience of SCIG (Vivaglobin) treatment in patients with MMN over a period of 6 months. Methods: Eight patients with MMN (42 to 66 years), on stable previous IVIG treatment, were administered weekly Vivaglobin at a monthly dose equivalent to previous IVIG. Muscle strength was determined on 40 muscles or muscle groups using the Medical Research Council (MRC) Scale at Week 8, 16 and 24. The primary efficacy endpoint was the difference in MRC sumscore from baseline to Week 24. Disability was assessed at the same time points using a modified Guy’s Neurological Disability Scale. Health-related quality of life (HRQL) was assessed via evaluation of treatment satisfaction, Life Quality Index (LQI) and global health status. Results: Muscle strength was maintained or slightly improved in 7 of 8 patients, while disability was maintained in 4 and improved in 1 patient. One patient had a transient worsening of muscle strength and disability, which improved after dose adjustment at Week 8. One patient’s muscle strength and disability worsened despite dose increase resulting in withdrawal from the study due to lack of efficacy. Seven patients rated home treatment as extremely good. Improvement in total LQI score was observed in 5 patients at the Completion Visit (16–69 points), while in 1 patient the score was similar to baseline. The health status was maintained or slightly improved in all 7 patients with available data. Four patients

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S106 experienced 18 adverse events (AEs), most of them mild (2 moderate AEs). Thirteen AEs in 2 patients were considered related to study treatment (12 of them local reactions in 1 patient). There were no serious AEs. Conclusion: MMN patients with stable clinical course on repetitive IVIG can be switched to SCIG at the same monthly dose without deterioration in muscle strength and with a sustained overall improvement in HRQL and global health status. This study was supported by CSL Behring AG, Berne, Switzerland.

P331 Mixed connective tissue disease—an unusual neurologic manifestation A.C. Ribeiro, F. Palavra, A. Godinho, A.S. Morgadinho, J.G. Gonc¸alves Coimbra’s General Hospital (Coimbra, PT) Introduction: The Mixed Connective Tissue Disease (MCTD) gathers a set of typical features from Systemic Lupus Erythematosus, Scleroderma and Polidermatomiosites in variable proportions for each patient, together with the presence of anti-U1-RNP antibodies in high titres. The neurological manifestations are rare and among the most frequently described are aseptic meningitis, trigeminal sensory neuropathy, transverse myelitis and neuropsychiatric disorders. Case Report: A 47-year-old male patient with a two month history of left hand and forearm paresthesias, accompanied by muscle weakness with a distal-proximal progression, also complains of right face and leg above the knee paresthesias. Neurologic Examination: left upper limb (LUL) motor deficit predominantly distal, right brachioradialis and triceps hyporeflexia with lower limb areflexia, bilateral facial hypoesthesia and limbs hyposthesia with an assymetric stocking-glove distribution; abolished vibration in LUL, joint position sense with more than 3 errors in all four limbs with difficulty in walking on his heels. Investigation: Strongly positive serum ANA, anti-SSA/SSB and anti-U1-RNP antibodies; high sedimentation velocity; normal cerebrospinal fluid testing, serologies and tumoral markers; normal cerebral and cervical CT and MRI-scans with electromyography findings suggestive of multiple mononeuropathy. Treatment begun with oral corticosteroids later replaced by azathioprine His neurological condition did suffer some improvement in the motor deficit. Conclusion: MCTD is a rare condition, especially in man, often difficult to diagnose and with a low incidence of peripheral nervous system manifestations (\10%). The most interesting features of this case are the type and timing of onset of neurological disorders. A multiplex mononeuropathy is not normally associated with this disease and it is unusual that its research leads to the diagnosis of an autoimmune disease.

P332 Atypical Guillain–Barre´ syndrome associated to dengue fever A.A. Barreira, L.C. Lopes, A.C. Santos, J.O. Ramos, P.G. Bastos, V.D. Marques, L.A. Castro-Jorge, B.A. Fonseca, W. Marques Jr. Medical School of Ribeira˜o Preto (Ribeira˜o Preto, BR) Objectives: To report an atypical case of Guilllain-Barre´ syndrome (GBS) associated with dengue fever. Methods: Serial neurological examinations and ancillary tests. Results: A sixty-year-old man was admitted complaining of fever, odinophagia, lumbalgia, abdominal pain, and cutaneous rash,

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followed by tingling in his hands and inferior limbs, urination retention, bilateral facial paresis, and parestesias of the inferior limbs and hands 10 days later. Neurological evaluation detected a bilateral facial paresis, a XII cranial nerve left paresis, a predominantly proximal inferior limbs paraparesis and areflexia, and normality of reflexes in the superior limbs. A cuirass hypoesthesia in the trunk as well as a stock and glove tactile and pain hypoesthesia were also found. Subsequently, a bilateral sensory ataxia, a light dysphagia, a partial loss of vibration sense in the limbs, and predominantly distal asymmetrical bilateral paresis of the superior limbs more intense at the left occurred. A subsequent flaccid paraplegia made the patient wheel-chair-bound at the fifth day from the first motor sign. The patient was treated with IgIV 400mg/Kg/day for 5 days. Six months later, there was only a complaint of parestesias in the toes without sensory loss. Two EMGs were taken at the acute phase and 3 weeks after the first motor sign, and both showed a predominantly demyelinating pattern. CSF examination at the acute phase revealed 18 cells/ dl (lymphocytes and neutrophils), and 113mg/dl protein level (normal = 48mg/dl). There was positivity of IgM against the dengue virus, and the new CSF taken four months later was normal, except for strong positivity of IgG against the dengue fever virus and a weak positivity for IgM. A serological panel locking for antibodies against the following viruses was negative: HIV, Herpes simplex, Herpes vtype 6, Varicelae zoster, Citomegalovirus, Adenovirus, and Epstein-Barr virus. Brain and spinal images were both normal. Conclusion: The sensory ataxia, the sensation loss and parestesias, the marked asymmetry of the neurological deficits, and the urinary retention indicating urinary sphincter involvement and suggesting a myelopathy are uncommon findings in GBS. This report indicates the possibility that GBS when associated with dengue fever can have a different neurological phenotype compared with the classical one. Fundac¸a˜o de Apoio ao Ensino e a` Assisteˆncia do Hospital das Clı´nicas de Ribeira˜o Preto

P333 Clinical features and electrophysiological findings of acute brachial plexitis H.Y. Jo Wallace Memorial Baptist Hospital (Busan, KR) Background: Acute brachial plexitis is an acute idiopathic inflammatory disease affecting brachial plexus, which is characterized by initial severe pain in shoulder followed by profound weakness of affected arm. This is a retrospective study to evaluate the clinical and electrophysiological profile of acute brachial plexitis. Methods: Sixteen patients with acute brachial plexitis were sampled. The electrodiagnostic studies included motor and sensory nerve conduction studies (NCSs) of the median and ulnar, sensory NCSs of medial and lateral antebrachial cutaneous nerves, and needle electromyography (EMG) of selected muscles of upper extremities and cervical paraspinal muscles. The studies were performed on both sides irrespective of the clinical involvement. Results: In most of our patient, upper trunk was predominantly affected (14 patients, 87.50%). Only two patients showed either predominant lower trunk affection or diffuse affection of brachial plexus. All had an acute pain followed by the development of muscle weakness of shoulder girdle after a variable interval (7±8.95 days). Ten patients (62.50%) had severe disability. In NCSs, the most frequent abnormality was abnormal lateral antebrachial cutaneous sensory nerve action potentials (SNAPs). On needle EMG, all the patients showed abnormal EMG findings in affected muscles. Conclusions: In this study, pain was the presenting feature in all patients, and the territory innervated by upper trunk of the brachial plexus was most frequently involved. The most common NCS

S107 abnormality was abnormal SNAP in lateral antebrachial cutaneous nerve. Our findings support that the electrodiagnostic test is useful in localizing the trunk involvement in acute brachial plexitis.

P334 A new mutation in the GJB1 gene causing a mild form of X-linked CMT F. Correia, H. Morais, D. Alves, J. Cerqueira, J.P. Basto, J. Sequeiros Hospital Pedro Hispano (Matosinhos, PT); Institute for Molecular and Cellular Biology (Porto, PT); University of Porto (Porto, PT) Introduction: Charcot-Marie-Tooth (CMT) is the most common inherited neuromuscular disorder and is characterized by chronic motor and sensory neuropathy. The affected patient typically has slowly progressive atrophy and weakness of distal muscles, often associated with mild to moderate sensory loss, depressed tendon reflexes and pes cavus. The nerve-condution studies subdivide CMT in 3 groups: demyelinating, axonal and intermediate form. X-linked Charcot-Marie-Tooth (CMTX) disease is the second most common variant of CMT (10-20% of all CMT patients), just after CMT1A (duplication of the PMP22 gene in the chromosome 17p11.2). CMTX is characterized by moderate to severe motor and sensory neuropathy in affected males and none or usually mild symptoms in carrier females. About 90% of CMTX cases are due to mutations in GJB1 gene, causing CMTX1. We present a case of CMT, whose family history and neurography findings direct the genetic study for GJB1, and in which we identified a mutation not described in the current literature. Clinical case: We reported a 20-year-old white Portuguese male with a history of progressive weakness of the legs for some years, particularly on the right, and without sensory complaints. The neurological examination showed the presence of pes cavus, slight limitation of feet dorsiflexion and decreased deep tendon reflexes in the lower limbs with intact sensitivity. Family history was negative except for a maternal uncle with pes cavus. The neurography showed a slowing of distal latencies, conduction velocities moderately decreased and reduced amplitude of motor compound potentials, with evidence of proximal conduction block (right tibial nerve) and absence of sensory compound potentials. The genetic test confirmed CMTX1 with the presence of a frameshift mutation of c.321delG (p.Glu109ArgfsX12), previously unreported. This mutation causes changes in the reading frame and introduces a premature stop codon. Conclusions: A typical clinical presentation, a family history and electrophysiological studies are determinant to guide the molecular diagnosis in highly heterogeneous disorder such as CMT. The case presented is peculiar because of the uncommon neurographic aspects (conduction block, previously regarded as almost pathognomonic of inflammatory polyneuropathies) that guided the genetic study and a new genetic mutation found of the gene GJB1 (CMTX).

P335 Comparison of Charcot-Marie-Tooth neuropathy type 2 and type 1A: clinical characteristics J. Nikodinovic, V. Milic Rasic, J. Mladenovic University of Belgrade (Belgrade, RS) Objectives: Comparing clinical characteristics of Charcot-MarieTooth neuropathy type 2 (CMT2) and type 1A (CMT1A). Methods: Both CMT2 and CMT1A patients diagnosed at Clinic for Child Neurology and Psychiatry, Belgrade. CMT2 diagnosed according to European Neuromuscular Centre Workshop criteria

(1997). CMT1A confirmed by 1.5Mb duplication in the chromosomal region 17p11.2. Neurological disability score (NDS) used for disability assessment (Dyck et al,1993). Conventional techniques applied for electroneurographic (ENG) studies (De Lisa et al.,1987) on Premier (Medelec) apparatus. Molecular genetics studies done in PCR lab, Belgrade and Neurogenetics lab, Antwerp. Results: 33 CMT2 patients (17 male, 16 female) and 30 CMT1A patients (18 male, 12 female). Groups were homogenous in regards to age and gender. There was no significant difference considering age of onset. NDS score in CMT2 group varied 10–118 (Mean=46.3; SD=23.77, Med=46), while 2-66 (Mean=29.03; SD=18.23, Med=26) in CMT1A patients. CMT2 patients had higher NDS than CMT1A, difference was statistically significant (Wilcoxon rank sum: p\0.01). Weakness NDS subscore (W-NDS) ranged 0-82 (Mean=25.45; SD=16.47, Med=24) in CMT2, and 1-36 (Mean=9.72; SD=9.07, Med=8) in CMT1A patients; difference was statistically significant (Wilcoxon rank sum test: p\0.001). There was no significant difference in preservation of muscle tendon reflexes or level of sensitive disturbance comparing subscores: R-NDS (reflexes NDS) and S-NDS (sensitivity NDS). Foot deformities were less frequent than expected in CMT 2 group (18.18% without deformities), with 9.09% planovalgus deformity that wasn‘t found with any CMT1A patients. Neuromyotonia was found in 7 female CMT2 patients, all with autosomal recessive trait of inheritance and undefined genotype. Neuromyotonia wasn‘t found in any CMT1A patients. Duplication/ deletion 17p11.2, MPZ, Cx32 excluded with most CMT2 patients, mitofuscin2 (MFN2) mutation confirmed with 5 CMT2 patents, all members of one family. Conclusion: Most CMT1A and CMT2 patients had the classical CMT phenotype. All clinical motor and sensitive signs showed length dependent deficit in both CMT2 and CMT1A patients. CMT2 patients had more difficult clinical presentation than CMT1A patients, main difference was greater degree of muscle weakness. Genotype stays undefined in most CMT2 patients.

P336 Scrub typhus-related sensory neuronopathy B.C. Suh, D.K. Jin, Y.B. Kim, H.S. Moon, P.W. Chung, D.S. Shim, S.B. Kim, S.M. Kim, I.N. Sunwoo Sungkyunkwan University School of Medicine (Seoul, KR); The Catholic University of Korea (Seoul, KR); Kyung Hee University (Seoul, KR); Yonsei University College of Medicine (Seoul, KR) Objective: Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi. Several cases of scrub typhus-related Guillain-Barre´ syndrome (GBS) and unusual neurologic presentations such as brachial plexopathy, acute transverse myelitis and encephalomyelitis have been reported. From those reports, we assume that scrub typhus can bring various types of damage on the nervous system. Case report: A 56-year-old male was referred after 7-day history of fever, myalgia, abdominal pain and 1-day history of both leg tingling sense and gait disturbance. An eschar was found at right popliteal fossa and serum antibody against Orientia tsutsugamushi was positive. Doxycycline was admistered for four days. During the first two days of admission, tingling sense spread to lower trunk, upper trunk and upper extremities gradually. The evolution of sensory manifestation was more similar to myelopathy than typical sensory neuropathy in that it mimicked sensory level of myelopathy (C7 sensory level bilaterally). Sensory ataxia with pseudoathetosis and ataxic gait was prominent without involvement of muscle power. Deep tendon reflex showed areflexia. There was no evidence of cranial nerve, brain or spinal cord involvement. There was no evidence of Sjogren’s syndrome or paraneoplastic syndrome. CSF showed high protein concentration without pleocytosis; protein 302 mg/dl, WBC 1

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S108 cell/mm3. Serum anti-ganglioside was negative. Initial nerve conduction studies showed reduction of amplitude in the sensory nerve action potentials (SNAPs). Motor nerve conduction study showed slow motor conduction velocity on only one nerve (right median nerve). Follow-up study in a year interval showed aggravation of SNAP reduction of lower limbs. The histopatholgy of right sural nerve revealed acute axonal neuropathy. After treatment with intravenous immunoglobulin for 5 days, the neurologic deficit showed slow and incomplete recovery. Conclusion: This is the first case of scrub typhus-related sensory neuronopathy (ganglionopathy). Considering previous reports of scrub typhus-related neuropathies, scrub typhus can bring various forms of damage to the nervous system. An acute febrile illness associated with rather sophisticated sensory or motor manifestations should bring scrub typhus under consideration. Especially in the fareast Asia where scrub typhus is endemic and is a major problem of public health, consideration of evaluation for scrub typhus cannot be overemphasized.

P337 Acute facial diplegia and paraesthesias following Parvovirus B19 (HPV-B19) infection F. Barbi, A. Ariatti, K. Funakoshi, S. Meletti, M. Meacci, M. Odaka, G. Galassi Institute of Neurosciences (Modena, IT); Dokkyo University (Tochigi, JP); University of Modena (Modena, IT) Objective: Clinical spectrum of Guillain-Barre´ syndrome(GBS)has expanded due to variants accounting for atypical presentations. Classic GBS with ascending paralysis overlap forms without progression which may reflect molecular mimicry mechanism.Human parvovirus B19 (HPV-B19) infection is known to produce clinical manifestations, including uncommon neurological syndromes. Methods: This 36 year old man three weeks after febrile illness experienced facial pain, difficulty in closing tightly both eyes, pursuing lips. By day 2, patient experienced hand numbness. Taste, lacrimation, swallowing, hearing were normal. On admission (day 2) neurological examination showed facial diplegia, depressed jerks throughout. Eye movements, lower cranial nerves, limb strength, coordination, sensory testing were unaffected. Results: Spinal fluid (day 2) showed increased protein (68 mg/dl, normal \45), no cells, mirror IgG pattern on isoelectric focusing. Brain MRI, auditory brainstem evoked responses were unremarkable. Microbiological, viral screenings were unremarkable. Search for antiganglioside antibody assay (day 3) was negative.HPV-B19 immunoassay suggested recent infection (IgM above 5, IgG titer 5.99); viral DNA tested by nested PCR was detected in CSF. Electrophysiological study (day 8) showed diminished amplitude of both peroneal muscle action potentials(within 2 and 3 mV), delayed peroneal F waves, slowed velocity in lower extremity (42–45 m/sec) partial proximal conduction block in median nerve. Sensory velocity, amplitude of potentials were within normal range. Patient received intravenous immunoglobulin (0.4 g/kg/die from day 4 to 9). By day 12, facial weakness improved, deep jerks could be elicited. On latest follow up (day 122) there were minimal right sided facial weakness, brisk reflexes; repeated electrophysiology confirmed slowing of peroneal, tibial conduction. HPV-B19 immunoassay (day 122) showed immunoglobulin IgM titer 0,79 and IgG 5,99. Conclusion: Our patient exhibited an acute neurologic disease with monophasic course and benign prognosis. Major signs were facial diplegia, without limb weakness, ataxia, hyporeflexia. Patient experienced transiently hand paresthesias. He had antecedent febrile infection. CSF showed albumino-cytologic dissociation, suggesting postinfectious autoimmune disorder. Overall features are compatible

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with those of GBS regional variant. Review of English literature turned up only two GBS cases following HPV-B19 infection; none presented as regional variant.

P338 Local lidocain and corticosteroid treatment in management of carpal tunnel sydrome O¨. Karadas, F. Tok, O. O¨z, B. Firtina, H. Akgu¨n, B. O¨ztu¨rk, U¨. Ulas, Z. Odabasi Gulhane Military Medical Academy (Ankara, TR) Introduction: Carpal Tunnel Sydrome (CTS) is the most common entrapment neuropathy caused by compression of median nerve between carpal ligament and flexor tendons of the hand at carpal tunnel level. Diagnosis of CTS is based on history, physical examination and electrodiagnostic evaluations. It is well established that local lidocain and corticosteroid may reduce the compression on median nerve by decreasing inflamation and edema in carpal tunnel by means of antiinflammatory efficiency. The aim of this study is to determine the efficiency of local lidocain and corticosteroid on CTS with electrodiagnostic and clinical evaluations. Material and method: 40 mg triamsinolon asetonid and 4 cc 1% lidocain were injected to carpal tunnel of 40 extremities of 23 patients who were diagnosed as CTS according to clinical and electrodiagnostic evaluations. Electrodiagnostic tests were applied and pain levels were recorded (according to Visuel Analog Scale (VAS)) before the injection. Same evaluation were applied 2 months after injection. Results: Six male and 17 female patients with a mean age 46,35 were included in our study. Median nerve sensory conduction velocity, compound muscle action potential amplitude recorded from abductor pollicis brevis muscle and VAS scores were improved significantly 2 months after injection(p\0.05). Also there was a corelation between duration of complaint and sensory conduction velocity. Discussion: Local lidocain and corticosteroid combination thearapy have favorable effects on electrodiagnostic evaluations and symptomatology in CTS.

P339 Hypoglossal nerve palsy after dental surgery S. Bek, T. Kasikci, G. Koc, Z. Odabasi Gulhane Medical Faculty (Ankara, TR) Introduction: The hypoglossal nerve is a pure motor nerve that innervates intrinsic and extrinsic muscles of tongue. The nerve can be damaged anywhere during its course. Isolated hypoglossal nerve palsy is a rare condition because of its proximity to other important anatomical structures throughout its pathway. We present an isolated hypoglossal nerve palsy due to hematoma following third molar surgery. Case presentation: A 61-year-old woman was admitted with speech difficulties lasting for over two months. Neurological examination revealed left hypoglossal nerve palsy (HNP) with ipsilateral atrophy. CT images revealed a mass lesion on the left sublingual area shifting genioglossus muscle and lingual septum. The lesion was hyperintense on MR images. When she was informed about hematoma and treatment options she mentioned about having left third molar surgery three months ago. She refused to have a surgery and she was planned to have CT follow ups. Conclusion: HNP without other neurological findings is a diagnostic challenge. While the information regarding isolated HNP is sparse and limited to case reports, there are a number of different etiologies that may interfere with the function of the hypoglossal nerve. Acquiring a true medical history has an essential role and

S109 imaging techniques should be selected in a fashioned order from central to peripheral lesion.

P340 A randomized clinical trial of acupuncture vs. oral steroid for carpal tunnel syndrome: a long-term follow-up M.H. Chang Taichung Veterans General Hospital (Taichung, TW) Objectives: To investigate the long-term effects of acupuncture treatment with steroid treatment in patients with mild-to-moderate carpal tunnel syndrome (CTS). Methods: A total of 77 consecutive patients with electrophysiologically confirmed mild to moderate CTS were randomized into two treatment arms: (1) two weeks of prednisolone 20 mg daily followed by two weeks of prednisolone 10 mg daily (n =39), and (2) acupuncture administered in 8 sessions over 4 weeks (n=38). After finished one month treatment, patients were extendedly followed up at 7 and 13 months by Global Symptom Score (GSS) and nerve conduction studies (NCS).The primary outcome was symptom relief in terms of the GSS, which rates symptoms on a scale of 0 (no symptoms) to 50 (most severe). NCS was used as secondary outcome assessments. All main analyses used intent-to-treat principle. Results: Compared with baseline, the percentages of patients with treatment failure, moderate improvement, good improvement were significantly different between the two groups at month 7, 10.5%, 2.6%, 86.8% for acupuncture group and 33.3%, 7.7%, 59.0% for steroid group, respectively (p=0.014) and month 13 (15.8%, 2.6%, 81.6% vs 51.3%, 0.0%, 48.7%, p=0.002). Acupuncture group also had a significantly better improvement NCS parameters when compared to steroid group throughout the one-year follow-up period (p\ 0.01). Furthermore, significant correlation was observed between change of GSS (month 13 - baseline) and all parameters of the electrophysiological assessments except for compound muscle action potentialamplitude. Conclusions: In patients with mild-to-moderate CTS, short-term acupuncture treatment provides long-term benefit, although the mechanisms warrant investigation. Most of responders maintained their effect for more than one year without any additional therapy. We concluded that short-term acupuncture treatment may result in longterm improvement in mild to moderate CTS. Although acupuncture is a time-consuming treatment, acupuncture treatment could be considered as an alternative therapy as other conservative treatments for those who do not opt for early surgical decompression.

P341 The carpal therapist device for alleviating carpal tunnel syndrome C. Walker Geneva Mobility Devices (St. Louis, US) Background: The Carpal Therapist is a wearable electromechanical device that manipulates the soft tissues of the wrist and forearm. Such manipulation is intended to alter the soft tissues within the carpal tunnel in order to obtain symptomatic relief from carpal tunnel syndrome (CTS). This study determined the extent to which subjects with moderate or severe CTS obtained symptomatic relief using this device. Methods: Twelve subjects with advanced CTS were assessed using a self-administered expanded version of the McGill Pain Questionnaire (MPQ). Each subject was personally instructed on using the Carpal Therapist twice daily for ten days. Subjects were given a Daily Diary to track compliance and assess efficacy. MPQ’s obtained at

baseline were then compared to those obtained after ten days of treatment. Relative changes were determined in scores for hand pain quality using the severity scale of 1) none, 2) mild, 3) moderate, 4) severe. Pain determinations based on severity over 24hours as well as measures of Activities of Daily Living (ADL) were also assessed. Results: The results showed that after ten days of treatment, every subject achieved significant relief from hand pain. Nine of eleven subjects had decreased pain sensations by two severity scale points, while two subjects decreased pain by one severity scale point. These results were nearly identically mirrored in the 24 hour severity and ADL measures. Conclusion: It is concluded that the Carpal Therapist can provide significant symptomatic relief from CTS quite rapidly. Other studies are underway to assess its long term therapeutic effects. Supported by the sponsor institution, Geneva Mobility Devices.

P342 Local lidocain treatment in management of carpal tunnel syndrome O¨. Karadas, F. Tok, O. O¨z, B. O¨ztu¨rk, H. Akgu¨n, U¨. Ulas, Z. Odabasi Gulhane Military Medical Academy (Ankara, TR) Introduction: Carpal Tunnel Syndrome (CTS) is one of the most common upper limb compression neuropathies. CTS account for approximately 90% of all entrapment neuropathies. It is due to an entrapment of the median nerve in the carpal tunnel at the wrist. It affects mainly middle aged women. It causes pain, numbness and parestesis in the hand. It is claimed that local lidocain administration in carpal tunnel reduce compression of median nerve due to its antiinflammatory and antiedema effects. The aim of this study is to determine the efficiency of local lidocain on CTS with electrodiagnostic and clinical evaluations. Material and method: 4 cc 1% lidocain were injected to carpal tunnel of 40 extremity of 29 patients who were diagnosed as CTS according to clinical and electrodiagnostic evaluations. Electrodiagnostic tests were performed and pain levels were recorded (according to Visuel Analog Scale (VAS)) before the injection. Same evaluation were applied 2 months after injection. Results: 3 male and 26 female patients with a mean age 46,75 were included in our study. Median nerve sensory conduction velocity values revealed as increased on second month control after injection. However this change was significant. Distal motor latance and pain levels improved significantly 2 months after injection. Discussion: Local lidocain administration to carpal tunnel have favorable effects on CTS patients. This improvement can be seen in electrodiagnostic evaluations and clinical findings.

P343 Hereditary neuralgic amyotrophy with bilateral brachial plexus involvement probably caused by de novo mutation—case report M. Sluzewska-Niedzwiedz, M. Nowakowska-Kotas, A. Robaczewska, B. Paradowski Wroclaw Medical Uniwersity (Wroclaw, PL) Background: Hereditary neuralgic amyotrophy (HNA) is a rare autosomal dominant disorder clinically characterized by episodes of brachial plexus neuropathy with muscle weakness and atrophy, usually preceded by severe pain in the affected arm. Sensory disturbances are less prominent. The age at onset is usually in the second and third decade of life. Recovery begins within one month to two years after

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S110 onset, but residual deficits are not uncommon. In some families, HNA is associated with minor dysmorphic features. The diagnosis of HNA is based on clinical findings. Mutations in the septin 9 gene were recently identified in some HNA patients. Most individuals diagnosed with HNA have an affected parent. The proportion of cases caused by de novo mutation is unknown. Case report: A 23-year-old male was admitted to a local hospital because of sudden weakness of the upper left limb preceded by strong pain in the left arm and shoulder. He was diagnosed with left radial nerve injury. Six months after the first symptoms he suffered severe pain of the right arm and shoulder followed by muscle wasting and atrophy of the right arm. Neurological examination revealed bilateral asymmetric atrophy of the shoulder girdle muscles, bilateral lack of radial reflex, weakness of the left biceps muscle and bilateral extensor muscles of the wrist and fingers, and bilateral hypoesthesia on the lateral part of the arm and posterior and lateral part of the forearm. Moreover, several dysmorphic features were present, including a long narrow face, long nasal bridge, mild hypotelorism, epicanthal folds, and gothic palate. The family history was negative. Electrophysiological examination showed signs of denervation of muscles innervated by affected nerves. MRI examination of both brachial plexuses did not show any anatomical anomalies. After one and half years from onset, the neurological examination as well as control electrophysiological examination showed almost complete recovery. Molecular genetic testing is in progress. Discussion: We present a rare case of neuralgic amyotrophy with bilateral involvement of the brachial plexus asymmetric in severity and almost complete recovery within one and half years of follow-up. The dysmorphic features indicated a genetic character of the neuropathy. This case fulfills HNA diagnostic criteria. As there was no such dysmorphic features or any signs of neuropathy in none of the patient’s relatives, we regard his case as a de novo mutation.

P344 A strange case of inflammatory demyelinating polyradiculoneuropathy F. Correia, H. Morais, D. Alves Hospital Pedro Hispano (Matosinhos, PT) Introduction: An inflammatory demyelinating polyradiculoneuropathy (IDP) is a disorder that causes a symmetrical, progressive, arreflexic motor weakness with or without sensory symptoms. In Guillain-Barre´ syndrome (GBS), the clinical deterioration should proceed for less than four weeks, unlike the more than eight weeks in the chronic inflammatory demyelinating polyradiculoneuropathy (CIDP). Between four and eight weeks there is an entity that many call as SIDP – subacute IDP. CIDP may present as a distal acquired demyelinating symmetrical neuropathy (DADS). This is often associated with monoclonal IgM band and with serum antibodies against myelin associated glycoprotein (MAG) and usually responds poorly to immunomodulatory therapy. We present a case of subacute progression of clinical findings suggestive of DADS with initial anti-MAG positive and with excellent clinical outcome after immunomodulatory treatment. Clinical case: We reported a 53-year-old male with a history of sensory complaints and progressive motor weakness with 5 weeks of evolution. The examination showed slight distal symmetrical tetraparesis, absent deep tendon reflexes and impairment of joint position sense. Cerebrospinal fluid examination showed an albumino-cytological dissociation, and the neurography showed sharply increased distal latencies with slightly decreased conduction velocities and increased F-wave latency (and decreased terminal latency index). He was treated with immunoglobulin and began to improve gradually. The protein immunoelectrophoresis in serum and urine was normal. Six months after discharge, the patient was asymptomatic, the neurophysiological findings showed slight

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improvement and screening of anti-MAG was positive. After two years of follow-up, neurological examination and neurographic study normalized and antibody anti-MAG became negative. Conclusions: Inflammatory polyneuropathies represent a wide spectrum of diseases, sometimes forming a nearly continuous, with boundaries difficult to define. In our case, the clinical course did not meet the definitions of GBS or CIDP, perhaps SIDP. The good response to treatment is more suggestive of SGB/SIDP, however the clinical and neurophysiological findings point to CIDP-DADS. The current medical literature does not describe the prevalence of antiMAG in GBS or SIDP, which leads us to the question of whether there is an entity SGB / SIDP linked to anti-MAG, with good response to treatment and subsequent negative anti-MAG.

P345 Local corticosteroid treatment in management of carpal tunnel syndrome O¨. Karadas, F. Tok, O. O¨z, B. O¨ztu¨rk, H. Akgu¨n, U¨. Ulas, Z. Odabasi Gulhane Military Medical Academy (Ankara, TR) Introduction: Carpal tunnel syndrome (CTS) refers to the most common compressive neuropathy in humans. Median nerve is compressed in carpal tunnel about 2 cm distal to the wrist groove. The most common CTS symptoms include paresthesias and numbness in the median sensory distribution, mainly at night, awakening patients, and, also in the morning and in same maintaining hand griping posture. CTS usually follows a three-phase evolution: first, with slight intermittent sensory symptoms; second, with persistent sensory symptomatology; and third, with persistent sensory negative symptoms and thenar atrophy. It is well known that local corticosteroids may reduce the compression on median nerve by decreasing inflamation and edema in carpal tunnel by means of antiinflammatory efficiency. The aim of this study is to determine the efficiency of local corticosteroid on CTS with electrodiagnostic and clinical evaluations. Material and Method: 40 mg triamsinolon asetonid was injected in to carpal tunnel of 40 extremities of 25 patients diagnosed as CTS according to clinical and electrodiagnostic evaluations. Electrodiagnostic tests were performed and pain levels were recorded (according to Visuel Analog Scale (VAS)) before the injection. Same evaluation were applied on second month after injection. Results: Two male and 23 female patients with a mean age 48,02 were included to our study. Median nerve sensory conduction velocities, motor amplitudes of abductor pollicis brevis muscle and VAS scores were improved significantly 2 months after injection (p\0.05). Also there was a correlation between duration of complaint and sensory conduction velocity. Discussion: Corticosteroid injection in to carpal tunnel have favorable effects on signs and symptomes in CTS. This improvement can be also seen in nerve conduction studies. However 6 and 12 months follow-up is necessary to find out long term effects.

P346 Subacute sensory neuronopathy associated with lymphoma-related ganglionopathy: a case report O¨. Karadas, M. Yu¨cel, H. Akgu¨n, O. O¨z, B. O¨ztu¨rk, E. Eroglu, Z. Odabasi Gulhane Military Medical Academy (Ankara, TR) Peripheral neuropathies may be seen in patients with lymphoma. Neuropathy may exist due to chemotherapy, opportunistic infections

S111 or lymphoma itself. Paraneoplastic neuropathy is also termed as sensory ganglionopathy. We report a 44-year-old female who developed dysesthesia in all extremities with severe loss of deep sensation and radiating radicular pain over one month. She was diagnosed as Hodgkin’s Lymphoma one year ago and was in remission when she applied with these sensory complaints. Sensory loss in hands and feet was the main complaint of the patient. Electrophysiologic studies revealed sensory polyneuropathy. We hypothesize that this neuropathy is associated with lymphoma-related ganglionopathy and among the possible causes, we suspect that a systemic cause such as a paraneoplastic syndrome is the most likely pathogenic etiology. Investigation for a probable lymphoma recurrence indicated omental lymphoma. However, further follow-up will be necessary to see whether sensory symptoms change with lymphoma treatment or not. Subacute sensory neuropathy may be preceding sign of lymphoma recurrence.

P347 Aggressive Guillain–Barre´ syndrome: a red flag to think of hidden tumours S. La Gioia, M. Rottoli, M. Poloni, F. Biroli Scientific Institute San Raffaele (Milan, IT); United Hospitals (Bergamo, IT) Non Hodgkin Lymphoma can cause neuropathy by directly compressing or infiltrating nerves or by remote effects. Inflammatory and dysimmune neuropathy such as Guillain-Barre´ Syndrome can occur in lymphoma due to the accompanying or preexisting immune perturbation. Antibodies likely derived from molecular mimicry of antigens in lymphoma cells may attack similar antigens in nerve cells. Treatment of Guillain-Barre´ Syndrome, regardless of the presence of cancer, includes plasma exchange and intravenous immunoglobulins. Response to therapy is described to be similar to that seen in patients without associated cancer. Aims: to describe aggressive and scarcely responsive GuillainBarre´ Syndrome in old patients as a red flag to think of a hidden tumor. Methods: We report the case of a 75 years old caucasian man, with a history of B cell chronic lymphatic leukemia of 8 years, who developed Guillain Barre` syndrome as a complication of unknown lymphoma. Results: Over a week he progressively developed diffuse myalgia, areflexia, tetraparesis and facial dyplegia. EMG showed subacute demyelinating motor neuropathy. Analysis of cerebrospinal fluid showed an albumin cytologic dissociation and Guillain-Barre´ Syndrome was diagnosed. In spite of a prompt intravenous immunoglobulins treatment, the disease course rapidly worsened compromising cranial nerves, respiratory and autonomic functions. Anti GQ1b antibodies resulted positive along with anticerebellar antibodies reacting against vessels. Supporting a paraneoplastic explanation, FGD-PET pointed out an hypermetabolic lymph node which resulted positive for small B Cell Non Hodgkin Lymphoma (CD5+ CD23-). A clinical response was lately obtained after plasmapheresis and treatment of lymphoma. Conclusions: Paraneoplastic etiopathogenesis of Guillain-Barre´ should always be considered before a scarcely responsive and aggressive forms of acute demyelinating neuropathy, especially in older patients. Its response to treatment isn’t always so prompt to usual treatment as frequently described in literature. We hypothesize a treatment resistence depending on protaction of immune pertubation and antigens persistence due to the occult presence of the tumor.

Motor neuron diseases P348 Cognitive impairment in amyotrophic lateral sclerosis patients: the Polish study K. Zur-Wyrozumska, B. Tomik, D. Zawislak, A. Golenia, M. Ostrowska, A. Szczudlik Jagiellonian University Medical College (Krakow, PL) Background: Amyotrophic lateral sclerosis (ALS) is a relentlessly progressive disorder of the upper and lower motor neuron. Cognitive impairment is increasingly recognized in patients with ALS. Clinical and pathologic features overlap in the frontotemporal lobar degeneration and ALS. Demographics, respiratory status, bulbar site of ALS onset, and disease severity are discussed as a potential risk factors for cognitive impairment in ALS. Material and methods: Looking for the cognitive decline in ALS patients the authors have reviewed the clinical history of 250 consecutive patients diagnosed with ALS and recorded in the MND database of Neurology Clinic of Jagiellonian University Medical College in Krakow, between 1999–2008 years. Results: We have discovered 26 ALS patients (13 male and 13 female), whom has complain for some cognitive dysfunctions (ALSci) and were examined by certificated neuropsychologist in our Clinic. The average age of disease onset in ALSci patients was 54.5 years (range: 22-69). Nine out of 26 was presented with bulbar site of onset, 16 with limbs and one with mixed site of onset at presentation. Nineteen ALSci patients were presented with predomination of UMN signs and 7 patient with LMN signs in the neurological examination. Middle score of ALSFRS-R at the time of diagnosis was 88.72 points (range: 30-109). Middle score of first MMSE was 25.42 points (ranged from 21 to 29). MRI examination of the brain was performed in 22(84.6 %) cases studied and have reveled cerebral atrophy especially in the frontal and the temporal lobes. The average age when diagnosis of cognitive impairments was performed was 56.3 years (from 23 to 71). Neuropsychological examination study have showed: visual memory perturbation-in 23 (88.5%) ALSci patients; deficits in the supervisory attentional system-in 22 (84.6%) patients; decrease of verbal fluency -in 18 (69.2%) ALSci patients and dynamic dyspraxia in 16 (61.5%) cases studied. Summarizing, the neuropsychological examinations have showed impairments signs of frontal lobes function in 16 cases, 6 patients were diagnosed with the global degeneration and 4(15.4%) patients was described as fronto-temporal lobes type of dementia. Conclusion: Fronto- temporal pattern of cognitive dysfunctions in ALS expressive early in the course of the disease and reflects functional deficits, however the population-based frequency, clinical characteristics and natural history of cognitive decline in ALS are still unknown.

P349 Frontal assessment battery as a screening method to evaluate frontal lobe dysfunction in patients with amyotrophic lateral sclerosis J.E. Kim, S.W. Ahn, S.H. Kim, J.S. Kim, S.M. Kim, Y.H. Hong, J.J. Sung, K.W. Lee Seoul National University Hospital (Seoul, KR); Seoul National University Boramae Hospital (Seoul, KR) Objectives: The patients with amyotrophic lateral sclerosis (ALS) have been reported to exhibit signs of frontal lobe deterioration,

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S112 including changes in personality, behavior, planning and organizational abilities, executive function, and language facility. Assessment of frontal lobe impairment in ALS is a matter of great importance, since frontal lobe impairments in ALS usually decrease medication and nursing compliance and shorten the survival time. The frontal assessment battery (FAB), a short and rapid method for the assessment of executive functions, consists of 6 subtests that explore different abilities related to the frontal lobe.We investigated the applicability of the FAB as a screening method for assessing cognitive impairments in ALS. Methods: We used the FAB as a screening assessment of cognitive impairment to survey 61 patients meeting the El Escorial and laboratory criteria for definite or probable ALS; we determined candidates for additional, more extensive neuropsychological testing. According to the FAB results, we classified the patients into 2 subgroups: FAB-normal and FAB-abnormal groups. We then evaluated their additional cognitive function using the Korean version of the mini-mental state examination (K-MMSE), a verbal fluency test (COWAT), a memory function test (RAVLT), and the neuropsychiatric inventory (NPI). Results: In this study, a considerable proportion (23%) of ALS patients had abnormal FAB scores. Conclusion: On the basis of the results of the analyses with extensive neuropsychological tests, the FAB shows promise as a screening measure for frontal lobe dysfunction in ALS.

P350 Influence of the age of onset in the ALS prognosis I. Sanz Gallego, F. Rodrı´guez de Rivera, C. Oreja Guevara, E. Dı´ez Tejedor Hospital La Paz (Madrid, ES) Background: Previous studies suggest that late age of onset and bulbar onset can determine a worse prognosis in ALS patients. Objective: To evaluate the influence of the age of onset and the form of the disease at onset on the ALS patient’s outcome. Methods: A descriptive study of consecutive patients who attended the ALS Unit between 2006 and 2009 was performed. The introduction of non-invasive ventilation. (NIV), the placement of gastrostomy, the use of wheelchair and death were the parameters studied. Results: Seventy-seven patients (43 males; 55.8%) were analysed, median age of onset of 59.45 years. Age of onset groups: 11 developed symptoms at less than 45 years (14.3%), 17 at more than 70 years (22.1%) and 49 between 45 and 70 years (63.6%). Average time to diagnosis was 21.71 months. Sixty-eight patients (88.3%) were treated with riluzole and 5 with lithium (6.5%). NIV was introduced in 28 cases (36.4%), gastrostomy in 20 (26%), wheelchair in 40 (51.9%) and 30 patients died (39%) with an average of survival of 43.77 months (range: 4–192 months). There is a negative correlation between the age of onset and the delay in the diagnosis (-0.352, pB0.05), the time of evolution to needing an NIV system (-0.686, pB0.05), to needing a gastrostomy (-0.607, pB0.05) and the time of survival (-0.611, pB0.05). In the group with disease onset after 70 years of age a statistically significant association was observed with NIV use (58% vs. 34.7% vs. 9.1%; pB0.05). No significant data were found in relation to the initial form of the disease. The frequency of bulbar onset in the group with onset at less than 45 years is less than in other groups of age (1 case, 9.1%). Conclusions: A later age of onset of the symptoms involves a more rapid diagnosis of the disease, an earlier need for NIV and gastrostomy and an early death. Bulbar onset is less frequent in younger patients. The initial form of the disease does not determine the ALS outcome.

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P351 Evidence for a decreased activity of the resting state motor network in patients with amyotrophic lateral sclerosis M. Filippi, M. Absinta, F. Agosta, P. Valsasina, N. Riva, A. Prelle, D. Caputo, M. Perini, R. Fazio, G. Comi University Hospital San Raffaele (Milan, IT); A.O. Fatebenefratelli e Oftalmic (Milan, IT); Scientific Institute Fondazione Don Gnocchi (Milan, IT); Hospital of Gallarate (Gallarate, IT) Objective: To explore spontaneous functional connectivity within the sensorimotor networks during rest in patients with amyotrophic lateral sclerosis (ALS). Methods: 3D T1-weighted and resting state functional MRI (fMRI) were obtained in 18 patients with probable or definite ALS and 15 healthy controls. To be included, patients had to have: (i) a diagnosis of probable or definite ALS according to the El Escorial revised criteria, (ii) a disease duration B6 years, (iii) an ALS Functional Rating Scale (ALSFRS-r) C 20. Connected brain networks were defined using independent component analysis (ICA) as implemented in GIFT. The Statistical Parametric Mapping (SPM5) was used to assess within- and between-group differences in RS pattern. The average percentage signal change of RS fluctuations of each significant SPM cluster was also compared between controls and patients. SPM5 and the Diffeomorphic Anatomical Registration using Exponentiated Lie algebra method were used to perform a voxelbased morphometry (VBM) analysis. Results: No significant GM tissue loss was found in ALS patients when compared to healthy controls. The VBM analysis identifies a significant WM tissue loss in the right premotor region in ALS patients vs. controls. ICA analysis revealed two brain functional networks related to the sensorimotor system. The voxelbased comparison showed that ALS patients had regions of decreased RS connectivity in the left primary sensorimotor cortex (SMC). Compared with controls, ALS patients also showed decreased average percentage signal change of resting state fluctuations in the SMC and the cerebellum bilaterally, in the supplementary motor area, and in the left inferior frontal gyrus and inferior parietal lobule. Conclusions: ALS patients show dysfunction of resting state connectivity of the sensorimotor network. Resting state analysis provides additional pieces of information on cortical reorganization in ALS patients which are complementary to those offered by a conventional analysis of fMRI. Functional abnormalities of the sensorimotor system may precede structural changes in ALS patients with mild disability.

P352 Increased immunoreactivity of Cu/Zn superoxide dismutase (SOD1) in the skin of sporadic amyotrophic lateral sclerosis S. Ono, K. Yasui, H. Ishikawa, M. Nomura, T. Watanabe, H. Mikami, M. Suzuki Teikyo University Chiba Medical Center (Ichihara, JP) Objectives: Cu/Zn-superoxide dismutase (SOD1) scavenges superoxide radicals generated in the respective compartments to protect the cell against injury by free radicals. Recently, it was shown that about 20% of patients with familial amyotrophic lateral sclerosis (ALS) have point mutations in the gene that encodes SOD1. However, in the sporadic type of ALS, the mechanism involved in the degeneration of motor neurons has not been elucidated. Most familial ALS cases are

S113 indistinguishable from sporadic ALS (SALS) on the basis of clinical and pathological criteria. Moreover, abnormal damage to proteins and lipids has been demonstrated in postmortem samples from both the cortex and spinal cord of familial ALS and sporadic ALS patients. These findings suggest that familial ALS and sporadic ALS may share oxidative stress as a common physiopathological mechanism. However, there has been no immunohistochemical study of SOD1 in the skin of sporadic ALS. Methods: Skin biopsy samples were taken from the left biceps from 15 SALS patients (59.1 plusminus 9.8 years) and 15 control subjects with other neurologic disorders (62.5 plusminus 6.4 years). Routine formalin-fixed paraffin-embedded 6 micrometer sections were immunostained according to standard techniques. A densitometric analysis was performed using an image analysis system. Results: SOD1 immunoreactivity was strongly positive in the epidermis and in some dermal blood vessels and glands of the reticular dermis in all SALS patients. These findings became more conspicuous as SALS progressed. On the other hand, the epidermis and dermal blood vessels and glands of the reticular dermis showed a weak SOD1 immunoreactivity in control subjects even after repeated antigen-retrieval trials. The optical density for SOD1 immunoreactivity of the epidermis in SALS patients (mean 2.25 plusminus 0.81) was significantly higher (p\0.001) than in control subjects (1.04 plusminus 0.16). Furthermore, the optical density of SALS patients showed a progressive increase in relation to duration of illness. This positive correlation was highly significant (r=0.77, p\0.001). There was no such relationship in control subjects. Conclusion: These data suggest that a metabolic alteration of SOD1 may take place in the skin of SALS and that the increased SOD1 immunoreactivity of skin in SALS may be relate to the absence of bedsore formation in SALS.

P353 Nocturnal capnography for assessing nocturnal respiratory insufficiency and anticipating compliance to NIV in patients with ALS J.S. Kim, S.M. Kim, J.E. Kim, S.W. Ahn, S.H. Kim, K.S. Park, Y.H. Hong, H.W. Nam, J.J. Sung, K.W. Lee Seoul National University College of Medicine (Seoul, KR); Seoul National University Boramae Hospital (Seoul, KR) Objectives: To evaluated the efficacy of nocturnal capnography (NC) and nocturnal pulse oximetry (NPO) for screening nocturnal respiratory insufficiency and anticipating compliance to following noninvasive ventilation (NIV) treatment in patients with ALS. Method: We included twenty six definite or probable ALS patients with respiratory symptoms or sign. The assessment of functional status, NC and NPO were performed. Twenty one patients were treated with NIV and their compliance to treatment was assessed. The correlation of NC and NPO with functional status, respiratory symptoms, results of ABGA, and the compliance to NIV were analyzed. Results: The values of NC correlated well with the degree of nocturnal respiratory symptoms of the patients (r = -0.502 * -0.572, p = 0.003 * 0.011) and the compliance to the NIV treatments (r = 0.614 * 0.713, p= 0.000 * 0.004). However, the values of nocturnal hypoxia had no correlation with nocturnal symptoms of patients and only marginally correlated with compliance to NIV treatment. Conclusion: NC can be a efficient respiratory screening tool in a patient with ALS, and might be more worth than NPO in assessing nocturnal respiratory insufficiency and anticipating compliance to the following NIV treatment.

P354 Can eye-tracking system communication improve quality of life and mood in ALS patients with locked-in syndrome? S. Giacone, A. Ilardi, V. Pasian, C. Moglia, M. Balma, A. Montuschi, F. Corno, A. Calvo, S. Gallo, A. Canosa, A. Chio` University of Turin (Turin, IT); Polytechnic of Turin (Turin, IT) Background: During the course of ALS the ability of communicate is progressively impaired. The complete loss of an useful communication is not uncommon and may heavily affect both patients and caregivers’ quality of life (QoL); nevertheless there are no studies on QoL and psychological aspects related to gaze system communication in locked-in ALS patients. Objectives: To assess the impact on QoL and mood of eyetracking system (ETS) for communication in a series of ALS patients with locked-in syndrome. Methods: Nine tracheostomized ALS patients (7 males; mean age 43,8, range 29-61), without clinical cognitive impairment, who daily use an ETS, underwent a questionnaire specifically created by our ALS Centre (Turin eye-tracking questionnaire), focused on the qualitative-organizing aspects from the patients’ perspective; they were also administered the McGill Quality of life questionnaire (MQoL), the Zung Depression Scale (ZDS), and the Satisfaction with Life Scale (SWLS). The questionnaires were sent to the patients and returned by email. MQoL, ZDS and SWLS had been already administered to the patients 2 to 5 months before tracheostomy. Results: All patients stated that the use of an ETS improved their life conditions and management activities conducted by caregivers; moreover patients felt that after the availability of the ETS they could be again in contact with the surrounding world. The major problems were tiredness related to the prolonged use of the ETS (7 patients) and early difficulties in using the ETS related to their poor previous experience with computers technologies (4 patients). In 7 patients QoL, as well as level of depression, improved after the use of the eyetracking system; only two patients were still depressed and reported a low level of QoL, although after the use of ETS both ratings improved compared to the evaluation performed before tracheostomy. SWLS score showed a high variability. Conclusion: Eye-tracking system appears to be effective in improving QoL and mood in locked-in ALS patients and their caregivers. Moreover, it effectively improves the patient’s communication with the outside world and give to patients the feeling to be able to better control their life.

P355 Glucagon-like peptide-1 protects against glucosamineinduced cytotoxicity in glutamate-sensitive NSC-34 cells J. Lim, W. Baek, D. Song, J. Lee Keimyung University (Daegu, KR); Fatima Hospital (Daegu, KR) Objectives: Glucosamine is widely used as a supplementary regimen for degenerative arthritis to control pain and inflammation. High dose of glucosamine has been known to induce insulin resistance in peripheral tissues and pancreatic b-cell dysfunction. However, there are few reports to reveal whether glucosamine exerts its cytotoxicity in motor neurons. We aimed to explore whether glucosamine is toxic or not in the motor neuron cell line NSC-34 cells at its pharmacological doses. In addition, the protective effects of glucagon-like peptide (GLP)-1 against the glucosamine toxicity was also evaluated.

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S114 Methods: NSC-34 cells were cultured in DMEM media with 10% fetal bovine serum (FBS). To differentiate them sensitive to glutamate, NSC-34 cells were incubated in the media with no FBS for 1–2 days. Then the remaining cells were maintained in the media containing 1% neonatal calf serum to proliferate. The MTT assay and 2deoxyglucose uptake experiments were performed with the fully differentiated, glutamate-sensitive cells. Results: The incubation of differentiated NSC-34 cells with glucosamine exhibited dose-dependent inhibition of cell survival. Glucosamine acutely inhibited cellular glucose uptake and activated AMP-activated protein kinase (AMPK), resulting in decreased phosphorylation levels of mTOR, P70S6K and the ribosomal protein S6RP. Glucosamine-mediated protein glycosylation appeared not to be significantly involved in this cytotoxicity. Pretreatment with GLP-1 significantly alleviated glucosamine-induced inhibition of cellular glucose uptake and cell survival. GLP-1 lowered glucosamine-induced activation of AMPK and thus recovered the levels of p-mTOR, p-P70S6K and p-S6RP. Glucosamineinduced ER stress was also alleviated by GLP-1. Conclusion: Glucosamine may inhibit cellular glucose uptake and thereby cell survival by independent mechanisms different from its induction of protein glycosylation. This glucosamine toxicity may be hampered by GLP-1, which recovers the impaired glucose uptake.

P356 Fronto-temporal dementia in three cases of familial amyotrophic lateral sclerosis with TARDBP A382T mutation A. Ilardi, A. Chio`, A. Calvo, C. Moglia, S. Giacone, G. Restagno, M. Balma, A. Canosa, S. Gallo, I. Ossola, M. Brunetti, A. Montuschi, A. Cistaro, A. Ticca, B.J. Traynor, M.G. Marrosu, G. Borghero University of Turin (Turin, IT); OIRM-Sant’Anna Hospital (Turin, IT); Positron Emission Tomography Center (Turin, IT); San Francesco Hospital (Nuoro, IT); National Institute on Aging (Bethesda, IT); University of Cagliari (Cagliari, IT) Background: TAR DNA-binding protein 43 (TDP-43), encoded by the TARDBP gene, has been identified as the major pathological protein of frontotemporal lobar dementia (FTLD) with or without amyotrophic lateral sclerosis (ALS) and sporadic ALS (SALS). Subsequently, mutations in the TARDBP gene have been detected in 2-3% of ALS patients (both familial ALS [FALS] and SALS cases). However, there is only one description of two FTLD patients with TARDBP gene mutations who later developed motor neuron disease. Objective: To describe three apparently unrelated families with TARDBP missense mutations in whom FTLD developed after ALS in all affected members. Methods: We studied thirthy-six patients with familial nonsuperoxide dismutase 1 gene (SOD1) (Online Mendelian Inheritance in Man [OMIM] 147450) ALS and 280 healthy controls. We included cases with a positive family history for ALS but we excluded cases with ALS and a positive family history for dementia or other neurodegenerative disorders. Genomic DNA was extracted from one ml of peripheral blood and screened for TARDBP mutations. Our patients underwent neuropsychological testing for the diagnosis of frontotemporal cognitive and behavioural syndromes in ALS and neuroimaging analyses. Results: We identified three index cases of FALS carrying the p.A382T missense mutation of the TARDBP gene and with clinical, neuroimaging and neuropsychological features of FTLD. The p.A382T missense mutation of the TARDBP gene was absent in the 280 controls. It was present in all affected members of the three families for whom DNA was available and in two healthy carriers

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(one presymptomatic carrier and one obligate carrier). All the affected members of the three families developed FTLD during the course of ALS, confirmed by neuropsychological testing and hypometabolism in frontal associative areas assessed with 18F-FDG PET/CT. Conclusion: Three apparently unrelated FALS families carrying the p.A382T TARDBP missense mutation developed FTLD. In these families FTLD co-segregates with ALS. FTLD may develop in ALS patients carrying TARDBP mutations.

P357 Case report: motor neuron disease associated with antiMa2 antibodies without evidence of carcinoma D. Leupold, B. Tettenborn, A. Felbecker Kantonsspital St. Gallen (St Gallen, CH) Objectives: Anti-Ma2 antibodies are known to be detectable in paraneoplastic neurological syndromes associated with limbic and brainstem encephalitis and are a highly specific marker for the presence of a germ-cell tumour of the testis. There are few reports of other neurological syndromes associated with anti-Ma2 antibodies including one case with encephalitis and progressive muscular atrophy. We report a patient with anti-Ma2 antibodies without evidence of carcinoma who presented with clinical signs of motor neuron disease without evidence of encephalitis. Methods: A 64-year–old Caucasian man presented with progressive muscular weakness of the lower extremities and continued weight loss for approximately one year. In addition to distally pronounced tetraparesis he showed severe muscular atrophy of all extremities, widespread fasciculations and increased reflexes in the upper extremities. At follow up the patient developed dysphagia. The diagnostic workup consisted of a detailed blood and cerebrospinal fluid analysis including routine blood tests, serologies of HIV, hepatitis, borrelia and syphilis as well as vasculitis markers and paraneoplastic antibodies. We also conducted extensive electrophysiological studies. For differential diagnosis magnetic resonance (MR) scans of brain and spine were performed. Furthermore we did an extensive tumour screening including sonography of the testis, chest and abdominal radiography as well as a positron emission tomography (PET) scan. Results: The clinical presentation and electrophysiological studies were consistent with a motor neuron disease with predominant signs of lower motor neuron involvement in 3 regions and upper motor neuron signs in at least one region. The MR imaging of the brain and spine were normal. The analysis of the cerebrospinal fluid revealed normal results apart from mild pleocytosis. The detection of increased anti-Ma2 antibodies originated the intensive search for a tumour (e.g. testicular germ-cell tumour), which could not be detected so far. Conclusion: This is the first report of a clinically typical motor neuron disease associated with anti-Ma2 paraneoplastic antibodies. Although no tumour could be detected in our patient yet, anti-Ma2 antibodies are highly suggestive for tumours, usually located in the testis. Paraneoplastic syndromes may occur many years before the manifestation of the tumour, probably due to immunological changes.

P358 Asymmetric oro-facial apraxia in primary lateral sclerosis—a perplexing clinical manifestation P. Pita Lobo, S. Pinto, L. Rocha, S. Reima˜o, M. Carvalho Hospital de Santa Maria (Lisbon, PT) Introduction: Orofacial or buccofacial apraxia refers to an impaired ability to perform voluntary facial movements, involving cheeks, lips,

S115 tongue or eyebrows. The patient fails to produce the correct movement in response to a verbal command or to imitate correctly a movement performed by the examiner. However, similar automatic movements are preserved. Rarely, apraxia has been reported in motor neuron disease (MND) a disease mainly characterized by progressive motor neuron degeneration. We report a patient with motor neuron disease (MND) who presented asymmetric orofacial apraxia. Case report: A 78-year-old woman was referred with a history of progressive dysarthria and dysphagia for 3 years. Her past and familial histories were not relevant. On neurological examination, we observed marked spastic dysarthria, spastic tongue (with no atrophy or fasciculation), brisk jaw jerk, very brisk deep tendon reflexes in the four limbs, extensor left plantar response and weak neck flexion (4 on the MRC scale); but no cognitive impairment (normal minimal mental state evaluation), primitive reflexes or limb weakness were noticed. When asked to close her eyes voluntarily or on verbal command, she was unable to initiate closure of the left eye. Moreover, when we asked her to show her teeth the left face looked paretic. Nevertheless, she clearly understood the request, and eyes closure and facial movements were symmetric on automatic movements (blink reflex and smiling, respectively). No other apraxic disturbance was observed. Routine blood tests and cranial and cervical MRI were normal. Electromyography needle recording of the facial muscles (bilaterally), tongue, neck and limbs muscles could not find signs of lower motor unit loss. Left orbicularis oculi jitter was normal. Transcranial magnetic stimulation confirmed lesion of the corticospinal tract. Formal neuropsychological evaluation confirmed normal memory and mild frontal dysfunction. A diagnosis of primary lateral sclerosis (PLS) was established. Diffusion tensor tractography showed a significant fractional anisotropy decrease in the precentral and in pre-motor white matter, predominantly in left side. On progression, the same apraxic dysfunction involed the right facial movements. Conclusion: We present a case of MND with orofacial apraxia. Apraxia is a rare sign in MND. To our knowledge this is the first report of an asymmetric presentation in a patient with PLS. This expands the phenotype features of MND.

P359 A rare case of Hirayama’s disease with reduced fractional anisotropy in diffusion tensor imaging of cervical spinal cord A. Robaczewska, M. Bilinska, M. Koszewicz, R. Podemski, M. Sluzewska-Niedzwiedz, P. Szewczyk, M. Szymczyk Wroclaw Medical University (Wroclaw, PL) Non- progressive juvenile spinal muscular atrophy of the upper limb (Hirayama disease), described in scarce case reports, is a rare and benign disorder, predominantly affecting the anterior horn cells of cervical spinal cord in young men. Although it is considered to be a type of cervical myelopathy, its patomechanism remains unknown. We present a case of Hirayama disease with the pathological findings revealed in diffusion tensor imaging (DTI) of the cervical spinal cord. The DTI technique enables to demonstrate tissue microstructure. Main DTI parameters are: fractional anisotropy (FA) – relevant for white matter fibers orientation and integrity and apparent diffusion coefficient (ADC), useful for evaluation of pathogenesis in gray matter. A 24- years-old right-handed man was admitted to our department with insidiously progressive (within six years) muscular weakness

and atrophy of the right hand, forearm and arm. The symptoms stabilized within recent year. History of injuries and family history for neuromuscular disorders were negative. No pyramidal or sensory signs were observed. Cervical magnetic resonance imaging (MRI) of the spinal cord in the neutral position was normal. Cervical X-ray, MRI of right brachial plexus and MRI of thoracic upper outlet showed no abnormalities. Neurophysiologic examination revealed severe neurogenic changes in right upper extremity muscles with normal right plexus neurography. The electromyography (EMG) of other muscles (left upper and both lover extremities) was within normal limits. Laboratory tests, including cerebrospinal fluid, showed no abnormalities. The DTI images demonstrated significant reduction in FA in the right part of cervical spinal cord, extending from C4 to C8. No significant changes were observed in assessment of the ADC. A unique case of Hirayama’s disease is presented, in which DTI measurements contributed to early detection and evaluation of abnormalities in the cervical spinal cord, in spite of its normal appearance in conventional MRI.

P360 Spinal and bulbar muscular atrophy associated with myasthenia gravis—a case report I. Basta, S. Peric, D. Lavrnic, Z. Stevic University of Belgrade (Belgrade, RS) Spinal and bulbar muscular atrophy (SBMA) or Kennedy’s disease is a slowly progressive lower motor neuron disease inherited in X-linked recessive pattern. There are just sporadic descriptions of decremental response to repetitive nerve stimulation in SBMA. All findings that suggest impaired neuromuscular transmission in SBMA were described only in muscles affected by the disease. Here we present a case of 49-year-old male patient suffered from muscle wasting, cramping and twitching in arms and legs, as well as with walking difficulties and nasal speech for approximately two years. Few months prior to the admission to the hospital new symptoms occurred. He noticed left eyelid drop and double vision, associated with chewing and swallowing difficulties. Nasal speech and limb muscles weakness became more prominent, predominantly in wrist extensors. He also reported significant muscle fatigability. Neurological examination revealed moderate, predominantly proximal weakness and fatigability of the upper and lower limb muscles, absent muscle reflexes and waddling gait. Prostigmine test was positive. Needle electromyography in all limbs disclosed the presence of chronic denervation and reinnervation, with decremental responce registrated after low rate nerve stimulation. Serum anti-AChR antibodies, as well as antibodies against muscle specific kinase(MuSK) were negative. Genetic testing revealed increased number of CAG repeats on the androgen receptor gene on the X chromosome, confirming the diagnosis of SBMA. It is well known that neuromuscular transmission impairment could be a part of clinical presentation of SBMA. Taking into account that bulbomotor neurons are spared in SBMA even in late stages of disease, ocular impairment, ptosis and diplopia observed in our patient were highly suggestive for the diagnosis of seronegative myashenia gravis (MG). Furthermore, significant improvement of his condition with pyridostigmin and prednisolone therapy supported this diagnosis. Although SBMA associated with MG has been reported only in one case so far, we strongly believe that our patient suffers from these two rare disorders.

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General neurology P361 Predictors of functional outcome in patients admitted to the neurologic intensive care unit S.B. Kwon, M.J. Lee, S.S. Hong, S.Y. Kang, S. Jung, S.H. Hwang Hallym University College of Medicine (Seoul, KR); SoonChunHyang University College of Medicine (Seoul, KR) Background and objectives: The specialization of Intensive Care Unit (ICU) toward specific patient populations led to the creation of neurologic ICU (neuro-ICU). Although many patients have been admitted and treated in such specialized ICU, there are sparse data about the functional outcome and quality of life of neuro-ICU survivors. The main objective of this study was to analyze survival, mortality, and functional outcome and to determine predictors of unfavorable outcome in consecutive stroke patients admitted to a neuro-ICU. Methods: Consecutive patients admitted to a neuro-ICU due to ischemic or hemorrhagic stroke during the 12-month period from Jul 2008 through Jun 2009 were included. We evaluated demographic data, comorbid condition, mortality, ICU stay, mechanical ventilation, NIHSS (National Institutes of Health Stroke Scale), TISS-28 (simplified Therapeutic Intervention Scoring System), APACHE II (acute physiology and chronic health evaluation) score, GOS (Glasgow outcome scale) and mRS (modified Rankin scale). Predictors for unfavorable outcome were determined by logistic regression analyses. Results: A total of 343 consecutive stroke patients were enrolled in the study. The main diagnoses for neuro-ICU management were intracerebral hemorrhage, subarachnoid hemorrhage, and ischemic cerebral infarction. A total of 62 patients (18.1%) died during neuroICU stay. The GOS and mRS were dichotomized into two groups determining unfavorable vs. favorable outcome (GOS 1–3 vs. 4–5 and mRS 2-6 vs. 0-1). Factors associated with unfavorable outcome in stroke patients according to logistic regression analysis were age, neuro-ICU stay, a high score in TISS-28, and high APACHE II score. Conclusion: Age, prolonged neuro-ICU stay, high TISS-28 and APACHE II scores are independent predictors of unfavorable outcome in stroke-related neurocritical care population.

P362 Brain death: clinical diagnosis and confirmatory tests V. Bogosavljevic, M. Ercegovac, L.J. Beslac Bumbasirevic Clinical Centre of Serbia (Belgrade, RS) Objective: Brain death (BD) is defined as the absence of all brain functions demonstrated by profound coma, apnoea and the absence of all brain-stem reflexes. Objective of this study was to analyse the causes of BD, findings of the clinical examination along with the results of the confirmatory tests: electroencephalogram (EEG) and transcranial doppler (TCD). Materials and methods: This study included patients that were treated at the Emergency department of the Clinical centre of Serbia, from january 2004. until december 2009. Inclusion criteria were complete cessation of brain function with profound coma of known cause, complete absence of brain stem reflexes, and positive apnea test.All evaluations were done by experienced neurosurgeons and neurologists. Results: There were 161 patients with the BD diagnosis. Considering the etiology of BD, the majority of cases 108 (67,1%) included spontaneous hemorrhagies (subarahnoidal and/or intracranial ones). In one patient the Lazarus sign was observed, and in another one

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spontaneous flexion movements of the feet were noticed. In most patients 60 (37,3%) the whole illness lasted 2 days, the longest period was 22 days. In 70% of cases the cardiac arrest happened in the next 24 hours from the moment of establishing the brain death, in 16% in 48 hours. In 20 cases (12,4%) the first EEG performed didn’t support the clinical diagnosis so another one or two had to be done. Finally in 6 cases (3,8%) EEG didn’t confirm the clinical diagnose of brain death. Beside EEG, TCD was also done as a confirmatory test,but only in 13 cases, and in all 13 (100%) has confirmed the brain death. Conclusion: Considering the etiology, in our group of patients spontaneous haemorragies were present in 67% cases which is similar with the most so far published studies in similar sample of patients. Even though it is well known that in brain dead patients spontaneous body movements are rare, in one patient the Lazarus sign was observed (while performing apnoea test), and in another patient spontaneous flexion movements of the feet were noticed. In almost all patients in our group (96,2%) the clinical diagnosis of BD was confirmed by the test performed afterwards.

P363 Progressive systemic sclerosis and stroke: a rare association R. Manso ´ vila, ES) Hospital Nuestra Sen˜ora de Sonsoles (A Objectives: Progressive systemic sclerosis (PSS) is a multisystem disorder characterised by inflammatory, vascular and fibrotic changes of the skin (scleroderma), the gastrointestinal tract, lungs, heart and kidney. Unlike other collagen diseases, the nervous system is rarely involved in PSS. We report a case of ischemic stroke and transient ischemic attack (TIA) as uncommon complications of PSS. Methods: A 63-year-old woman with typical PSS developed right third nerve palsy and left hemiparesis (Weber syndrome). Medical history records revealed, she had noted the onset of Raynaud’s sign on her upper extremities, arthralgias and xerophthalmia at the age of 34. This was followed by necrosis and repeated infection, and as a result, shortening of her fingers in her 40’s. The disease progressed and involved lower extremities, face and body in her 50’s. Cardiomyopathy was diagnosed at 60, but systemic hypertension was not noticed. She was treated with prednisone and methotrexate. Laboratory values on admission revealed prolonged ESR, positive C-reactive protein, anti-nuclear-antibody 1/40 and mild ferropenic anemia. A chest X-ray evidenced pulmonary fibrosis and an EKG ruled out dysrhytmia. Brain MRI showed ischemic lesions in right mesencephalus and parieto-occipital cortex. Ultrasonography of supra-aortic trunks detected a calcified atheroma plaque in the right common carotid artery bifurcation without stenosis. Clopidogrel was added to the treatment, with partial improvement. At six-months follow-up, a complete A-V block requiring a pacemaker was found. Results: Two years later, the patient presented a new episode of transient acute dysarthria and left hemiparesis during exposure to cold. Brain TC and ultrasonography revealed no changes with regard to the previous study. Conclusion: Central nervous system involvement is rare in PSS, possibly due to the paucity of adventitial fibrous tissue and limited fibrous elements in normal media of cerebral arteries. When it occurs, cerebral ischemia is generally associated with evidence of renal failure or hypertension. Nevertheless, vascular and dysimmune mechanisms may produce cerebral ischemia in the absence of systemic atherosclerosis or any vascular risk factors. The findings in our patient probably relate to intracerebral microangiopathic processes, including cerebrovascular calcinosis and correlate well to diffuse abnormalities noted on cranial MRI. Otherwise, a vasospastic phenomena might explain some TIAs.

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P364 Meta-analysis of botulinum toxin A (DysportÒ) in poststroke upper-limb spasticity M. Iskedjian, M. Van Zandijcke, G. Stoquart, I. Van den Arend, J. Berbari, B. Farah Pharmideas (Lyon, FR); AZ Sint Jan (Bruges, BE); Cliniques Universitaires St. Luc (Brussels, BE); Ipsen Group (Paris, FR); Pharmideas (Ottawa, CA) Objectives: A meta-analysis evaluating responder rates and sustainability of response with botulinum toxin A (BTxA) - Dysport, was undertaken in adult patients with post-stroke upper limb spasticity. Methods: Articles were searched on Medline, EMbase and Cochrane databases, followed by data selection, quality assessment and data extraction, by two independent researchers. An Intent-to-treat (ITT) random-effects meta-analysis was performed evaluating response rates at specific time-points, then estimating the sustained response rates over longer periods. Binary data were expressed as change in the Modified Ashworth Scale (MAS). Heterogeneity was assessed using Box’s variant of the Bartlett test for homogeneity of variances and Cochrane’s Q-Test was applied to detect differences among rates from different studies. Results: Out of 726 retrieved references, 7 randomized controlled trials were scrutinized for data extraction; 4 were excluded for inadequate outcomes, and 3 were retained. All three scored C3 out of 5 on the Jadad scale for quality. Response rates were assessed at 4 weeks post- injection of various doses BTxA (500, 1000 and 1500 MU). For each Full Response (FR), Partial (PR) and Non-Response (NR) rates, analyses were performed across arms with results as mean (SD). At 4 weeks after 500 MU injection, 44.7% (SD=24.1%) of patients had a FR, 33.2% (SD=13.3%) had PR and 15.4% (SD=9.6%) had NR; 1000 MU yielded 62.3% (SD=10.4%) FR, 23.5% (SD=6%) PR, and 12.9% (SD=4.7%) NR; 1500 MU yielded 52.6% (SD=8.1%) FR, 26.3% (SD=7.1%) PR, and 21.1% (SD=10.1%) NR. Placebo rates were 9.8% (FR), 14.0% (PR), and 76.1% (NR). For 500 MU, the rates of sustained FR were [99% for 4-12 weeks. For 1000 MU, the sustained FR rates were 96%, 93% and 99% at 2, 6 and 12-weeks respectively. No data were found for sustained effect of 1500 MU. Conclusion: This meta-analysis of responder rates for BTxA generated relatively high rates of FR and PR for all formulations when compared to placebo for the treatment of post-stroke upper limb spasticity in adults. Sustainability of response was also reported. Financial support received from Groupe IPSEN

P365 Primary brain abscess caused by Nocardia farcinica in a patient with acquired immunodeficiency syndrome (AIDS) J.M. Duarte, I. Tiraboschi, M. Almuzara, C. Vay, M. Corti, M. Melero

Results: The MRI showed two left-sided ring enhancing frontoparietal masses with significant mass effect, and a right sided frontal mass, with surrounding edema. The open brain procedure revealed two left sided frontoparietal masses (3 9 1 cm, 8 9 0.6 cm). Direct examination by microscopy of the material revealed the finding of a brain abscess caused by Nocardia sp. Culture of the material, and PCR analysis identified a gram positive rod organism, Nocardia farcinica. No skin, lung or bone lesions which might be caused by Nocardia spp were found Antitoxoplasma therapy was discontinued, and the patient was then treated with high dose of Cotrimoxazole. His neurological condition improved gradually. One month later he developed a Fournier’s syndrome: blood cultures grew Pseudomona aeruguinosa, and the patient died three days later. Conclusion: Brain masses in HIV-positive patients are most frequently due to Toxoplasma, primary central nervous system (CNS) lymphoma or Chagas disease. A nocardial primary brain abscess is really infrequent in patients with AIDS, probably due to the great incidence of prophylactic treatment with Cotrimoxazol, when CD4 counts are below 100/uL.

P366 Cerebral haemodynamic change of presyncopal attack during head-up tilt test J.J. Lee, Y.E. Shin Daegu Fatima Hospital (Daegu, KR); Ulsan Dongkang Hospital (Ulsan, KR) Objectives: The neurocardiogenic syncope showed drop of both diastolic and mean blood velocities in transcranial doppler(TCD) during head up tilt test (HUTT). Drop rate of cerebral blood velocity reached to below 50% of baseline level in patients with positive response of TCD. Several cases showed that mean cerebral blood velocity did not reach to below 50% of baseline level but diastolic blood velocity reached. Methods: We performed TCD with HUTT on 69 cases which patient with transient loss of consciousness from January 2009 to January 2010. We assessed drop rate of diastolic and mean cerebral velocities in TCD. Results: Thirty-seven (54%) cases had positive response of HUTT and TCD. 32(46%) cases had negative response of HUTT and TCD, but 8 (11.6%) cases had positive response of TCD which meant cerebral type syncope. In both groups, 7 (10.15%) cases had drop in only diastolic blood velocity, 6 (8.7%) cases had drop in only mean blood velocity but 7 (10.15%) cases had not drop in both diastolic and mean velocities. The group which drop in only diastolic blood velocity also felt dizziness, loss of tone, faintness during HUTT. Conclusion: We can propose the cases which drop in only diastolic blood velocity and feel symptoms such like dizziness, loss of tone but not loss of consciousness during HUTT with TCD means presyncopal attack.

University Hospital (Buenos Aires, AR) Objectives: To report the rare ocurrence of a primary brain abscess caused by Nocardia farcinica in a patient with AIDS Patient and methods: A 39-year-old man, HIV-infected, (category C3, Centre for Disease Control classification) was admitted in our unit of internal medicine with a 15-day history of progressive right sided motor deficit, mild hyperthermia and headache. His medical history was significant for mucocutaneous Kaposi’s Sarcoma, recurrent candidiasis and AIDS related thrombocytopenic purpura. He underwent a TC scan, and was empirically treated with Antitoxoplasma therapy. No skin or lung lesions were found. With a worsening of the motor deficit and the ocurrence of partial seizures he underwent a magnetic resonance imaging (MRI), and an open brain biopsy.

P367 Cognitive deterioration, emotional and behavioural disturbances in a case of young male-diagnosis difficulties—case report S. Petrescu, P. Ionescu, G. Vanghelie, C. Panea Elias Emergency University Hospital (Bucharest, RO); Alex Obregia Psychiatric Hospital (Bucharest, RO) Objectives: Late infection with Treponema Pallidum is causing different neurological and psychiatrical complication, being known like ‘‘a great imitator’’.

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S118 We report a case of a young male who developed subacutelly cognitive and behavioural symptoms for whom was established the diagnostic of neurosyphilis. Methods: A 34 years old male, without any personal pathological events, developed memory trouble and his wife has remarked behavioural disturbances during the previous six months. He was evaluated by neurologist and psychiatrist who recommended: examination of central nervous system by magnetic resonance imagining (MRI), biological assessment, electroencephalogram EEG. Results: Neurological examination didn’t find abnormalities, with mild cognitive deterioration (mini mental state examination -MMSE of 26). Psychiatric examination found memory dysfunction for recent events with confabulation, impairment of the thinking processes with a lowering of analyzing and abstraction capacity, poor time and activity structure and decreasing professional skills, decreased of spontaneous thoughts and emotional responses, loss of initiative, eating behavioural disturbances, with a score of 55 on the global assessment of functioning scale- GAF. The MRI of the brain showed a non specific lesion placed on the left putamen. EEG registration revealed epileptiform discharges of theta waves: spontaneous and also after hyperventilation. Biological assessment excluded a vasculitis, but it had been found high titres of Treponema Pallidum Haemagglutination Assay-TPHA and Venereal Disease Research Laboratory-VDRL in blood and cerebrospinal fluid, with negative antibodies against HIV. The usual check of cerebrospinal fluid was normal but we found immunological markers: oligoclonal bands and high titres of TPHA and VDRL. The patient was followed every 3 month with biological (blood and CSF) and psychiatric assessments; after 1 year our patient had lower titres of TPHA and VDRL in CSF. The psychiatrist reported a better score of GAF. The patient received penicillin G iv for 21 days every 3 month. Conclusion: Neurosyphilis should be taking into account when we are in front of patients with neuro- psychiatrical symptoms especially if they are young (there a lot of neurological and psychiatric disorders which could have o similar onset). The cerebral parenchymatous neurosyphilis has a poor prognosis as in the case of our patient; in the absence of treatment death could happen within 3–4 years.

P368 Primary central nervous system post-transplant lymphoproliferative disorders M. Suzuki, N. Shibata, A. Kohama, H. Akagawa, K. Tanabe, A. Sannomiya, S. Uchiyama Tokyo Women’s Medical University (Tokyo, JP) Objectives: The PTLD compose a diverse group of abnormal lymphoid growths, most of which are of B cell-type that can be associated with Epstein-Barr virus (EBV) infection. We report two patients with primary CNS-PTLD after transplantation and review the literature. Case reports: Case 1 (51yo, F) underwent renal allografting. Twenty years later, she was referred to our department with rightsided weakness. Her posttransplant immunosuppressive therapy consisted of administration of PSL, mycophenolate mefetil (MMF), and tacrolimus. MRI revealed a mass lesion with enhancement and edema in the left frontoparietal regions. Serum soluble interleukin-2 receptor (IL-2R) were elevated, at 1520 U/ml. Serum EBV DNA levels were elevated. A brain biopsy was performed, and histopathologic examination revealed reactive lymphocytic infiltration. The lesion regressed after methylpredonisone pulse therapy. Three months

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later, MRI revealed a new lesion in the left corona radiata. The second biopsy revealed polyclonal infiltration of lymphocytes positive for the latent infection membrane protein LMP-1 but negative for the EBV nuclear antigen EBNA-2 as well as EBV-encoded RNA (EBER). Another course of methylpredonisone pulse therapy with reduced doses of tacrolimus and MMF induced regression of the brain lesion. Case 2 (58yo, F) exhibited visual symptoms and gait disturbance. She had undergone renal allografting ten years previously and had taken tacrolimus, MMF, and PSL. MRI revealed multiple lesions with ring enhancement and cerebral edema. IL-2R levels were elevated, at 1120 U/ml. A brain biopsy revealed infiltration of T cell-dominant polymorphic lymphocytes positive for LMP-1 and EBER. After discontinuation of tacrolimus therapy and reduction of the dose of MMF, the brain lesions regressed. Discussion. PTLD is not a single disease and instead a heterogeneous syndrome that includes abnormal reactive and neoplastic lymphoid growths, ranging from a benign, self-limited form to a malignant, widely disseminated form. Our patients were diagnosed with polymorphic PTLD, which is considered benign. These brain lesions regressed with reduction of immunosuppressive agents. Conclusion: In the case of diagnosis of PTLD, it is important to consider several disorders in the differential diagnosis including primary CNS lymphoma, inflammatory demyelinating encephalopathy, and metastasis of a malignant neoplasm. Long-term follow-up and serial MRI studies are also needed.

P369 Brain ischaemia and coronary steal during cardiopulmonary bypass. Where and why blood migrates? Y. Carrascal, A.L. Guerrero, J. Arroyo, J. Rey, J.R. Echevarrı´a, J.J. Fuertes University Hospital (Valladolid, ES) Objectives: Coronary-subclavian steal syndrome (CSSS) is an unusual event, secondary to decreased or reversed flow in patients with patent internal mammary to coronary artery graft. Most frequent cause of CSSS is ipsilateral subclavian artery stenosis. Methods: 60-year-old male, admitted due to three vessel coronary artery disease and postinfarction angina. Past history of subclaviansubclavian bypass due to complete symptomatic occlusion of brachiocephalic trunk. A computed tomography angiography showed right common carotid, right vertebral and right subclavian arteries filling through the bypass, occlusion of left internal carotid and moderate stenosis (60%) of right internal carotid. Right middle cerebral artery filled through patent anterior and right posterior communicating arteries. Emergent coronary artery bypass surgery was performed; right internal mammary artery was connected to left internal mammary artery (LIMA) and 4 sequential coronary artery bypass grafts were constructed. During cardiopulmonary bypass (CBP) weaning, severe left ventricular dysfunction and cardiogenic shock was identified. Doppler flowmetry (DF) showed reversal flow through LIMA pedicle leading to suspicion of massive CSSS. Then, pedicle was disconnected and anastomosed to ascending aorta, blood flowed back from aorta into coronary artery tree, and patient was successfully weaned from CBP. After surgery a confusional state, mild right distal brachial paresis, minor sensory aphasia and left homonymous hemianopsia were detected. A Magnetic Resonance Imaging revealed multiple acute small cortical and subcortical infarctions with hemorrhagic foci, suggesting embolic and hemodynamic origin. Patient was discharged home after a significant improvement. Results: In present description, CSSS was not identified during CBP despite intraoperative graft patency verification by DF. After

S119 aortic declamping, coronary vascular beds presumably offered superior resistance to flow than vascular bed depending on subclaviansubclavian bypass, which would have acted as high-flow fistula causing CSS. This probably favoured embolic and hemodynamic brain ischemia observed after surgery. Conclusion: Massive CSSS impairing wean from CBP has not been reported up to now. We consider intraoperative flow measurement in LIMA graft is essential to detect CSSS, especially when patients with diffuse cerebrovascular and peripheral vascular disease are submitted to coronary bypass with arterial grafting.

P370 Rheumatoid arthritis: risk factor or cause of ischaemic stroke? H. Nicolae, M. Comanescu, R. Gurgu, C. Panea Elias University Hospital of Emergency (Bucharest, RO) Case-report: We present the case of a 48-year old female patient known with rheumatoid arthritis (RA), under Sulfasalazine treatment for 5 years, who came to the hospital for aphasia and right limbs motor deficit, simptoms instalated progressively over the past week. The angio-MR exam disclosed a recent ischemic stroke located on the left superior parietal lobe and multiple microangiopathic lesions. The Doppler exam revealed left ICA extracranian oclusion and left ICA intracranian stenosis. The biological lab values showed no activity of the RA at that moment (ESR=2mm/h, Fbg=336mg/dl, CRP=negative). The diagnosis of acute ischemic left sylvian atherotrombotic stroke was made. Discussions: RA is known to rarely affect the CNS, either directly as a vasculitic process or indirectly as a risk factor by accelerating atherothrombosis. Both traditional risk factors and inflammationassociated factors are involved in RA-associated atherosclerosis. The particularity of our case was the ultrasonografic finding of an oclusion of the left ICA, unusual in a 48-year old patient with no significant risk factors. Some of the MRI findings resembled those seen in patients with cerebral vasculitis (multiple, bilateral and supratentorial.lesions), supporting the question if the etiology was vasculitic or atherothrombotic. Giving the fact that there were no clinical or biological findings to indicate activity of the disease and that RA is known to accelerate atherosclerosis, we concluded that in this patient RA was a risk factor and not a direct cause of the acute ischemic stroke.

P371 Deep cerebral vein thrombosis in adults: clinical presentation and computed tomography findings in two cases E. de Pablo Ferna´ndez, A. Villarejo Galende, A. Labiano Foncuberta, J.F. Gonzalo Martı´nez, F. Sierra Hidalgo, E. Correas Callero 12 de Octubre University Hospital (Madrid, ES) Objectives: Deep cerebral venous thrombosis (DCVT) has a variable and not specific clinical presentation ranging from progressive coma to less severe syndromes without affecting consciousness. We report 2 cases and describe the radiological findings. Methods: Case 1: A 90-year-old woman was admitted with a 2-day progressive history of altered conciousness. On neurological examination she was comatose with a left hemiparesis and bilateral extensor plantar responses. Case 2: A 52-year-old woman taking oral contraceptives presented to the emergency department with a 2-day history of changes

in her mental status with mutism and apathy. There was no consciousness impairment or other neurological abnormalities on examination. Results: CT showed in both cases a bilateral thalamic hypodensity and hyperdensity of deep cerebral veins consistent with their acute thrombosis. CT venography confirmed the thrombosis of the deep cerebral vein system. Despite heparinisation, patient 1 died three days after admission. Patient 2 was treated with anticoagulant therapy and made a good recovery. Conclusion: DCVT diagnosis is difficult due to its clinical variability as in the cases reported here. Identification of CT findings is important in order to make an early diagnosis in the emergency room and start anticoagulant treatment as soon as possible.

P372 Demyelinating disease and papillomavirus vaccine: report of three cases M.J. Alvarez-Soria, A. Hernandez-Gonzalez, S. Carrasco-Garcia de Leon, J. Dominguez-Bertalo, M.J. Gallardo-Alcan˜iz, M.A. Del Real-Francia Hospital General (Ciudad Real, ES) Objectives: Primary prevention by vaccination against the major cause of cervical cancer, the carcinogenic human papillomavirus (HPV) types 16 and 18, is now available worldwide. Postlicensure adverse effects have been described. We report three cases that received HPV vaccine and developed neurological symptoms. We suggest an association between HPV vaccination and demyelinating events possible through an immunological mechanism. Methods: Patient 1: 27 years old woman admitted because ascending paresthesias to the top of the chest, hypoesthesia (medullary level T4), hyperreflexia and clonus of lower limbs. She received the HPV vaccine one month before. Patient 2: 17 years old woman complaining decreased right visual acuity seven days after the first dose of the HPV vaccine. Seven months after, she suffered similar symptoms following the second dose of the vaccine. Patient 3: 26 years old woman with right hemiparesthesia, hemihypoesthesia and hyperreflexia, one month after the third dose of the vaccine. Results: Patient 1: MRI showed a paraventricular lesion without gadolinium enhancement. Patient 2: MRI showed two subcortical hyperintensities lesions with gadolinium enhancement and prolonged latency on right visual evoked potential. In the second episode, the results were similar. Patient 3: MRI revealed several supratentorial and infratentorial lesions with gadolinium enhancement. CSF oligoclonal bands were detected in all three cases. The four episodes resolved with a steroid cycle. The patients are asymptomatic after a year of follow-up, and control MRI (at 3 to 8 months) remained unchanged, without criteria of temporal dissemination. Conclusions: The pathogenesis of demyelinating disease is likely of autoimmune nature, and triggered by various environmental factors, including vaccinations. Adverse effects following immunization by HPV vaccine have been described: syncope, local site reactions, dizziness, nausea, headache, hypersensitivity reactions, urticaria, venous thromboembolic events, anaphylaxis, pancreatitis, seizures, autoimmune disorders such as Guillain-Barre´ syndrome or transverse myelitis, motor neuron disease and death. We describe four demyelinating episodes following HPV vaccination: transverse myelitis, two optic neuritis and isolated demyelinating syndrome, all of them without criteria for multiple sclerosis diagnosis until now. We suggest that vaccine may trigger an immunological mechanism leading to demyelinating events, perhaps in predisposed youngs.

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P373 Temperature dysregulation as the main manifestation of autonomic dysfunction in SLE: a case report G. Gervasi, P. Bramanti, A. Marra, R.S. Calabro` IRCCS Centro Neurolesi ‘‘Bonino-Pulejo’’ (Messina, IT) Introduction: Nervous system involvement in systemic lupus erythematosus (SLE) may present with different neurological or psychiatric symptomatology and may involve both central and peripheral dysfunction. Presentation may range from mayor neurological manifestation (such as stroke, psychosis and finally coma) to soft neuropsychiatric problems (such as paresthaesias and depressive mood swing). Some of this clinical manifestation may antedate the appeareance of diagnosable SLE by months or even years. We describe a case of a young-adult man presented with autonomic dysfunction as SLE main features. Case Report: A 54-years-old man was referred to our department for a persistent alteration in cold sensation. His personal history was positive for depressive mood disorder, sporadic episodes of pre-syncope, loss of consciousness and arthralgia. Five years ago was admitted to a Nephrology unit for a sudden anuria, and after a specific laboratory screening, diagnosis of ‘‘Acute Renal Failure due to Systemic Lupus Erythematosus’’ was posed. Our neurological examination was unremarkable. A brain MRI showed diffuse white matter lesions and the cardiovascular reflex tools pointed out an autonomic dysfunction, indicating a possible SLE nervous system involvement. Conclusion: Autonomic neuropathies are a collection of syndromes and diseases affecting both parasympathetic and sympathetic system. There exist a close association between autonomic nervous system dysfunction and autoimmune rheumatic disease. In particular autonomic neuropathy may be quite common in SLE. To our knowledge, only a few cases have reported the presence of hypothermia in SLE as a consequence of corticosteroid therapy. In our patient, dysthermia started in young age (about 20 years) and preceded by many years the appereance of the mayor manifestation of SLE suggesting that autonomic dysfunction have to be take into account while investigating patient with autoimmunity disorders.

__________________________________ Poster session 3 Cerebrovascular disorders: experimental stroke/mechanisms P374 Quantitative T2’ normal values of brain parenchyma in a spontaneously hypertensive stroke prone rat stem at 3 Tesla U. Jensen, R. Bo¨hm, J. Ho¨cker, R. Ruhe, J. Brdon, S. Ulmer, T. Herdegen, O. Jansen University Schleswig-Holstein (Kiel, DE); University Hospital (Basel, CH) Objective: Regarding therapy and prognosis of acute ischemic stroke the identification ischemic penumbra is pivotal. In a clinical setting the penumbra is defined as PWI-DWI mismatch using MRI. Due to methodical problems of this approach and the potential harmful use of contrast agent other means of depiction are desirable. A promising candidate is BOLD-imaging using qT2’-maps (Geisler et al., Stroke

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2006; 37: 1778-84). Normal values for humans at 1.5 Tesla have already been published (Siemonsen et al., AJNR 2009; 29: 950-55). For valid interpretation of experimental data in animals normal values for qT2’ are needed. Since 3 Tesla scanners become more and more available and signal extraction is expected to be better at higher field strengths, normal values were acquired at 3 Tesla. Material and Methods: 20 spontaneously hypertensive stroke prone (SHR-SP) rats (10 males and 10 females) were examined in a 3 Tesla scanner using a dedicated small animal coil. Mean weight was 147.84 ± 9.35 g and mean age was 56.5 ± 3.8 days. The scanning protocol included a DWI sequence and T2w images. For the calculation of qT2’ multiple T2w and T2*w images were acquired. qT2 and qT2* were calculated according to formula 1. qT2’ was calculated using formula 2. ROIs were placed into deep and cortical gray matter. No ROI was placed into white matter because blurring with gray matter could not be excluded. (1): (2):

SI(t) = SI(0)*e-(t/T2) and SI(t) = SI(0)*e-(t/T2*) qT2’ = 1/(1/T2* – 1/T2)

Results: No animal had a spontaneous infarct. Mean qT2’ for cortical gray matter was 73.24 ± 27.8 ms and 63.35 ± 12.9 ms for deep gray matter (no statistically significant difference; two-sided ttest for unpaired samples). For qT2 it was 78.9 ±3.17 ms and 70.85 ± 2.03 ms (p \ 0.01) respectively. For qT2* it was 34.2 ± 4.65 ms and 32.02 ±2.95 ms (p \ 0.01). There were no significant sex or side dependent differences. Conclusion: As expected, qT2’ did not differ for deep and cortical gray matter as oxygen consumption should not be different among different localisation of gray matter as least not measurable by our methods. The obtained values can serve as reference values for further studies examining the ischemic penumbra in a rat model. Further studies producing normal values in humans at 3 T should be conducted.

P375 Analysis of permanent focal cerebral ischaemia in the isolated guinea pig brain and evaluation of treatment with diazoxide R. Galbusera, G.L. Breschi, S. Beretta, G. Sala, C. Ferrarese, M. de Curtis University of Milan-Bicocca (Monza, IT); Neurological Institute Carlo Besta (Milan, IT) Objectives: The study aims at defining the earliest events of cerebral ischemia in our model and at determining and evaluating possible hyperacute effects of diazoxide, a putative neuroprotective agent, which selectively opens mitochondrial potassium channels and has been reported as an early mediator of brain preconditioning. Methods: We developed a new model of focal ischemia by occluding permanently the middle cerebral artery (MCA) in the isolated guinea pig brain maintained in vitro by arterial perfusion. We performed continuous extracellular electrophysiological recordings from selected cortical areas (piriform cortex and olfactory tubercle) before and during occlusion of the MCA. Diazoxide was administered 30 min. before the artery occlusion. After 3h occlusion, samples from the above-mentioned areas and from the basal ganglia were dissected and homogenated. Total ATP tissue levels and markers of oxidative damage were then assayed. In a subset of experiments, brains were fixed and histological immunostaining for MAP-2 (Microtubule Associated Protein-2, a marker of dendritosomatic neuronal injury) and magnetic resonance (MR) scanning with diffusion weighted imaging (DWI) were performed. Results: The electrophysiological recording of the ischemic hemisphere highlighted an anoxic depolarization in the piriform

S121 cortex, whereas the tubercle only underwent to a temporary depolarization phenomenon. ATP loss in the piriform cortex and the basal ganglia was quantified in about 70%; in the tubercle it was equal to circa 20%. No increase in oxidative damage was demonstrated under our experimental conditions. In the experiments performed under treatment with diazoxide a reduction in the gravity of depolarization phenomena and a stronger electric response were detected in the tubercle; moreover, the MRI imaging pointed out a reduction in the signal intensity loss of the ischemic hemisphere. Conclusion: The observation of a clear gradient of energetic loss confirmed the electrophysiologic data and established the presence of a ‘‘core’’ region, represented by the piriform cortex and the basal ganglia, and a ‘‘penumbra/oligoemia’’ region, represented by the olfactory tubercle, so that our model could be further validated. The administration of the drug lead to a better preservation of the electrical activity in the penumbra and to a reduction of the signal intensity loss of the ischemic hemisphere at the MRI imaging, that could be interpreted as a decrease in cytotoxic oedema.

P376 Simultaneous administration of hyperbaric oxygen and recombinant tissue plasminogen activator (tPA) appears more effective than tPA alone after experimental stroke in rats during a 24-hour observational period D. Michalski, L. Ku¨ppers-Tiedt, M. Raviolo, W. Ha¨rtig, D. Schneider, C. Hobohm University of Leipzig (Leipzig, DE) Objectives: In numerous pre-clinical studies, hyperbaric oxygen therapy (HBO) following focal cerebral ischemia has shown beneficial effects concerning survival, neurological impairment and size of infarction. The present study focuses on a potential impact of coadministered HBO to recombinant tissue plasminogen activator (tPA), which is widely in use as recanalisation strategy, extending the tPA time window and attenuating toxic effects of tPA. Methods: Embolic middle cerebral artery occlusion (eMCAO) was induced in 20 male Wistar rats. Starting two hours after embolisation, 11 rats underwent HBO (2.4 ATA for 60 minutes) simultaneous to intravenously applied tPA (9 mg per kg bodyweight), and 9 rats received tPA alone. Neurological impairment was assessed by Menzies score immediately after eMCAO and at 24 hours. Magnet resonance imaging was performed within 12 hours after therapy including diffusion- and T2-weighted imaging for infarct size calculation, and T2*-weighted imaging detecting hemorrhagic transformation. Results: Concerning neurological impairment, tPA+HBO-treated animals improved significantly more than tPA-treated animals (effect size, 1.13 vs. 0.80; p\0.05 vs. non-significant) within the first 24 hours. Ischemic infarction was seen in all tPA-treated rats, but only in 54.5 % of the tPA+HBO-treated animals (p\0.05). Cerebral hemorrhage was not observed in the tPA group, but occurred in 27.3 % of the tPA+HBO group, which fails statistical significance. The size of infarction showed a non-significant trend with superiority for tPA+HBO-treated animals in both diffusion- and T2-weighted imaging. Conclusion: Following eMCAO, combined HBO and tPA results in improved neurological recovery within a 24 hours observational period, and tends to lead in reduced infarct sizes but increased incidence of hemorrhagic transformation. Further studies with long-term follow-up are needed to evaluate the hypothetic beneficial effects of this combined treatment strategy.

P377 Apolipoprotein-E controls ATP-binding cassette transporters in the ischaemic brain A. El Ali, D.M. Hermann University Hospital Essen (Essen, DE) Objectives: Blood-brain barrier prevents pharmacological compounds from brain entry by expressing ATP-binding cassette (ABC) transporters, which eliminate variety of drugs from the brain. We have previously shown that ABC transporters exhibit profound expression changes on ischemic cerebral microvessels, impeding drug accumulation in the stroke brain. As such, the luminal transporter ABCB1, which extrudes drugs from the brain into blood, is upregulated, whereas the abluminal transporter ABCC1, which carries drugs in the opposite direction from the blood to brain, is downregulated upon stroke. The signal pathways controlling the expression of ABC transporters after stroke were unknown. Methods: To investigate the regulation of ABC transporters in the ischemic brain, we herein submitted wildtype, apolipoprotein-E (ApoE)-/- mice to focal cerebral ischemia, induced by middle cerebral artery (MCA) occlusion. By means of genetic knockout and protein delivery studies, which we combined with protein expression analysis and pharmacological experiments, we investigated mechanisms responsible for ABCB1 and ABCC1 regulation at the blood-brain barrier after stroke. Results: Expression patterns of ABCB1 and ABCC1 in ApoE-/mice fundamentally differed from wildtype mice. As such, ABCB1 was downregulated in ischemic brain capillaries, whereas ABCC1 was upregulated. In protein expression and interaction studies, combined with pharmacological experiments, we show that ApoE is de novo expressed on ischemic brain capillaries together with its receptor, ApoER2. We demonstrate that ApoER2 interacts with Jun N-terminal kinase (JNK)-1/2 interacting protein (JIP)-1/2. JIP1/2 in turn targets MKK-7 and MKP-7, as we observed, to either phosphorylate or dephosphorylate JNK1/2, depending on the presence or absence of ApoE, thus influencing ABC transporter expression. Conclusion: Selective inhibitors of luminal ABC transporters to improve drug access to the diseased brain increased drug accumulation in rodents, studies in humans were disappointing. As such, it was realized that larger sets of transporters may have to be modulated pharmacologically or by transcriptional regulation to facilitate drug brain entry. The surface receptor ApoER2 is a promising target for drug delivery purposes, as its deactivation resets those transporters regulated by the stroke. Future studies will have to demonstrate whether by deactivating ApoER2 the efficacy of neurological therapies may be improved.

P378 Liver X receptor activation enhances vascular integrity in the reperfused ischaemic brain A. El Ali, D.M. Hermann University Hospital Essen (Essen, DE) Objectives: The blood-brain barrier (BBB) is characterized by highelectrical resistance contacts between endothelial cells, the tight junctions, which prevent the diffusion of blood-borne molecules into the brain. The BBB is complemented by active transporters located on the endothelial membranes, among which ATP-binding cassette (ABC) transporters have received particular interest in the past. Ischemic stroke causes an altered expression and phosphorylation of tight junction proteins, such as occludin and zona occludens (ZO)-1, leading to their disassembly, and the dysregulation of ABC

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S122 transporters. Moreover, the influx of Ca2+ into endothelial cells activates calpain proteases, matrix metalloproteinases (MMP) and Rho GTPases, which are widely regarded as hallmarks of BBB breakdown. Methods: Liver X receptors (LXR) are cell sensors controlling glucose and lipid metabolism, which attenuate atherosclerotic plaque formation. Their role in the maintenance of blood-brain barrier integrity remained unknown. We herein delivered the LXR agonist T0901317 to mice submitted to 30 min of intraluminal middle cerebral artery (MCA) occlusion. By using enzymatic activity assays, pull down assays and co-immunoprecipitation experiments we investigated the role of LXR activation in blood-brain barrier maintenance. Results: We show that the LXR agonist T0901317 reduces brain swelling and leakage upon stroke, by upregulating its target calpastatin that deactivates calpain-1/2, which in turn stabilizes p120 catenin. p120 catenin specifically interacts with RhoA and Cdc42, the former of which being inhibited and the latter overactivated, thus restoring the post-ischemic expression of the tight junction proteins occludin and zona occludens-1, modulating occludin’s phosphorylation and increasing its assembly with zona occludens-1. Moreover, T0901317 deactivates matrix metalloproteases-2/9 and inhibits apoptotic pathways in cerebral microvessels by deactivating JNK1/2 and caspase-3. It also upregulates the ATP-binding cassette transporters ABCA1, ABCG1, ABCB1 and ABCC1 and thereby furthermore strengthens barrier function. Conclusion: The preservation of blood-brain barrier integrity by LXR offers fascinating perspectives for the treatment of post-ischemic vasogenic edema. Since LXR activation promotes BBB integrity, at the same time providing vascular protection, LXR agonists possess a promising profile that might render them suitable for therapeutic purposes in humans.

P379 The role of 17-b-esteradiol on the expression of cytokines in astrocytes M. Mohsenzadeh, A. Piroozi Gerash University of Medical Sciences (Gerash, IR) Recent studies have shown a positive correlation between astrocyte apoptosis and rapid disease progression in persons with neurodegenerative disease. These cells are one of the most important cells of the ‘‘central nervous system’’ and They have important functions such as protection of neurons against injuries, ischemia, etc. Findings from other researchers suggest that Wnt signaling pathway plays an important role in many developmental process such as differentiation, migration and apoptosis. GSK3-b ‘‘glycogen synthase kinase-3b’’, a key molecule of the Wnt signaling pathway. The aim of this study was to study the possible role of 17-b-esteradiol on the expression of cytokines such as TGFb1 and TGFb2 in cultured astrocytes. Cultured astrocytes were treated with 25 nM, 50 nM and 100 nM of 17-b-esteradiol. After 48 hours, the treated cells were isolated and the expression of TGFb1mRNA and TGFb2mRNA were examined by real-time RT-PCR. Our results show that treated cells express higher amounts of TGFb1 and TGFb2 in comparison with the controls and treated cells with 17-b-esteradiol have a different morphology in comparison with untreated cells. To seem the inhibition of GSK3-b by 17-b-esteradiol increases of the expression of cytokines which points at the key role of some signaling pathway in regulating survival and function of astrocytes.

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P380 Erythropoietin-transduced human mesenchymal stromal cells improve neurological functions of ischaemic stroke animal model S.H. Koh, J. Kim, K.Y. Lee, Y. Lee, S. Kim Hanyang University (Seoul, KR) Erythropoietin (EPO) exhibits diverse cellular functions including neurotrophic, anti-oxidant, anti-apoptotic, and anti-inflammatory effects in non-hematopoietic tissues. This study evaluated whether bone marrow mesenchymal stromal cells transduced with the EPO gene (EPO-MSCs) promoted neural cell survival and improved neurological deficits caused by ischemic stroke. EPO-MSCs stably produced high levels of EPO (10 IU/ml) without any alteration of their mesenchymal phenotype. Both EPO-transduction and treatment with 10 international unit (IU) recombinant human EPO (rhEPO) provided protection from H2O2-induced oxidative injury in human bone marrow mesenchymal stromal cells and SH-SY5Y cells. EPOMSCs were more protected than were 10 IU rhEPO-treated MSCs (10U-MSCs). We also found that the expression of neurotrophic factors such as PD-ECGF, HGF, SDF-1a, and TGF-1b increased in EPO-MSCs, while only TGF-1b increased in 10U-MSCs. Implantation of EPO-MSCs in an animal model of ischemic stroke significantly improved neurological functions and decreased infarct volumes. An evaluation of the brain tissue 21 days after implantation showed that EPO and phosphorylated Akt, a downstream mediator of EPO, increased only in brains implanted with EPO-MSCs. Transduction of the EPO gene into MSCs induced secretion of EPO and various trophic factors that may provide excellent neuroprotective effects in both in vitro and in vivo models of ischemic stroke.

P381 Comparison of endothelial dysfunction in patients with acute ischaemic stroke and chronic heart failure N. Scherbakov, T. Szabo, T. Kung, G. Turhan, S. von Haehling, S.D. Anker, W. Doehner Charite´ University (Berlin, DE) Background: Endothelial dysfunction (ED) is a key pathophysiological feature in chronic heart failure (CHF). It is also relevant for the development of acute ischemic stroke (AIS). Both, ED and arterial stiffness reflect functional alterations in arteries that are among others determined by plasma lipid status and cholesterol concentrations. The aim of this study was to examine endothelial function in patients with AIS and with CHF in comparison to healthy controls. Methods: In patients with AIS (n=30), patients with stable, ambulatory treated CHF (n=15) and in healthy controls of similar age (con: n=20) endothelial function and arterial stiffness were assessed by non-invasive EndoPAT2000 technology. Endothelial dysfunction was estimated using reactive hyperaemia index (RHI), defined as a ratio between the post- and pre-occlusion PAT signal corrected for baseline vascular tone. Arterial stiffness was estimated by augmentation index (AI) calculated from PAT signal pulse pressure curves. Total cholesterol, high-density and low-density cholesterol (CHO, HDL, LDL, respectively) and triglyceride (TG) concentrations were measured from venous blood samples after overnight fasting. Results: All groups were similar for age (AIS: 67±12y vs. CHF: 61±8y vs. con: 44±19y; all: mean±SD, ANOVA p\0.01) and BMI (AIS 25.4±4.2 vs. CHF 26.5±3.94 vs con 29.3±3.8; p=0.07). RHI was significantly decreased in AIS as well CHF compared to controls (1.797±0.35 vs 1.854±0.5 vs 2.176±0.7, respectively, p=0.032). AI was significantly elevated in AIS (19.2±15.9) and in CHF (12.2±17.7) compared to controls (7.4±13.4; ANOVA

S123 p=0.039). Patients with AIS and CHF (29% AIS and 75% CHF patients on statin therapy) had lower CHO (AIS 183.5±51.3 vs CHF 170.2±39.3 vs con 235.4±34.2 mg/dl, p=0.003) and lower LDL levels (AIS 113.7±49.9 vs. CHF 106.3±26 vs con 152.6±38.6 mg/dl, p=0.026), but higher TG concentration (AIS 167.4±73 vs CHF 132.6±61.1 vs con 110.8±47.4 mg/dl, p=0.041). HDL was the highest in the control group (con 60.7±17.3 vs. AIS 43.5±9.8 vs CHF 42.8±14.4 mg/dl, p\0.001). In linear regression analysis a correlation of higher RHI with higher HDL (r=0.329, p=0.0161) as well as with lower TG (r=0.284, p=0.039) was found. Conclusion: These data show that endothelium function and vascular elasticity is even further impaired in acute stroke patients than in CHF patients as compared to healthy controls. This impaired vasodilator capacity relates to dyslipidemia characterised by high TG and lower HDL.

P382 Post-stroke infections and previous statins treatment L. Rodrı´guez de Antonio, M. Martı´nez Martı´nez, R. Cazorla-Garcı´a, P. Martı´nez-Sa´nchez, B. Fuentes, E. Dı´ez-Tejedor University Hospital La Paz (Madrid, ES) Introduction: Clinical and laboratory studies have attributed an inmuno-supressor effect to the statins. Furthermore, the administration of simvastatine in the acute onset of stroke has been associated with an increased frequency of infections. Our objective is to assess whether the risk of infection after ischemic stroke is higher in those patients treated with statins previously. Patients and methods: Observational study of patients with acute ischemic stroke admitted at a Stroke Unit of a University Hospital. Demographic data, vascular risk factors, stroke severity, stroke subtype and statins previous treatment were recorder. The following infections were registered: pneumonia, urinary tract infection, pseudomembranous colitis and sepsis. The patients were classified in two groups, depending on previous statin treatment. Results: A total of 2045 patients were included (1165 were male, aged 69,05 ± 12,5 years). Of these, 306 (15%) patients were receiving statins prior stroke. These patients had more frequently: arterial hypertension, DM, peripheral arteriopathy and hypercholesterolemia than the patients who were not treated with statins (p\0,0001). There was not statistically significant difference between in-hospital infection frequency in patients treated with statins and no-statins treatment, globally (11,8% vs 13%), neither in each infection type analysis: pneumonia (7,8% vs. 10,2%), urinary tract infection (4,2% vs. 2,8%), pseudomembraous colitis (0,3% vs. 0,7%) and sepsis (2,6% vs. 4,4%). In the atherotrombotic stroke subtype statins were associated with a less frequency of sepsis (not adjusted OR,0,949; 95% CI 0,928-0,971). Conclusions: Previous treatment with statins in patients with ischemic stroke is not associated with an increase of risk of in-hospital infections.

P383 Validation of copeptin as prognostic marker in ischaemic stroke G.M. De Marchis, M. Katan, A. Weck, H. Mattle, C. Breckenfeld, P. Schu¨tz, C. Foerch, M. Seiler, F. Heini, J. Papassotiriou, M. Christ-Crain, M. Arnold University Hospital (Berne, CH); University Hospital (Basel, CH); Goethe University (Frankfurt/M., DE); B.R.A.H.M.S. (HennigsdorfBerlin, DE) Objectives: The rapid and reliable estimation of prognosis in ischemic stroke is pivotal to optimize clinical care. In a recent study we

demonstrated that Copeptin is a new accurate prognostic marker in ischemic stroke. This ongoing study aimed to validate Copeptin as prognostic marker in ischemic stroke. Methods: Data of the first 198 patients with ischemic stroke who were consecutively admitted to the emergency department of the Inselspital Bern were analysed. On admission, severity of ischemic stroke was assessed by the National Institute of Health Stroke Scale (NIHSS). In all patients, Copeptin levels were measured within 24 hours of symptom onset and compared with outcome after 3 months as assessed with the modified Ranking scale (mRS). Results: Of the 198 patients with ischemic stroke, 34% patients were female and the median age was 67 years. The median NIHSS was 5 (interquartile range [IQR] 2–14), and 61 patients (30.1%) had an unfavorable outcome (mRS [ 2). Copeptin levels on admission were higher in patients with an unfavorable outcome compared to those with a favorable outcome (31.9 pmol/l, IQR 15.2–76.6 versus 9.25 pmol/l, IQR 4.8-27.2, p\0.0001). After multivariate logistic regression analysis adjusted for age (OR of 1.06 (95% CI 1.03–1.10)) and NIHSS (OR of 1.19, 95% CI 1.11-1.26)), Copeptin remained an independent predictor for unfavorable outcome with an OR of 2.29 (95% CI 1.11-4.73, p=0.02); Conclusion: Elevated Copeptin levels measured on admission were independently associated with an unfavorable outcome three months after ischemic stroke. Our data strengthen the value of Copeptin as an independent prognostic marker in ischemic stroke.

P384 Pathophysiological approach with near infrared spectroscopy in acute ischaemic stroke S. Viola, P. Viola, P. Litterio, M.P. Buongarzone, L. Fiorelli Hospital of. S. Pio Vasto (Vasto, IT); Emergency Medical Service (Lanciano, IT) Introduction: Near Infrared Spectroscopy (NIRS) measures the degree of oxygenation (TOI) and the amplitude of arterioles pulse wave of microcirculation (APWCM) of cerebral cortex. Some authors found a linear correlation between APWCM amplitude and cerebral blood flow (CBF). Some studies have identified the TOI threshold for cerebral ischemia. TOI can be converted in the Oxygen Extraction Fraction (OEF). CBF and OEF are important parameters to establish if cerebral tissue is at early risk of infarction. Objective: to determine if NIRS technique is able to identify the patients at risk of cerebral infarction in acute ischemic stroke within 3 hours of onset of symptoms. Methods: by an innovative NIRS system we studied 3 patients with acute ischemic stroke in the middle cerebral artery territories within 3 hours of onset of symptoms and 10 age-matched healthy control subjects. Results: in the first patient with acute right hemiplegia (NIHSS 18) NIRS documented a normal value of TOI (75%) and APWCM amplitude (0.53 U-NIRS) in the cortical territory of left MCA, TCD showed a sub occlusion of left MCA. Cranial CT was normal. After 48 hours (NIHSS 10) cranial CT showed a large subcortical necrotic area in the territory of left MCA. In the second patient with acute aphasia (NIHSS 6) NIRS documented a modest reduction of APWCM amplitude (0.40 U-NIRS) and TOI (49%) in the cortical territory of left MCA compared to the contralateral side and healthy subjects. TCD showed a severe stenosis (systolic velocity 287 cm/sec) of left MCA. After 48 hours (NIHSS 0). MRI showed only a small ischemic lesion in the left lenticular capsule. In the third patient with acute left hemiplegia (NIHSS 19), NIRS documented a marked reduction of APWCM amplitude (0.20 UNIRS) and TOI (27%) in the cortical territory of right MCA compared

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S124 to the contralateral side and healthy subjects. TCD showed sub occlusion of right MCA. Cranial CT resulted normal. After 48 hours (NIHSS 14) we had a normalization of TCD and NIRS parameters (recanalisation) but cranial CT showed a large subcortical-cortical necrotic area in the territory of right MCA. Conclusions: by reduction of TOI and the APWCM amplitude, NIRS, non-invasive, safe,low cost, bedside technique, seems able to detect the patients at risk of cortical cerebral infarction within 3 hours of onset of symptoms. Further studies will be needed to estimate the sensitivity and accuracy of the NIRS method.

P385 Levels of glomerular filtration rate in patients with stroke M. Ninkovic, S. Peric, O. Nikolic Sveti Apostol Luka General Hospital (Doboj, BA); University of Belgrade (Belgrade, RS) Objectives: Glomerular filtration rate (GFR) is the quantity of glomerular filtrate formed each minute in the nephrons of both kidneys. Level of GFR is an indicator of kidney’s efficiency. Cerebrovascular diseases represent a wide spectrum of brain dysfunction caused by cerebral blood vessel damage. A stroke is the rapidly developing and permanent loss of brain functions due to disturbance in the blood supply to the brain. It might be ischemic or hemorrhagic. Aim of this study was to assess GFR in patients with stroke. Method: The retrospective study was performed from June 1st, 2007 to May, 31st 2008. One hundred thirty nine patients with stroke were included in the study. In all patients GFR of creatinine was measured by adequate calculator. Results: Majority of patients with stroke was in the age between 70 and 79. Results revealed that 40 of them (29%) had impaired GFR. Among patients with impaired GFR, 31 of them (78%) showed just early symptoms of kidney disease, 6 of them (15%) reached the fourth stage of GFR damage, while just 3 patients (7%) reached the fifth stage of GFR damage. In female patients with coexistence of stroke and kidney disease, majority was in the second stage of GFR damage. It is also interesting that 3 women were even in the fifth stage of GFR damage. However, most of men with stroke and kidney disease reached just the first stage of GFR damage. Conclusion: In our group of patients with stroke 29% had an abnormal GFR. This shows that the status of kidney’s blood vessels might be a window for surveillance of the blood vessels of other vital organs.

P386 Leptin – An important link between cerebrovascular diseases and metabolic syndrome M. Pyzik University Hospital (Lodz, PL) Background: Leptin an important hormone for body weight regulation - primary involved in the regulation of food intake and energy expenditure - may be involved in the pathogenesis of cerebrovascular manifestations of obesity. Its concentration is proportional to body adiposity. The Metabolic Syndrome is a cluster of highly interrelated risk factors that together increase the risk of cerebrovascular disease. Methods: To this study were qualified patients with early ischemic stroke and referents without cerebrovascular diseases, matched with age and gender. We examined lipid pattern, blood glucose level, blood pressure, body mass index and central fat - measured by waist

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circumference (WC) and waist to hip ratio (W/H) - in every patient. On the basis of these parameters we diagnosed the presence of metabolic syndrome, defined according to American Heart Association 2005. Every patients Ultrasonographic scanning of the carotid artery was performed in every patient to to evaluate the IMT (intima-media thickness) and arteriosclerosis. To evaluate the correlation between leptin level and IMT we divided all subjects into two groups: with high ([30ng/ml) and low (\10ng/ml) leptin level. Plasma leptin level was measured by an enzyme linked immunosorbent assay. Results: To this time we have examined 45 participants with stroke and 17 without vascular diseases. Metabolic Syndrome was diagnosed in 64% of stroke cases. It was significantly more than in non-stroke patients group. Leptin concentrations were higher (but not statistically important) in the stroke group: 23,38ng/ml vs. 16,77ng/ ml. Hyperleptinemia was more often present in patients with diagnosed metabolic syndrome (p\0.01) and in subjects with markers of abdominal obesity (p\0.001). The presence of IMT (an early marker of asymptomatic atherosclerosis) was more often presence in stroke group. Hyperleptinemia was associated with IMT. Conclusion: Plasma leptin concentration was positively associated with presence of Metabolic Syndrome and IMT - an early marker of asymptomatic atherosclerosis. Adipose tissue (or leptin per se) may have an influence on the developement of cerebrovascular disease in obese people. The study was supported by Medical University in Lodz.

P387 Seasonal, monthly and weekly variations in admissions, in-hospital mortality and length of stay in patients with acute ischaemic stroke hospitalized in general ward G. Telman, S. Fahoum, E. Sprecher, E. Kouperberg Rambam Medical Center (Haifa, IL) Background: The issue of chronobiological variations in cerebrovascular diseases was a subject of numerous studies. Patients and Methods: We explored the seasonal, monthly and weekly variations in admissions, in-hospital mortality and length of stay in 2778 patients suffering from the acute ischemic stroke and hospitalized in general wards of the largest tertiary hospital in Northern Israel during the period from 2000 till 2008. Results: The only statistically significant finding was winter excess in in-hospital mortality in patients with acute ischemic stroke. There were no seasonal, monthly or weekly differences in number of admissions and length of stay. These results did not change after adjustment by age, sex and main vascular risk factors. Conclusions: We found association between higher in-hospital mortality and winter season in patients with acute ischemic stroke hospitalized in general ward in northern Israel.

P388 Serum SDF-1a level is correlated with long-term prognosis S.H. Koh, J. Kim, K.Y. Lee, Y. Lee Hanyang University (Seoul, KR) Background and purpose: Stromal cell-derived factor-1a (SDF-1a) is known as a chemokine produced by bone marrow (BM) stromal cells and a potent chemoattractant for hematopoietic stem cells. It has been suggested in animal studies that SDF-1a plays a role in ischemiainduced trafficking of BM-derived cells from peripheral blood to the damaged brain and can promote neuronal repair and recovery of function. However, there is no report about the level of SDF-1a in ischemic stroke patients. We investigated 1) whether serum SDF-1a

S125 level in acute stage of ischemic stroke patients is increased as compared with normal control, 2) whether it is proportioned to infarct volume, 3) and whether it is correlated with long-term prognosis. Methods: From march 2007 to may 2009, we evaluated patients who experienced an ischemic stroke for the first time, defined as SVD (n=76) or LVD (n=74) using the TOAST classification. Age-matched normal persons, who did not experience an ischemic stroke especially, were recruited as healthy control (n=10). Serum samples were taken immediately after admission (within 24 h of stroke onset) to evaluated SDF-1a levels. At admission and after 3 months, NIHSS scores and modified Rankin scale (mRS) were evaluated for all patients. Results: Serum SDF-1a level in the acute stage of ischemic stroke was significantly increased as compared with control and was proportioned to infarct volume. The increase in serum SDF-1a level in the acute stage was well correlated with an improvement of NIHSS score and mRS after 3 months and the significance still remained after adjustment for covariates, especially infarct volume. Conclusion: These results show 1) that SDF-1a increases in patients with acute ischemic stroke as well as in vivo animal model for ischemic stroke, 2) that its level increases in an infarct volume-dependent manner, and 3) that a significant correlation exists between serum SDF-1a level in the acute stage and the long-term prognosis of ischemic stroke.

P389 Risk factor profile of patients with stroke, north-eastern Nigeria M.M. Watila, Y.W. Nyandaiti, S.A. Bwala, I. Abdullahi, S. Balarabe, I.D. Gezawa, A. Tahir University of Maiduguri Teaching Hospital (Maiduguri, NG); Federal Medical Centre (Azare, NG); Usman Danfodio University Teaching Hospital (Sokoto, NG) Objective: Various factors have been outlined as aetiologic factors associated with ischaemic stroke. Studies conducted in many parts of the world have shown that hypertension is the most important risk factor. Methods: A total of 376 patients were seen during the period at the emergency department or neurology clinic. Risk factors were evaluated and clinical examination were conducted, necessary investigations were done to assess risk factors. Results: There were 237(63%) males and 139 females(37%), a M:F ratio of 1: 1.7. Hypertension is the commonest risk factor, present in 321(85.4%), 49(15.3%) of these patients had no prior knowledge of being hypertensive, but presented with hypertension or features of hypertensive heart disease, and only about 24(7.5%) of patients who had prior knowledge of being hypertensive were compliant to antihypertensive medications. Past history of stroke was found in 45(12%) of individuals, significant alcohol intake in 41(10.9%), Diabetes mellitus in 34(9%) of individuals, Transient Ischaemic Attack (TIA) in 21(5.6%), smoking in 21(5.6%). Seven(1.9%) of our patient had HIV/AIDS as the only risk factor, 6(1.6%) presented with atrial fibrillation, Heart failure in 2(0.5%), Peripartum eclampsia in 2(0.5%), Chronic kidney disease 2(0.5%), Myocardial infarction 1(0.3%), Antiphospholipid antibody syndrome in 1(0.3%), Nephrotic syndrome in 1(%). Of the total number of patients, 92(24.5%) had more than one risk factor, with the commonest combinations being Hypertension and alcohol intake 23(6.1%), Hypertension and Diabetes 21(5.6%) and Hypertension, TIA and smoking in 15(4.0%). 12(3.2 %) had no discernable risk factor and half of these patients were young (\45yrs). Conclusion: We found that Hypertension is the commonest risk factor, and most hypertensives were not compliant with antihypertensive medications.

P390 Emptying velocity of left atrial appendage measured by transoesophageal echocardiography is the sole predictor of intracardiac thrombus as the embolic source of cerebral infarction N. Mitsuma, K. Kawabata, S. Yamada, S. Yokoi, K. Oyama, T. Mano, A. Araki, N. Nakai, K. Yasui, Y. Hasegawa Daini Red Cross Hospital (Nagoya, JP) Objectives: Transesophageal echocardiography (TEE) is useful in detecting intracardiac thrombus that causes cardiogenic embolism when combined with transthoracic echocardiography (TTE). Dysfunction of left atrium (LA) or left atrial appendage (LAA) observed by TTE and TEE is known to relate to formation of intracardiac thrombus. Nevertheless it is difficult to make definite diagnosis if no intracardiac thrombus is found in LA or LAA. We investigated the contribution of echocardiographically measured value by TTE and TEE to detect or predict existence of intracardiac thrombus as the embolic source of cerebral infarction. Methods: Out of 188 patient hospitalized and received TTE and TEE in Nagoya Daini Red Cross Hospital from January 2006 to December 2009, we extracted four groups of patients; definite cardiogenic embolism patients with atrial fibrillation (Af) or paroxysmal atrial fibrillation (pAf), suspected cardiogenic embolism patients without Af/pAf, arteriosclerotic infarction patients with Af/pAf, and arteriosclerotic infarction patients without Af/pAf. Diagnosis and echocardiographic findings were confirmed by specialized neurologists and cardiologists. Measured values in TTE and TEE that relate to function of LA or LAA (ejection fraction, early filling/atrial filling of left ventricle, LA diameter, LAA diameter, emptying velocity of LAA, etc.) were statistically compared and analyzed between four groups and were evaluated for contribution of detecting cardiogenic embolism patients. Results: Emptying velocity of LAA was classified into two groups. Cardiogenic embolism patients (definite and suspected) tended to have lower emptying velocity, thus belonging to the lower velocity group with statistical difference compared to arteriosclerotic patients that tended to belong to the higher velocity group. Other measured values did not have clear statistical difference between groups nor had independent correlation with cardiogenic embolism. Conclusion: Emptying velocity of LAA is easily measured using TEE and is the sole predictor of intracardiac thrombus as the embolic source of cerebral infarction.

Dementia/Higher function disorders: dementia P391 FUS/TLS genetic variability in sporadic frontotemporal lobar degeneration D. Galimberti, C. Cantoni, C. Fenoglio, F. Cortini, E. Venturelli, C. Villa, F. Clerici, A. Marcone, L. Benussi, R. Ghidoni, S. Gallone, D. Scalabrini, M. Franceschi, S. Cappa, G. Binetti, C. Mariani, I. Rainero, M.T. Giordana, N. Bresolin, E. Scarpini University of Milan (Milan, IT); San Raffaele Turro Hospital (Milan, IT); IRCCS ‘‘Centro S.Giovanni di Dio-FBF (Brescia, IT); University of Turin (Turin, IT); Casa di Cura Santa Maria di Castellanza (Varese, IT); Centro S.Giovanni di Dio-FBF (Brescia, IT) Objective: To test genetic variability in the fused in sarcoma/translated in liposarcoma gene (FUS/TLS) for association with Frontotemporal Lobar Degeneration (FTLD).

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S126 Background: Recently, mutations in the FUS/TLS gene have been shown to be one of the cause of familial Amiothrophic Lateral Sclerosis (ALS). The FUS/TLS protein is 526 amino acids long and is encoded by 15 exons. It is a multifunctional protein, implicated in several steps of gene expression regulation including transcription, RNA splicing and transport, translation. Due to the well known similarities between FTD and ALS covering genetic, clinical and pathological aspects a role of FUS in FTLD could be conceivable. Methods: Two hundred and fifty one Italian patients with sporadic FTLD and 259 age-matched controls were tested for association with the tagging Single Nucleotide Polymorphisms (SNPs) rs741810 and rs1052352. Haploview 3.1 software was used to test for association. Results: Considering each SNP alone, no differences in either allelic or genotypic frequencies between patients and controls were found (P[0.05), even stratifying according to gender or the presence of concomitant Motor Neuron Disease. Haplotype analysis failed to detect haplotypes associated with FTLD. Conclusions: According to these results, FUS/TLS does not act a susceptibility factor for the development of sporadic FTLD. Nevertheless, a confirmatory analysis is needed to conform these preliminary results.

P392 Substitute decision-making for dementia patients without decision-making capacity R.J. Jox, E. Denke, R. Mendel, J. Hamann, H. Fo¨rstl, G.D. Borasio Munich University Hospital (Munich, DE); Technical University Munich (Munich, DE) Aims: In many central nervous system diseases, we face the ethical problem of patients losing their decision-making capacity. Advance directives are rarely present or sufficient to guide medical decisions. Therefore, substitute decision-making by relatives or professional guardians is routine. Empirical studies have questioned the ability of these decision-makers to represent the patient’s actual will. Therefore the questions emerge: How do they make their decisions, which considerations are decisive and are there differences between relatives and guardians? Methods: We perfomed a qualitative study using the Think Aloud Method which allows real-time insights into cognitive processes. We addressed 15 relatives and 15 non-relative guardians, experienced in deciding for dementia patients. They were given two hypothetical case vignettes and had to decide about (1) a feeding tube placement and (b) a pacemaker operation in end-stage dementia patients. During the task of decision they had to verbalize their thoughts. This was tape-recorded and analysed according to protocol analysis. Results: A majority of participants decided rather instinctively just after having read the cases and afterwards reflected on the reasons for their decision. Only a few pondered the arguments before reaching a decision. In both vignettes, the participants were not concordant in their decisions although there was a tendency towards treatment limitation. The relatives more often objected to the proposed treatment, while the non-relative guardians were more often prepared to give their consent. The non-relative guardians placed more weight on the physicians’ recommendations and focused more on the patient’s well-being. The relatives, on the other hand, were more heavily relying on the patients’ earlier statements and presumptive wishes. Conclusion: Substitute decision-makers have different decisionmaking strategies, focus on different factors and come to divergent results. Relatives tend to be more autonomy-oriented than professional guardians.

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P393 How are the interests of incapacitated research participants protected through legislation? An Italian study on legal agency for dementia patients S. Gainotti, S. Fusari Imperatori, S. Spila Alegiani, L. Maggiore, N. Vanacore, C. Petrini, R. Raschetti, C. Mariani, F. Clerici National Institute of Health (Rome, IT); University of Milan (Milan, IT) Objectives: In Italy incapacited patients with dementia may participate in research only if the informed consent has been obtained by a legal representative, including the power of attorney (PoA), who is appointed by the courts (law 6/2004). This study is aimed to evaluate the timing for appointment of a PoA in Italy and to identify the predictive variables of appointment. Methods: Between July 2007 and September 2009 all consecutive patients diagnosed with dementia at the ‘‘Luigi Sacco’’ Hospital (Milan, Italy) and their caregivers were included in the study and were provided information on the law 6/2004. At each scheduled check-up we gathered information on the time interval passing between the presentation of the law to the patient, the registration of the application for appointment of the PoA at the law court chancellery and the sentence of appointment of the PoA. Results: The study involved 172 demented patients, 3 of which had already appointed a PoA. Seventy-eight patients (46.2%) out of 169 applied for appointment. Nearly two months passed between the presentation of the law and the patient’s registration of the application to the law court chancellery (median time 57 days). Fifty-five applications (70.5%) out of 78 ended up with appointment of the PoA. An average time of four months passed between registration of the application and the sentence of appointment (median time 121 days). The PoA was a relative in the quasi totality of cases. The subjects who started up the procedure of appointment had been suffering from dementia for a longer time (2.3±2.2 versus 1.6±1.8 yrs; p=0.02) than those who did not start up the procedure. Also, the multivariate analysis showed that the patients who started up the procedure of appointment were younger (\80 yrs versus C 80 yrs, OR 2.40; 95% CI 1.03–5.53) and made more use of memantine (OR 4.93; 95% CI 1.01–24.12). Conclusion: In Italy the requirement that the legal representative is appointed by the courts may impede a subject’s participation in clinical research, as relatives may find it difficult to carry on the procedure of appointment. We can hypothesise that, due to the complexity of the procedure of appointment of the PoA, only some ‘‘privileged’’ categories of patients succeed in achieving it. The system which is actually in place in Italy does seem far from effective in balancing the needs of protection of subjects with dementia and the need of rapid times for subject’s enrolment in clinical research. This study was supported by the "Associazione per la Ricerca sulle Demenze - ARD ONLUS") and by the Italian Medicines Agency (AIFA) contract no. FARM68SY5C". Funders had no role in study design, data collection and analysis or preparation of the abstract

P394 The metabolic syndrome and development of cognitive impairment in patients with cerebrovascular disorders C. Tiu, E. Terecoasa, A. Roceanu, C. Gavan, S. Ioacara, O. Bajenaru University Hospital Bucharest (Bucharest, RO); Institute N. Paulescu (Bucharest, RO) Background: The metabolic syndrome, a constellation of metabolic abnormalities that confer increased risk of vascular disease, is a

S127 frequent finding among persons with acute ischemic stroke and other cerebrovascular disorders. Our objective was to investigate the prevalence of metabolic syndrome amongst Romanian patients with cerebrovascular disorders and the possible relationship between metabolic syndrome and cognitive impairment. Methods: We performed this cross-sectional study on 247 patients consecutively hospitalized for acute ischemic stroke and other cerebrovascular disorders. Patients were assessed for metabolic syndrome using ATP III criteria and for cognitive impairment using The Mini Mental State Examination (MMSE). We considered two cut-off points for cognitive impairment (MMSE 27 and MMSE 24). Results: We divided the 247 patients in two groups: Group Onewith metabolic syndrome (106 patients, 43%) and Group Two-without metabolic syndrome (141 patients, 57%). The mean MMSE score was 24,5 in Group One and 23,2 in Group Two, with a t-test statistically significant (p=0,04); The number of patients with a MMSE score \/= 27 was 86 in Group One and 80 in Group Two and this correlates with an OR of 3,27 (95%CI; 1,81-5,9; p value=0,00006284). The number of patients with a MMSE score \/ =24 was 55 in Group One and 49 in Group Two and this correlates with an OR of 2,024 (95%CI; 1,209–3,389; p value=0,0091). Using logistic regression we also assesed the influence of the ischemic stroke upon cognitive impairment. Conclusion: We found a statistically significant association between the metabolic syndrome and the presence of cognitive impairment. Patients with metabolic syndrome have three-fold greater chance to have a MMSE under 28 and a two-fold greater chance to have a MMSE under 25, comparing with patients without metabolic syndrome independent of the associated cerebrovascular disease. Although mild cognitive impairment does not include MMSE score for definition, patients with metabolic syndrome should be evaluated systematically for cognitive function, considering that early diagnosis and adequate treatment of cognitive impairment can improve the prognosis.

P395 Corticobasal syndrome as initial presentation of sporadic Creutzfeldt-Jakob disease S. Costa, A. Timoteo, J. Pimentel, A. Herrero Hospital Professor Doutor Fernando Fonseca EPE (Amadora, PT); Hospital Santa Maria (Lisbon, PT) Background: Corticobasal Syndrome (CBS) encompasses different entities such as Alzheimer disease, sporadic Creutzfeldt-Jacob disease (CJD) and Corticobasal Degeneration (CBD). Symptoms at early stages can be similar. Some procedures as neuroimaging are helpful to distinguish them. Case report: A 74-year-old female with hypertension, dyslipidemia and right mastectomy for malignancy 22 years ago; had an acute onset one month before of speech and walk abnormalities. On admission she presented with low verbal fluency, ideomotor, ideational and oculomotor apraxia, cortical sensory loss, dystonic posture of both hands, apraxic gait and wayward right hand phenomena. MRI showed bilateral high-signal-intensity abnormalities in the diffusionweighted images, in occipital-temporal cortex bilaterally. EEG and routine laboratory parameters were normal. A lumbar puncture was performed with cytochemical and serological results normal or negative. There was a progressive neurological impairment in a month with total mutism, disphagia and generalised myoclonus. Then EEG showed periodic sharp wave complexes. The 14-3-3 LCR protein determination was positive with no PRNP mutation. Two Months later, the patient died. Post mortem examination showed: extensive spongiform change and neuronal loss on cerebral cortex (mainly occipital), cerebellum and basal ganglia, with diffuse PrP staining in a synaptic pattern (3F4).

Conclusions: This case confirms the CBS clinical heterogeneity. Neuroimaging can be an useful tool at early stages for differential diagnosis, especially some procedures as diffusion-weighted images.

P396 A case of variant Creutzfeldt-Jakob disease in Cantabria, Spain P. Sa´nchez-Juan, I. Gonza´lez-Aramburu, E. Rueda, A.B. Rodriguez, E. Rodriguez Rodriguez, J. FernandezTorre, R. Carpizo, N. Villagra, E. Marco, O. Combarros, J. Figols, M. Gala´n, C. Navarro, R. Juste, J. Berciano, J. Polo University Hospital Marque´s de Valdecilla (Santander, ES); Institute Neiker (Bilbao, ES); Health Council (Santander, ES); Hospital of Meixoeiro (Vigo, ES) Objectives: To describe the fifth Spanish case of variant CreutzfeldtJakob disease (vCJD). Methods: Case report of a patient attended by our Neurology Service during 2008 and 2009. Results: The patient was a 48 years old female, from Santander (North Spain), who was first seen in our Unit on April 2008 due to a nine months history of behavioral disturbances (anxiety, insomnia, phobias and obsessions) that did not respond to conventional treatments. In the previous three months she also had developed progressive cognitive impairment and gait ataxia. The initial MRI showed images that were compatible with a pulvinar sign. The EEG was normal, and the CSF 14-3-3 protein test was negative. Variant CJD diagnosis was suspected, and compassionate treatment with doxycycline was administered to the patient showing no significant improvement. During the following months the patient’s neurological status worsened rapidly until a state of akinetic mutism. On August 2008 she developed generalized myoclonus, fulfilling clinical diagnostic criteria for probable vCJD. Four months later the pulvinar sign persisted in a subsequent MRI, along with cortical hyper-signal in the right occipital lobe. The EEG showed at this terminal stage of the disease pseudo-periodical activity. The patient died in January 2009. The diagnosis of vCJD was confirmed by post mortem neuropathological examination and with the detection in brain tissue of the type 2B prion protein strain. An epidemiological survey was unable to determine any risk factor or predisposing circumstance. Conclusion: The phenotype of our patient was similar to that reported in the literature. The recognition of the pulvinar sign on the MRI scan was capital for the early diagnosis.

P397 Headache prevalence in an outpatient cognitive impaired elderly group. A preliminary survey G. Pavan, B. Colombo, G. Magnani, D. Dalla Libera, D. De Feo, V. Martinelli, G. Comi San Raffaele Hospital (Milan, IT) Objectives: To assess the prevalence of tension-type headache, migraine, and other headache subtypes (according to IHS classification) in an elderly cohort of patients affected by cognitive impairment who consecutively referred to the Memory Disorders Centre of our hospital in a 2 months observational period. Methods: We considered a group of patients (n=100) affected by memory disorders such as Alzheimer’s Disease (AD), Frontotemporal Dementia (FTD), Levy Body Disease (LBD), Mild Cognitive Impairment (MCI), Vascular Dementia and others (by an interview). A standardised headache questionnaire was submitted, with support

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S128 of caregivers. A complete clinical evaluation was performed by an expert neurologist. Secondary headache was ruled out. Headache diagnosis was done according to the classification of the International Headache Society. We considered as a control group a cohort of healthy elderly subject (mean age 76 years) evaluated in our centre and published in a previous study. Results: A group of 100 patients was studied (60% women; mean age: 78 years). 79 patients were affected by AD, 2 by FTD, 6 by MCI, 1 by LBD and the others by vascular dementia. Seventy-two patients didn’t report headache (controls: 76%). Fourteen subjects (4 men and 10 women) had troublesome headache in their past (before diagnosis of cognitive impairment) and tensive headache was more prevalent (71% vs. controls: 23%) than migraine (29% vs controls:19%). Six patients went on suffering from headache also after the diagnosis of cognitive impairment. Eight subjects (women: 62%) reported, after the diagnosis of memory disorder, a de novo tensive-headache (AD=6, vascular dementia=2); 2 of them reported headache related to rivastigmine treatment. They presented with tension-type headache of mild-moderate intensity, and a variable headache occurrence. They were successfully treated with NSAIDs. Conclusions: Our study suggests that the prevalence of headache in elderly patients affected by memory disorders is similar to the prevalence we found in a comparable healthy control group. We can hypotize that degenerative disorders are not responsible for an increase in headache frequency in elderly patients. Correlations of headache with other variables in elderly people (hypertension, diabetes, cardiological and pneumological diseases, mood disorders) are discussed.

P398 Bilateral perisylvian polimicrogyria, normal cognitive functions in a profound modified brain – a clinical and imaging case-study M. Lauterbach, G. Leal, I. Martins University of Lisbon (Lisbon, PT); Hospital Santa Maria (Lisbon, PT) Objectives: Polymicrogyria is a malformation of cortical development in which the brain surface is irregular and the normal gyral pattern is replaced by multiple small, partly fused gyri separated by shallow sulci. The typical clinical syndrome shows mild mental retardation, epilepsy and pseudobulbar palsy. A case of bilateral perisylvian polimicrogyria (BPP) is presented by its clinical, neuropsychological and imaging features. Methods: A woman suffered a marked verbal communication disorder (SLI) and a oropharyngeal dysphagia from early childhood. At 54 years old she undertook a detailed clinical and neuropsychological examination as well as a structural (T1,T2 and DTI) and functional MRI (motor and language paradigms) brain imaging and EEG. Her neuropsychological data was compared to an age and education matched control group. Results: The patient presented a moderate dysarthria; she had no voluntary control over her tongue and showed subtle motor signs in fine finger movements of both hands. In the neuropsychological testing she performed within normal range in all tests. EEG was normal. Structural MRI shows an abnormal gyral folding with predominance in the perisylvian region. Activation of hand motor area was in a typical prefrontal localization. Language was clearly lateralized into the left hemisphere. The DTI data showed a rarefaction of the fibres of the two anterior parts of the posterior arm of the internal capsule that contains the cortico-bulbar and cortico-spinal fibres of the mouth and arm. Conclusion: Although there were profound modifications of the anatomical structure in cortical folding and thickness, this patient had normal cognitive functions, apart from expressive language function, and normal social competence. Functional areas appear in the expected localizations. Only the disturbance of the ‘‘hard wired’’ cortico-bulbar

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and in less extent the cortico-spinal tracks seem to cause the clinic symptoms described above. The rarefaction of fibres observed in DTI suggests it to be the morphological correlate of these symptoms. This case questions the relationship between structure and function and calls attention for a careful interpretation of morphometric studies. This study was supported by FCT grant PTDC/PSI/74294/2006

P399 Efficacy of citicoline in the treatment of patients with vascular cognitive impairment O. Kopchak Central Hospital of Ministry of Internal Affairs (Kiev, UA) Objectives: Prevention and treatment of vascular cognitive impairment (VCI) in the elderly patients has assumed increasing importance in an aging population. Modern strategies of treatment of cognitive decline include drugs correcting the cholinergic deficit (tacrine, donepezil, rivastigmine, and galantamine), medications that targets NMDA receptors, such as memantine and putative nootropic agents (piracetam). Usage of drugs with neuroprotective effects should be one of the most effective trends for prevention and treatment of VCI. Citicoline is one of such agents that stimulates cholinergic processes and improves functions of brain synapses. The aim of the study was to elucidate efficacy of citicoline in the treatment of patients with VCI. Methods: There were 76 patients with VCI (42 men and 34 women with mean age 57,8±9,8 years) enrolled into the study. Diagnostic evaluation included medical history, physical and neurological examination, magnetic resonance imaging of the brain. Cognitive function was assessed by Mini-Mental State Examination (MMSE). The Paired Associates Learning Test (PALT) was used to asses immidiate and delayed memory for verbal stimuli. Depending on the treatment all the patients were devided into two groups: main and control. In patients of the main group citicoline was administered additionally to the main treatment. In the second group patients received only traditional treatment for VCI (piracetam). Results: Treatment of the patients with VCI with citicoline led to more significant improvement of cognitive functions, the total MMSE score in the main group increased from 23,8±2,5 to 25,2±2,2 (ð\0,05). In the control group total MMSE score did not change significantly after treatment (from 24,4±2,1 to 24,7±2,1, ð[0,05). After use of citicoline in the main group was observed significant improvement of immediate (from 40,3±1,4 to 48,8±1,7, ð\0,001) and delayed memory (from 21,3±0,75 to 25,2±0,8, ð\0,001) according to PALT data. Treatment of the control group patients with piracetam did not led to significant improvement of immediate (from 44,0±0,98 to 44,8±1,6, ð[0,05) and delayed memory (from 22,9±0,46 to 23,1±0,7, ð[0,05) according to PALT data. Conclusion: Treatment protocols with citicoline as a neuroprotector could be recommended in patients with VCI for improvement of their cognitive functions. Our investigation was conducted with Somazina (citicoline) and supported by Ferrer Internacional S.A.

P400 Apparent diffusion coefficient in the study of normal pressure hydrocephalus P. Caroppo, F.D’Agata, M. Caglio, L. Rizzi, M. Croce, P. Pacca, M. Fontanella, F. Ferrio, M. Coriasco, G.B. Bradac, P. Mortara University of Turin (Turin, IT) Objective: The Normal Pressure Hydrocephalus (NPH) is a pathology of the elderly characterized by the presence of cognitive deficits, motor impairment and urinary incontinence. Recently the role of MRI

S129 in the selection of patients responders to the surgical intervention has been highlighted. Particularly an alteration of Apparent Diffusion Coefficient (ADC), a measure of the water content in brain regions of interest, has been correlated to the shunt outcome [1], supporting the hypothesis that one of the most important cause of clinical features of the pathology is related to the brain water accumulation. Methods: In our study we perform ADC in a group of patients with NPH correlating values with clinical (Tinetti scale, UPDRS, gait analysis, visual and auditory Reaction Time), neuropsychological features (MMSE, Frontal Assessment Battery, Weigl’s test, CPM, Verbal Fluencies, Judgement of Line Orientation, Short Story, Paired Words Association, Digit Span, Rey’s Figure, Visual Memory,), psychological aspects (depression, anxiety, quality of life, apathy) and the outcome after the tap-test. Results: We found an almost similar profile of ADC in patients that respond to the tap-test and controls. Patients that not respond have a value that is higher indicating a irreversible zone of degeneration. The values of ADC correlates with some neuropsychological performance and psychological characteristics. Conclusion: ADC could be used to select patients for surgery, excluding cases this irreversible damage or with severe cerebrovascular disease and as a marker of progression of cognitive and motor deficits in the follow-up. This study could support the fact that water accumulation is the most important factor related to the clinical features of patients. We presume that the use of specific therapy can reduce the water accumulation in special cases. 1. Corkill RG, Garnett MR, Blamire AM, Rajagopalan B, CadouxHudson TA, Styles P. Multi-modal MRI in normal pressure hydrocephalus identifies pre-operative haemodynamic and diffusion coefficient changes in normal appearing white matter correlating with surgical outcome. Clin Neurol Neurosurg. 2003 Jul;105(3):193-202.

P401 Subcortical focal encephalopathy in a patient with Hashimoto’s thyroiditis F. Fincke, R. Witte, G. Schittko, A. Engelhardt Evangelic Hospital Oldenburg (Oldenburg, DE) Objectives: Hashimoto’s encephalopathy is a rare neuroendocrinological disease associated with high serum antithyroid antibody concentrations. The most common clinical features include cognitive impairment, myoclonus and epileptic seizures besides a broad range of other symptoms. The central pathological event is yet unknown whether a direct anti-neural-antibody effect is currently discussed. There does not appear to be a connection between encephalitic features and thyroid function since most patients are euthyroid at onset of clinical symptoms. Methods: A 52-year-old woman presented with progressive cognitive impairment, ideomotoric apraxia and tremor in both hands. No additional neurological deficits were observed. Onset of symptoms dates back 6 months to admission. Except for a treated hypothyroidism history revealed no prior illness. Family history for dementia was negative. Diagnostic tests including MRI, CSF, EEG, HMPAOSPECT and blood tests were performed. Results: Serology revealed an elevated titer of anti-thyroid peroxidase antibody. MRI-scan showed no abnormality. EEG showed a focal slowing in the left temporal and parietal lobe. HMPAO-SPECT revealed an extensive hypoperfusion in the left parietal lobe and basal ganglia. CSF analysis showed no evidence for infectious activity, cell count and protein levels were within normal range. Further diagnostic tests showed no signs of an underlying neoplasia. Test results for antiHu, anti-Yo, anti-Ri–antibodies were negative. The patient was diagnosed Hashimoto’s encephalopathy and treated with corticosteroids. According to our knowledge patients symptoms gradually improved 3 months after start of treatment.

Conclusions: The case demonstrates that Hashimoto’s encephalopathy is a potential cause for encephalopathy even when lesion pattern appears to be of focal origin. Additional tests should be performed to rule out other causes. Therefore in patients presenting with otherwise unexplained encephalopathic symptoms of acute/ subacute onset Hashimoto’s encephalopathy should be taken into account. Especially, since it is a potentially treatable cause for encephalopathy.

P402 Chromosome 9 and sporadic Frontotemporal Lobar Degeneration: KIF24, but not UBAP1, is a risk factor in Italian population D. Galimberti, E. Venturelli, C. Villa, C. Fenoglio, F. Clerici, A. Marcone, L. Benussi, R. Ghidoni, S. Gallone, D. Scalabrini, F. Cortini, S. Cappa, G. Binetti, M. Franceschi, I. Rainero, M.T. Giordana, C. Mariani, N. Bresolin, E. Scarpini University of Milan (Milan, IT); San Raffaele Turro Hospital (Milan, IT); IRCCS Centro S.Giovanni di Dio-FBF (Brescia, IT); University of Turin (Turin, IT); Casa di Cura Santa Maria di Castellanza (Varese, IT) Background: Linkage analysis identified a region on chromosome 9p associated with Frontotemporal Lobar Degeneration (FTLD). A detailed analysis of candidate genes lying in this region demonstrated an association with Ubiquitin Associated Protein (UBAP)1. Subjects and methods: The distribution of three Single Nucleotide Polymorphism (SNPs) located in the chromosome 9 haplotype identified via linkage analysis, including UBAP1 rs7018487, KIF24 rs17350674 and rs10814083, has been determined in a population of 284 patients diagnosed with FTLD, including 245 with behavioural variant Frontotemporal dementia (bvFTD), 23 with Progressive Aphasia and 16 with Semantic Dementia, compared with 318 age-matched controls. Results: A statistically significant increased frequency of the KIF24 rs17350674 AA genotype was observed in patients compared with controls (7.4 versus 2.5%; P=0.0068, OR: 3.63, CI: 1.58-8.35). Considering each syndrome separately, similar results where obtained in bvFTD versus controls (7.7 versus 2.5%, P=0.005, OR: 3.26, CI: 1.40-7.57). Stratifying for gender, a statistically significant increased genotypic frequency was observed in female patients as compared with female controls (8.9 versus 2.5%, P=0.008, OR: 3.85, CI: 1.3610.93). In-silico analysis predicted that the substitution from W to L caused by the rs17350674 affects protein function (P\0.05). Conclusions: The KIF24 rs17350674 polymorphism likely acts as a risk factor for sporadic FTLD, but a replication study would be needed to confirm these preliminary findings.

Neuro-imaging P403 Pathological correlates of MRI-detected normal whitematter damage in multiple sclerosis N. Moll, A.M. Rietsch, S. Thomas, A.J. Ransohoff, J.-C. Lee, R. Fox, A. Chang, R.M. Ransohoff, E. Fisher University Pierre et Marie Curie (Paris, FR); Lerner Research Institute (Cleveland, US) MTR abnormality has been noticed in normal-appearing white matter (NAWM) in multiple sclerosis (MS) and correlated with clinical

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S130 course and disability in MS patients. However, pathological substrates of MTR abnormality in MS NAWM have not been yet defined. Objective: Our study was aimed to determine the pathologic basis of MTR changes in NAWM in MS. Material and methods: Brain tissues from four patients with secondary progressive MS were obtained through a rapid post-mortem protocol that included in situ MRI. Image characteristics were used to guide tissue sampling. Four types of MRI-defined regions of interest (ROIs) were identified: (1) T2T1MTR lesions, defined as regions that were abnormal on T2, T1, and MTR images; (2) NAWM regions with slightly-abnormal MTR that were close to lesions (sa-WM Close); (3) NAWM regions with slightly-abnormal MTR that were far from lesions (sa-WM Far); and (4) NAWM regions with normal MTR that were far from lesions (NAWM). Immunohistochemical analysis was performed for each ROI and comprised of immunostaining for myelin, axonal markers, activated microglia/macrophages, astrocytes, serum protein and blood vessels. Results: In total, forty-eight ROIs from four MS brains were analyzed. Myelin density was significantly lower in T2T1MTR lesions but there were no detectable differences in myelin density across the nonlesional ROIs. Sa-WM Close ROIs were associated with significantly elevated numbers of axonal swellings. Increased numbers of activated MHCII(+) microglia and macrophages were detected in sa-WM Far as well as sa-WM Close and T2T1MTR lesions. Sa-WM ROIs were often adjacent to demyelinating cortical lesions. There were no significant changes in GLUT-1 blood vessel numbers or serum IgG deposition in the studied MS ROIs. Astrocyte numbers did not differ significantly between sa-WM ROIs and NAWM. Conclusions: The pathologic substrate for MTR abnormality in NAWM of MS brains varies based on distance from focal WM lesions. In regions close to WM lesions, axonal pathology and microglial activation may explain slightly-abnormal MTR. In regions distant from lesions, profound microglial activation associated with proximity to cortical lesions might underlie decreased MTR. This study was supported by the National Institute of Health, National Institute of Neurological Disorders and Stroke, P50 NS 38667.

P404 Atypical idiopathic inflammatory demyelinating lesions – a prospective registry in the MAGNIMS group M. Wallner-Blazek, A. Rovira, D. Miller, M. Filippi, A. Gass, J. Fredrickson, J. Flores, H. Gama, F. Fazekas Medical University Graz (Graz, AT); Hospitals Vall d0 Hebron (Barcelona, ES); University College London (London, UK); University of Milan (Milan, IT); University of Basel (Basel, CH); University of Copenhagen (Copenhagen, DK); National Institute of Neurology (Mexico City, MX); Santa Casa de Misericordia de Sao Paulo (Sao Paulo, BR) Introduction: Atypical idiopathic inflammatory demyelinating lesions (AIIDL) have been repeatedly described in the literature. In an earlier work of the MAGNIMS group (1) four possibly distinct types of AIIDLs were identified which we termed megacystic, infiltrative, Balo-like and ring-like. The goals of our study were to see if we can categorize AIIDLs observed in MAGNIMS centers according to suggested description and to analyze the clinical and imaging course associated with these lesions. Methdods: We collected 90 patients of MAGNIMS centres and of two MS centres in South America aged 18 years or older with C1 AIIDL. These lesions were categorized according to above charac-

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teristics and we counted the number of atypical and MS typical lesions on baseline and follow-up MRI blinded to clinical information. In a separate step we tabulated the clinical condition at baseline at follow-up with special emphasis on further relapses. Disability was recorded with the EDSS. Results: There were 61 female and 29 male patients. Their age at presentation with an AIIDL ranged from 19 to 62 years (mean 35years). 35 patients fulfilled characteristics of the infiltrative, 16 of the megacystic, 16 of the ring-like and 10 of the Balo-like lesion type. Six cases were considered as non-specific and four cases had an intermediate morphologic appearance. 40 patients also showed MS typical lesions at presentation. Follow up MRIs were obtained in 68 patients with a median follow-up time of 3,5 years. New atypical lesions were found in 6 cases (3 infiltrative, 2 Balo-like and 1 ring-like). New MS typical lesions were detected in 21 cases - mostly in the infiltrative and ring like subtype. Relapses were observed in 25 patients with most of them in the ring like subtype (61%). The best clinical outcome was seen with the Balo-like subtype, a worse outcome was more frequently seen in the infiltrative subtype. Conclusions: From this analysis of a new collection of AIIDLs suggested classification in 4 major lesion types appears feasible. Ring-like lesions appear closest to typical MS as indicated by the highest proportion of associated MS like lesions and subsequent relapses. Furthermore AIIDLs need not indicate a bad prognosis. Interestingly the best outcome in this cohort was observed for the Balo-like subgroup especially in the presence of additional MS typical lesions at presentation.

P405 Early MRI activity during interferon b-1a therapy predicts disease activity at 5 years in patients at high risk for developing clinically definite Multiple Sclerosis R. Hyde, R. Kinkel, A. Pace, J. Simon, P.O’Connor on behalf of the CHAMPIONS Study Group Objective: Recent analyses have shown that the number of new T2 or gadolinium-enhancing (Gd+) lesions on an MRI scan 6 months after beginning intramuscular interferon (IM IFN) b-1a treatment can predict conversion to clinically definite multiple sclerosis (CDMS) over 3 years. The objective of this study was to determine whether MRI activity 6 months after initiating treatment with IM IFN b-1a predicts disease activity at 5 years in the CHAMPIONS open-label extension study of CHAMPS. Methods: In CHAMPS, a randomised, double-blind, placebo-controlled, phase 3 clinical study, patients with a first demyelinating event and cranial MRI evidence of subclinical demyelination were treated with either IM IFN b-1a 30 mcg (n=193) or placebo (n=190) once weekly for up to 36 months. All patients who did not experience a relapse consistent with CDMS underwent MRI scans 6, 12, and 18 months after randomisation. Fifty-three percent of patients from CHAMPS (203/383) enrolled in the CHAMPIONS 5-year extension study. Results: Of the 91 patients who received immediate treatment with IM IFN b-1a in CHAMPIONS and underwent an MRI scan 6 months after initiating treatment, 29.7% had lesion activity (C2 new T2 or Gd+ lesions) suggesting a suboptimal response to treatment. In these patients, the risk of developing CDMS by year 5 was significantly higher compared with patients with \2 new T2 and Gd+ lesions at month 6 (hazard ratio: 5.26; 95% confidence interval: 2.69, 10.26; P\0.0001). Patients with \2 new T2 and Gd+ lesions at

S131 6 months had significantly lower Expanded Disability Status Scale (EDSS) scores at 5 years compared with those with C2 new T2 or Gd+ lesions (mean EDSS score: 0.9±0.93 vs. 2.2 ±1.65; P=0.0002). Patients with \2 new T2 and Gd+ lesions were significantly more likely to have an EDSS score \=2.0 than those with C2 new T2 or Gd+ lesions (93.5% vs. 73.1%; P=0.0135). Patients with \2 new T2 and Gd+ lesions had significantly fewer confirmed relapses (0.4 ±0.72) compared with patients with C2 new T2 or Gd+ lesions (1.8 ±1.72, P\0.0001). In addition, patients with C2 new T2 or Gd+ lesions were less likely to have stable disease between year 4 and 5 compared with patients with \2 new T2 and Gd+ lesions (57.7% vs. 88.7%; P=0.0013). Conclusions: MRI lesion activity 6 months after initiating treatment with IM IFN b-1a is a predictor of disease activity, EDSS status, and conversion to CDMS at 5 years. This study was supported by Biogen Idec, Inc.

P406 Periaqueductal lesions in multiple sclerosis A. Papadopoulou, O. Yaldizli, M. Amann, J. Hirsch, Y. Naegelin, E.W. Radue, L. Kappos, A. Gass University Hospital of Basel (Basel, CH); University of Bremen (Bremen, DE); Medical Image Analysis Centre (Basel, CH) Background: The aqueduct of Sylvius is a small channel (1.5-1.8 cm in length, 1-2 mm in width) that traverses the midbrain connecting the third and fourth ventricle. The periaqueductal (PA) tissue consists of grey matter implicated in pain modulation. Multiple sclerosis (MS)lesions in this area are relatively frequent. We sought to investigate PA lesions further by using a large cohort of MS patients and sensitive Magnetic Resonance (MR) sequences. Methods: In 260 MS patients who participated in a genotype/ phenotype MS study the thin slice Proton Density-weighted (PD-w) axial MR images were analysed. Two experienced readers evaluated the images by consensus. Normal MRI characteristics of the PA area were determined in 11 healthy control subjects. The brainstem/midbrain area was evaluated on 5 consecutive 3mm slices. MS studies were rated as abnormal when an asymmetric hyperintense lesion was identified on a minimum of 2 consecutive slices. In 23 patients with PA lesions depicted on PD-w images further data were acquired with a 3D Double Inversion Recovery (DIR) sequence that shows the highest contrast of grey matter lesions. The DIR images were used to describe the signal presentations and topographical relationship of PA lesions to surrounding structures in further detail. Results: The conservative image review process identified periaqueductal abnormalities in 50 of 260 MS patients (19%) on PD-w images. Multiple logistic regression analysis revealed that total brain T1-hypointense (p=0.002) and T2 hyperintense (p=0.002) lesion volumes correlated with the presence of PA lesions, while gender, age, disease duration, disease course and EDSS did not correlate. Multiplanar analysis of DIR images showed that PA lesions were mainly isolated lesions involving the surrounding grey matter and white matter, in some cases they were extensions of periventricular subependymal lesions of the 3rd ventricle extending towards the aquaeduct and involving the PA grey matter. Conclusions: PA lesions involving the surrounding grey matter and white matter are common in MS and can in some cases be extensions from subependymal periventricular 3rd ventricle lesions rostrally towards the aqueduct. The association with T2w- and T1wlesion volumes indicates that this lesion location belongs to the spectrum of typical MS lesion sites. The DIR sequence is of particular value as it allows to identify such lesions easier due to its strong lesion to grey matter (and white matter) contrast.

P407 The cortical plaques in multiple sclerosis – Correlations between fatigue, physical and cognitive disability S. Petrescu, A. Chirita, P. Ionescu, G. Vanghelie, N. Munjev, C. Panea The Emergency University Elias Hospital (Bucharest, RO); The Unirea Medical Center (Bucharest, RO); The Psychiatric Hospital Professor Doctor Alexandru Obregia (Bucharest, RO) Objectives: For a long time multiple sclerosis was considered a white matter disease, but during last years it had been proved the involvement of gray matter by histological and imaging studies. Our aim was to identify a possible correlation between fatigue, physical and cognitive disability with the number of cortical plaques. Methods: Ten patients diagnosed with relapsing remitting multiple sclerosis have been evaluated by magnetic resonance imaging to asses the cortical plaques by three dimension fluid attenuated inversion recovery sequence. Modified fatigue impact scale (MFIS), paced auditory serial addition test (PASAT) and expanded disability status scale (EDSS) were performed in order to assess fatigue, physical and cognitive disability. Results: In our batch median age was 28.75 years, with female predominance and median EDSS was 2.2. All patients had cortical plaques. It hasn’t been found a statistically significant correlation between EDSS score and cortical plaques number using Kendall method. We obtained a negative correlation between PASAT score and number of cortical plaques (a p value of 0.2- non statistically significant). The MFIS questions related with physical disability correlates with EDSS score but don’t correlate with number of cortical plaques. Conclusion: Our study sustains the relation between cognitive deficits and number of cortical plaques. Physical disability tests were related between them but were not related with cortical plaques number drawing the EDSS limitation in cognitive disability. Our study has had a small amount of patients and this is one of its limits.

P408 Correlation of magnetization transfer ratio and expanded disability status score in relapsingremitting multiple sclerosis patients in Iran E. Rahimian, M. Tahsini, R. Abolfazli Parto Teb Haghighat (Tehan, IR); Tehran Medical University (Tehan, IR) Objectives: Our objective was to measure Magnetization Transfer Ratio (MTR) and normalized T1 signal intensity at Multiple Sclerosis (MS) plaques to find their correlation and evaluate whether they have correlation with Expanded Disability Status Score (EDSS). Methods: A total of 131 white matter lesions seen which was detectable on T2, non contrast T1 weighted and magnetization transfer images were selected in 16 MS patients [ 1 man, age 27 years and 15 women, age 32 ± 8.5 years (mean ± standard deviation)] were evaluated. MR images were obtained on a 1.5 Tesla AVANTO SIEMENS System. T2 Fast spin echo, T1 Fast Inversion Recovery and magnetization transfer imaging with a 2D-FLASH Gradient Echo sequence (550/4.7/30) covering the entire brain at the axial plane,5 mm thickness with a 208 x 320 acquisition matrix were performed. Axial T1-weighted images were used to classify the lesions as hypointense to white matter but hyperintense to gray matter (56 lesions)and hypointense to gray matter (75 lesions).there

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S132 were no lesions isointense to white matter and cerebrospinal fluid. The magnetization transfer ratio of each lesion was calculated, and minimum and average values of magnetization transfer ratio for each subcategory were determined. The patients with cord involvement were excluded and EDSS were enrolled by a well qualified neurologist. Results: We found a good correlation between normalized lesion T1 intensity values with their corresponding magnetization transfer ratios (r= 0.65). The average magnetization transfer ratio for lesions hypointense to white matter but hyperintense to gray matter and hypointense to gray matter was 23.96 ± 3.6 and 19.80 ± 3.81 (mean ± SD) respectively. Also there was a strong correlation between minimum values of magnetization transfer ratio of lesions and EDSS(r=0.76) while weak correlation (r= 0.48) between minimum normalized lesion T1 intensity and EDSS was found. Conclusion: The minimum value of MTR has good correlation with EDSS and seems MRI quantification methods can have predictive values.

P409 High-field proton MR spectroscopy and optical coherence tomography to assess neuroaxonal injury in clinically isolated syndrome, relapsing- remitting multiple sclerosis and secondary progressive MS N. Putzki, O. Yaldizli Kantonsspital St. Gallen (St. Gallen, CH); University Hospital Basel (Basel, CH) Objective: To characterize neuroaxonal pathology in clinically isolated syndrome (CIS), relapsing remitting MS (RRMS) and secondary progressive MS (SPMS) Background: Newer techniques to image neurodegeneration and repair have led to some achievement in linking imaging data and impairment in MS. Proton MR spectroscopy (MRS) allows the characterization of pathological chemical profile in the brain. Optical coherence tomography (OCT) is another non-invasive imaging technique that could increase our understanding of the mechanism of tissue injury in MS. Methods: With use of a 3T MRI system, single voxel 1H-MRS was performed in 22 patients. The voxel was 50 mm left-right, 70 mm antero-posterior and 18 mm craniocaudal angulated parallel to the corpus callosum. Metabolite concentrations of NAA, Cr, Cho and Myo were determined. Retinal nerve fibre layer (RNFL) were assessed with OCT on both optic nerve heads. Correlation analyses were performed with non-parametric Mann-Whitney-U test and rank correlation test (adjusted p-value 0.006; Bonferroni correction). Results: 22 patients (46% female; 8 newly diagnosed, untreated CIS patients, 7 RRMS, 7 SPMS) were included with a mean age of 41.3±9.5 years, mean MS duration of 6.1±7.4 years, mean EDSS of 2.6±1.4 years (0–6 years). Mean treatment duration (all IFN-b) was 2.2±2.9 years in RRMS and SPMS. Mean annualized relapse rate in the past year was 0.55±0.6 (range 0-2). SPMS patients were older (48±8 yrs vs. 38.2±8.7 yrs., p=0.02), had higher EDSS scores (3.9±1.2 vs. 2.0±0.9, p=0.001) and longer disease duration than RRMS patients (13.9±8.3 vs. 2.5±3.0 yrs; p=0.001). There were no differences between groups regarding gender, treatment and frequency of abnormal visual evoked potential. NAA levels and NAA/Cr ratio was highest in CIS (p[0.2). EDSS and disease duration did not correlate with NAA/CR. There was a trend to thinner RNFL in patients with longer disease duration (p=0.04; r=-0.47). RNLF thickness was lower in patients with abnormal VEP (p=0.05) independent from disease course.

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Conclusions: MRS revealed subtle baseline differences between CIS and relapsing forms of MS. OCT abnormality is largely dependent on VEP abnormality suggestive of previous clinical or subclinical affection of optic nerves. Lack of correlation between OCT/MRS and disease characteristics is due to low number of patients. The main interest of this study is to mirror changes in all groups over one year and the study is ongoing. Supported by Bayer Healthcare Switzerland.

P410 Correlation between magnetic resonance imaging lesions and intrathecal immunoglobulin synthesis in patients with multiple sclerosis G. Kosehasanogullari, S. Ozakbas, E. Idiman Dokuz Eylul University (Izmir, TR) Objective: The source of IgG has been one of the main problems in multiple sclerosis. The aim of the present study was to evaluate the correlations between the intrathecal immunoglobulin G synthesis and number, size, and localizations of the lesions in cranial and spinal cord magnetic resonance imaging (MRI) in patients with MS. Method: In the present study, 42 patients (27 female) with clinically definite MS according to Poser’s criteria were included. Most of patients had relapsing remitting course (31 out of 42). Clinical assessment was done by expanded disability status scale (EDSS). Magnetic resonance imaging (MRI) was performed, and oligoclonal bands (OCB), and IgG index were studied. MRI was assessed on the basis of lesion localization and size. Results: Oligoclonal bands were positive in 57.1% of the patients. The percentage of IgG index greater than 0,7 was 28,6%. Number of OCB was found to be correlated with number of total brain, periventricular, brainstem, juxtacortical, callosal, thoracic cord, cervical cord, and total spinal cord lesions (p\0.05). IgG index was correlated with number of thoracic cord, total spinal cord, and corpus callosum lesion (p\0.05). OCB positive patients had greater number of whole brain, periventricular,brainstem, juxtacortical, cervical cord, thoracic cord and total spinal cord lesions than the OCB negative patients (p\0.05). The median IgG index was 0.61. Number of lesions in thoracic spinal cord of the patients whose IgG index was greater than 0.61 was greater than the number of thoracic lesions of the patients whose IgG index was less than 0,61 (p=0.025). Conclusion: We concluded that; the lesions located close to the cerebrospinal fluid such as periventricular, brainstem, juxtacortical, cervical spinal, and especially thoracic region affect the cerebrospinal fluid IgG levels much more than the other lesions located far away from the cerebrospinal fluid.

P411 Brain MRI with diffusion weighted abnormalities in sporadic Creutzfeldt-Jakob disease: a 10-year experience at a single institute in Argentina L. Schottlaender, C. Begue´, J. Campos, C. Romero, A. Cammarota, A. Taratuto, M. Nogue´s Neurological Research Institute (Buenos Aires, AR) Objectives: The World Health Organization (WHO) diagnostic criteria for Sporadic Creutzfeldt Jakob Disease (sCJD), include as complementary studies the electroencephalogram (EEG) and the analysis of 14-3-3 protein in cerebrospinal fluid (CSF). Hyperintensities in basal

S133 ganglia and cerebral cortex have been described in brain magnetic resonance imaging (MRI) with diffusion-weighted imaging (DWI) and fluid attenuated inversion recovery (FLAIR). Nevertheless, brain MRI is not part of WHO criteria yet. The aim of this presentation is to evaluate the usefulness of brain MRI with DWI in the diagnosis of sCJD. Methods: Thirty three patients with suspected sCJD at onset, evaluated at Neurological Research Institute (FLENI) since 1999 were analyzed retrospectively. The percentages of characteristic abnormal brain MRI findings, periodic sharp wave complexes (PSWCs) on the EEG and detection of 14-3-3 protein in CSF on the first examination were compared. Results: Nineteen patients were male and fourteen female. The average age was 63.5 years and the overall survival was 11.3 months since initial symptoms. According to WHO criteria, fifteen were definite cases, twelve probable and six possible. In the definite group, 43% had PSWCs on EEG, 43% positive 14-3-3, and 80% characteristic changes on DWI. In the probable group, 58% had PSWCs, 82% positive 14-3-3 protein and 92% DWI changes. All possible cases showed typical changes on DWI. Considering categories with epidemiological value (definite and probable patients), a 50% had typical EEG, a 62% positive 14-3-3 and the 86% characteristic abnormal brain MRI findings. Conclusions: In almost all patients with confirmed sCJD, brain MRI with DWI and FLAIR showed characteristic bright signal in basal ganglia and/or cerebral cortex. In cases in which PSWCs on EEG are absent and 14-3-3 protein in CSF is negative DWI is particularly useful for the early recognition of the disease. Its inclusion among the diagnostic criteria should be considered.

P412 Non-motor symptoms of Parkinson’s disease and nigrostriatal dopaminergic degeneration: a study with Datscan A. Todorova, M. Buxton-Thomas, K. Ray Chaudhuri King’s College Hospital (London, UK) Parkinson’s disease (PD) results from progressive degeneration of the substantia nigra pars compacta and consequent dysfunction of the nigrostriatal dopaminergic pathway, expressing the motor dysfunction of PD. However, little is known about the association of non motor symptoms (NMS) of PD with the striatal dopamine depletion. Objectives: The aim of this study was to examine if quantitative assessment of nigrostriatal dopaminergic degeneration is associated with NMS in patients with PD. Methods: We investigated 51 patients with PD clinically and by means of 123I-FP-CIT-SPECT (DATSCAN). Clinical assessments included the validated PD Non Motor Symptoms Scale (NMSS), UPDRS and PDQ-8 to assess non motor, motor function and quality of life. Results: The mean specific dopamine transporter (DAT) binding in all (mean age 66,8±9,6 yrs, median HY=2,5, m/f=28/23) was low. Among the range of NMS measured by the NMSS, excessive daytime sleepiness (EDS) showed significant inverse correlation with mean DAT binding in the striatum (r=-0.30, p=0.03) and the caudate nucleus (r=-0.37, p=0.007). Additionally, there were significant correlations between the mean striatal DAT binding and gastrointestinal domain of NMSS, as well as attention/memory score of NMSS and caudate nucleus DAT binding. There was no correlation of the EDS score with age, disease duration and UPDRS motor score. Conclusion: EDS among a range of NMS seems to be particularly associated with striatal and caudate DAT binding. To our knowledge

this is the first study, using NMSS attempting to correlate NMS with functional imaging of PD.

P413 Potential relevance of low-intensity microembolic signals by TCD monitoring G. Telman, E. Kouperberg, E. Sprecher Rambam Medical Center (Haifa, IL) Background and purpose: The significance of low-intensity microembolic signals (MES), as well as their relationship with highintensity MES, has not yet been studied. Methods: We monitored MES by TCD in 256 arteries of 229 patients with carotid stenosis. All microemboli were detected automatically without a preliminary set threshold. Results: For those 110 patients who evidenced any emboli, the correlation between the number of high- and low-intensity MES was r=0.50, p\0.0001. A statistically significant relationship between both types of MES was found, with a degree of association of 0.42, as assessed by Cohen’s kappa. Later occurrence of high-intensity MES based on early low-intensity MES was statistically significant, with a chi-square p= 0.0006 and a degree of association of 0.24, as assessed by Cohen’s kappa. Conclusion: There is a significant relationship between low- and high-intensity MES, thereby indicating that many MES routinely rejected because of their low intensity are real.

P414 fMRI–EEG integrated cortical source imaging during a Stroop-like task J.J. Gonzalez-Rosa, G. Riccitelli, A. Inuggi, M.A. Rocca, M. Filippi, G. Comi, L. Leocani Scientifc Institute San Raffaele (Milan, IT) Background: Very few studies have employed the two major noninvasive brain mapping techniques, electroencephalography (EEG) and functional magnetic resonance imaging (fMRI), to examine the spatio-temporal neural organization of cognitive processes occurring during typical cognitive task. Objective: The present study addressed this question by using fMRI and event-related potentials (ERPs) in order to develop a multimodal strategy that combine their complementary advantages, obtaining a high spatial-temporal resolution of information processing of brain regions involved in the performance of the Stroop task. Methods: We applied fMRI and ERP techniques in separate sessions and identical task timing during which 21 healthy participants performed a Stroop-like task with three experimental conditions (Congruent, Incongruent and Neutral). First, fMRI data were analyzed using standard analysis software to detected changes in BOLD signal in those regions of interest specific of the different experimental conditions. Next, EEG data were analyzed by first identifying the classical ERPs components and then by reconstructing their spatiotemporal pattern through Cortical Current Density (CCD) method using fMRI-derived activation maps as priors in the source reconstruction process. Results: Anatomical areas and the Talairach coordinates of brain regions that showed significant activations in any of the three conditions were identified. CCD reconstruction allowed to estimate the sources time course with a millisecond temporal resolution. Our findings are consistent with classical ERP components and fMRI activated areas commonly observed in Stroop-like studies and show a

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S134 temporal neuroanatomical pattern involving specific brain frontal networks. Conclusions: Our data support the view that: 1) a combined fMRI and EEG approach for studying cognitive performance enhances our knowledge about the time course of activation of different sources; 2) the proposed method provides a reliable method for fMRI–EEG integration and may offer a significant advancement to cognition studies in neurological diseases.

P415 Quantification of N-acetylaspartate concentration of hippocampus in vivo by multivoxel 1H MR spectroscopy: comparison with singlevoxel method Z.W. Shen, L. Pang, X.Q. Guo, X.F. Chen, L. Ning, Z. Xu, Y.W. Chen, Q.C. Qiu, R.H. Wu Shantou University (Shantou, CN) Objectives: to investigate the accuracy for quantification of brain Nacetylaspartate (NAA) concentration of hippocampus in vivo using multivoxel 1H MR spectroscopy (MRS). Methods: Phantom and seven volunteers were studied using a GE 1.5T scanner. Each volunteer was measured for multivoxel MRS data and singlevoxel MRS data separately. The position resolved spectroscopy (PRESS) sequence was used with TE=135 msec and TR=1000 msec for multivoxel MRS data and the stimulated echo acquisiton mode (STEAM) sequence was used with TE=20 msec and TR=3000 msec for singlevoxel MRS data. The two adjacent voxel containing the hippocampus were selected as the region of interest (ROI) by multivoxel MRS method. The mean NAA value of the two MRS were aquired as NAA of the hippocampus. The multivoxel data were analysised by SAGE/LCModel software and the NAA concertration was calibrated by the GE standard spherical mode as the external standard model. The singlevoxel data were processed by LCModel and the water was used as an internal standard. Results: As for the ues of long TE and PRESS sequence, the SNR of the multivoxel MRS (4.2±2.6, n=14) were higher than the singlevoxel MRS (2.3±0.7, n=7). The region of interest can be choosed more properly. In the multivoxel MRS, the mean concentration of NAA+NAAG was 5.440±0.622 mmol/kg; the mean concentration of NAA+NAAG was 5.477±1.014 mmol/kg in the singlevoxel MRS. There were statistically significant differences between two methods (P[0.05). Conclusion: The brain NAA concentration of hippocampus measured by PRESS sequence multivoxel MRS with long TE is more accurate and convenient than by singlevoxel MRS method with short TE STEAM sequence. This research was supported by grants from National Natural Science Foundation of China (#30930027, #60971075) and Medical Scientific Research Foundation of Guangdong Province (B2008128)

P416 Mapping brain pH and brain ATP using multivoxel 31P MR spectroscopy: a preliminary study R.H. Wu, Y.W. Chen, W.W. Liu, Q.C. Qiu, K. terBrugge, D. Mikulis Shantou University (Shantou, CN); University of Toronto (Toronto, CA) Although brain adenosinetriphosphate (ATP) studies can be found in multi-voxel 31P MR spectroscopy, previous studies of intracellular brain ‘‘potential of hydrogen’’ (pH) was conducted in single-voxel

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31P MR spectroscopy. The hypothesis of this study was that if multivoxel 31P MR spectroscopy could be used to measure brain metabolites directly, we should be able to generate brain pH map indirectly. Therefore, the purpose of this study was to explore the feasibility of mapping brain pH and brain ATP by using multivoxel 31P MR spectroscopy. Phantom studies were carried out by using a GE 3T scanner firstly. Many available sequences were tested using phantom and the 2D PRESSCSI sequence was selected because of better signal to noise ratio. TR was 1000 msec and TE 144 msec with 128 scan averages. The acquisition matrix was 16 x 16 phase encodings over a 24-cm FOV. Slice thickness was 10 mm. Then two healthy volunteers from MR research team were studied. Data were processed offline using the SAGE/IDL software. Baseline and phase corrections were performed. Multivoxel spectra and brain ATP map were analyzed. Brain pH values were calculated from the difference in chemical shifts between inorganic phosphate (Pi) and phosphocreatine (PCr) resonances. Color scaling map was generated using MatLab software. Multivoxel 31P spectra were obtained for phantom and the healthy volunteers. At this moment, there was noise for multivoxel 31P spectra in volunteer studies. Roughly, phosphomonoester (PME) peak, inorganic phosphate (Pi) peak, phosphodiester (PDE) peak, phosphocreatine (PCr) peak, cATP peak, aATP peak, and bATP peak could be identified. The individual spectra were with similar quality. From the data of same scan, corresponding metabolite maps could be generated by SAGE/IDL software. A color scaling pH map was generated using MatLab software. Red color represents higher pH value and blue color represents lower pH value. What multivoxel 31P MR spectroscopy measures at this time is limited in quality, but it does provide a window to noninvasively measure small structure of brain tissue. Although our results of generating brain ATP map and brain pH map are preliminary, bright future could be expected in terms of technique improving. At this moment, MR hardware and software are not perfect so that our brain ATP map and brain pH map might just be at their earliest stage.

P417 Vision and oxygen inhalation affect mitochontrial activity: a 31P magnetic resonance spectroscopy study R.H. Wu, H. Wang, J. Poublanc, K. terBrugge, D. Mikulis Shantou University (Shantou, CN); Southeast University (Nanjing, CN); University of Toronto (Toronto, CA) Previous study showed that human brain is active in sedentary status and sensitive to oxygen supplementation. However, less concern is addressed to study whether vision will affect brain activity or not. Eleven healthy volunteers underwent 31P MRS examination. Seven volunteers took part in the first stage of the study, before and after breathing hyperoxic air (100% O2) only, with eyes closed. Four volunteers participated in the second stage, 2 scans with eyes closed same as the first stage, and the 3rd scan breathing hyperoxic air (100% O2) with eyes opening. All volunteers were from MR research team and gave informed written consent. The studies were performed on a 3-T GE scanner. Nasal cannula was placed before MR examination. A spin echo MRS sequence was utilized for 31P scans with a GE service coil. TR was 2000 msec and TE 35 msec with 128 scan averages. The voxel size was 4x4x4 cm3 placed in the occipital lobes. Data were processed offline using the SAGE/IDL software. Baseline and phase corrections were performed. Peak integral values of inorganic phosphor, phosphocreatine, cATP, aATP, bATP, and ‘‘potential of hydrogen’’ (pH) were measured. Good 31P spectra were obtained for all volunteer studies. From visual inspection, we can observe decreased Pi peak and increased cATP, aATP, and bATP peaks from the 3rd scan breathing hyperoxic

S135 air with eyes opening. Decreased Pi peak integral values and increased peak integral values of cATP, aATP, and bATP can be measured using SAGE/IDL software, after 100% oxygen inhalation with eye closed. Compared with first scans, peak integral values of cATPs were increased from 0.75 % to 15.97 % (5.76±4.03) on second scans; aATP from 1.21% to 16.05% (6.23±5.35); bATP from 1.01% to 7.12% (2.67±2.04). Compared with second scans, peak integral values of cATPs were increased from 3.53 % to 9.12 % on third scans of 4 volunteers; aATP from 3.65% to 10.72%; bATP from 2.45% to 8.82%. The pH values among 3 scans were not changed obviously. Oxidative phosphorylation and the generation of adenosine triphosphate (ATP) are the central functions of mitochondria. In this study, we observed the influence of breathing hyperoxic air and vision on brain mitochondria in sedentary healthy volunteers. Brain mitochondrial activities were increased and more ATPs were produced after oxygen inhalation in healthy volunteers. Vision will affect mitochontrial activity also. More energy is needed in visual status.

P418 Investigation of pH imaging using magnetization transfer to a 1.5T clinical scanner L. Ning, Q.C. Qiu, Z.W. Shen, R.H. Wu Shantou University (Shantou, CN) Objectives: Acid-based balance is altered in a variety of common pathologies, including ischemia, renal failure, cancer and inflammation. It is known that there are few effective tools available to evaluate pH values in vivo and recently the Magnetic Resonance is found to provide a non-invasive tool of estimating pH value. MRS was first introduced to measure intra- and extracellular pH, but the inherent low resolution of spectroscopy makes it difficult to be applied to clinic. A new technique known as Chemical Exchange Saturation Transfer (CEST) may provide an image of the spatial distribution of pH values in humans. In this abstract, we used the MT-SE sequence to scan the tissue-like pH phantom on 1.5T scanner. Methods: All experiments were conducted on a GE Signa 1.5T scanner, and a standard GE head-neck coil was used. Images were acquired using a Spin Echo (SE) pulse sequence. Prior to image data acquisition, an MT off-resonance preparation pulse train was applied. Other relevant imaging parameters were TR 4200 ms, TE 20 ms, slice thickness 10 mm, imaging matrix 256x256, FOV 12 cm, NEX 0.75, the receive BW 31.25 kHz. For MT imaging, we acquired Z-spectra using Fermi pulse trains with RF frequency offset from 400 to 1600 Hz (about 20 ppm at 1.5T), and a frequency interval of 200 Hz (3.25 ppm at 1.5T). The total scanning time was approximately 50 min. The phantom consisted of 0.2 M Phosphate buffer, one of which contained 50 mM Cr. And the second phantom consisted of 50 mM Cr and 3% agarose (w/w) tubes (pH 5.5, 6.8 and 7.4, 0.2 M Phosphate buffer) inserted in a 50 ml beaker. All data processing was performed with eFilm Workstation, and the magnitude of region of interest (a 0.8 cm2 circle) was fitting on Origin software. Results: A decrease (50±10 machine unit) in the water signal is observed when the MT pulse was added prior to SE sequence. Comparing to routine SE, the magnitude of water decreased about 16.1 machine unit from pH 5.5 to pH 7.4 while exerting MT pulse. Conclusion: Recently, a variety of Magnetic Resonance Imaging methods have been proposed to measure pH values in tissue using MT methods, but all of them were performed in high field animal imager. Our results suggest that, it’s possible to obtain a pH imaging in vivo on a clinical scanner. In order to implement this, appropriate correction must be introduced to the original MT pulse sequence, which was used to pre-saturate the pH-dependent labile protons.

This research was supported by grants from National Natural Science Foundation of China (#30930027, #60971075) and Medical Scientific Research Foundation of Guangdong Province (B2008128)

P419 Quantitative 1H-MRS of human precentral gyrus and hippocampus: absolute concentrations of metabolites X. Cheng, R.H. Wu Shantou University Medical College (Shantou, CN) Background: In vivo proton MRS allows the noninvasive evaluation of cerebral metabolic patterns in both healthy subjects and patients with various brain diseases. Absolute quantification is a more objective, accurate approach and capable of helping establish quantitative basis for studying neurochemistry in vivo. Precentral gyrus and hippocampus are hot issues in medical field, and considered to be associated with many diseases. Objective: To study the metabolic characteristics and concentrations of precentral gyrus and hippocampus using proton magnetic resonance spectroscopy with LCModel software. Methods: 1H-MRS data of 14 healthy adults were collected by GE 1.5T MR scanner, using short TE STEAM sequence (TE: 20 ms). The voxels were located over the left precentral gyrus and hippocampus.Spectral analysis was performed using fully automated LCModel software. Absolute metabolic concentrations of N-acetylaspartate (NAA), total creatine (tCr), total choline (tCho), myoinositol (mI), Glx (glutamate [Glu] + glutamine [Gln]) were measured.The paired-samples T test was used to compare the metabolic concentrations between precentral gyrus and hippocampus. Bivariate Correlations and Linear regression analysis were performed to determine whether some metabolites were correlated with Cr levels. Both procedures were performed on SPSS 10.0 software package. Statistical significance was set at P\0.05. Results: Results showed significantly lower NAA level and higher Cho and MI in hippocampus than in precentral gyrus, while no significant difference for Cr and GLX concentrations in these two locations was observed. Correlation analysis of the precentral gyrus and hippocampus metabolite concentrations revealed a correlation between NAA and Cr (precentral gyrus, Pearson correlation coefficient :r = 0.664, and P = 0.013; hippocampus, r=0.632, p=0.015) in both locations. Linear regression analysis showed a linear relation between NAA and Cr both in precentral gyrus and hippocampus. No linear correlations between Cho and Cr and between MI and Cr were observed in either location. Conclusion: There are differences of the metabolites between precentral gyrus and hippocampus. There are linear correlations between some metabolites and Cr in precentral gyrus and hippocampus. Sponsored by NSFC(Natural Science Foundation of China) 30570480

P420 Non-contrast brain CT signs of spontaneous intracranial hypotension C.R. Gordon, D. Yaffe Meir Medical Center (Kfar Saba, IL) Objective: Spontaneous intracranial hypotension (SIH) is very rare in clinical practice and sometimes constitutes a diagnostic challenge, especially in the emergency setting. Although brain and spinal MRI are still the gold standard for diagnosis, the presence of some

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S136 particular CT findings in cases of SIH has not been described. Our objective is to present a number of non-contrast brain CT findings which strongly suggest the presence of intracranial hypotension in patients with postural headache. Methods: We evaluated seven patients fulfilling the clinical and MRI criteria of SIH who were admitted to the emergency room during the years 1999-2008. The brain CT findings performed on admission were compared with those of six patients with severe orthostatic headache following epidural anesthesia. Results: MRI pachymeningeal enhancement and subdural collections were found in all SIH patients. Non-contrast brain CT was abnormal in five out of seven cases: a clear tentorial subdural hygroma was found in four cases; supratentorial subdural hygroma and cervical spinal venous engorgement were found two other cases. Similar findings (four tentorial and four supratentorial subdural hygroma) were found in five out of six patients with severe orthostatic headache following epidural anesthesia. Conclusions: The presence of tentorial and less frequently supratentorial subdural hygroma or spinal engorgement on non-contrast brain CT in a patient with postural headache may strongly suggest the presence of intracranial hypotension. These CT signs can be of high clinical significance in an emergency setting or in cases of orthostatic headache following lumbar punction or epidural anesthesia.

P421 MRI and clinical outcome among normal pressure hydrocephalus patients M. Motamed, S. Meysami, A. Hoseinpoor Rafati, M. Ardalan Iran University of Medical Sciences (Tehran, IR) Objectives: Patients with normal pressure hydrocephalus (NPH) are currently considered candidates for treating by shunt operation if repeated lumbar punctures (LPs) reveal clinical improvement. We compared the clinical outcome of repeated LPs among patients with NPH and NPH & small vessel disease (SVD)on MRI assay. Methods: We conducted a prospective study (2004–2009) in which NPH patients were enrolled from a teaching hospital. They had at least 2 out of three clinical features (including :dementia,urinary incontinence, gait apraxia) and MRI assay favoring NPH. Patients with cortical atrophy and Papilledema were excluded. Therapeutic LPs achieved in all patients and they were followed 48 hours later. A score for each initial symptom and total scores were calculated,(max 3 scores for each patient).Patients were categorized into two groups depending on complete or incomplete initial symptoms resolution following LPs. Results: Totally 40 patients were enrolled with mean age of 63.5(Sd: 5.5) Y/O. Most of them were males, 25(62.5%). MRI findings supported NPH diagnosis in 21 and NPH with coexisting SVD in 19 patients. The mean of age and the time interval between onset of symptoms and definite diagnosis (months) were significantly higher among patients with NPH & SVD on MRI,(P\0.05); However,the median of initial symptoms score was 3(min-max:2–3) in both groups,(p[0.05);The median number of LPs did not differ in two groups [NPH: 2(min-max:1–4) vs. NPH&SVD 2(min-max:1–3); P[0.05].Although, significant clinical improvement found in both groups following repeated LPs,(P=0.001) but this improvement was statistically greater among patients with NPH alone on MRI,(P=0.001).Logistic regression analysis verified that just MRI suggesting NPH (OR=17.2,95%CI:3.5–84.7;p=0.001) independently predicts the probability of complete resolution of initial clinical symptoms following repeated LPs and other variables such as age,gender, time interval between onset of symptoms and definite

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diagnosis, Number of LPs,number of initial clinical symptoms (3 vs.2 symptoms) did not have significant effect on complete resolution of symptoms on multivariate analysis. Conclusion: Coexisting SVD on MRI assay in patients with NPH is a strong predictor of incomplete resolution of symptoms following LPs.

P422 Idiopathic hypertrophic cranial pachymeningitis: a case report with no need for constant medication during a 7-year follow-up C. Karakasis, E. Kyriazopoulou, J. Rudolf, G. Deretzi, I. Tsiptsios Papageorgiou Hospital (Thessaloniki, GR) Objectives: Idiopathic hypertrophic cranial pachymeningitis (IHCP) is a rare inflammatory disease characterized by diffuse dural thickening, dural mass, sinus thrombosis, and venous congestion. Adequate management is still a matter of debate and depends on patient’s clinical aspects. Case Report: A 47 year old female patient was referred to a neurology clinic for diplopia, unspecified headache and drowsiness. CT revealed high signal thickening in the cerebral falx and tentorium. Initially she was diagnosed as hyparachnoid haemorrhage and treated with high doses of Dexamethasone IV for a week with complete regression of the mentioned symptoms. During her 7 years follow up, there was always the same enhancement and thickening in the falx and tentorium in brain MRIs compatible with hypertrophic pachymeningitis and the patient complained about mild headaches only. Diagnostic work-up excluded other causes of pachymeningitis, including sarcoidosis, tuberculosis meningitis, rheumatoid arthritis, syphilis, and occult malignancy. In the dural biopsy specimen there were no signs of neoplastic cells, vasculitis or infectious agents. She is still not under any medication (steroids, methotrexate or azathioprine as mentioned in other cases) as there isn’t any strong symptom that needs to be treated. Conclusion: Since the introduction of CT and MRI, IHCP has been increasingly reported in recent literature. The clinical picture can be heterogeneous including headache, cranial nerve palsy and ataxia and the patient may not need a constant medication if the symptoms of the disease are minor.

P423 Silent disruption of white matter in type 2 diabetes patients: evidence from diffusion tensor imaging Y. Moon, S. Han University Hospital of Konkuk (Seoul, KR) Objectives: There is accumulating evidence that diabetes mellitus is associated with cognitive impairment. Many brain imaging studies which are assessed to evaluate the relationship between cognition and diabetes shows the cognitive decline is not only associated with brain atrophy, but also with subcortical ischemic changes. We tested the subclinical white matter disruption of the type 2 diabetes patients using diffusion tensor imaging (DTI) to investigate the structural disruption precedes the cognitive decline. Methods: Whiter matter integrity was assessed in 20 diabetes patients (mean age 65.1±9.5) and 22 age-matched control patients (mean age 64.9±11.5) who were screened for cognitive dysfunction with the Mini Mental State Examination (MMSE), without silent infarcts or white matter change. For each individual, fractional

S137 anisotropy with region-of-Interest (ROI)-based analysis were obtained in the anterior and posterior corpus callosum and bihemispheric orbitofrontal, inferior frontal (operculum), deep temporal, anterior and posterior periventricular, posterior internal capsule and occipital white matter. Results: Type 2 diabetes patients showed significant low FA values at left orbitofrontal, deep temporal white matter and right occipital whiter matter (p\0.01). Left periventricular, operculum and occipital white matter and right operculum also have decreased FA values, compared with controlled group. (p\0.05). Conclusion: In patients with type 2 diabetes, white matter disruption is processing without cognitive symptoms. Relative regional differentiation of the left frontal areas suggests that the left frontal lesion may have relation with the cognitive declines in type 2 diabetes patients.

Preclinical neurology P424 The involvement of the CREB activation on creatineinduced spatial learning enhancement R.S. Scalco, M.A. Souza, D.V. Magni, G.P. Guerra, L. Pereira, S.V. Marquez, J. Ferreira, L.F. Royes, J.C. da Costa, M.R. Fighera Pontifical Catholic University of Rio Grande do Sul (Porto Alegre, BR); Federal University of Santa Maria (Santa Maria, BR) Objectives: Creatine (Cr) is a guanidine compound that is utilized as an energy buffer, as well as an energy transport molecule preventing ATP depletion caused by several conditions, such as, neurodegenerative diseases and cerebral ischemia. Furthermore, it has been demonstrated that long-term Cr supplementation leads to an increase in health life span in mice accompanied by favorable effects on neurobehavioral functioning, especially memory skills. Although a considerable body of evidence has demonstrated that cellular energy status increase elicited by Cr enhances intelligent test scores, its implications for learning and memory are not clear. In this context, we decide to investigate the involvement intracellular trafficking in spatial learning improvement elicited by Cr in rats. Methods: For this propose, we investigated involvement of Ca2+/ calmodulin-dependent protein kinase II (CaMKII) and the levels of phosphorylated cAMP response element binding (pCREB) and activation CaMKII signaling pathway in the spatial learning after intrahippocampal injection of Cr on Barnes Maze. Results: Statistical analysis revealed that, intrahippocampal coinjection of Cr (2.5 nmol/hippocampus) and STO-609, an inhibitor of CaMKII (5nmol/hippocampus) post-training on Barnes-Maze test decreased the effect of Cr on latency for escape [F(1,36)=5.40; P\0.05] and the mean number errors [F(1,36)=4.11; P \0.05]. In addition, injection of Cr increased the levels of pCREB in hippocampus after 30 minutes [F(1,10)=6.89; P\0.05], suggesting that pCREB was expressed in the hippocampus during the process of spatial memory formation. In addition, we demonstrated that posttraining administration of Cr was able to increase pCaMKII [F(1,12)= 5.15; P\0.05] levels suggesting that intracellular CaMKII/CREB pathway play a key role in the Cr-induced spatial learning. Conclusion: Therefore, if the participation of CAMKII/CREB detected in this study also occur in patients with memory deficit is tempting to propose that the administration of Cr should be considered as an adjuvant therapy for these patients. However, further indepth studies are necessary to establish a definitive mechanism for Cr action on the spatial learning facilitation.

P425 Behavioural and electroencephalographic effects of lipopolysaccharide on glutaric acid-induced seizures in rats R.S. Scalco, D.V. Magni, M.A. Souza, A. Oliveira, J. Ferreira, L.F. Royes, J.C. da Costa, M.R. Fighera Pontifical Catholic University of Rio Grande do Sul (Porto Alegre, BR); Federal University of Santa Maria (Santa Maria, BR) Objectives: Glutaric acidemia type I (GA-I) is an inherited metabolic disease characterized by accumulation of glutaric acid (GA) and seizures. Considering that seizures are precipitated by common infections in children with GA-I, we decided to investigate the effects of lipopolysaccharide (LPS) on electrographic and neurochemical alterations induced by GA in pups rats (21 days of life). Methods: The effect of LPS on convulsive behavior induced by GA (0.13; 0.4; 1.3 lmol/site) was measured and different electroencephalographic (EEG) frequencies were obtained from freely moving rats. After EEG recordings, we measured the levels of interleukin 1b (IL-1b) in GA-injected striatum after LPS injection. Results: Behavioral and electrographic recordings revealed that injection of GA (1.3 `ımol/site) induced the appearance of seizures determined by latency [H(3)=24.08, P\0.01] and duration [H(3)=25.58; P\0.01] of convulsive episodes. LPS injection (2 lmg/ kg; i.p.), 6 hours before of GA administration, reduced the latency [H(7)=66.54; P\0.05] and increased the duration [H(7)=66.05; P\0.05] of convulsions compared to GA (1.3 lmol/site) alone. In addition, LPS administration 3 [F(3,11)=11.49; P\0.01] and 6 hours [F(3,10)=8.26; P\0.01] before GA injection increased striatal levels of IL-1b time dependent. Furthermore, the intrastriatal injection of IL1b antibody (200 ng/2 ll) before LPS, prevented against latency reduction [H(3)=17.26; P\0.01] and duration increase [H(3)=20.43; P\0.05] of LPS/GA-induced seizures. Conclusion: These data suggest that inflammatory processes, during critical periods of development, may reduce threshold and potentiate the seizures induced by GA. Thus, the present study may explain, at least partly, seizures evidenced after inflammatory process in children with GA-I. g

P426 Nogo-A mRNA expression in the central nervous system of C57BL/6 mouse P. Theotokis, A. Lourbopoulos, E. Salta, R. Lagoudaki, E. Polyzoidou, S. Ravanidis, N. Tascos, P. Markoulatos, N. Balatsos, N. Grigoriadis Aristotle University of Thessaloniki (Thessaloniki, GR); University of Thessaly (Larissa, GR) Objectives: Nogo-A, a neurite outgrowth inhibitor, has been found to play a significant role in controlling axonal regrowth after injury. The expression patterns of Nogo-A have been studied in the central nervous system (CNS) of naive and under various injurious animal models in adult rats. Nogo-A mRNA was abundantly expressed in most brain nuclei of naive animals, including neurons of the olfactory bulb, piriform cortex, hippocampus, septum, basal ganglia, preoptic nuclei, thalamus, hypothalamus, midbrain nuclei, pons and medulla oblongata nuclei, cerebellum and spinal cord. However, no similar pattern expression has been studied so far for the adult C57BL/6 mouse. Materials and methods: Naı¨ve, 8–12 week old C57BL/6 mice (n=4) were humanly sacrificed with diethyl ether and transcardially

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S138 perfused with 4% paraformaldehyde in DEPC-PBS. Brains and spinal cords were processed for 26lm freezing microtome frontal and sagittal sections of brain and spinal cords respectively. In situ hybridization for Nogo-A mRNA was performed in these sections using digoxigenin-labelled riboprobes (sense and anti-sense). Both riboprobes were synthesized by in vitro cloning of Nogo-A specific fragment, in our laboratory. Results: Nogo-A mRNA was expressed in most brain and spinal cord areas studied. Nogo-A mRNA was specifically localized in piriform cortex, hippocampal formation CA1-3, preoptic nuclei, thalamic and hypothalamic regions. Nogo-A was also found in substantia nigra pars compacta, oculomotor nucleus, specific pontine nuclei, motor and spinal trigeminal nuclei, vestibular and facial nuclei, in raphei and inferior olive. Conclusion: Nogo-A mRNA expression pattern in C57BL/6 mice was roughly found similar to that of naı¨ve adult rats. We confirmed Nogo-A’s mRNA universal expression in most brain nuclei, and a profound localization in cranial nerve nuclei, indicating a possible role of this molecule in organization of the cognitive and kinetic circuits, complementary to it’s primary inhibitory function. Supported by the grant PYTHAGORAS II (EPEAEK) of the Greek Ministry of National Education and Religious Affairs and the European Union

P427 Involvement of spinal neurotrophin-3 in the electroacupuncture analgesia and inhibition of spinal glial activation in rat model of monoarthritis W. Mi, Q.L. Mao-Ying, X.W. Wang, Y.Q. Wang, G.C. Wu Fudan University (Shanghai, CN) Although electroacupuncture (EA) is proved to be effective at pain relief in arthritis, the underlying mechanism of EA analgesia remains to be further investigated. The analgesic effects of EA had been reported to be associated with its counter-regulation to spinal glial activation. Neurotrophin-3 (NT-3) was demonstrated to be involved in many physiological and pathological functions including pain regulation, and could be up-regulated by EA treatment after spinal cord injury. Using an inflammatory pain model induced by intraarticular injection of complete Freund’s adjuvant (CFA) in rats, the present study demonstrated that (1) Repeated EA stimulation of ipsilateral ‘Huan-Tiao’ (GB30) and ‘Yang-Ling-Quan’ (GB34) acupoints remarkably suppressed CFA-induced hyperalgesia; (2) EA treatment markedly enhanced the up-regulation of NT-3 mRNA and protein level in spinal dorsal horn of rats following CFA injection; (3) Antisense oligodeoxynucleotide (ODN) specifically against NT-3 intrathecally administered during EA treatment, since the 3rd day following CFA injection, and lasted for 7 days significantly attenuated the EA analgesia, compared with NS or sense treatment; (4) The suppression of the expression of glia fibrillary acidic protein (GFAP, astrocytic marker), OX-42 (microglial marker), as well as proinflammatory cytokines, interleukin (IL)-1b, IL-6 and tumor necrosis factor (TNF)-a in spinal dorsal horn by EA treatment was significantly attenuated following NT-3 antisense ODN treatment. These data indicated that endogenous NT-3 might be involved in EA analgesia on inflammatory pain of rats and this effect is possibly through the inhibition of spinal glia activation as well as the proinflammatory cytokines level. Thus, the present study may initiate the discussion on the possible roles of NT-3/glia/cytokines in the therapeutic effects of acupuncture and shed light on the deeper understanding of mechanism underlying acupuncture analgesia in arthritis. Spinal NT-3 involved in EA analgesia on inflammatory pain of rats through the inhibition of spinal glia activation as well as the proinflammatory cytokines production.

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P428 Involvement of normal cellular prion protein in the pathogenesis of vitamin B12 (cobalamin)-deficient peripheral neuropathy of the adult rat G. Scalabrino, E. Mutti, D. Veber, A. Calligaro, G. Tredici University of Milan (Milan, IT); University of Pavia (Pavia, IT); University of Milan-Bicocca (Monza, IT) Objectives: Intramyelinic and interstitial oedema are the typical cobalamin (Cbl) deficiency-induced (CDI) lesions in rat central and peripheral nervous systems (PNS). Cellular prion protein (PrPC) functions in the PNS are still unclear although it seems they play a myelinoprotective role. We investigated whether PNS PrPC is involved in the pathogenesis of rat CDI peripheral neuropathy by administering anti-PrPC antibodies (Abs) to totally gastrectomised (TGX, i.e. Cbl-deficient) rats or (to falsify the hypothesis) mouse PrPC (Santa Cruz Biotechnology) to normal rats, and searching for morphological and functional signs of peripheral neuropathy. Methods: A polyethylene guide cannula was stereotaxically (1 mm posterior and 4 mm lateral from bregma) placed in rats’ left lateral ventricle. The TGX rats intracerebroventricularly (i.c.v.) received 1.2 lg of endotoxin-free or heat-inactivated anti-PrPC mouse Abs (with the epitope within the octarepeated region (Abs1) or within 142-156 aa (Abs2); both bought from the University of Zu¨rich) twice weekly for 7 weeks, starting 1 week after total gastrectomy. The PrPC -treated rats received 2 microinjections (60 ng each) weekly for 7 weeks. Controls (laparotomised, TGX, and unoperated rats) received the same amounts of saline i.c.v. twice weekly for 7 weeks. At the end of the period of treatment, nerve conduction velocity (NCV) was determined in the tail nerve following routine procedures. Semithin (1 lm) and thin sections of the sciatic and tibial nerves (biopsied before sacrifice) were stained with toluidine blue or uranil acetate and lead citrate, and used for light and electron microscopy. Results: The nerves of the TGX rats treated with active Abs1 (like the nerves of the TGX, Cbl-treated rats) had a normal ultrastructure and significantly higher NCV values than those of the saline-treated TGX rats, whereas those of the TGX rats treated with heat-inactivated Abs1 showed typical CDI lesions. The TGX rats treated with Abs2 died quickly. The PrPC -treated rats showed intramyelinic and interstitial oedema, and significantly decreased NCV values. Conclusion: We conclude that: a) Cbl disguises potential PrPC induced nerve toxicity in vivo; b) given the in vivo beneficial effects of Abs1, the octarepeated region may be nerve toxic; c) membrane and secreted PrPC s are more likely to be responsible for CDI nerve lesions in TGX rats. G.S. thanks Prof. A. Aguzzi (Zu¨rich) for helpful discussions. This project was financed by Fondazione Banca del Monte di Lombardia (Pavia, IT).

P429 Tricarboxylic acid cycle activity is impaired in rats with kaolin-induced hydrocephalus D. Kondziella, Ø. Risa, T. Melø, A. Ha˚berg, U. Sonnewald University Hospital (Copenhagen, DK); Norwegian University of Science and Technology (Trondheim, NO) Objectives: The monitoring of early changes in cerebral metabolism in hydrocephalus might help to develop new treatment strategies. In this study, metabolism in experimental hydrocephalus was studied for the first time using in vivo 13C Magnetic Resonance Spectroscopy (MRS).

S139 Methods: We examined label incorporation in neurotransmitter amino acids and other compounds, using in vivo and ex vivo 13C MRS combined with the infusion of [1,6-13C]glucose, two weeks after hydrocephalus was induced by kaolin injection into the cisterna magna of 12 rats. 12 sham-operated rats served as controls. Results: In hydrocephalic rats, labeling of most amino acids derived from [1-13C]glucose showed no alterations in metabolites from the first turn of the tricarboxylic acid cycle, but TCA clycle rate (VTCA) was decreased as was 13C labeling of glutamate, glutamine and GABA from subsequent turns. Concentrations of glutamate, alanine and taurine were also decreased. Furthermore, the concentration of N-acetyl aspartate, a neuronal marker, was decreased. Conclusions: We have shown in an earlier study that astrocyte metabolism is impaired in rats with experimental hydrocephalus. The present study using in vivo 13C MRS suggests that also neuronal metabolism is severely affected.

P430 Modification of peroxiredoxin antioxidant enzyme expression in activated and quiescent human astrocytes in vitro N.J. Gutowski, J.E. Holley, K. Szabo-Taylor, P.G. Winyard Royal Devon and Exeter Foundation Hospital (Exeter, UK); Peninsula Medical School (Exeter, UK) Objectives: The Peroxiredoxin (PRDX)-based system consists of a family of thiol-based antioxidant enzymes that have been identified in several neurological diseases. Astrocytes are multi-functional supporting cells. Astrocytes become activated during pathological processes and develop reactive and/or scarring phenotypes featuring characteristic changes in protein expression. Astrocyte activation can be beneficial, however scarring astrocytes inhibit repair. Little is known about astrocyte expression of the PRDX family. Nevertheless, altered expression or inactivation of PRDXs may contribute to pathology. This preliminary study investigated PRDXs and related redox enzymes in a human astrocyte culture system that mimics the phenotypes of quiescent, reactive/scarring astrocytes in vivo. Methods: Human astrocytes, isolated from post-mortem sub-ventricular deep white matter were grown in conditions inducing quiescence or activation. RNA was extracted and cDNA obtained by reverse transcription PCR. Expression levels of PRDXs 2,3,5, sulfiredoxin (SRX), thioredoxin (TRX) and thioredoxin reductase (TR) in quiescent and activated astrocytes was assessed by qPCR. Results: Quiescent astrocytes expressed low basal PRDX 2, 3 and 5 mRNA. Following activation, PRDX 3 mRNA levels were unchanged. However, a threefold increase of PRDXs 2 and 5 expression was seen. Conversely high basal levels of SRX, TRX and TR mRNA in quiescent astrocytes, were decreased in activated astrocytes. Conclusion: Changes in PRDX expression are linked to astrocyte phenotype. Further work will elucidate the functional properties of the PRDX-based antioxidant enzyme system.

P431 Central angiotensin peptides: pre-clinical findings and possible implications for dementia treatment A. Ciobica, W. Bild, R. Popescu, L. Hritcu, I. Haulica Alexandru Ioan Cuza University (Iasi, RO); Romanian Academy (Iasi, RO) Objectives: Recent studies suggested that pharmacological manipulation of angiotensin ligands may be of clinical importance in slowing

the cognitive deterioration seen Alzheimer’s disease. Although angiotensin II is the major effector of the renin–angiotensin system (RAS), various other angiotensins are now recognized as being biologically active. Angiotensin (1–7) is considered to be an important peptide fragment of the RAS, because it has important actions which are often opposite to those of angiotensin II. Methods: Losartan, PD 123177 (AT1 and AT2 antagonist), captopril (ACE inhibitor), angiotensin II and angiotensin 1–7 were administered in the left cerebral ventricle. The ability of the rats to acquire the operant task was studied by Y-maze task, passive avoidance and radial-arm-maze task. The anxiety state was measured in elevated-plus-maze. We also assessed the levels of some enzymatic antioxidant defences like superoxid dismutase (SOD) and glutathione peroxidase (GPX), as well as lipid oxidation makers like MDA (malondialdehyde), from the temporal lobe. Results: In Y maze, radial arm-maze and passive avoidance task the inhibition of Ang II and the administration of angiotensin 1–7 resulted in an increase of both short-term and long-term memory, compared to control group. In elevated plus maze measuring anxiety, losartan, PD 123177, captopril and angiotensin 1–7 diminished anxiety state, while angiotensin II exerted anxiety-like effects in comparation with naive rats. Alterations in the specific activity of the antioxidant enzymes (SOD and GPX) were found in the temporal lobe of angiotensin IItreated rats. Also, the level of MDA was increased in angiotensin II treated rats. On the contrary, blocking of angiotensin II or administration of angiotensin 1–7 exerted antioxidant effects. Conclusions: The use of angiotensin 1–7 or antihypertensive drugs, particularly ACE inhibitors and angiotensin receptor blockers, may be associated with a lower rate of cognitive decline in older adults and possibly in those with Alzheimer disease. Also, manipulation of the central angiotensins might be considered as a therapeutic target in the treatment of cognitive dysfunctions. A better understanding of the interactions between the various angiotensins, memory processes and neuronal oxidative stress is necessary and may lead to new therapeutic treatments. This research was supported by Romanian Academy.

P432 K-27, a promising new oxime-type cholinesterase reactivator D. Lorke, S. Nurulain, M. Hasan, K. Kuca, G. Petroianu Florida International University (Miami, US); United Arab Emirates University (Al Ain, AE); University of Defense (Hradec Kralove, CZ) Organophosphate (OP) poisoning represents a serious problem in developing countries, mainly due to pesticide exposure. OPs inhibit acetylcholine esterase, the enzyme terminating the synaptic action of acetylcholine. Standard therapy includes atropine and oxime-type enzyme reactivators (pralidoxime=2-PAM, obidoxime), but results are unsatisfactory. New bispyridinium (K-) oximes have therefore been synthesized. Objectives: 1. To compare in vivo the protective effect of eight novel K-oximes (K-27, K-48, K-53, K-74, K-75, K-107, K-108 and K-113) with that of established oximes when administered after OP exposure. 2. To compare the mortality-reducing effect of the most efficacious oxime, when given before OP exposure, with that of established pretreatment regimens. 3. To assess brain penetration of the most efficacious K-oximes. Methods: The relative risk of death (RR) over time was estimated by Cox survival analysis in rats that were first injected OP (paraoxon or DFP) and then oxime, and in rats that received oxime, pyridostigmine or physostigmine before OPC exposure. Oxime concentrations at

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S140 various points in time were measured in brain and plasma using HPLC and the area under the curve was determined. Results: Best protection was conferred by K-27, reducing the RR to 16% of controls after DFP and 20% after paraoxon exposure, which was significantly better than that of the established oximes obidoxime (RR = 0.19 for DFP/ 0.64 for paraoxon) and 2-PAM (RR = 0.62/ 0.78). Marked reduction in mortality was also achieved by K-48 (RR = 0.28/ 0.32), K-53 (RR = 0.22/ 0.36), K-74 (RR = 0.38/ 0.42) and K75 (RR = 0.29/ 0.35). When given as pretreatment, best in vivo protection was obtained by physostigmine (RR=0.02/ 0.30) and K-27 (RR=0.18/ 0.34), which was significantly superior to all other tested compounds, including the established substance pyridostigmine (RR=0.28/ 0.76). Brain levels of K-27 were only about 2% of plasma levels; K-48 reached 5% of plasma levels in the brain, and obidoxime 6%, irrespective whether administered alone or after paraoxon. Conclusions: K-27, K-48, K-53, K-74 and K-75, due to their far superior in vivo efficacy, are promising candidates to replace 2-PAM and obidoxime. Entry of K-27 and K-48 into the brain is minimal and cannot explain their better therapeutic efficacy. K-27 may be considered a more efficacious alternative to pyridostigmine as prophylactic agents, when passage into the brain is not wanted. The support by Sheikh Hamdan Grant is gratefully acknowledged

Neuro-ophthalmology P433 Vestibular-somatosensory interaction. A study of caloric stimulation M. Iida Tokai University School of Medicine (Isehara, JP) Introduction: Somatosensory signals relate the vestibular input during locomotion. The nystagmus (arthrokinetic nystagmus: AKN) could be induced when the horizontally extended arm of a stationary subject was passively rotated about a vertical axis in the shoulder joint. Apparent stepping around nystagmus (ASAN) was demonstrated by stepping in circles in the dark. The aim of the present study is to evaluate the correlation of the vestibulo-ocular reflex (VOR) and the somatosensory input. Subjects and method: Five healthy young adults (age 26–34, mean age 29, all right handler) participated in this study. Caloric stimulation was achieved in the subjects by irrigating the left external ear canals with 20 ml of hot water (44C) for 5 sec, while the subjects lay in a supine position with eyes closed. The two patterns of somaosensory stimulations were given during caloric stimulation. A: active somaosensory stimulation shows to lift the 10 Kg - dumb-bell by both arms, B: passive somaosensory stimulation indicates the dumb-bell press to the both arms. The horizontal nystagmus elicited by the caloric stimulation were evaluated by Electronystagmography (ENG) in the both patterns. Results: During the caloric stimulus in the condition A (active somatosensory stimulation), the rapid-phase eye velocity (RPEV) was decreased. In the condition B (passive somatosensory stimulation), the slow-phase eye velocity (SPEV) was decreased. conclusin 1. VOR were influenced by somatosensory inputs. 2. Superior colliculus(SC), Velocity Storage Mechanism and Burst Generator may be related to the somatosensory inputs. 3. Passive somatosensory input may influence to the peripheral vestibular apparatus, active somatosensory input may influence to the central (SC).

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P434 Optic nerve as structural biomarkers in multiple sclerosis S. Petrescu, A. Chirita, G. Vanghelie, R. Pascu, L. Voinea, M. Moldovan, N. Munjev, C. Panea The Emergency University Elias Hospital (Bucharest, RO); The Unirea Medical Center (Bucharest, RO) Objectives: Multiple sclerosis is known as an autoimmune inflammatory disease, but during last years the neurodegenerative process has been accepted and proved as a key of disability. The optic nerve, part of the central nervous system (CNS) is frequently involved in the pathogenic mechanisms of disease. Our goal was to look on the optic nerve using different methods and correlate these data with clinical evaluation of disability by expanded disability status scale (EDSS). Methods: A small batch of 10 patients diagnosed with relapsing remitting multiple sclerosis underwent on magnetic resonance imaging examination of CNS, with spectroscopy of optic nerve (N–acetyl aspartate, choline level and N-acetyl aspartate on creatine ratio). Demyelination of optic nerve was measured by the latency of the P100 wave (reversal pattern visual evoked potential :VEP) and axonal loss was measured by the retinal nerve fibre layer thickness (RNFL) at the level of the optic nerve head (Heidelberg Retinal Tomography). All patients were clinically evaluated by EDSS score. Results: On fluid attenuated inversion recovery sequence the radiologist remarked the presence of hyper intensities on the optic nerve intra and extra orbital and gadolinium enhancement at this level for almost all the eyes examined. We couldn’t detect a positive correlation between the level of metabolism products, VEP and retinal nerve fibre layers values with EDSS score. Conclusion: Analyzing the optic nerve could provide some structural biomarkers for multiple sclerosis. Our study revealed some structural changes for this segment using MR imaging, which needs to be assessed using large cohorts, trying on to make correlation between these changes and the others methods to evaluate optic nerve damage in multiple sclerosis.

P435 Cerebellar and visual grey matter brain volume increases in congenital nystagmus K. Hu¨fner, T. Stephan, V.L. Flanagin, A. Deutschla¨nder, T. Dera, C. Karch, S. Glasauer, M. Dieterich, M. Strupp, T. Brandt Ludwig-Maximilians University (Munich, DE) Objectives: We aimed to identify structural brain abnormalities associated with idiopathic congenital nystagmus. Methods: Voxel-based morphometry was used to compare the gray matter brain volumes of 14 individuals with idiopathic congenital nystagmus to those of a group of controls. Further, gray matter brain volumes were correlated with nystagmus intensity. Results: Intergroup comparison exhibited significant volume increases in the human motion sensitive complex V5/MT+, the fusiform gyrus, and the middle occipital gyrus bilaterally in congenital nystagmus. A positive correlation (linear model) of nystagmus intensity with cerebellar gray matter volume was seen in the following areas: vermal parts VIII-X as well as hemisphere lobule II, hemisphere VI, crus I, crus II, and lobule VII-IX bilaterally. No gray matter volume decreases were detected in individuals with congenital nystagmus.

S141 Conclusion: The gray matter volume increases identified in the visual areas of subjects with congenital nystagmus may be associated with excess visual motion stimulation due to involuntary retinal slip of the visual scene. There is evidence that the reported gray matter volume changes in the vestibulo-cerebellum, which correlated with nystagmus intensity, are more likely to reflect the subject’s attempt to maintain fixation rather than the generation of nystagmus. This work was supported by grants from the German Ministery of Education and Research (BMBF) to the IFBLMU and the Hertie Foundation.

P436 Positional convergence spasm C.R. Gordon Meir Medical Center (Kfar Saba, IL) Objective: Convergence spasm is generally considered functional in origin but it could be associated with organic disease. To our knowledge, only one case of convergence spasm elicited by extending the neck was described by Cogan in a patient with downbeat nystagmus. Our objective is to report three cases of convergence spasms elicited by positional changes. Methods: A complete neuro-otological examination was performed in three cases suspected to have benign paroxysmal positional vertigo (BPPV). All three patients were examined and videotaped because of brief attacks of dizziness when turning over in bed, extending the neck to look up, bending over or straightening up. Results: In all patients, brief episodes of convergence and miosis were elicited by positioning maneuvers, especially from sitting to the head-hanging position (Dix-Hallpike test) as well as when lying down in bed and head turned rapidly to either side. The episodes lasted few seconds to one minute and were accompanied by dizziness and horizontal diplopia. The rest of their neuro-otological examination was normal. In case 1, convergence spasms resolved within 24 hours after a single dose of promethazine 25 mg. In case 2, caloric test revealed right paresis of 40%. Symptoms persisted over two years follow-up and treatment with diazepam and carbamazepine was ineffective. There were no complaint of significant disability and no psychological factors could be identified. Case 3 was previously diagnosed and treated for posterior canal BPPV with only transient relief. Positional convergence spasms persisted over 3 months follow-up with complaint of disability and anxiety. Conclusions: These cases are probably the first report of positional convergence spasm with otherwise normal clinical neurological and neuro-otological examination. Positional convergence spasm must be distinguished from BPPV. This work was supported by grants from the German Ministery of Education and Research (BMBF) to the IFBLMU and the Hertie Foundation.

P437 Monocular acute visual loss in an immunocompromised patient S. Petrescu, B. Mocanu, A. Ciocalteu, R. Gurgu, M. Carciumaru, C. Panea Elias Emergency University Clinic Hospital (Bucharest, RO); Hociota Hospital (Bucharest, RO); Eyes Hospital (Bucharest, RO); Matei Bals Hospital (Bucharest, RO) Objectives: Acute visual loss of one eye could represent a provocation in order to establish a correct diagnosis for a neurologist. There are different etiologies of acute persistent monocular visual loss, one of

them is fungal infection of nasal spaces with retinal and cerebral complication. Methods: A 54 years old woman, non diabetic, with chronic hepatitis with C virus, in treatment with interferon Alfa stopped by her gastroenterologist (high level of hepatic enzyme) was admitted on ward for an acute symtomatolgy: acute visual loss of her right eye, swelling of the right facial skin, fever (under 38 Celsius degree), headache. Neurological examination revealed visual loss of right eye, with mydriasis and no response at light exposure. MRI of the cranium revealed pan sinusitis and the patient was referred to an ear nose throat doctor. During the operation there were removed some black tissues from her nasal spaces and the ENT doctor didn’t find any sign of infection. These tissues were sent to a pathologist. Results: The patient had been seen by ophthalmologist who diagnosed acute obstruction of the central retinal artery based on typical aspect of the retina. The patient developed other neurological signs: incomplete ophthalmologic deficit of her right eye, and after some weeks right hemi paresis with disorder of speech. Serial MRI of the brain revealed initially thrombosis of the right cavernous sinus and some weeks later ischemic stroke of the left basal ganglia. The pathologist reported fungal infection with mucormycosis. The patient received antifungal therapy with amphotericin B and antibiotics, but the outcome was unfortunate, our patient died because of stroke. Conclusion: Rhinocerebral mucormycosis is a devastating fungal disease with a high mortality rate. Our patient had an immunological compromise background and based on this status she developed arterial and venous retinal and cerebral thrombosis. We decided to present her case because of the modality of onset (monocular loss of vision with pansinusitis).

P438 A 38-year old woman with recurrent optic neuritis G. Akdal Dokuz Eylu¨l University (Izmir, TR) Objectives: To determine the clinical follow in a patient with recurrent optic neuritis.Recurrent optic neuritis (ON) might predict multiple sclerosis, neuromyelitis optica or remain as idiopathic Methods: A 38 year female was evaluated for visual loss in her left eye. Over 4 years she had 8 episodes of ON. She received intraveneous corticosteroids in each attack. She had normal 3 MRI scans of brain and 2 of spinal cord. Her NMO-IgG levels were negative twice in last 2 years Results: She did not have any attack for a year without any medication between. Her visual acuity was full in right and LE 0.8. After her 2nd ON attack she was given azathioprine and monthly intravenous corticosteroids and oral corticosteroids. She had 2 more ON attacks when she was just started azathioprine. Then she was free from attacks for nearly for a year with azathioprine and low dose daily oral corticosteroids. Her visual acuity was full in RE and was 0.8 in LE during that time.She had a left and then a right ON attack in September 2009 and received 10 days of intravenous corticosteroids. In November 2009, her visual acuity in RE was 0.9 and in LE was 0.7. After this attack she received intravenous corticosteroids every 3 weeks for 6 months in additon to azathioprine. In the end of January 2010 she had another ON in her right eye. She was treated with the same protocol for 5 days. Her blood was sent for NM0-IgG for the third time. Conclusion: During 4 year period our patient did not progress to MS or NMO but still having ON attacks. She might benefit from a different immounsuppresant medication.

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P439 Chronic relapsing steroid-dependent optic neuritis: a case report M. Della Corte, A. Gallo, A. Bisecco, L. Latanza, R. Morrone, S. Bonavita, G. Tedeschi Second University of Naples (Naples, IT); Antonio Cardarelli Hospital (Naples, IT); Diagnostic Centre of Morrone (Caserta, IT) Background: Optic neuritis (ON) is an inflammatory condition of the optic nerve determining a moderate/severe reduction of visual acuity. Atypical ON, with a tendency to chronicity, steroid-dependency and no evidence of other disease has been described as chronic relapsing inflammatory optic neuropathy (CRION). CRION is a very rare entity. Little is known about its pathogenesis and management. Case report: A previously healthy 49 year-old woman developed a subacute non painful visual loss (best corrected visual acuity 2/10) in her right eye on April 2007. She was diagnosed an ON by an ophthalmologist and started a 3-day course of i.v. methylprednisolone (MP), followed by oral steroid (OS) tapering, with a full recovery. Few days after suspension of OS, she experienced a rapid visual loss in the right eye. A second course of i.v. MP was given, followed by a very slow OS tapering: visual recovery was incomplete. Since then, every time she tried to discontinue OS, her visual acuity declined, requiring i.v. MP courses and continuous OS therapy. The patient was referred to us in September 2008 when she was on 15 mg/day of prednisone. General and neurological examination were unremarkable. Visual acuity was 8-9/10 in the right eye. Routine bloods, an extensive inflammatory/autoimmune panel, including serum ACE and NMO-IgG, serological tests for a wide range of infectious diseases and a chest X-ray were all normal. VEP showed increased latency on the right side, with normal SEP and BAEP. A Gd-enhanced brain, spine and orbits MRI showed an enlarged right optic nerve with high signal on T2-weighted images and enhancement on post-contrast T1-weighted images. At the last follow-up (May/2009), while the patient was still on OS (15 mg/ day), visual acuity in the right eye was 6-7/10. A new Gd-enhanced MRI was acquired and showed a little attenuation of previous findings. In order to further reduce and eventually discontinue the OS, Azathioprine was started (50 mg/day) and soon discontinued because of abdominal discomfort and an increase in AST/ALT enzymes. Conclusions: A small percentage of patients present with atypical ON. In these patients an extensive diagnostic work-up is needed to rule out a demyelinating disease and other systemic inflammatory/ autoimmune diseases. When a definite diagnosis is not reached, a chronic granulomatous process of the optic nerve should be considered and a diagnosis of CRION made. The optimal management of CRION is still controversial.

P440 Ophthalmoplegia in common carotid artery occlusion syndrome may be related to ischaemic myopathy T. Sander, S. Gottschalk, S. Hertel, B. Neppert, C. Helmchen University Lu¨beck (Lu¨beck, DE) Ocular muscle palsies are a rare but known finding following carotid artery disease. The pathomechanism of ophthalmoplegia, however, is not fully understood. It is usually thought to be caused by ischemia of the nerve supplying vessels of the cranial oculomotor nerves. Here, we provide some evidence in favour of an ischemic myopathy of extraocular eye muscles (EOM) as the morphological correlate of ophthalmoplegia.

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We studied a patient with a common carotid artery occlusion syndrome (CCAOS) presenting with ophthalmoplegia, amaurosis, and Horner syndrome on the left side, partial aphasia and mild right-sided hemiparesis. Trigeminal nerve was not affected. Duplex-sonography and MR-angiography showed an occlusion of the left common carotid artery (ACC). Fundus photography of the left eye revealed a cherryred spot of the macula indicating retinal ischemia. MRI of the orbita showed oedematous swelling of all left EOM as compared to the healthy right side. Using MRI short-tau inversion recovery (STIR) sequences showed hyperintensities and a prolonged T2-relaxation time in EOM indicating muscle oedema. ACC occlusion resolved incompletely within days. Ophthalmoplegia improved remarkably over the next 4 weeks when oedema of the EOM decreased. Signal alterations and swelling of muscles can be detected by MRI within only a few days after denervation and in muscle ischemia. However, some lines of evidence argue in favour of ischemic EOM myopathy in our patient. First, signal alterations in muscle ischemia are usually larger than those following denervation. Second, muscle oedema in ischemic myopathy can be reversible within days depending on reperfusion. Accordingly, our patient showed rapid decrease of muscle swelling and signal alteration within 2 weeks. In contrast, muscle oedema due to neuropathy usually increases over time to reach a maximum at about 1 to 4 months after denervation. Wallerian degeneration following an ischemic axonal block with subsequent nerve sprouting and functional recovery of muscles could not have developed within 2 weeks after denervation. Third, ischemia of the oculomotor nerves should have also affected the trigeminal nerve due to its common vascular supply. Thus, oedematous swelling of the EOM as assessed by MRI may be the morphological correlate of functional ophthalmoplegia after ipsilateral CCAOS and possibly reflects ischemic myopathy.

Multiple sclerosis: therapy P441 Consistent efficacy of cladribine tablets across multiple sclerosis and patient characteristics, in the doubleblind, 96-week CLARITY study P. Rieckmann, G. Comi, S. Cook, G. Giovannoni, K. Rammohan, P. Soelberg Sørensen, P. Vermersch, P. Chang, A. Hamlett, R. Verjee, B. Musch, S. Greenberg Bamberg Hospital (Bamberg, DE); University Vita-Salute San Raffaele (Milan, IT); University of Medicine and Dentistry (Newark, US); Barts and The London School of Medicine and Dentistry (London, UK); Ohio State University (Columbus, US); Copenhagen University Hospital (Copenhagen, DK); University of Lille - Nord de France (Lille, FR); Merck Serono S.A. (Geneva, CH) Objective: The 96-week CLARITY study demonstrated the efficacy of short-course treatment with cladribine tablets at cumulative doses of 3.5 or 5.25 mg/kg, with significant benefits on the annualised relapse rate (ARR, the primary endpoint), risk of sustained 3-month disability progression, and MRI lesion measures in patients with relapsing–remitting multiple sclerosis (RRMS). Here we explore the efficacy of cladribine tablets across the spectrum of baseline demographic and disease characteristics. Methods: Post-hoc subgroup efficacy analyses were performed for the ITT population (n=437, 433 and 456, respectively, for patients randomised to placebo, cladribine tablets 3.5 and 5.25 mg/kg). Cohorts were stratified according to baseline demographic and disease characteristics including gender, age, disability status, MRI-assessed

S143 disease burden, relapse rate and disease duration prior to study entry, and prior treatment with disease-modifying drugs (DMDs). Results: Treatment with cladribine tablets resulted in consistent reductions in the ARR in each patient stratum, compared with placebo; for men vs. women relative reductions in ARR were 60.5% vs. 54.8% for 3.5 mg/kg and 68.4% vs. 48.4% for 5.25 mg/kg (all p\0.001); for DMD-treated vs. DMD-naı¨ve patients, relative reductions were 45.0% vs. 61.2% (3.5 mg/kg) and 57.5% vs. 58.1% (5.25 mg/kg) (all pB0.0013); for patients with B1, 2 or C3 relapses in the previous 12 months, relative reductions were 48.2%, 68.9% and 65.7% (3.5 mg/kg) and 51.9%, 57.8% and 76.1% (5.25 mg/kg) (all pB0.006); and for patients with an Expanded Disability Status Score (EDSS) 0–1.5, 2.0–2.5 or C3.0, relative reductions were 62.5%, 60.0% and 54.6% (3.5 mg/kg) and 78.1%, 57.1% and 48.5% (5.25 mg/kg) (all p\0.001). Additional results will also be presented. Conclusion: Findings from these post-hoc analyses indicate that treatment with cladribine tablets is efficacious across a number of clinically important patient subgroups. The suggestion of incremental efficacy in certain subgroups requires additional investigation. These data support the potential for cladribine tablets as a promising new therapeutic option in RRMS. Sponsored by Merck Serono S.A.–Geneva, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany.

at Week 96, compared with baseline, proportions of CD8+ T cells against the total number of lymphocytes were increased +2.2% and +2.9% in the cladribine tablets 3.5 and 5.25 mg/kg groups versus placebo, +0.3% (p=0.008 and 0.005, respectively); proportions of CD19+ B cells were increased +5.8% and +6.1% versus placebo, +0.3% (both p\0.001); and proportions of CD16+/56+ natural killer cells were increased +4.4% and +5.1% versus placebo, –1.1% (both p\0.001). A more comprehensive, assessment of the impact of treatment with cladribine tablets on the reconstitution of the lymphocyte pool will be presented. Conclusion: The reduction in the proportion of CD4+ T cells translates into only a moderate absolute CD4 lymphopenia while the proportions of other lymphocyte subtypes are preserved or increased. Investigation of the modulation of lymphocyte subtype ratios may shed further light on the presumed mode of action. Sponsored by Merck Serono S.A.–Geneva, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany.

P442 Reconstitution of circulating lymphocyte subsets after treatment with cladribine tablets in the 96-week CLARITY study in relapsing–remitting multiple sclerosis P. Soelberg Sørensen, P. Rieckmann, G. Comi, S. Cook, G. Giovannoni, K. Rammohan, P. Vermersch, D. Bock, A. Hamlett, T. Fevr, B. Musch, S. Greenberg

Merck Serono S.A. (Geneva, CH)

Copenhagen University Hospital (Copenhagen, DK); Bamberg Hospital (Bamberg, DE); University Vita-Salute San Raffaele (Milan, IT); University of Medicine and Dentistry (Newark, US); Barts and The London School of Medicine and Dentistry (London, UK); Ohio State University (Columbus, US); University of Lille - Nord de France (Lille, FR); Merck Serono S.A. (Geneva, CH) Objective: Cladribine tablets offers targeted, sustained effects on T and B lymphocytes, providing the rationale for use as a short-course annual treatment in multiple sclerosis (MS). The CLARITY study demonstrated efficacy and safety of treatment with cladribine tablets at cumulative doses of 3.5 or 5.25 mg/kg, administered as two or four short courses, starting at Weeks 1 and 5 or 1, 5, 9 and 13, during the first 48 weeks and as two short courses, starting at Weeks 48 and 52, during the second 48 weeks. This analysis was designed to assess the reconstitution of circulating lymphocyte subpopulations at Week 96 in patients with relapsing–remitting MS (RRMS) treated with cladribine tablets. Methods: Patients were randomised to placebo (n=437) or cladribine tablets at cumulative doses of 3.5 (n=433) and 5.25 mg/kg (n=456). Blood was sampled at predefined intervals from baseline to Week 96 for analysis of lymphocyte surface markers in a subset of 300 patients equally distributed among the 3 treatment groups. Percentage counts represent the mean percentage of a given cell subtype against the total number of lymphocytes (100%) at the given time point. Results: At Week 96, compared with baseline, proportions of circulating CD4+ T cells were decreased –12.8% and –15.1% against the total number of lymphocytes in patients treated with cladribine tablets 3.5 and 5.25 mg/kg versus placebo, +1.3% (both p\0.001), with corresponding –7.9% and –7.4% decreases in CD4+/ CD45RA+ cells versus placebo, +1.8% (both p\0.001). In contrast,

P443 Late stage clinical development plan for cladribine tablets in the treatment of multiple sclerosis V. Viglietta, S. Greenberg, D. Mikol, J. Weiner, E. Alteri, P. Chang, D. Krumwieh, B. Musch Objectives: Treatment with cladribine tablets induces preferential reduction of T and B lymphocytes, making it a suitable candidate therapy for inhibiting pathogenic autoimmune processes in multiple sclerosis (MS). The late stage clinical development plan (CDP) for cladribine tablets was designed to provide efficacy and safety data in relapsing forms of MS and in clinically isolated syndrome (CIS). These data will support the registration of cladribine tablets as a therapy for MS. Methods: The CDP centres on a series of large multinational studies. The phase III CLAdRIbine Tablets Treating MS OrallY (CLARITY) trial enrolled 1326 patients with RRMS who were randomised to placebo (n=437) or cladribine tablets 3.5 (n=433) or 5.25 mg/kg (n=456) cumulative doses over 96 weeks of treatment. The primary endpoint was annualised relapse rate. The randomised CLARITY EXTENSION will further assess the safety and efficacy of cladribine tablets over 96 weeks in patients completing the CLARITY study (patients enrolled, n=*800). The phase III ORAl CLadribine in Early MS (ORACLE MS) study in patients with a first clinical event at high risk of converting to MS will evaluate the efficacy and safety of two dose regimens of cladribine tablets vs. placebo over three treatment periods (initial treatment [96 weeks] and maintenance or long-term follow-up treatment periods [96 weeks each]) and will provide long-term clinical and MRI data (target enrolment, n=642). The phase II Oral Cladribine Added-ON to Interferon-b in Patients With Active Relapsing Disease (ONWARD) study will assess the safety, tolerability and efficacy of cladribine tablets + IFN-b over 96 weeks in patients with active relapsing disease despite therapy with an approved IFN-b (patients enrolled, n=*200). The ONWARD EXTENSION portion of the study will further evaluate the safety and tolerability of cladribine tablets + IFN-b over an additional 96 weeks. Results: The CLARITY study resulted in a statistically significant relative reduction in annualised relapse rate of 55% in the cladribine 5.25 mg/kg group and 58% in the 3.5 mg/kg group vs. placebo (both p\0.001). The other trials are ongoing. Respective trial designs will be detailed. Conclusion: Primary and secondary endpoints of the CLARITY study were met. Other trials in the CDP will provide safety, efficacy and immunological data for the use of cladribine tablets in relapsing forms of MS and CIS.

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S144 Sponsored by Merck Serono S.A.–Geneva, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany.

P444 Evaluation of the long-term safety of cladribine tablets in multiple sclerosis: design of PREMIERE, a prospective, observational 8-year safety registry M. Miret, J. Weiner, L. Gedney, S. Greenberg, E. Alteri Merck Serono S.A. (Geneva, CH) Methods: This is an observational, multicentre, international, cohort registry study. All subjects enrolled into a selected sponsor phase I–III clinical trial of the cladribine tablets development plan (including those subjects randomised to placebo) will be eligible for enrolment in the registry once their participation in a cladribine tablets trial has ended. Subjects will be followed up for a total of 8 years after enrolment into the clinical trial or upon termination of the registry (preliminary estimate is mid2018). During the first 2 years of the registry, each subject will be interviewed every 3 months and thereafter the interviews will occur every 6 months until the end of follow-up. Preliminary analyses of the study findings will be performed when sufficient patient-time in the registry has been accrued, and periodically thereafter. Primary endpoints include incidence of selected infections, malignancies and deaths; dynamics of treatment-induced lymphopenia; frequency of pregnancies and pregnancy outcomes among female participants, and female partners of male participants. Potential confounding factors, including comorbid conditions and use of medications, will be collected during the observational period and will be taken into account in the analyses. Results: More than 2100 subjects will participate in the cladribine tablets clinical development studies and will be eligible for enrolment in the PREMIERE registry. It is estimated that 75% of eligible subjects will be enrolled from approximately 50 countries and across 400 sites. Enrolment of patients in PREMIERE started in November 2009. Conclusion: The PREMIERE registry is committed to the longterm active safety surveillance of subjects who previously participated in cladribine tablets clinical trials. Results from this registry will build on existing knowledge about the safety profile of cladribine tablets and support the long-term risk-benefit evaluation. Sponsored by Merck Serono S.A.–Geneva, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany.

P445 Oral fingolimod (FTY720) has consistent, beneficial effects on disability progression outcomes in relapsing multiple sclerosis: 24-month, placebo-controlled results from the phase III FREEDOMS study L. Kappos, P.A. Calabresi, P.O’Connor, R. Hohlfeld, C.H. Polman, C. Agoropoulou, D. Ha¨ring, L. ZhangAuberson on behalf of the FREEDOMS (FTY720 Research Evaluating Effects of Daily Oral therapy in Multiple Sclerosis) Study Group Objectives: Oral fingolimod (FTY720) leads a new class of sphingosine 1-phosphate receptor modulators and is being assessed in patients with relapsing–remitting multiple sclerosis (RRMS) (New Engl J Med 2006; 355: 1124–40). In a 24-month, phase III study (FREEDOMS), fingolimod significantly reduced annualized relapse rates by 54–60% compared with placebo (New Engl J Med 2010; 362:online at NEJM.org). Here we analyze several disability

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progression endpoints from the FREEDOMS study to determine the potential benefits of fingolimod compared with placebo. Methods: In this randomized, double-blind, placebo-controlled, multicentre study, patients with RRMS aged 18–55 years with Expanded Disability Status Scale (EDSS) score 0–5.5, and C 1 relapse in the previous year (or C 2 in the previous 2 years) were randomized equally to oral fingolimod (0.5mg, 1.25mg) or placebo capsules once daily for 24 months. Disability progression was defined as a 1-point EDSS score increase from baseline (or 0.5-point increase if baseline EDSS was C5.5). ‘Confirmed’ disability requires that the EDSS change be re-affirmed at a later assessment, after either 3 or 6 months. ‘Sustained’ disability progression requires that the EDSS increase (including intervening EDSS scores) be maintained until month 24 or patient termination from the study. Hazard ratios and corresponding p values were generated using Cox models adjusted for treatment, country, baseline EDSS and age. Results: Of the 1272 patients enrolled, 1033 (81%) completed the study. The risk of disability progression confirmed after 3 months was significantly reduced vs placebo by 30% with fingolimod 0.5mg (hazard ratio [HR] 0.70; p = 0.02) and by 32% with fingolimod 1.25mg (HR 0.68; p = 0.02). The risk of disability progression confirmed after 6 months was significantly reduced vs placebo by 37% with fingolimod 0.5mg (HR 0.63; p = 0.01) and by 40% with fingolimod 1.25mg (HR 0.60; p = 0.01). Fingolimod also significantly reduced the risk of sustained disability progression, either based on 3month confirmation (39% with both doses vs placebo; HR 0.61; p\=0.01 for both doses) or 6-month confirmation (40% with fingolimod 0.5mg vs placebo; HR 0.60; p = 0.01 and 43% with fingolimod 1.25mg vs placebo; HR 0.57; p = 0.01). Conclusions: Fingolimod treatment has consistent, beneficial effects on disability progression in patients with RRMS. The study was supported by Novartis Pharma AG, Switzerland.

P446 Significant treatment effects of alemtuzumab amongst relapsing-remitting multiple sclerosis patients who experience thyroid abnormalities A. Vladic on behalf of the CAMMS223 Study Group Objective: To characterize the efficacy of alemtuzumab in relapsing remitting multiple sclerosis (RRMS) patients who developed thyroid abnormalities. Background: In a 3-year efficacy and safety trial, alemtuzumab demonstrated superior efficacy compared to subcutaneous IFNB-1a in treatment naı¨ve RRMS patients. Alemtuzumab significantly reduced the risk for sustained accumulation of disability (SAD) by 71% and the rate of relapse by 74% (all assessments p\0.001.) The annualized relapse rate at 3 years was 0.10 (95% CI: 0.07, 0.12) for alemtuzumab and 0.36 (95% CI: 0.29, 0.44) for IFNB-1a. Alemtuzumab patients, however, developed thyroid abnormalities at a greater rate than IFNB 1a patients (23% vs. 3%, respectively). Design/methods: 334 early, active RRMS patients were randomized 1:1:1 to subcutaneous IFNB-1a (44 mcg SC 3x/week), 24 mg/day alemtuzumab, or 12 mg/day alemtuzumab. Alemtuzumab was administered IV during 2 or 3 brief annual cycles. EDSS was assessed quarterly. Relapses were assessed as needed. Thyroid function was assessed quarterly. Efficacy analyses compared the subset of 43 alemtuzumab patients experiencing thyroid-related AEs during the 3 years on study to all IFNB-1a patients. Results: Thyroid AEs occurred in 43 alemtuzumab-treated patients between 6 and 36 months after first dose. Alemtuzumab patients who developed thyroid abnormalities experienced a 63% reduced risk for SAD compared to IFNB-1a patients (p=0.045). Among this subset of alemtuzumab patients, 12.5% (95% CI: 5.4; 27.9) experienced SAD

S145 compared to 26.2% (95% CI: 18.3; 36.7) of IFNB-1a patients over 3 years. Alemtuzumab patients with thyroid abnormalities also experienced a 75% reduced rate of relapse compared to IFNB-1a patients (p=0.0001). The annualized relapse rate over 3 years for this subset of alemtuzumab patients was 0.09 (95% CI: 0.05; 0.16) compared to 0.36 (95% CI: 0.29; 0.44) for IFNB-1a patients. Conclusions: Patients with early RRMS who develop thyroid abnormalities after alemtuzumab therapy experience comparable effects on all examined efficacy measures as those observed among alemtuzumab treated RRMS patients overall. Efforts to characterize and predict the development of thyroid abnormalities related to alemtuzumab treatment are ongoing. Funding support for this study has been provided by Genzyme Corporation.

P447 The TYSABRIÒ (natalizumab) pregnancy exposure registry: preliminary assessment of outcomes L. Cristiano, C. Bozic, M. Kooijmans Biogen Idec, Inc. (Cambridge, US) Objectives: To evaluate pregnancy outcomes in women with multiple sclerosis (MS) or Crohn’s disease (CD) who were exposed to natalizumab within 3 months prior to conception or at any time during pregnancy. Methods: The TYSABRI Pregnancy Exposure Registry (TPER) is a global observational, exposure-registration, follow-up study of pregnant women with MS or CD who were exposed to natalizumab within 3 months prior to conception or at any time during pregnancy. Information on natalizumab exposure, potential confounding factors, and pregnancy outcomes are collected. A minimum of 300 MS pregnancies (and any additional CD pregnancies) will be registered prospectively, where the outcome of the pregnancy is unknown at the time of enrolment. Reports of pregnancy where the outcome is already known at the time of the initial report will also be collected, and will be analysed separately (i.e., retrospective reports). Results: Through 23 August 2009, 185 pregnancies have been registered in the TPER, including 155 prospective and 30 retrospective reports. Of the 155 prospective reports, 52 are pending delivery. One hundred six (106) prospective outcomes were reported (3 women completed twin pregnancies) including 80 live births, 20 spontaneous pregnancy losses, and six elective pregnancy terminations. Conclusion: Given that MS often affects women during their reproductive years and natalizumab is frequently used by women of childbearing potential, the pregnancy exposure registry is a vital source of information concerning how natalizumab exposure may affect pregnancy and infant outcomes. Although data are limited, they do not suggest any effect of natalizumab exposure on pregnancy outcome; however, additional data are required before definite conclusions or recommendations regarding how best to counsel patients can be made. The TPER is currently enrolling. Supported by Biogen Idec, Inc.

P448 Progressive multifocal leukoencephalopathy during natalizumab treatment: a ase report L. Moiola, F. Sangalli, M. Radaelli, V. Barcella, S. Gerevini, P. Cinque, V. Martinelli, G. Comi University Hospital San Raffaele (Milan, IT) Objective: To report on the first Italian case of progressive multifocal leukoencephalopathy (PML) during natalizumab (NTZ) treatment.

Methods: Case report. Results: He is a 46-years-old man who developed multiple sclerosis in 2001. Between 2002 and 2003 he underwent 6 cycles of Mithoxantrone for a cumulative dose of 120 mg. Then he was treated with Interferon b-1b till July 2007 when he presented a clinical relapse with incomplete recovery and increase of lesional load at brain MRI. Therefore he began NTZ therapy in September 2007. Since then he received 29 doses of NTZ till 19 December 2009 with clinical and neuroradiological control of the disease. At the end of December 2009 he began to complain of mild mood deflection. After one week he developed numbness and tingling in his left hand, mild gait imbalance and presented an episode of visual-spatial disorientation. He underwent a brain MRI which revealed diffuse bilateral cortical and subcortical signal changes in frontal and parietal areas without enhancement. He was then admitted to our neurological department were the neurological examination revealed impairment in short memory tests with dyscalculia, dysphoria; mild left motor faciobrachiocrural hemisyndrome with difficulty in fine movements of hand; mild dysmetria at left arm and inferior limbs; mild gait imbalance. A PCR assay of cerebrospinal fluid for JCV-DNA was positive (1545 copies of JCV per milliliter). Clinical, neuroradiological and virological data were consistent with PML diagnosis. He underwent five plasmaexchange procedures to remove NTZ in order to obtain immunoreconstitution. He was also treated with mirtazapine 15 mg/die and mefloquine 250 mg once a day for 3 consecutive days and then once a week. During the first days of hospitalization he presented a slight worsening of cognitive impairment and gait imbalance and then his neurological condition stabilized. Two repeated brain MRI scans showed substantial stability of the over described lesions except for more evidence of T1-hypointensity always involving the bilateral parietal and frontal areas without enhancement. He was discharged on stable conditions and he will continue a close clinical and neuroradiological follow-up. Conclusions: We report this case to emphasize the possible discrepancy between mild clinical features and diffuse involvement at brain MRI. Moreover we remark the importance of prompt diagnosis in order to begin a proper treatment.

P449 Headache occurrence in patients with multiple sclerosis treated with natalizumab: a 1-year prospective study D. Dalla Libera, B. Colombo, P. Annovazzi, S. Bucello, G. Pavan, D. De Feo, V. Martinelli, G. Comi Scientific Institute San Raffaele (Milan, IT) Methods: The aim of the study is to evaluate the correlation between headache onset and Natalizumab (NAT) therapy in 163 patients (females 70%) consecutively recruited in 2 MS-Centres and submitted to a semistructured interview to evaluate headache characteristics during 18 months average (range 4-36) of therapy. Results: Seventy-two out of our 163 MS patients (44%) were suffering from headache before diagnosis. According to IHS criteria, 54% of them suffered of migraine, 39% of tensive headache and 7% of a mixed form. Fourty-four patients (27%) undergoing NAT therapy reported headache (migraine 41%, tensive 59%), defined as moderatesevere in 50% with a median duration of 3 hours (range 30’–36 hours). No sex-difference was evident. Associated symptoms were: fatigue (40%), nausea (58%), myalgia (20%), vertigo 10%; fever (5%). Notably, in 66% patients this was a new onset headache (73% for IFN). 44% patients described headache in the first hours after NAT administration, 50% after a few days, and 6% immediately at drug administration. Only 5 of the 15 patients with a previous headache history complained of worsening in term of frequency and

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S146 duration of attacks present already before MS diagnosis, however they described a worsening in term of intensity. Twelve patients with NAT- related headache already suffered of headache with IFN or COP. Comparing NAT-related headache and IFN or COP-related headache we found a better outcome in frequency in patients treated with NAT (IFN 6, COP 3, NAT 1 per month respectively). Interestingly, 68% of patients began to experience headache already at the first drug administration: 75% had recurrent headache (at every infusion), 10% presented with a single headache episode during the first infusions (1–5), 2% during infusion 1–10, 8% during infusion 1015 and 5% during infusion 15–30. There was a possible associated delayed allergic reaction in first 15 infusions (70%; NAB negative in 100%). No correlation of disease activity on MRI or with other disease (i.e. PML) was evident. In most cases headache was manageable with analgesics (62%); only 10% had a long-duration attack and no drug response. In 3 cases prophylaptic drug was proposed with benefit. Conclusion: Headache is a relevant side effect affecting MS patients undergoing NAT administration, although of less impact than other DMD therapies. Frequency of attacks ameliorates during time and headache did not result in any case in discontinuation of NAT treatment.

P450 Natalizumab in multiple sclerosis patients: efficacy and safety data from an Italian multicentre observational study F. Sangalli, S. Bucello, L. Moiola, P. Annovazzi, G. Vitello, M. Radaelli, A. Ghezzi, L. Grimaldi, V. Martinelli, G. Comi University Hospital San Raffaele (Milan, IT) Objective: To evaluate efficacy and safety of Tysabri (Ty) in a large number of relapsing remitting multiple sclerosis (MS) patients (pts), attending 3 italian MS centers. Methods: We included 350 consecutive MS pts (F/M ratio 2,2:1; mean age 34,7 + 9,5 ys; mean disease duration 9,6 + 6 ys) receiving Ty since licensed. Pts underwent an MRI scan before inclusion and every 6 months. All pts had a severe MS with a mean annualised relapse rate (ARR) of 2,1 in the previous year and a mean new T2weighted lesions of 3,3 and Gd enhancing lesions of 3,2. Pts that switched from other disease modifying drugs (82%) previously underwent an average of 2,5 different treatments, including immunosuppressant in about 40% of cases. Clinical, neuroradiological and safety data were registered every 6 months. Neutralizing antibody (Nab) were tested after 6 months or in occurrence of allergic reactions. Results: Our pts received a mean of 19± 9 cycles with a mean follow-up of 18.5 months. More than 100 pts have exceeded 24 treatment infusions. The proportion of patients who remained relapse free during follow up was 85% at year 1 and 76% at year 2. The proportion of patients defined as ‘‘MRI free’’ reached 78% and 65% at 12 and 24 months, respectively The ARR significantly decreased during Ty treatment, with a reduction of 90% in comparison to that registered during the 12 months preceding the beginning of therapy. A further reduction was observed during the second year of therapy (61%). The proportion of ‘‘disease free pts’’ (absence of any clinical and/or neuroradiological activity) was of 73% and 63% at months 12 and 24, respectively. The proportion of treatment interruptions was 10%, mainly during the first year. Ty was stopped principally owing to Nab positivity (17 pts). We report two interruption for severe infections. Moreover another patient, previously treated with immunosuppressant drug, recently developed PML, after 29 cycles of treatment. Delayed allergic reactions were detected in 15 cases.

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Conclusions: Our data confirm the great efficacy of Ty, even in a post-marketing study with more restrictive selection criteria. Our cohort of patients in fact presented a more aggressive disease course respect the registrative studies. We also confirmed the safety profile of the drug.

P451 Natalizumab in clinical practice: a meta-analysis from Germany and Switzerland N. Putzki on behalf of German and Swiss study group of natalizumab in clinical practice Objective: to investigate efficacy natalizumab when used according to restricted indication in Europe and Switzerland Background: Natalizumab has been recommended for the treatment of relapsing-remitting multiple sclerosis (RRMS) in patients with insufficient response to interferon-b/glatiramer acetate (DMT) or for aggressive MS. European and Swiss authorities formally restricted use of natalizumab to these groups. Howeevr, the pivotal trials were not conducted to investigate natalizumab monotherapy in this patient and efficacy of natalizumab in such a population is uncertain. Methods: Meta-analysis of two similar, retrospective, multicenter studies in Germany and Switzerland. Seven major MS centers in both countries reported all RRMS patients who initiated natalizumab [/=12 months prior to study conduction to establish a database. Results: 164 RRMS patients were included [71% female, mean age 37.4 years, mean Expanded Disability Status Scale (EDSS) 3.3; 90.8% were pre-treated with DMT], mean treatment duration with natalizumab was 19.7 ± 4.1 months. We found a reduction of the mean annualized relapse rate from 2.2 to 0.3, 80% were relapse free with natalizumab and 91.4% were progression free (change of C1 EDSS point) over 12 months. The mean number of Gd enhancing lesions was reduced to 0.1 (0.9 at baseline). Discontinuation rate was 9.7% (5.6% for antibody-positivity) over the observational period. Conclusions: Natalizumab leads to a reduction of clinical and MRI activity in patients with insufficient response to other DMT. Efficacy in highly active MS is comparable to efficacy demonstrated in pivotal trials for natalizumab. In Switzerland, this study was supported by Biogen Dompe´.

P452 Ten-year follow-up of immunomodulatory therapies in early relapsing- remitting multiple sclerosis J. Haas Jewish Hospital Berlin (Berlin, DE) Objectives: Immunomodulatory therapies (IMTs) still represent the first line therapeutic options for the treatment of relapsing remitting Multiple Sclerosis (RRMS). Comparative long term data on efficacy, tolerability and patient adherence are helpful for recommending initial treatment. The objective of this study was to evaluate the longterm efficacy, safety and patient adherence of four IMTs in daily clinical practice over a period of ten years. Methods: This follow-up analysis was based on a prospectively organized clinical database, including 285 patients, initially treated with b-interferons (INF-b-1a im (Avonex), INF-b 1b sc (Bferon), INF-b -1a 22lg sc (Rebif), and glatiramer acetate (Copaxone) for up to10 years. Adherence to initial treatment was analyzed by KaplanMeier Survival Analysis. Additional efficacy parameters were annual relapse rates, and progression of the disease.

S147 Results: After ten years, 14% of the 285 patients were still on the initial treatment (Glatiramer acetate 21.5%, INF-b-1a im 10%, INFb 1b sc 11.7% and INF-b -1a 22lg sc 12.2%). It was shown by Kaplan-Meier-Analysis that adherence to individual IMT treatment was significantly higher in the Glatiramer acetate group, compared to INF-b-1a im (p\0.01). The mean adherence time under Glatiramer acetate was 56 months, compared to INF-b-1a im (44 months), INF-b 1b sc (49 months) and INF-b -1a 22lg sc (47 months). The number of patients switching the therapy was lowest in patients who started treatment with Glatiramer acetate (45.2% compared to 59.7% under INF-b-1a im, 69.1% under INF-b 1b sc and 62.8% under INFb -1a 22lg sc). Annual relapse rates after ten years of treatment remained significantly lower compared to the annual relapse rates of the 2 years prior to the study in all treatment groups. The number of patients with progression was lowest, although not significantly, in the Glatiramer acetate group (19.1%) compared to the other IMTs. Conclusions: More patients stayed on Glatiramer acetate than on other treatment regimens and the time of adherence was more prolonged under Glatiramer acetate treatment as well. The tendency to switch treatment to another drug was also lowest in patients initially on Glatiramer acetate. Relapse rates and freedom of progression remained on low favourable levels in all treatment groups,although the average disease duration in these patients was close to 15 years.

P453 Retrospective data collection of multiple sclerosis patients treated with disease-modifying therapies in Latvia M. Metra, L. Elsone, M. Murzina, J. Kalnina, A. Paegle Latvian Maritime Medicine Center (Riga, LV) Background: Data of all Multiple Sclerosis (MS) patients in Latvia are collected in the database of the Riga MS center. Objective: The analysis of the disease status of the MS patients treated with disease modifying therapies (DMT), follow-up of two years, and evaluate factors which might influence the disease evolution. Methods: Retrospective review of patients treated with DMT for at least one consecutive year. Disease history, disease status at first symptom, at diagnosis, at start of DMT and after a follow-up of two years. Results: Of 200 treated patients 198 (61.6% female) were included in the analysis. Two patients with less than one year on therapy were excluded. Interferon b 1b (IFNb 1b) was prescribed in 44%, interferon b 1a SC (IFNb 1a SC) in 37.4%, interferon b 1a IM (IFNb 1a IM) in 10.1% and glatiramer acetate (GA) in 8.6% of the patients. The mean age at first symptom was 26.2 yrs (SD 8.4), 0.89 yrs (SD 9.3) at MS diagnosis (McDonald criteria) and 32.4 yrs (SD 9.6) at treatment start. The mean time between MS diagnosis and treatment was 17.9 mths (SD 26.0). Almost 30% of patients started treatment less than 3 months after diagnosis. At start of treatment the mean EDSS was 2.3 (SD 0.9) but was 3.7 (SD 1.4) for patients switching therapy later and the Annual Relapse Rate (ARR) was 1.6 (SD 0.8), and 2.6 (SD 1.1) for later switchers. On MRI 33.5% of patients had T1 lesions, 96.5% had = or [9 T2 and 31% Gadolinium enhancing lesions. The mean duration of follow-up is 2.1 yrs (SD 0.2), patients who stopped the initial therapy were treated for 1.6 yrs. Eight patients switched to another treatment. Seventeen (48.6%) of 37 patients stopped treatment within the two years due to loss of reimbursement and 7 patients (20%) due to lack of efficacy. Only 2 patients changed due to adverse events. During follow-up 47.2% of the patients were relapse free. The ARR of patient who completed two year of therapy was 0.96 at

follow-up and 3.8 for switchers to other therapies. The EDSS was stable in the patients on therapy and increased by 1.7 in switchers. Of 148 patients tested 41.9% had neutralizing antibodies (Nabs) (IFN b 1b= 65%, IFN b 1a SC =33.4%, IFN b 1a IM=5.9%), and 17.7 % of the Nab positive patients had = or [ 3 relapses for 3.5% in patients without Nabs. Conclusions: In a follow-up of two years almost half of the MS patients treated with DMT were relapse free. Baseline EDSS and ARR where higher in patients failing therapy. Loss of reimbursement was the major cause of treatment interruption. Study supported by: A grant from Gedeon Richter and Biogen Idec and Medical writing assistance from Biogen Idec

P454 Higher incidence of nocebo responses to diseasemodifying treatments than symptomatic treatments in multiple sclerosis trials D. Papadopoulos, D.D. Mitsikostas Evangelismos General Hospital (Athens, GR); Athens Naval Hospital (Athens, GR) Objective: The development of non-specific adverse effects following the administration of an active or inert substance is referred to as nocebo phenomenon. This is linked to decreased adherence to treatments in clinical practice as well as difficulty in assessing the adverse effect profile and increased drop-out rates in clinical trials. This study aimed to estimate and compare the incidence and severity of nocebo responses in randomised placebo-controlled trials of symptomatic (STs) and disease-modifying treatments (DMTs) for multiple sclerosis (MS). Methods: We conducted a systematic Medline search for all randomised, placebo-controlled MS trials published between 1989 and 2009. Meta-analysis of the incidence of nocebo responses was performed by pooling the percentage of placebo-treated patients that exhibited adverse events. Nocebo severity was calculated from the percentage of placebo-treated patients that dropped-out due to drugrelated adverse events. Results: Data were extracted from 56 DMT and 44 ST eligible trials. The pooled incidence of nocebo responses was 25.3% (95% CI: 15.24- 36.90) in ST trials and 74.4% (95% CI: 69.92– 88.30) in DMT trials and was significantly higher in the latter (P\ 0.0001). The pooled nocebo severity was 2.1% (95% CI: 1.6 – 2.67) in DMT and 2.34% (95% CI: 1.54–3.29) in ST trials. Meta-regression analysis revealed that nocebo severity in DMT trials exhibited an association with the year of study publication (P= 0.011). Conclusions: The incidence of nocebo responses is higher in trials of disease-modifying treatments than symptomatic MS treatments. Nevertheless, there was no difference in severity of nocebo responses between DMTs and STs. Nocebo responses in MS trials are substantial and appear to have increased significantly in recent years.

P455 Outcomes from the AVONEXÒ (interferon b-1a) pregnancy exposure registry R. Hyde, P. Foulds, S. Richman, G. Glick, T. Onigman Biogen Idec, Inc. (Zug, CH); Biogen Idec, Inc. (Cambridge, US) Objective: The onset of multiple sclerosis (MS) typically occurs between the ages of 20 and 40 years. Because this commonly coincides with a woman’s reproductive years, disease-modifying therapies (DMTs) are likely to be widely used by women of childbearing

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S148 potential. However, there is limited published information on the effects of DMTs on pregnancy outcomes. The objective of this study was to analyse pregnancy outcomes in women with MS who were exposed to intramuscular (IM) interferon b-1a (IFN b-1a) during the first trimester of pregnancy (including 1 week pre-conception). Methods: Pregnant women with MS in the United States who were exposed to IM IFN b-1a within approximately 1 week of conception or during the first trimester of pregnancy were enrolled in an observational, exposure-registration and follow-up study, the AVONEX Pregnancy Exposure Registry. Information on IM IFN b-1a exposure, potential confounding factors (eg, medical history, other medications, smoking), and pregnancy outcomes was collected at 4-5 months of pregnancy and 8–12 weeks after delivery. Reported rates from the registry were compared with available background rates from data sources such as the Metropolitan Atlanta Congenital Defects Program, March of Dimes, and the National Vital Statistics Reports. Results: As of October 2, 2009, a total of 262 pregnancies have been enrolled, and of these, 30 are pending outcome. Of the 232 pregnancy outcomes, there have been 193 live births, 28 spontaneous abortions, 4 induced abortions, 1 still birth, and 6 lost to follow-up. Fifteen of the 193 live births have been associated with defects. The rate of major/serious birth defects was not increased with IM IFN b1a exposure. No malformations or groups of malformations were overrepresented compared with background rates in the general population. Conclusion: IM IFN b-1a was not associated with an increase in the rate of major/serious birth defects, and no malformations or groups of malformations were overrepresented in this prospective registry when compared with the general population. These data should be reassuring for cases where IM IFN b-1a exposure has occurred during pregnancy. Supported by Biogen Idec, Inc.

P456 Associations between annualized relapse rate and longterm exposure to subcutaneous interferon b-1a in the Prevention of Relapses and disability by Interferon b-1a Subcutaneously in Multiple Sclerosis (PRISMS) longterm follow-up study B. Uitdehaag, C. Constantinescu, P. Cornelisse, D. Jeffery, L. Kappos, D. Li, M. Sandberg-Wollheim, A. Traboulsee, E. Verdun, V. Rivera University Medical Center (Amsterdam, NL); University of Nottingham (Nottingham, UK); Merck Serono S.A. (Geneva, CH); Wake Forest University (Winston-Salem, US); University Hospital (Basel, CH); University of British Columbia (Vancouver, CA); University Hospital (Lund, SE); Baylor College of Medicine (Houston, US) Objectives: Consistently better clinical and radiological outcomes are obtained when patients with relapsing–remitting multiple sclerosis (RRMS) are treated with interferon (IFN) b therapy right from onset of disease compared with delayed start of treatment. Long-term follow up (LTFU) of patients in the PRISMS study provides an opportunity to investigate relationships between treatment exposure and measures of disease progression over a 7 to 8 year period. Methods: Patients were eligible to enroll in the LTFU study if they had been randomized to treatment in the original PRISMS study. LTFU visits took place 7–8 years after enrollment and included previously discontinued patients (Kappos et al, Neurology 2006;67:944–953). For these post-hoc exploratory analyses, LTFU

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data from patients randomized to the three original study arms (IFN b-1a 44 mcg sc three times weekly [tiw; n=136], 22 mcg sc tiw [n=123], and placebo [n=123]) were pooled and ranked from lowest to highest (a) cumulative time on treatment, and (b) cumulative dose exposure, by quartiles. Annualized relapse rates (ARRs) across 2year intervals were assessed in the minimum (lowest quartile, MIN) and maximum (highest quartile, MAX) groups. ARRs were also calculated in patients initially randomized to IFN b-1a 44 mcg sc tiw and receiving ‘continuous’ or ‘non-continuous’ (interrupted) therapy. Results: Analyses were conducted in 191 patients (96 in the MIN groups, 95 in the MAX groups). From baseline to LTFU, the MAX time group had a lower mean [standard deviation, SD] ARR compared with the MIN time group (0.51 [0.49] vs. 0.76 [0.55]). These results were mirrored by those seen in the MAX dose group versus the MIN dose group (0.52 [0.51] vs 0.72 [0.55]). When examined over time intervals, the MAX cumulative time and dose groups had consistently lower ARRs than the MIN time and dose groups across baseline to Year 2, Year 2 to Year 4, and Year 4 to LTFU. Similarly, uninterrupted therapy was associated with lower ARRs across all time intervals compared with non-continuous therapy. Conclusion: Results from these post-hoc exploratory analyses of data from the PRISMS LTFU study show that, in patients with RRMS, the greatest reductions on ARR were observed with the highest cumulative time and dose exposures to sc IFN b-1a, for up to 8 years. These findings are consistent with data presented previously and support the importance of patient adherence to long-term, highdose, high-frequency IFN b-1a. Study supported by Merck Serono S.A. – Geneva, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany.

P457 Rationale and design for a study to evaluate the efficacy and safety of PEGylated interferon b-1a in patients with relapsing multiple sclerosis P.A. Calabresi, D. Arnold, L. Balcer, A. Boyko, B.C. Kieseier, J. Pelletier, Y. Zhu, G. Davar Johns Hopkins University (Baltimore, US); McGill University (Montreal, CA); University of Pennsylvania (Philadelphia, US); Russian State Medical University (Moscow, RU); Heinrich-Heine University (Du¨sseldorf, DE); Poˆle de Neurosciences Cliniques (Marseille, FR); Biogen Idec, Inc. (Cambridge, US) Objectives: PEGylation is a well-established process that can enhance exposure to protein-based therapies while maintaining the safety and tolerability of the parent compound. A PEGylated form of interferon b-1a (PEG IFN b-1a) with enhanced in vivo activity, longer half-life, and prolonged exposure is being developed for treatment of MS. The primary objective of this Phase 3 study is to evaluate the efficacy of PEG IFN b-1a in reducing relapse rate at 1 year. Secondary objectives include evaluation of MRI efficacy, the proportion of subjects who are relapse free, quality of life, and disability progression. Methods: ADVANCE is a 2-year, randomised, double-blind, placebo-controlled study evaluating the efficacy and safety of subcutaneous PEG IFN b-1a 125 mcg administered every 2 or 4 weeks. Eligible patients must be 18–55 years old and have confirmed relapsing MS (McDonald criteria) with a baseline Expanded Disability Status Scale (EDSS) score B5.0. Patients must have had C2 relapses within the last 3 years and C1 relapse 12 months prior to randomization. Approximately 1260 patients will be randomized 1:1:1 to placebo, PEG IFN b-1a every 2 weeks, or PEG IFN b-1a

S149 every 4 weeks. Patients on placebo will be rerandomised to PEG IFN b-1a every 2 or 4 weeks after 1 year. Results: Efficacy of PEG IFN b-1a vs. placebo will be assessed using clinical relapses, MRI (± gadolinium), EDSS, MSIS-29 physical score, global impression of change, Multiple Sclerosis Functional Composite score, visual function, and the Symbol Digit Modality Test. QoL will also be assessed using a 12-item short-form health survey, EuroQoL questionnaire, and MS Impact Scale. Safety and tolerability will be evaluated throughout the study by a combination of physical and neurological examinations, vital signs, electrocardiograms, clinical laboratory assessments, Beck Depression Inventory, immunogenicity, injection site assessments, adverse event reporting, and concomitant medication use. Blood will be collected for population pharmacokinetic (PK) and pharmacodynamic, intensive PK, and other biomarker analyses. Conclusion: PEG IFN b-1a is being developed to offer patients with MS the proven safety and efficacy of IM IFN b-1a with improved convenience of administration and, as such, holds promise to be a significant addition to the therapeutic armamentarium for MS treatments. Study supported by Biogen Idec, Inc.

P458 Postmarketing utilization and safety of intramuscular interferon b-1a R. Hyde, P. Foulds, S. Richman, S. Friend Biogen Idec, Inc. (Zug, CH); Biogen Idec, Inc. (Cambridge, US) Objective: Intramuscular interferon b-1a (IM IFN b-1a) was first approved by the US FDA for multiple sclerosis (MS) in May 1996 and is now authorised in 77 countries. Since first approval, an estimated 375,450 patients have been treated with IM IFN b-1a with 1,239,934 cumulative years of exposure. The objective of this study was to report utilisation and safety data for IM IFN b-1a in the postmarketing setting. Methods: Suspected adverse events (AEs) with IM IFN b-1a that have been reported worldwide to Biogen Idec, Inc., since first approval have been maintained in a safety database. Terms have been classified in accordance with regulatory authorities. All suspected adverse drug reactions (ADRs) in the database from the most recent 3-year reporting period (May 2006-May 2009), including spontaneous reports, literature case reports, and serious suspected ADRs from clinical trials, were analysed. ADRs of special interest and the safety profile in special populations (eg, paediatric, elderly, pregnant women) were also evaluated. Results: During the reporting period, an estimated 51,950 new patients with 373,971 person-years of exposure were treated with IM IFN b-1a. The most frequent ADR was flu-like symptoms, similar to the package insert. Reporting rates of malignancies were consistent with background incidence rates and there was no indication of a causal relationship with IM IFN b-1a. ADRs in children and adolescents (age\18 years) suggest that the safety profile of IM IFN b-1a in this population is consistent with that of adults. ADRs reported in elderly patients (age C65 years) were in agreement with those in patients age\65 years. The nature and character of pregnancy-related events did not indicate that IM IFN b-1a produced any teratogenicity or maturation defect. Conclusions: The overall safety profile of IM IFN b-1a in MS is consistent with current prescribing information and no new safety issues were identified during this reporting period. The nature of ADRs over time has remained constant, and there has been no increased risk in the occurrence of any unexpected AEs not seen with shorter term use. Supported by Biogen Idec, Inc.

P459 Predictive factors of response to first-line immunomodulatory treatment in patients with relapsing-remitting multiple sclerosis: evaluation of the first two years of treatment in an Italian single-centre study M. Romeo, M. Rodegher, F. Martinelli Boneschi, V. Martinelli, M. Radaelli, L. Straffi, G. Comi University Hospital San Raffaele (Milan, IT) Objectives: The objective of the study is to evaluate the efficacy of first-line immunomodulatory treatments (IMT) and to identify clinical and neuroradiological predictors of response to therapy in a large cohort of patients affected with relapsing-remitting multiple sclerosis (RRMS) and treated at the Multiple Sclerosis Centre of the Scientific Institute San Raffaele in Milan. Methods: This is a retrospective and single-center study conducted on 1.374 RRMS patients who had received IMT in a time frame period between January 1996 and July 2009. A follow-up of 2 years have been considered for the analyses. Patients were visited every 3 months and performed a brain MRI every year. Potential predictors of efficacy assessed were: gender; age and disability (EDSS) at the beginning of treatment; type of onset (unifocal/multifocal); time interval between onset and first relapse and between onset and start of the treatment; annualized relapse rate (ARR) in the 2 years preceding treatment; T2 lesion number and active lesions at the beginning of treatment; type of IMT treatment (Interferon(IFN) b-1a, INF b-1b and glatiramer acetate (GA)). Criteria of 2-year efficacy were: full responder (no relapse during treatment; no new T2 or T1 active lesions at MRI); non responder (reduction of ARR on treatment less than 50% compared to the 2 years before treatment or accumulation of [2 new T2 lesions or [2 active T1 lesions at annual MRI scan); partial responder. Analyses have been performed according to an intention-to-treat approach. Potential predictors were tested using a multivariate logistic regression model with backward variable selection. Results: Predictors of full response to IMT were: higher age at drug start (p\0.0001), lower EDSS at disease onset (p\0.0001) and lower ARR before treatment (p: 0.02), while predictors of full/ partial response were: higher age at drug start (p=0.002), lower EDSS at onset (p=0.07) and at the time of drug start (p\0.0001). Moreover, high-dosage of IFN (Rebif44; Bferon) and GA were predictive of a better response than lower-dosage of IFN (Rebif22; Avonex) (p\0.002). Conclusion: The identified algorithms of predictors could help in the selection of RRMS patients who could benefit more from treatment in the daily clinical practice of MS centers. Moreover, comparison across treatments confirms the results of head-to-head clinical trials and post-marketing studies, showing a greater efficacy of high dose IFN-b and GA over low dose IFN-b.

P460 ‘Induction therapy’ strategy for highly aggressive multiple sclerosis at onset G. Liberatore, M. Rodegher, L. Straffi, M. Bianco, M. Romeo, V. Martinelli, G. Comi San Raffaele Hospital (Milan, IT) Objectives: to report 9 cases of early highly aggressive Multiple Sclerosis (MS) treated with immunosuppressive drugs, Cyclophosphamide (CTX) or Mithoxantrone (MTX), or Natalizumab (NTX). Methods: 9 patients who experienced a first aggressive episode suggestive of MS (mean age 26 years), with an EDSS at onset ranging

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S150 from 4.0 to 7.5 were admitted into the Neurological Department of S. Raffaele Institute in Milan. We considered these cases as ‘‘malignant MS’’ either for clinical aspects (very severe relapses) or for the MRI aspects (very high lesional load or pseudo-tumoral lesion evidence), or both. The patients were hospitalized in our MS centre within 6 months from the symptom onset. All 9 patients were treated initially with i.v. high-dose Methylprednisolone, three patients were considered unresponsive and therefore had plasmaexchange to control the disease activity. Afterwards, a more aggressive treatment was required with ‘‘second-line therapy agents’’: immunosuppressive drugs, such as MTX or CTX, or NTX. Three patients were treated with monthly infusions of CTX at dosage of 800 mg/m2 (the lowest number of infusions was 8), three patients received monthly infusions of MTX at dosage of 10 mg/ m2 for 6 cycles and subsequently they continued treatment with immunomodulants, while three patients were treated with NTX (12 infusions). Results: at a follow-up of 12 months all patients showed a significant clinical and neuroradiological improvement. Eight patients had an EDSS from 1.0 to 2.0 and one patient treated with NTX had a higher residual disability (EDSS 4.0). No clinical relapses were documented during the short-term follow-up. Brain MRI was performed after one year of therapy and showed a relevant decrease of lesion load and absence of enhancing lesions. The treatments were well tolerated and adverse events were minimal. Conclusion: Although rarely, MS may have a highly malignant aspect at onset. Despite the absence of clinical studies that unequivocally support the use of intensive immunosuppression in patients with rapidly worsening MS, in our experience an ‘‘induction therapy’’ strategy has been effective both in improving and stabilising patients with early aggressive disease. However, the therapeutical decision in each case should be taken individually considering clinical and neuroradiological severity, in order to obtain from therapy the greatest reduction in the risk of accumulation of irreversible disability at the very initial stage of the disease.

P461 Autologous haematopoietic stem cell transplantation in multiple sclerosis: myeloablative versus non-myeloablative conditioning regimens Y. Motuzova, A. Fedulov, A. Uss, N. Milanovich, V. Zmachinsky, A. Baida, M. Minzer, E. Chernysh, I. Bulaev, V. Smolnikova, L. Drazhina, N. Solovieva Belorussian State Medical University (Minsk, BY); Belorussian Center of Transplantation and Cell Biotechnology (Minsk, BY) Objectives: Autologous haematopoietic stem cell transplantation (AHSCT) is a promising therapeutic strategy in severe multiple sclerosis (MS) refractory to conventional therapy. The efficacy of AHSCT is due to the intense immunosuppressive therapy, which eradicates the autoreactive clones and also leads to the resetting of the immune system. The choice of the conditioning regimen (CR) with the best efficacy and safety profile is still debated. In our study we used both low- and intermediate-intensity regimens to establish whether they have similar clinical and side effects. Methods: Twenty-one patient with pharmacoresistant MS was included. For 11 patients CR consisted of cyclophosphamide (60 mg/ kg for 2 days), antithymocyte globulin (20 mg/kg for 3 days) and methylprednisolon (125 mg for 5 days) (CY+ATG+MP), and 11 patients got treatment according to the BEAM regimen. The median baseline EDSS score in the group CY+ATG+MP was 6.5 (range, 2.5– 7.0) and in the group BEAM – 5.5 (range, 2.0–6.5). The median follow-up time is now 52,9 months (range, 36–67) in the group CY+ATG+MP and 20,5 months (range, 9–34) in the group BEAM.

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Results: After CY+ATG+MP five patients experienced continuous neurologic stabilization in disability and two patients had improvement of 1 and 3.5 points in the EDSS score. Three patients had gradual progression with EDSS scores increase of 0.5 points within 24 to 48 months after AHSCT. One of them progressed after the period of improvement of 48 months in 0.5 EDSS points. Nine patients after BEAM remained neurologically stable. One patient had improvement in 1 point in the EDSS score, but 1 patient had progression after 6 months in 0.5 points. MRI evaluations were obtained at baseline, 6 months, and every year after AHSCT. After CY+ATG+MP only one patient developed new enhancing lesions on gadolinium-enhanced brain MRI and MRI of patients after BEAM were without new gadolinium-enhanced lesions. Regimen-related toxicities were mild for both regimens. Complications included hematologic toxicity, hepatotoxicity, fatigue, nausea, vomiting, fever, that reduced spontaneously. Conclusion: Both conditioning regimens have an acceptable toxicity, are well tolerated, do not show any mortality and clearly reduce the progression of MS in the period up to 67 and 34 months of followup in CY+ATG+MP and BEAM groups, respectively. Further followup is necessary to establish the real efficacy of both conditioning protocols on the long-term evolution of MS.

P462 Allogeneic haematopoietic stem cell transplantation in severe recurrent transverse myelitis M. Radaelli, L. Moiola, V. Martinelli, F. Sangalli, V. Barcella, P. Vezzulli, R. Greco, F. Ciceri, G. Comi University Hospital San Raffaele (Milan, IT) Objectives: To report our experience of HLA identical sibling stem cell transplantation (Allo-HSCT) in patients with recurrent transverse myelitis (rTM). Methods: case report. Results: The patient (pt) is a 30 years old man who developed rTM in march 2007. The determination of IgG-NMO antibodies was persistently positive. The spinal cord MRI revealed longitudinally extensive transverse myelitis involving dorsal regions. Serial brain MRI were normal. He showed several clinical relapses, with only partial recovery after both steroids and plasmaexchange (PE). He was treated with high dose Cyclophosphamide (Cy) and then with Rituximab (RTX) without a control of the disease. Therefore, in march 2008 he underwent autologous HSCT with Thiotepa and Cy conditioning. In September 2008 and subsequently in February and April 2009 he developed three clinical and neuroradiologial relapses with partial recovery after high dose steroids and PE. Because of the important disease activity with no response to several immunosuppressive drugs he underwent Allo-HSCT. The EDSS at baseline was 6.0. After signed informed consense he received a Treosulfan-Fludarabine based myeloablative conditioning regimen, consisting of: Fludarabine i.v. 30 mg/m2/d day -6 to -2,Treosulfan i.v. 14 g/m2/d day -6 to -4, ATG i.v. 10 mg/kg day -4 to -2, RTX i.v. 375 mg/mq day -1. The graft source was peripheral blood stem cells. At day 0 pt received 5.98x106 infused CD34+cells/Kg. The prophylaxis for graft-versushost disease was based on standard cyclosporine plus short course methotrexate. Hematopoietic recovery required 21 days for neutrophil and 6 days for platelet engraftment. Twelve days after Allo-HSCT pt experienced a clinical relapse reaching an EDSS of 8.0, with worsening of the dorsal spinal cord lesion with gd enhancement and slow recovery after high dose steroids. There were no major adverse events. In the following months he presented a progressive improvement of clinical condition and no more relapse were observed. At a maximum follow-up of nine months the EDSS is 5.0

S151 and no enlargement and enhancement of the spinal cord lesion was observed. Conclusions: our experience suggest that Allo-HSCT may be beneficial in patients with neuromyelitis optica spectrum of disorders reducing disease activity and arrest the disability progression, with safety profiles and low toxicities. Obviously a longer follow-up and other patients are warranted in order to assess the real risk/benefit ratio.

P463 Sodium channel blockers and disease progression in multiple sclerosis T. Counihan, G. Gormley, S. Saidha Department of Neurology (Galway, IE); National University of Ireland (Galway, IE) Objectives: Multiple Sclerosis (MS) is a chronic, immune-mediated demyelinating disease of the CNS. Disease progression and long-term disability are thought to result from secondary axonal damage, mediated through Na-channel dysfunction. Pharmacological blockade of axonal Na channels in animal models of MS is neuroprotective. The effects of Na-channel blockade in MS patients is unknown. Our specific aim was to determine if patients with MS who have been treated with widely available Na-channel blockers for symptom management, have altered disease progression over time. Methods: Retrospective study, as part of the establishment of an MS database of patients attending a regional Neurology Unit. Data was collated on disease duration, expanded disability severity score (EDSS) and Multiple Sclerosis Severity Score (MSSS) for the cohort as a whole, and compared to a subset of patients who had been exposed to Na channel blockers for a minimum of 3 months. Results: Data was available on 100 patients with MS. For the whole cohort, the mean disease duration was 12 years; the mean EDSS score was 4.2 and the mean MSSS was 5.1. Twenty patients had been exposed to Na channel blockers; of this subset of patients, mean disease duration was 18.8 years: mean EDSS was 4.73 and mean MSSS was 5.15. Conclusion: The findings of this study suggest that MS patients exposed to Na channel blockers may have slower rates of disease progression. Completion of the MS database may provide further insight into the potential disease-modifying effect of Na channel blockade in patients with MS.

P464 MS-like disease after anti-TNF therapy in a patient with severe rheumatoid arthritis carrying a TNFRSF1A D12E mutation J. Havla, R. Hohlfeld, P. Lohse, T. Ku¨mpfel Ludwig-Maximilians-University (Munich, DE) Objectives: Mutations in the TNFRSF1A gene result in the autoinflammatory disease tumor necrosis factor receptor 1-associated periodic syndrome (TRAPS), which is characterized by recurrent, self-limiting attacks of fever, abdominal pain, diarrhea, arthritis, myalgia, and conjunctivitis. Recently, the TNFRSF1A gene has been identified also as a new susceptibility locus for multiple sclerosis (MS).We describe a 28-year-old woman with severe rheumatoid arthritis (RA), TRAPS-related symptoms, and a TNFRSF1A D12E mutation, who developed possible MS after anti-TNF treatment. Case Report: Our patient reported her first attacks of arthritis during pregnancy in 2002. Her arthritis worsened subsequently. In

addition, she had episodes of diarrhea, conjunctivitis, and abdominal pain. A diagnosis of RA was made and anti-rheumatic treatment with prednisolone and methotrexat initiated. Since her arthritis responded insufficiently, anti-TNF therapy was begun in 2005 which led to an improvement of her rheumatological symptoms. After a syncopal episode in 2007, cerebral MRI was performed which showed multiple periventricular white matter lesions. CSF analyses revealed positive oligoclonal bands suggesting possible MS. AntiTNF therapy with Enbrel was discontinued and anti-rheumatic therapy with Orencia (abatacept) started. A MRI of 03/2009 showed disease activity with new, partly contrast-enhancing lesions without clinical correlate. Due to the unusual medical history and presentation, genetic testing was performed which revealed a D12E mutation encoded by exon 2 of the TNFRSF1A gene. Treatment with Arava (leflunomid) was initiated because this might have a positive effect both on RA and MS. Conclusion: To our knowledge, this is the first patient with a TNFRSF1A D12E substitution who developed severe rheumatological disease before as well as MS-like disease after anti-TNF therapy. The mutation may have increased the inflammatory response and led to the presentation of severe RA and TRAPS-related symptoms such as abdominal pain and conjunctivitis in this patient. Both, the D12E mutation and the anti-TNF therapy, may have triggered the MS-like disease. This may have important implications for the treatment of RA and MS. This case also highlights the close pathogenetic relationship between TNF signalling, and autoimmune diseases such as RA and MS.

Neuro-oncology P465 Tie2/TEK modulates the interaction of glioma cells with tumour micro-environment D. Liu, J. Fueyo, V. Martin, J. Xu, N. Cortes-Santiago, H. Jiang, E. White, C. Gomez-Manzano M.D. Anderson Cancer Center (Houston, US) Objectives: Our group has previously reported that the tyrosine kinase receptor Tie2/TEK is expressed in the nonstromal compartment of gliomas and is associated with the malignant progression of gliomas. In the current study, we sought to determine whether the angiopoietin 1 (Ang1)/Tie2 axis regulates crosstalk between glioma cells and the tumor microenvironment. Methods: In vitro experiments involved glioma, brain tumor stem cells (BTSCs), and endothelial cells (ECs). Cellular biology experiments were designed to study adhesion of several components of gliomas and invasion using modified Boyden chambers in the presence of several neutralizing antibodies. FACS, Western Blotting, and immunohistochemistry were utilized to analyze the expression of molecules related to the modulation of tumor microenvironment. In vivo experiments included intracranial implantation of brain tumor stem cells, and glioma cells in combination with ECs, in immunocompromised animals. Results: Adhesion experiments revealed that Ang1 enhanced the adhesion of Tie2-expressing glioma cells and BTSCs to ECs. Conversely, specific siRNA knockdown of Tie2 expression inhibited the capability of glioma cells to adhere to ECs. Tie2 also mediated integrin b1 and N-cadherin upregulation, and neutralizing antibody against these molecules inhibited the adhesion of glioma cells to ECs, suggesting a significant role in the Tie2-mediated adhesion of glioma cells to the tumor microenvironment. In addition, Tie2-positive glioma cell invasion was enhanced with Ang1 treatment and inhibited by

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S152 decreasing Tie2 expression using by siRNA or when the experiment was performed in the presence of neutralizing antibodies against integrin b1. We also found that the interaction of Tie2-positive glioma cells with ECs when implanted intracranially in mice resulted in the development of diffusely invasive tumors characterized by the presence of cell clusters surrounding glomeruloid vessels, which suggested an in vivo interaction between Tie2-positive glioma cells and endothelial cells mimicking a ‘‘tumor niche’’ organization. Conclusion: Our findings suggest that Tie2 signaling is involved in the adhesion of glioma cells to stromal components and that this adhesion is critical to the ability of malignant gliomas to acquire an invasive phenotype, situating Tie2 as a key ‘landscape’ regulator in brain tumors, and a potential therapeutic target. The work presented here was partially supported by the American Brain Tumor Association and the Elsa U. Pardee Foundation.

P466 Experimental cytoregulatory therapy of brain glial tumours with cell systems of haematopoietic precursors epigenetically reprogrammed for apoptosis induction: victory in vitro and failure in vivo A. Bryukhovetskiy, I. Bryukhovetskiy, V. Chekhonin, V. Baklaushev NeuroVita Clinic (Moscow, RU); State Research Centre of Social and Forensic Psychiatry (Moscow, RU) Objectives: Establishing a theoretical, experimental and technical basis for C6 glioma cytoregulatory therapy (CRT) in rats in vitro and in vivo. Methods: Passaged rat C6 glioma culture as well as CD34+ & CD 45- human hematopietic stem cells (HSC) were used for the experiment. Epigenetic reprogramming (ERp) for HSC apoptosis was achieved through ricin. The script of HSC and hematopietic precursors (HP) ERp to induce instructive apoptosis in brain glial tumours (BGT) cells was to nanocapsulate ricin into biodegradable nanocontainers (biodegradation period 24 hours), to implant them into HSC and HP and to transplant into tumour. The scheme of less than 500 nm nanocontainers preparation was offered. The treatment in vivo was performed in 20 adult Wistar male rats with experimental brain C6 glioma in left hemisphere. Control group A consisted of 7 C6 glioma rats received no treatment; control group B had 7 C6 glioma rats received native HSC and HP transplanted into tumour; control group C – 7 C6 glioma rats had ricin intracerebrally injected into tumour. CRT was given 7 days after stereotaxic implantation of C6 glioma. Results: In vitro model of glioblastoma therapy (joint culturing of glioma cells and ERp HSC and HP for 7 days) proved the opportunity of inductive instructive apoptosis in brain tumour cell possible and displayed high therapeutic efficiency of the cell preparation with predetermined properties: C6 glioma cell number reduced by 52%. Regulation and management of rat C6 glioma cells were demonstrated in vitro. The results in vivo: in experimental group ERp of HSC and HP increased C6 glioma growth almost twice as compared to A group, while B group displayed tumour volume reduced by one third as compared to A group; C group showed total necrosis of brain substance in the site of implantation of apoptosis inductor and cortical areas. The immunochemical and histological signs of instructive apoptosis in tumour cells in vitro and in vivo caused by HSC and HP ERp are present. Phenomenon of brain tumour increase after HSC and HP ERp in vivo can be explained by early degradation of nanocontainers and by insufficient time for the cells to distribute through tumour. Conclusion: HSC and HP ERp in vitro permit intracellular biomanagement and interstitial regulation of BGT growth. It is required

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to change the mode of biodegradation of HSC and HP implanted nanocontainers that is to increase it to 7–10 days.

P467 Molecular signatures in meningioma tumours A. Montinaro, C. Gianfreda, O. D’Urso ‘‘V.Fazzi’’ Hospital (Lecce, IT) The ability to distinguish benign from atypical and anaplastic tumors is important because of its impact on treatment decisions. Existing criteria do not adequately predict the rates of tumor growth or the likelihood of tumor recurrence. Also, the histopathological classification system provides no information on underlying molecular alterations. In contrast, a molecular based classification system has the likelihood of being a better prognostic indicator and is useful for identifying alterations in pathways and networks that drive tumor progression and growth. The information obtained can potentially be translated into more effective and less toxic targeted therapies. We tested a method for genome wide expression profiling of formalin-fixed, paraffin-embedded tissues. We applied the method to the analysis of the clinical outcome of meningioma tumor. All analyses were performed with the use of GenePattern. We investigated whether gene-expression profiles of meningioma tumors were associated with the clinical outcome. For each of the 51 patients in the training set, tumor-containing portions of the formalin-fixed paraffin embedded blocks were macrodissected away from surrounding tissue. Using a standard leaveoneout cross-validation procedure, we found the meningioma signature to be significantly correlated with survival (P = 0.0001). The survival correlated signature contained 219 genes and was tested in the validation set. These results support the validity of the survival signature and highlight the potential role of tumoral meningioma tissue in predicting the outcome for patients with meningioma tumors.

P468 Survival-related factors in 82 patients with glioblastoma. Experience at a single-centre in Argentina L. Schottlaender, J. Alderuccio, M. de la Fuente, H. Martinetto, A. Muggeri, B. Diez, M. Nogue´s Neurological Research Institute (Buenos Aires, AR) Objective: The purpose of this presentation is to evaluate if age (C or \ to 50 years), gender, Karnofsky Performance Status (KPS) (C or \ 70), type of resection (debulking surgery versus biopsy), epidermal growth factor receptor (EGFR) amplification and methylguanine desoxyribonucleic acid- methyltransferase (MGMT) promoter status impacted on progression free survival (PFS) and overall survival (OS) in our series of patients. Methods: 82 consecutive patients with histologically confirmed GBM treated at Neurological Research Institute (FLENI) between May 2005 and August 2009 were analyzed retrospectively. All patients were treated with surgery followed by induction with focal RT (60 Gy) plus continuous daily TMZ in a dose of 75 mg per square meter of body surface per day for 42 uninterrupted days, and subsequent maintenance with 28-day cycles of TMZ for two years or until disease progression or unacceptable toxicity. MGMT promoter status was assessed in 40 of 82 patients with real time polymerase chain reaction. EGFR gene amplifications were assessed in 49 of 82 patients with a multiplex real time reaction including glyceraldehyde 3-phosphate dehydrogenase as reference gene.

S153 Survival was analyzed by Kaplan-Meier method and prognostic factors with two-sided Log-rank test. Results: The median age was 60 years (range 18-75). 62% were males. The median follow-up was 13 months (range 2-54). 89% undergone debulking surgery. 83% presented with a KPS C 70. Twenty nine out of fourty nine analyzed patients had EGFR amplification and nineteen out of fourty had a methylated MGMT promoter. At 12 and 24 months PFS was 39,1% and 22,1% respectively and OS was 64% and 41,2%. Age, gender, type of resection, EGFR amplification and MGMT promoter status were not associated with improovement of PFS and OS. The KPS C 70 was statistically significant (p = 0.02) for survival. Conclusion: The 12 and 24 months PFS was 39,1% and 22,1% respectively. The 12 and 24 months OS was 64% and 41,2%. In our series only KPS impacted significantly on survival.

P469 Bebacizumab in recurrent glioblastoma: clinical and radiologic challenges S. Carrasco Garcı´a de Leo´n, A. Herna´ndez Gonza´lez, M.J. Alva´rez Soria, J. Domı´nguez Be´rtalo, M.J. Gallardo Alcan˜iz, J. Vaamonde Gamo Hospital General Ciudad Real (Ciudad Real, ES) High-grade gliomas are highly vascularized tumors that represent attractive targets for antiangiogenic therapies. Bevacizumab is an anti-vascular endothelial growth factor antibody with activity against recurrent glioblastoma multiforme (GBM). It induces vascular normalization of tumor, inhibits tumor growth, and restores the bloodbrain barrier integrity reducing peritumoral edema. One of its more common adverse effects is hypertension and it has been described as cause of reversible posterior leukoencephalopathy syndrome (RPLS). We report a case of recurrent GBM after bevacizumab treatment that offered a diagnostic pitfall because the clinical and radiologic characteristics. A 58 year old man was diagnosed of left occipital GBM. Surgical resection followed by radiotherapy and temozolomide chemotherapy was established. Local recurrence appeared twenty months later. After local radiosurgery, bevacizumab plus irinotecan treatment was initiated. The blood pressure remained within the usual range during chemotherapy. At sixteenth week, he suffered an abrupt increase in blood pressure with cortical blindness, anosognosia, headache, and spatial disorientation. T2-weighted and fluid-attenuated inversion recovery images on magnetic resonance imaging (MRI) showed non-enhancing high signal intensity lesions in left posterior parieto-occipital and right temporo-occipital regions, without restricted water diffusion pattern. The clinical and radiologic findings were suggestive of RPLS. Bevacizumab was stopped and antihypertensive therapy and dexamethasone were started, with partial resolution of symptomatology. A new MRI performed fifteen days later, showed a contrastenhancing lesion at right temporo-occipital lobe. Recurrence of GBM was confirmed at follow-up. Radiographic assessment of tumoral response, measured primarily by change in the contrast enhancing tumor volume, is problematical with antiangiogenic therapies. Bevacizumab reduces vascular permeability resulting in loss of contrast enhancement. So, images of seeming remission may mask infiltrating growth. Moreover, RPLS may complicate the therapy, offering a challenge to discriminate among tumoral infiltration, edema, gliosis or treatment-related encephalopathy. Neuro-oncologists and radiologists should be aware of these questions in order to optimize therapeutic decisions.

P470 Late recurrent thymoma. A case series J.E. Spillane, N. Hirsch, D.M. Kullmann, C. Taylor, R. Howard Institute of Neurology (London, UK) Background: In patients with MG, thymoma may recur many years after initial resection Aim: To describe cases of late recurrent thymoma amongst myasthenic patients in a tertiary referral centre. Methods: Cases of late recurrent thymoma were retrospectively identified and medical notes were reviewed. Results: 5 patients with a recurrent thymoma were identified. 4 were male. The average age at first tumour presentation was 47.6. 4 patients presented with MG. 4 had apparent full excision of their thymoma. One patient had invasive disease at first presentation with incomplete resection and adjuvant radiotherapy. The mean disease free interval to recurrence was 13.5 years. Three cases of recurrence were detected on routine scanning whereas the other 2 patients presented with cough or chest pain. Four patients had repeat surgery. Two patients had palliative radiotherapy and two had chemotherapy. 3 patients died. One patient was successfully treated for recurrence but developed sporadic motor neuron disease. One patient remains disease free 3 years after repeat surgery. Conclusion: Thymoma may recur many years after surgery even if the initial tumour has apparently been completely resected. Tumour recurrence may be associated with a poor prognosis. Surveillance scanning after thymoma resection is essential and should continue indefinitely.

P471 Primary spinal Non-Hodgkin lymphoma: a case report J. Rallis, N. Andronas, P. Tsirigotis, S. Papageorgiou, S. Sgouros, I. Panagiotidis, A. Andrikopolou, C. Arvaniti, G. Raptis, N. Oikonomopoulos, M. Papathanasiou, E. Stamboulis Attikon University Hospital of Athens (Athens, GR) Primary CNS lymphoma is a rare Non-Hodgkin lymphoma that accounts for 1–2% of all intracranial tumors in immunocompetent patients. It usually presents as a brain mass lesion, but may also involve other locations such as the leptomeninges, the eyes and the spinal cord. A 51 year-old male was referred to our department for further investigation due to cervical pain, right arm weakness and gait disturbances that developed during the previous month. His history was unremarkable, except for arterial hypertension. On clinical examination Horner’s pupil was noted on the right eye, right hemiparesis with reduced propioception ipsilaterally, as well as decreased pain and temperature sense on the left with a sensory level at T2. Cervical MRI revealed three intramedullary lesions: a larger one at level C3-C4 and two smaller ones at C2 and C5-C6. Each lesion was surrounded by edema and enhanced homogenously after contrast administration. Treatment with intravenous methylprednisolone was initially accompanied by remarkable clinical improvement. On MRI only two of the lesions were visible after corticosteroid therapy with substantially decreased size and perifocal edema. During the following months his symptoms recurred with increased intensity and he gradually developed quadriparesis. MRI showed focal enlargement of the spinal cord at level C3-C4 and surrounding edema that extended into the thoracic region. Surgical biopsy was performed and a high-grade B-cell Non-Hodgkin lymphoma was diagnosed on pathologic examination. The patient received combination therapy with high-dose Methotrexate, high dose cytarabine, intra-Omaya Rituximab followed by radiation treatment, unfortunately without significant improvement. Primary intramedullary lymphomas of the spinal cord are rare and until now 19 cases have been reported in the literature. Treatment

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S154 strategies usually include combination chemotherapy and irradiation treatment but the prognosis in most cases is not favorable. Primary spinal lymphoma should be considered in the differential diagnosis in cases of atypical and recurrent intramedullary lesions, especially if there is dramatic improvement with corticosteroid therapy.

P472 Ependymal localization of cerebral melanoma: an atypical presentation E. Coppi, L. Moiola, V. Barcella, F. Scomazzoni, M. Radaelli, F. Sangalli, M. Terreni, V. Martinelli, G. Comi University Hospital San Raffaele (Milan, IT) Background: during embryogenesis melanocytes migrate from the neural crest to the basal layer of the epidermidis; some of them populate the uveal tract and leptomeninges in adults. Methods: a 54-year-old woman presenting a progressive clinical deterioration (persistent headache, weight loss at first, vomit, hearing loss and dizziness with increasing difficulties in walking later) was admitted to a Neurologiacal department where a brain MRI study showed a periventricular ependymal and leptomeningeal enhancement; a lumbar puncture showed increase in proteins (194 mg/dL), cells (12/ mm3) and ACE-index (15.6) in the cerebrospinal fluid (CSF). Bacteriological and virological analysis on plasma and CSF were negative. Patient was treated with i.v. ganciclovir, riphampicin, teicoplanin, fluconazole and methylprednisolone without any clinical improvement; she was discharged with diagnosis of ‘‘possible neurosarcoidosis’’, even with a negative chest CT study and normal blood concentration of ACE. The day after the patient was admitted to our department; psychomotor retardation, memory loss, severe hypotrophy and flaccid hypotone in lower limbs with impossibility in walking were found. Also progressive decrease in consciousness occured. A MRI follow-up confirmed the pathological enhancement in the periventricular ependyma and in leptomeninges with a corresponding FLAIR hyperintensity. At second lumbar puncture testing only a greater increase in proteins (313 mg/dL) was found. Bacteriological and virological analysis (including M.tuberculosis, Borrelia, Brucella, Cryptococcus, enterovirus, adenovirus, herpesviruses) were negative. Moreover, dermatological and ophthalmologic examinations were negative. An endoscopic biopsy of the periventricular ependyma showed brownish material covering lesions; histological analysis showed a high grade cancer and immunohistochemistry revealed positive reactions to melanoma markers. Few days later patient deceased and permission for autopsy was denied. Conclusions: mean survival time in cerebral primitive melanoma is usually 5 years but the prognosis drops dramatically to 6 months if leptomeningeal dissemination occurs, while metastatic melanomas have a rapid course but usually present with multiple axial lesions. Without autopsy diagnosis is uncertain. Since MRI study recall a primitive melanoma and no other systemic localization of desease were found we speculate that an ependymal localization of a primitive melanoma may be suspected.

P473 Primary central nervous system lymphoma in immunocompetent patients: a 15-year experience at a single neurological centre in Argentina M. de la Fuente, L. Schottlaender, A. Muggeri, M. Nogue´s, B. Diez Neurological Research Institute (Buenos Aires, AR) Objective: To analyse demographic as well as clinical and radiographic findings in a group of patients diagnosed with primary central

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nervous system lymphoma (PCNSL) at Neurological Research Institute (FLENI), Argentina. Methods: Thirty immunocompetent patients with histological confirmation of PCNSL evaluated at FLENI between 1995 and 2009 were analyzed retrospectively. To exclude systemic disease, initial diagnostic work-up included general physical examination, human immunodeficiency virus testing, serum lactate dehydrogenese assay, lumbar puncture with cell count, total protein count, cerebrospinal fluid (CSF) cytology and flow cytometry, ophthalmologic evaluation with slit-lamp examination of both eyes, contrast-enhanced cranial and spinal magnetic resonance imaging, bone scan and computed tomography of the chest, abdomen and pelvis. Results: Median age was 63.5 years (range 32–82), with a male-tofemale ratio of 3.2:1. Six patients referred personal history of another cancer. Karnofsky Performance Scale was C 70 in 73% of patients. Median time at diagnosis was 4 weeks (range 0–40). At clinical manifestations 20 patients presented with progressive motor deficits, 9 progressive cognitive impairment, 6 aphasia and 1 seizures. Three patients had sudden onset. Radiological findings: unifocal lesions 21 (70%), multifocal 9 (30%), 28 (93.33%) supratentorial and 2 (6.66%) infratentorial, frontal lobe was the most commonly affected (43%). CSF: atypical cells were found in 2 (6%). None patient had ocular o spinal lymphoma at diagnosis. Diagnosis: 12 stereotaxic biopsies (40%), 7 open biopsies (23.33%) and 11 resections (36.66%). Histopathological analysis: diffuse B cell lymphoma 28 (93.33%) and large B cell lymphoma 2 (6.66%). Conclusions: Compared to PCNSL previously reported series we found a shorter time from presentation to diagnosis. Our study also showed a lower incidence in ocular and spinal lymphoma. Among the other demographic, clinical and radiographic findings we obtained similar results to other series.

P474 Paraneoplastic cerebellar degeneration. Would you search for endometrial cancer? G. Vlachos, V. Zouvelou, M. Rentzos, D. Manoli, I. Evdokimidis National and Kapodistrian University of Athens (Athens, GR) Introduction: Paraneoplastic neurological syndromes are rare, but their importance lies in the fact that they sometimes precede a malignancy and can therefore evoke the diagnostic work-up necessary to detect an occult tumour. Case presentation: A 58-year-old woman presented with an acute (10-day) history of gait unsteadiness. Neurologic examination revealed a wide-based gait, inability to tandem walk, mild bilateral horizontal gaze-evoked nystagmus, saccadic pursuit, bilateral dysdiadochokinesia and hyporeflexia. Magnetic resonance imaging of the brain revealed no lesions or atrophy of the cerebellum. Cerebrospinal fluid analysis showed a lymphocytic pleocytosis of 18 cells/mm3, an increased IgG index and oligoclonal bands. A possible paraneoplastic etiology was considered and the patient underwent further investigations. Anti-Yo were positive, Cancer Antigens 125 and 15-3 were abnormal and the pelvic computed tomography revealed a mass beneath the abdominal wall. Paraneoplastic cerebellar degeneration was diagnosed and urgent gynaecological assessment was sought, because of high suspicion for an occult ovarian malignancy. The clinical examination, pelvic ultrasound and Pap smear were negative, but on reassessment one month later the endometrial biopsy showed serous endometrial

S155 adenocarcinoma. She underwent hysterectomy and bilateral salpingooophorectomy in the first week of 2010. Her neurologic examination has been stable since then. Discussion: Paraneoplastic cerebellar degeneration is usually a complication of small-cell lung cancer, ovarian and breast tumours and Hodgkin’s lymphoma. Very few cases associated with endometrial cancer have been described so far. The syndrome is usually acute (within hours to weeks) and relentless, leaving the patient severely handicapped. What sets our patient apart is the relatively mild presentation. Although her gait is affected, she remains able to ambulate short distances without assistance and her speech is normal.

P475 A case of paraneoplastic cerebellar degeneration due to breast cancer detected by MRI R. Real, A. Oliveira, G. Nadais Hospital S. Joa˜o (Porto, PT) Paraneoplastic neurological syndromes (PNS) are a group of rare and heterogeneous disorders complicating cancer through immunemediated mechanisms. They typically arise prior to the diagnosis of malignancy, thus constituting its first clinical manifestation. The diagnosis of a PNS mandates a search for the underlying tumour, as adequate tumour management is essential for both neurological prognosis and overall survival. Current guidelines recommend conventional imaging (usually CT) followed by PET scan as a general screening approach. It is not uncommon, though, that the aforementioned strategy produces a negative result on a first attempt, so that periodic re-evaluations are recommended until a positive tumour diagnosis is achieved. We present the case of a 43 year-old female patient who presented with a subacute cerebellar syndrome associated with the onconeural anti-Yo antibody. A paraneoplastic aetiology was suspected and the underlying tumour looked for. The preliminary investigation included a chest x-ray, a mammogram, a pelvic ultrasound and a pap smear, a thoracic, abdominal and pelvic CT scan and finally a whole-body FDG-PET scan, none of which contributed to a positive diagnosis. Because paraneoplastic cerebellar degeneration presenting in women with positive anti-Yo antibodies is most frequently associated with ovarian carcinoma, exploratory laparoscopy has been suggested as a possible strategy to look for occult gynaecological malignancy. But since this is an invasive procedure and our patient had a family history of breast cancer (the second most frequent malignancy occurring in association with cerebellar degeneration and anti-Yo antibodies), a breast MRI was performed, which revealed the presence of an enhancing nodular lesion. This was subjected to fine needle aspiration biopsy that revealed a high grade ductal carcinoma in situ. Although this represents a typical case of PNS, it highlights the importance of directing tumour search for the most probable locations and also the need to use the most sensitive diagnostic modalities appropriate for each target organ. We therefore suggest that breast MRI be included in the routine investigation of female patients with paraneoplastic cerebellar degeneration associated with anti-Yo antibodies, particularly in the presence of a positive family history of breast cancer. A more targeted diagnostic approach may ultimately reduce the time to tumour diagnosis with obvious prognostic implications.

P476 Lacosamide in brain tumour patients with refractory seizures: efficacy and tolerability H. Newton, J. Connelly, J. Lima, H. Cunningham, D. Pearl, M. Malkin Ohio State University Medical Center (Columbus, US); Medical College of Wisconsin (Milwaukee, US) Objectives: Seizures are a common complication of primary brain tumors, affecting more than 75% of all patients during the course of their illness. Anticonvulsant therapy of these tumor-induced seizures is often inadequate with conventional antiepileptic drugs (AEDs), due to a variety of factors such as activation of glutaminergic NMDA receptors, immune-mediated neuronal damage, and anatomic alterations of inhibitory neuronal input pathways. Locasamide is a new AED with a novel mechanism of action, that involves selective enhancement of slow inactivation of voltage-gated sodium channels, which results in stabilization of hyper-excitable neuronal membranes, as well as binding to neuronal collapsin response mediator protein-2 (CRMP2). Because of this unique mechanism, it has been postulated that lacosamide may be effective in controlling refractory tumor-induced seizures. Methods: To address this issue, we have performed a retrospective chart review of all neuro-oncology patients at our Medical Centers who have received lacosamide for seizure control. Results: Thirteen patients were reviewed (8 male, 5 female), with a median age of 47 years (range 31-70). The types of PBT included GBM – 4, oligo – 4, oligoastrocytoma – 1, pilocytic astrocytoma – 1, pineoblastoma – 1, DNET – 1, and gliomatosis cerebri - 1. Lacosamide was used as an add-on AED in 11 patients and as monotherapy in 2 patients, with a median dose of 100 mg/day (range 50–225 mg/day). The baseline median seizure frequency for the cohort was 2 per week. After the addition of lacosamide, the median seizure frequency was reduced to less than 1 per month (46% of patients noted complete seizure control). Overall, the seizure frequency was reduced in 10 of 13 (77%) patients and unchanged in two others (p=0.004; Wilcoxon signed rank test). The most common toxicity was mild dizziness, noted in several patients. Conclusion: Lacosamide showed significant anti-seizure activity and was well tolerated in this small cohort of brain tumor patients with refractory seizures. Lacosamide should be considered for add-on therapy to current AEDs in this group of patients and, in selected cases, may also be considered for monotherapy.

P477 Efficacy of C knife radiosurgery in recurrent oligodendrogliomas J.H. Park, S.Y. Yang Kangwon National University College of Medicine (Kangwon-do, KR); DongGuk University College of Medicine (Gyeonggi-do, KR) Object: To evaluate the efficacy of stereotactic C knife radiosurgery (GKRS) performed as an adjuvant treatment in 35 patients with recurrent low- and high-grade oligodendrogliomas. Methods: Between December 1997 and April 2009, 35 patients with recurrent low- and high-grade oligodendrogliomas (12 Grade II and 23 Grade III) were treated using GKRS in a single institution. The mean patient age was 43.4 years (range, 11–71). Of these 35 patients, 28 received a full course of radiotherapy after primary diagnosis with a median dose of 55.4Gy in conventional fractionation and 12 received at least one chemotherapeutic regimen including procarbazine, cyclophosphamide, and vincristine (PCV). The mean time

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S156 between microsurgery and GKRS was 60.9 months (range, 4.1– 146.0). The mean target volume was 5.10 cm3 (range, 0.04–25.60) and the mean margin dose was 16.2Gy (range, 10–23). Results: At a mean of 54.1 months of follow-up (range, 6.8–141.0) after GKRS, 18 patients were dead and 17 were living. Mean overall survival after primary diagnosis was 162.8 months for patients with oligodendroglioma and 89.5 months for patients with anaplastic oligodendroglioma. Mean survival after GKRS was 119.7 months for patients with oligodendroglioma and 50.3 months for patients with anaplastic oligodendroglioma. Postradiosurgical chemotherapy and histology were significant in influencing survival after GKRS. Mean progression-free survival after GKRS was 71.5 months for oligodendroglioma and 26.3 months for anaplastic oligodendroglioma. Factor associated with an improved progression-free survival was histology. At tumor progression after GKRS, tumor resection was conducted in 13 patients and chemotherapy was performed in 11 patients, including the administration of temozolomide, bevacizumab, irinotecan, or PCV, taking into consideration prior systemic treatments. Conclusion: GKRS offers considerable treatment option as a salvage therapy for a subgroup of patients with smaller lesions of recurrent oligodendrogliomas.

P478 Intrathecal rituximab in Bing-Neel syndrome M.C. Kyrtsonis, M. Siakantari, N. Karandreas, J. Gianouli, C. Kilidireas

Department. The immnohistochemical analysis of the cerebral mass sustained the diagnosis of plasmocytic plasmacytoma with secretion of Kappa chains and he received 3 cycles of polychemotherapy (vincristin+adriamicin+dexamethasone), the last one just 3 days before the presentation. On physical examination the patient had fever (40 degrees Celsius), was confused, agitated, without nuchal rigidity or motor deficit, Babinski sign present bilaterally, unresponsive to simple or complex tasks. The brain MRI revealed a meningeal lesion located parietal superior on the right side, parasagital. The lumbar puncture showed marked elevated CSF proteins (607mg/dl), with 2680 elements/mm3. The cultures were positive for Streptococcus pneumoniae and the patient received antibiotherapy according to this, with good outcome. Antiepileptic treatment has also been given having in consideration both repetead tonico-clonic seizures and meningeal lesion. The patient was discharged after 21 days with mild tetraataxia and without cognitive impairment (MMSE score 29/30). Discussions: The initial presentation of a multiple myeloma with CNS involvement, the clinical course complicated by bacterial meningoencephalitis (probably in context of the immunosupressive treatment) and with generalized seizures make this case particular. The overall incidence of CNS involvement according to the literature is about 1%. Even more unusual is CNS involvement as the initial presentation of multiple myeloma. The two largest series on record have included a total of 27 patients; CNS involvement was diagnosed concurrently with multiple myeloma in only one of those cases. Long-term survival is poor. Median survival is estimated at approximately 4–5 months. In our case, 7 months after the initial diagnosis the clinical status of the patient is still good.

University of Athens (Athens, GR) A 50 years old female with an underlying disease history of Waldenstrom’s macroglobulinemia (WM), presented right hemiypesthesia subjective sensory symptoms and weaknes of right arm. MRI revealed leptomeningeal involvement and Bing-Neel syndrome was diagnosed. WM is an indolent B-cell lymphoma (CD20+) characterized by bone marrow lymphoplasmacytic infiltration, serum IgM monoclonality and frequent lymph node involvement. Extranodal involvement including CNS is very rare. I.V treatment with monoclonal anti-CD20 antibody (rituximab) is effective in WM. In the present case, intrathecal rituximab resulted in improvement of patient’s condition as it is reflected in clinical scales [10-15% improvement in MRC, hand grip, vibration threshold, two point discrimination, sensory sum score, 9hole peg test]. Neurophysiological testing showed no change in the subclinical sensory axonal neuropathy and slight improvement in SSEP. MRI remained unchanged after treatment but PET-scan was negative. The patient remained in stable condition for 3 years and then presented lymphoma relapse manifested by lymph node swelling and serum IgM increase correlated with neuropathy worsening. However no CNS relapse was observed. In conclusion, intrathecal rituximab may be helpful in CNS B-cell neoplastic disorders. Further studies are needed for determination of the exact dose and length of therapy required.

P479 Intracerebral plasmacytoma complicated with bacterial meningoencephalitis: case report M. Comanescu, G. Vulpe, S. Petrescu, L. Manta, C. Panea Elias University Hospital of Emergency (Bucharest, RO) Case report: We present the case of a 62-year old man with a medical history of multiple myeloma (M.M.) stage IIIA, reffered to our Department for altered mental status and fever. The diagnostic of M.M. was established after the detection of an intracerebral plasmacytoma surgically removed 4 months before the admission in our

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__________________________________ Poster session 4 Cerebrovascular disorders: genetics/clinical observations P480 CADASIL: report of a family with a new mutation c.3766_3771 dup in the exon 22 in the NOTCH-3 gene D.A. Garcı´a-Este´vez, F. Barros Hospital Comarcal de Monforte de Lemos (Lugo, ES); University of Santiago de Compostela (La Corun˜a, ES) Introduction: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a familial arteriopathy of the brain caused by missense mutations in NOTCH-3 gene on chromosome 19, and it is an important cause of stroke in young adults. Affected patients typically experience recurrent subcortical ischemic events, leading to a stepwise cognitive decline; migraine and depression are also common. We report the case of a Spanish CADASIL family in which a novel mutation in NOTCH-3 gene was found. Case report: The propositus case was a 78-year-old man who had a history of migraine with visual aura and mild high blood pressure treated with 5 mg of enalaprile. He had had three ischemic strokes (2 LACI, 1 PACI), and recently he was diagnosed of atrial fibrillation and treatment with acenocumarol was started. Magnetic resonance imaging (MRI) of the brain showed lacunar infracts and leukoencephalopathy. Granular osmiophilic material was not identified in skin biopsy. The genetic analysis revealed a novel mutation c.3766_3771 dup/normal in the exon 22 of NOTCH-3 gene. This mutation produces the insertion of arginine and cysteine in the protein.

S157 The patient’s father had died because of stroke in his forties. In the second generation there are other two affected relatives (patient’s sisters, 87 and 83 year-old). They had a history of migraine with visual aura and lacunar stroke, they had diffuse leukoencephalopathy on brain MRI. The genetic study confirmed that they had the novel mutation. Nobody had dementia. Conclusions: We report a Spanish CADASIL family with a new mutation c.3766_3771 dup in heterozygosis in the exon 22 in NOTCH-3 gene. This mutation seems to affect elderly people and it is not accompanied by vascular dementia.

P481 The association of single nucleotide polymorphism Thr312Ala a-chain fibrinogen gene (rs6050) with ruptured and unruptured intracranial aneurysms in a Polish population sample K. Spisak, E. Szczygiel, M. Wnuk, J. Jagiella, M. Moskala, M. Krupa, M. Opalka, J. Pera, A. Slowik

unruptured aneurysms (Pera J. Stroke 2010). C-reactive protein (CRP) is an inflammatory protein that contributes to the risk of vascular diseases. Some single-nucleotide polymorphisms (SNPs) in the CRP gene are reportedly associated with the CRP plasma levels. The aim of the presented study was to investigate association between the C1444T polymorphism of the CRP protein gene (rs1130864) and the risk of ruptured or unruptured aneurysms. Methods: We genotyped 466 patients with aneurysms (410 ruptured and 56 unruptured) and 532 controls matched for age and gender. The C1444T SNP was studied by the Real–Time PCR Analysis. Results: The distribution of the studied polymorphism did not differ between all cases and controls (cases: CC–47,94%, CT–35,62% TT–7,94% vs. controls: CC–44,92%; CT–44,56%, TT–10,52%., p=n.s.).There was not a significant difference in the distribution of the studied SNP when patients with ruptured and unruptured aneurysms were considered separately. Conclusion: The C1444T polymorphisms of the CRP protein gene is not associated with the presence of aneurysm (ruptured or unruptured) in a Polish population. The study was supported by grant no. K/PBW/000343

Jagiellonian University Medical College (Krakow, PL) Background and purpose: There is a growing evidence that ruptured and unruptured aneurysms present with different expression of inflammatory genes (Pera et al. Stroke 2010). Fibrinogen is an acute phase protein synthesized in the liver, which plasma levels reflects the intensity of inflammatory process. The significance of different fibrinogen polymorphisms, including the Thr312Ala one, and the risk of ruptured or non ruptured intracranial aneurysms was not studied before. The fibrinogen a Thr312Ala allele alters fibrinogen a-a chain cross-linkage and affects plasma fibrinogen level. We performed the study analyzing the significance of the Thr312Ala a-chain polymorphism (rs6050)of the fibrinogen gene in patients with ruptured and unruptured intracranial aneurysms in the Polish population sample. Methods: We genotyped 459 patients with the diagnosis of intracranial aneurysm (56 with unruptured aneurysm and 403 with ruptured aneurysm) and 550 controls matched for age and gender whithout any history of neurological disease and normal neurological examination. The SNP was studied by Real–Time PCR Analysis. Results: The distribution of the studied polymorphism differed significantly between patients with unruptured intracranial aneurysm: ThrThr – 41.07%, ThrAla - 53.57% AlaAla - 5.35% and controls: ThrThr - 59.28%; ThrAla - 34.36%, AlaAla – 6.36%., p=0.02.There was no significant difference in the distribution of the studied polymorphism between patients with subarachnoid hemorrhage due to ruptured aneurysm (ThrThr – 60.54%, ThrAla - 35.23% AlaAla - 4.21%) and the controls (ThrThr - 59.28%; ThrAla - 34.36%, AlaAla – 6.36%., p=n.s.). Conclusion: The study show that patients with ruptured and ruptured aneurysms present with different distribution of the polymorphism which affect the inflammatory response. The study was supported by grant no. K/PBW/000343

P482 The association of single nucleotide polymorphism C1444T of the CRP protein gene (rs1130864) with subarachnoid haemorrhage in a Polish population sample E. Szczygiel, K. Spisak, M. Wnuk, J. Jagiella, M. Moskala, M. Krupa, M. Opalka, J. Pera, A. Slowik Jagiellonian University Medical College (Krakow, PL) Background and purpose: Recent data show that inflammatory genes present with altered expression in the wall of both ruptured or

P483 Bilateral paramedian thalamic infarction with hypothalamic dysfunction E. Papuc, K. Rejdak, A. Brzozowska-Jaskiewicz, Z. Stelmasiak Medical University of Lublin (Lublin, PL) Objective: Acute bilateral infarction of thalamus is not common as it represents 0.6% of first ever acute ischemic strokes, but is usually associated with specific neurological and neuropsychological symptoms. Here we present an atypical case of acute bilateral paramedian infarct with concomitant hypothalamic dysfunction. Methods: 58 years old patient was found at home in comatose state, with preserved breathing and circulation; toxic causes of coma were excluded before admission to our department. The patient remained comatose for 3 days. Since the 4th day the consciousness was fully recovered, but the patient presented hypersomnia, amnesia, transcortical aphasic syndrome with confabulations, vertical gaze palsy and discrete right hemiparesis. We performed in the patient brain angio-CT, brain MRI, duplex sonography of the carotid and vertebral arteries with transcranial Doppler, ECG, 24-hour ECG monitoring, echocardiography. Results: Brain MRI revealed ischemic lesions located bilaterally in the paramedian thalamus. Brain angio-CT scans showed a filling defect of both P 1 portions of posterior communicating arteries. 24hour ECG monitoring revealed one paroxystic short lasting episode of atrial fibrillation. We have not found other risk factors for stroke in the patient. Results of more accurate blood tests revealed hypothalamo-pituitary dysfunction. Conclusions: Bilateral paramedian thalamic infarcts may result from occlusion of one paramedian thalamic artery. Paramedian artery (originating from P1 section of the posterior cerebral artery)and tuberothalamic artery (originating from posterior communicating artery) and are two arteries responsible for the vascular supply of posterior hypothalamus. We hypothesize that in lack of both posterior communicating arteries in our patient, paramedian artery was responsible for blood supply to the posterior hypothalamus, thus its occlusion resulted in bilateral thalamic infarct with hypothalamic dysfunction. Atrial fibrillation remains the most frequent cause of cardio-embolic stroke, but it usually escapes from standard ECG or Holter monitoring. Emboligenic source is the second cause of stroke in patients with bilateral thalamic involvement. However our case and data from literature show that in paramedian infarcts,

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S158 cardioemboligenic source is more frequent than in other thalamic infarcts.

P484 Bilateral paramedian thalamic infarct: reports of 7 cases and review of literature M. Gioulis, S. Zambito Marsala, F. De Biasi, R. Berletti, L. Capus, R. Candeago, F. Ferracci, C. Marchini, M. Gentile Hospital San Martino (Belluno, IT); University of Trieste (Trieste, IT) Objective: To investigate clinical presentation of bilateral paramedian thalamic infarct (BPTI) and possible correlation between symptomatology and anatomical structures. Background: Paramedian artery arise from the P1 section of the posterior cerebral artery, and supply the paramedian part of the upper midbrain and the thalamus, including the intralaminar nuclear group and most of the dorsomedial nucleus. In some cases one single pedicle may supply the paramedian territory on both sides and the corresponding infarcts may be bilateral. Methods: We studied 7 patients admitted with BPTI. They underwent complete neurological examination, brain CT and MRI, EEG and neuropsychological assessment with regular follow up. Results: Disturbances of vigilance was the initial symptom in the majority usually recovered in few days. Cognitive deficits with disorientation, difficult access to vocabulary, non fluent speech, impairment of selective attention and immediate memory were frequent and with poor outcome. One patient showed severe bulimia and compulsive obsessive attitude. Oculomotor disorders consisted in vertical gaze and ocular eyelid apraxia. Focal motor symptoms were transitory even if mild disequilibrium may persist and invalidate motor autonomy. One patient showed an epileptic status as initial presentation. Conclusion: Our survey disclosed that BPTI usually presents with sudden acute consciousness impairment, vertical gaze palsy and slight transitory motor symptoms. Generally vigilance improves while oculomotor disorders may be unchanged. Neuropsychological abnormalities and emotional dysregulations constitute the real sequelae of disease. Cognitive deficits may be related to lesions of the anterior nucleus, non specific thalamic nuclei, mammilothalamic tract, as well as to a thalamic-prefrontal dysconnection syndrome. The evidence of epileptic status in one patient as initial symptom is intriguing. We hypothesize the possible role of reticular and intralaminar nuclei.

P485 Retinal infarct after excessive use of oxymetazoline nasal spray M. Martinez-Corral, E. Peral, M.J. Esquerre´-Victori, M. Bolea-Soler, C. Serrano-Munuera St. Joan de Deu Hospital (Barcelona, ES) Objective: To report a case of retinal infarct related to chronic abuse of decongestant (oxymetazoline) nasal spray. Methods: A 42-year old man was evaluated for acute unilateral vision loss. Retinal ischemia suggestive of right central retinal artery occlusion was observed. The patient had no risk factors for cardiovascular disease and his past history revealed only chronic allergic rhinitis and excessive use of oxymetazoline (0,05%) nasal spray (2-3 drops up to 10 times per day during more than one year; recommended dosage: maximum 3 times per day up to 3 days).

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Results: Investigation of possible causes of retinal infarction (EcoDoppler of carotid arteries, magnetic ressonance imaging (MRI) angiograpy, electrocardiogram and echocardigram, cardiac rhythm monitoring for 24h, lipids, serologies and coagulation studies) was negative. Cerebral MRI was also normal.The patient recovered well, remaining only a small central scotoma with normal funduscopic exam after one month. Transient vasospasm of the central retinal artery due to oxymetazoline was suspected to be the cause of the retinal infarct. Conclusion: Nasal decongestants have been associated with ischemic and hemorrhagic stroke related to hypertensive crisis and vasculitis-like mechanisms. Branch retinal artery obstruction in a patient with platelet aggregation hypersensitive to epinephrine and a case of ischemic optic neuropathy in a patient with predisposing risk factors have also been described. Reversible segmental intracranial vasoconstriction has been described in a patient with thunderclap headache. Central retinal artery occlusion due to local vasospasm was only recognized before as a complication of nasal mucosa anesthetic with adrenaline. Although in recommended doses oxymetazoline has no significant effect on retrobulbar hemodynamics, we propose local vasospasm of the central retinal artery as a plausible adverse effect of oxymetazoline nasal spray overdose.

P486 Intracranial venous sinus thrombosis with involvement of internal jugular vein, complicated by intracranial haemorrhage – A case report M. Nowakowska-Kotas, A. Pokryszko-Dragan, A. Robaczewska, M. Szymczyk, R. Podemski Wroclaw Medical University (Wroclaw, PL) Introduction: Cerebral venous sinus thrombosis is a rare (less than 1%) cause of strokes. Thrombosis of internal jugular vein also occurs rarely (although it is considered to be underestimated), usually as a complication of malignancy, oropharyngeal infection or trauma. The patients described presented with a unique coexistence of these two conditions. Case report: A 36- years-old woman was admitted to our clinic due to pain in parietal region and right side of neck, which was constantly increasing during a few days. On admission two seizures occurred. Past relevant history included: cigarette smoking for two years, oral contraceptives for one year. Computed tomography (CT) scan performed at the onset of symptoms was normal. CT repeated after seizures (together with angioCT) revealed haemorrhage in right parietal lobe, with no presence of aneurysm or vascular malformation. The magnetic resonance imaging and magnetic resonance venography (MRI/MRV) of brain showed thrombosis of right sigmoidal and transverse sinuses and Labbe’s vein.Doppler ultrasonography revealed thrombosis of right internal jugular vein. Other tests, including D-dimer concentration in serum, were unremarkable. No features of thrombophilic, malignant or autoimmune diseases were found. The patient was treated with low-molecular-weight heparin (LMWH), antiepileptic drugs and antibiotics (due to concomitant pharyngitis). On follow-up five months later the patient’s neurological status was stable and on MRV there was no sign of thrombosis in MRV examination, only the narrowness of sigmoidal and transverse sinus with decreased blood velocity in that area. Conclusion: Rare coincidence of thrombosis of intracranial sinus and internal jugular vein, with accompanying headache, deserves special attention as a serious potential risk factor for cerebral stroke.

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P487 Cerebral air embolism after haemodialysis in a patient with atrial septal defect J.H. Kwon, Y.E. Shin Ulsan University Hosptial (Ulsan, KR) Cerebral air embolism sometimes develops after invasive procedure such as open heart surgery or central venous catheterization. Even it would develop after hemodialysis (HD) without cautious manipulation of circuit. We report a patient who developed cerebral infarction associated with air embolism after HD due to inadequate manipulation of circuit. A 49-year old woman with hypertension admitted our hospital complaining of loss of consciousness after HD. She had a history of end stage renal disease due to glomerulonephritis under treatment by HD. When the 4-hour HD had been completed uneventfully, she lost her consciousness and about 5 cc air was remained in the HD circuit. She also complained of headache, dizziness and nausea after recovery of her consciousness. Generalized tonic clonic seizures developed 1 day after admission and weakness in the right upper and lower extremities was manifested. She was treated with hyperbaric oxygen therapy and intravenous phenytoin. MR image and angiography taken 5 days after symptom onset showed subacute infarctions in bilateral frontal lobes, more severe on the left side. Atrial septal defect with left to right shunt and aneurysm in the intraatrial septum were observed on the transthoracic echocardiography. In conclusion, her cerebral infarction might be due to paradoxical air embolism in the presence of cardiac shunt. Physicians should be concerned of possibility of cerebral air embolism when the patient with HD shows neurologic deficits immediately after HD other than disequilibrium syndrome.

P488 Ischaemic posterior optic neuropathy in CREST syndrome – case report A.C. Ribeiro, A. Leita˜o, P. Coelho, A.S. Morgadinho, J.G. Gonc¸alves Coimbra’s General Hospital (Coimbra, PT) Introduction: The relationship between CREST (acronym for its five main features: Calcinosis; Raynaud’s phenomenon; Esophageal dysmotility; Sclerodactyly and Telangiectasia) Syndrome and Cerebrovascular Disease is not well established in current scientific literature. Nonheless, some articles refer to the association of this syndrome with neuropathological changes typical of vasculitis or small caliber brain arteries mineralization. Case Report: Forty-year-old female patient with previously diagnosed CREST Syndrome (for nearly one year) complains of a sudden left facial hypoesthesia latter followed by sudden loss of visual acuity in the left eye. Her nailfold capillaroscopy was compatible with skin capillary vasculitis; she presented frequent migraine headaches and easy bruising (with minor trauma or non-steroidal anti-inflammatory drugs) as well as severe hematoma (during surgical procedures) and two miscarriages, one associated with severe bleeding. Her blood analysis showed no hemorrhagic tendency or pro-thrombotic positive risk factors with the exception of high titres of ANA. At that time she was medicated with oral prednisolone 20mg/day and pantoprazol 40mg/day and had discontinued azathioprine for about one month. Her neurological examination showed severe visual acuity impairment on the left eye, with only 2/10 of vision; normal fundoscopy; afferent papillary defect; diminished left eye corneal reflex; left hemifacial hyposthesia and left 4+ grade hemiparesis on the BMRC scale with left Babinski’s sign and loss of all sensations on the left hemibody. The CT-scan revealed no acute lesions and the brain MRI demonstrated a non-specific right semi-ovale center lesion with similar punctiform lesions on the subcortical white matter substance in both

cerebral hemispheres. Her orbit MRI and fluoresceinic angiogram were both normal. The optical coherence tomography and visual evoked potentials regarding her left eye were abnormal. The final diagnosis was of a posterior ischemic optic neuropathy (PION). Conclusion: The association of CREST Syndrome and Cerebrovascular disease is considered rare even though large vessel disease was recognized for more than a decade ago with the onset of Raynaud’s phenomenon. As currently endorsed, this disease maybe associated with systemic or primary central nervous system (CNS) vasculitis and whether it is due to secondary vasculopathy or a more primary involvement, the cause of CNS vascular injury still remains unknown.

P489 Cerebral vascular disease in a cystinotic patient D. Neutel, R. Geraldes, J. Pimentel, T. Pinho e Melo Hospital de Santa Maria (Lisbon, PT) Introduction: Cystinosis is an autosomal recessive lysossomal storage disease due to a CTNS gene defect leading to intralysosomal cystine accumulation in many tissues, mainly in the kidney, liver, eye and thyroid. Associated cerebrovascular disease has rarely been reported. Case report: A 32-year-old woman with infantile nephropathic cystinosis, diagnosed at the age of two, presented with sudden onset of speech and gait disturbance. She was on cyclosporine for renal transplantation for 17 years. Currently she was on chronic dialysis, had hypothyroidism and hypertension. Neurologic examination showed severe bilateral visual loss, pendular nystagmus, right central facial palsy and crural paresis. MRI showed cerebral atrophy and acute left anterior cerebral artery ischemia. Transcranial Doppler and MR Angiography showed stenosis of right carotid artery (upper to choroidal artery emergence) and medial cerebral artery, occlusion of the right A1 segment, congenital defect of the posterior cerebral arteries, filiform vertebral and basilar arteries and a stenosis of the right external carotid artery. She was readmitted 3 months after discharge for global aphasia and right hemiparesis. MRI showed left posterotemporal acute ischemia in the territory of medial cerebral artery. She suddenly died for unknown reasons. Neuropathological examination disclosed an atrophic brain with cortical, left frontal and parietal, sub-acute, ischemic infarctions, polyfocal perivascular inflammatory mononuclear infiltrate, patchy cortical spongiform change and dysplastic focal calcifications. Medial and anterior cerebral arteries presented segmentar subintimal thickening suggesting early atheromatous plaques. Small vessels were unremarkable. No cystine crystals deposits were observed. Discussion: Neuropathological descriptions of patients with cystinosis are scarce, especially in those with longstanding disease. A cystine crystal associated vasculopathy has been described. However these patients have several cerebrovascular risk factors, mainly related to renal failure. In our patient we could not find vessel crystal deposition and an atherosclerotic vasculopathy could explain the cerebrovascular events. Yet, similarly to previous descriptions, the post mortem examination disclosed indirect evidence of cystinosis brain involvement, such as atrophy and perivascular inflammatory infiltrates.

P490 Transient spinal cord ischaemia as presenting manifestation of polycythemia vera S. Costa, J. Marques, J. Campillo, A. Valverde Hospital Professor Doutor Fernando Fonseca EPE (Amadora, PT); IPO Lisboa (Lisbon, PT) Background: Spinal arterial vascularization is supplied by a large anastomotic net, making spinal ischemic events far less common than

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S160 ischemic cerebral strokes. Usually the causes of spinal ischemic events are aortic or vertebral artery disease, compression/trauma, iatrogenic, and less frequently systemic diseases such as vasculitis or severe systemic hypotension. Polycythemia vera is a rare hematologic disease associated with blood hyperviscosity and higher risk of thrombotic events. Case Report: Fifty-two year old male, presented a sudden onset of low back pain without radiating pain, with motor deficit in the lower limbs. Initial neurologic examination disclosed proximal paraparesis with abolished myotatic and plantar reflexes, bilaterally. Spontaneous clinical recovery was observed, and 24hours later only hyperactive myotatic reflexes in the left lower limb were observed. Five months later, a new episode with same symptoms occurred, resolving in 30 minutes. Initial laboratory evaluation showed only high erythrocyte and platelet counts, with increased hemoglobin and hematocrit. Lumbar puncture, somatosensitive evoked potentials, spinal MRI and electromyogram were normal. A spinal angiography was performed, showing the origin of artery of Adamkiewicz at the D11 level, with no ascending branch. Diagnosis of Polycythemia Vera was confirmed after bone marrow biopsy and myelogram, findings of splenomegaly on CT-scan, low levels of Erythropoietin and positive JAK2 V617F mutation. He was treated with phlebotomies, hydroxyurea and a platelet inhibitor. No new neurologic symptoms have been reported since treatment was started. Conclusions: Polycythemia vera, due to blood hyperviscosity and activated platelet aggregation, is associated with a higher risk of arterial and venous thrombotic events, namely in the cerebral, ocular, coronary and pulmonary territories. We report a patient with spinal cord transient ischemic attacks, a rare presenting manifestation, which highlights the thrombotic potential of this disease.

P491 Thrombosis of anterior spinal vein INA 15 Y/O girl with immediate recovery after superselective intraarterial thrombolysis R. Rangel-Guerra University Hospital (Monterrey, MX) Introduction: Spinal venous thrombosis is an extremely rare clinical entity and there very few reports in the literature. Objective: To present case of a progressive paraparesis, produced by thrombosis of the arterial spinal vein. Material and methods: 15 y/o WF with flaccid paraparesis of 3 week duration which progressed to paraplejia. This was preceded by lumbar pain with radiation to lower limbs. No sphincter involvement. hyperreflexia in lower extremities with bilateral Babinski sign. MRI of spinal column: apparent dural fistula, in upper throracic cord which, induced to perform spinal panangiography which showed that there was no dural fistula but the films showed absence of filling of the anterior spinal vein with vascular stasis in the territory of anterior spinal artery. Thrombolysis with rt PA was performed through the Adam Kiewicz artery, with filling (6 seconds later) of the anterior spinal vein, with immediate recovery of the paraplegia Neuroprotective drugs were also used. Results: Occlusion of the anterior spinal vein is rare and the differential diagnosis with occlusion of the anterior spinal artery is sometimes difficult, but in the first case the deficit is gradual and the arterial occlusion the symptoms are acute. There was an irripressive response and the patient began to walk immediately after the hemodynamic procedure.

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Conclusion: Clinical case with thrombosis of the anterior spinal vein, (which is an extremely rare entity), was resolved successfully with superselective thrombolysis.

P492 Stroke due to transient occlusion of the middle cerebral artery in a young patient with sporadic Torg-Winchester syndrome S. Mittas, B. Tettenborn, A. Felbecker Kantonsspital St. Gallen (St.Gallen, CH) Objectives: The Torg-Winchester syndrome is a genetic disorder of the matrix metalloproteinase–2 with multicentric osteolysis with predominant involvement of the hands and feet. Affected persons are prone to develop renal failure. We present a young patient with sporadic Torg-Winchester syndrome and stroke due to middle cerebral artery (MCA) occlusion. Methods: We describe the case of a 22-year-old Caucasian patient with sporadic Torg-Winchester syndrome, who suffered a stroke due to an occlusion of the MCA. The patient’s past medical history was significant for renal transplantation and multiple aneurysms in both arms, which did not extend to the afferent brain vessels. Recently, he has suffered a thrombosis of an aneurysm in the right axilla and was treated with low-molecular-weight heparine at the time of admission. He has the clinical features but no family history of osteolytic syndromes. The patient reported to our clinic with a sudden appearance of a complete left central facial weakness. He received extensive diagnostic work-up including MRI with MR-angiography, echocardiography, Doppler-sonographic evaluation of the cervical arteries, 24h-ECG and a blood coagulation screening. Results: Cranial MR imaging with MR-angiography a few hours after the onset of symptoms revealed a complete thrombotic occlusion of the right MCA in the M1 segment and an infarction of the right striatum. A few hours post –stroke the patient’s facial palsy had attenuated. A second cranial MRI with angiography four days after admission showed a revascularized MCA and an infarction of almost the whole MCA territory in the diffusion-weighed images, even though clinical symptoms had resolved almost completely at that time. Aetiologic assessment revealed no embolic sources, a blood coagulation screening showed a homozygous Plasminogen Activator Inhibitor 1 4G Promotor Polymorphism. Conclusion: This is the first case report of a cerebrovascular event in a patient with idiopathic multicentric osteolysis. TorgWinchester syndrome (autosomal recessive) and Hereditary Osteolysis (autosomal dominant) are multicentric osteolysis - syndromes with loss-of-function-mutations in the gene encoding for the matrix metalloproteinase - 2 (MMP-2). Matrix metalloproteinases are known to play a role in angiogenesis and vascularization. We discuss the possible role of MMP-2 in our patient’s cerebrovascular disease.

P493 Spontaneous subdural haematoma during weightlifting A. Antunes, R. Geraldes Hospital Santa Maria (Lisbon, PT) Introduction: Spontaneous Subdural Haematoma (SSH), without a history of traumatism or vascular malformation, is rare. Clinical case: A previously healthy 23 year-old male presented with a one-week history of an exertion (weightlifting) headache that progressively got worse, vomiting and photophobia. He had no

S161 history of orthostatic headache, hemorrhagic diathesis, or illicit substance use. The neurologic exam was normal. Brain CT scan showed a SH with left lateralization on the cerebellar tentorium, extending to the left side of the falx and a small extra-axial frontal collection. A complete coagulation workup was unremarkable. Brain MRI confirmed the haematic collection on extra-axial localization with subacute characteristics, and excluded parenquimatous lesions and showed no meningeal gadolium reinforcement. Classical cerebral angiography (including external carotid arteries) did not identify any vascular malformation. There was spontaneous resolution of the headache and no treatment was warranted. Discussion: Although rare, SSH were more frequently described in late middle age males, associated to coagulopathies, alcohol/ illicit substances, brain tumours, vascular malformations, arachnoid cysts and intracranial hypotension and most required neurosurgical intervention. There are very few reports of SSH in association with Valsava maneuver. The pathogenesis of these SSH has been associated to increase in arterial pressure and central venous pressure during straining, but there are reports demonstrating sudden intracranial hypotension after Valsava maneuver, leading to cerebral retraction and tearing of bridging veins. Apart from the age of onset and a completely normal investigation, the infrequent blood distribution and benign course adds interest to our case.

P494 Analysis of specificity of the Cincinnati Prehospital Stroke Scale performed by SAMU of Joinville/Brazil as prehospital screening for stroke A.P. Miranda, A.F. Volkman, R.S. Menegatti, L.S. Freitas, P.S. Magalha˜es, K.C. Fernandes, M.Z. Borba, C.H. Moro Hospital Municipal Sa˜o Jose´ (Joinville, BR) Objective: To evaluate patients brought by the prehospital team SAMU to the Sa˜o Jose´ Municipal Hospital with possible diagnosis of stroke detected by CPSS, analyzing the following items: specificity of the scale, thrombolysis rates, and percentage of cases by Bamford’s classification. Material and methods: Historic cohort study involving 125 patients brought by previously trained professionals of SAMU from February to December 2008 with possible diagnosis of stroke, analyzing the specificity of the scale, thrombolysis rates, and percentage of cases by Bamford’s classification. Results: Of the 125 patients, 117 (93.6%) had been confirmed with stroke in the hospital. Among these cases, 112 were ischemic, and a thrombolysis rate for this group was 19.64% (22 patients). As for the National Institute of Health Stroke Scale (NIHSS), the SAMU patients presented in the admission an average value of 11.28, and in the discharge 6.84, but if we only analyze the thrombolyzed patients the averages were 16.77 and 9.56 respectively. As for the Bamford’s classification, the results were: lacunar infarction: 16.92%, partial anterior circulation infarction: 44.62%, total anterior circulation infarction: 24.62%, posterior circulation infarction: 13.85%. And as for the percentage of symptoms presented analyzed by the CPSS, 67.53% had facial asymmetry, 79.22% had alterations in the arms0 strength, and 74.03% presented speech variations. Conclusion: In this study it was possible to verify that the use of the CPSS in Joinville by the prehospital team has been quite effective, with high specificity for diagnosis of stroke, observed trough comparisons in the CPSS study. This high specificity is observed even in the lightest cases of stroke, leading to great thrombolysis rates among patient.

P495 Acute stroke in the basal ganglia – effects on reward-based learning U.K. Seidel, M. Wicking, O. Todica, C. Bellebaum, I. Daum, D.M. Hermann University Hospital Essen (Essen, DE); Ruhr University (Bochum, DE) Objectives: The basal ganglia (BG) play an important role in feedback learning. Reversal learning in particular seems to depend on the dorsal striatum. However, the specific contribution of different subregions within the BG to other processes of reward based learning is controversially discussed. Deficits in reversal learning are presumably associated with focal lesions in the dorsal striatum. So far, research on BG functions has mostly been carried out in patients suffering from Parkinson’s Disease, which does not only affect the BG, but also other brain regions. The present study examines patients suffering from acute stroke in the BG in order to broaden our understanding of the differential role of BG-subregions, such as the putamen and caudate nucleus, for reward-based learning. Methods: A probabilistic learning task based on feedback has been completed by 5 patients suffering from stroke in the BG, 7 patients with comparable cardio-vascular risk factors, 2 patients with a stroke localized presumably outside the BG circuits and 2 healthy controls. Subjects had to form associations between different visual stimuli based on differential monetary feedback. Different aspects of reward-based learning, such as acquisition, reversal learning, impact of the quantity of the reward and acquired equivalence, were analyzed. Preliminary findings: Performance of stroke patients and healthy controls corresponded to a large degree in memory acquisition. In the second part of the experiment patients revealed a deficit in learning a stimulus-stimulus-association (acquisition) from feedback. Conclusion: While the patients’ performance of the learning task did not differ in a first acquisition -, reversal learning - or acquired equivalence task patients typically did not reach a predefined learning criterium in a second acquisition task. This indicates that a stroke in the BG impairs the ability to learn from feedback. A deficit in reward based learning could be an explanation for the poor prognosis of motor recovery after BG stroke, because it interferes with a learning process that is fundamentally based on positive feedback.

P496 Functional outcome after out of hospital cardiac arrest: a prospective study from the intensive care unit to the rehabilitation unit A. Peskine, C.E. Luyt, F. Baronnet, P. Pradat-Diehl Assistance publique - Hoˆpitaux de Paris (Paris, FR) Objectives: Cardiac arrest survivors may experience hypoxic brain injury that results in cognitive impairments which frequently remains underdiagnosed, especially for those patients that recovers basic level of functioning. Their cognitive deficiencies may lead to limitations in daily life activities that cannot be assessed after a few days in a cardiologic unit. We propose a prospective study. Our aim is to describe the functional status of cardiac arrest survivors, 6 months after the onset. Methods: In this prospective study, all adult patients admitted alive after an out of hospital cardiac arrest in one intensive care unit have been consecutively included between March 2008 and March 2009. Exclusion criteria included terminal illness, psychoactive or

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S162 anticonvulsive medication, known history of neurologic disease or alcohol or drug abuse. All patients were included within the first week after the cardiac arrest; follow up consisted of regular consult with the PMR specialist. The primary outcome measure was the Glasgow Outcome Scale Extended GOS E 6 months after the cardiac arrest. Neuropsychological assessment focused on executive and memory functioning have been proposed when possible as well as behavioural assessment (DEX questionnaire). Results: 13 patients have been consecutively included. 3 died before the 6 months assessment. At 6 months, 2 patients had a GOS E score at 3 or minimally conscious state, 2 presented with severe limitations, consistent with a GOS E score 4, 3 patients were autonomous for daily life activities but needed hep for elaborate activities, score GOS E 6 and 3 patients were autonomous for life activities but presented with neuropsychological sequelae preventing them to returning to their premorbid level of functioning, notably vocational, score GOS E 7. None of the patients scores 8 that is good recovery without limitation. Conclusion: Cardiac arrest leads to neurological sequelae that need systematic assessment. Literature is rich with trials assessing predictive factors for the bad outcome patients (deceased, chronic vegetative state, minimally conscious state). But for all the others patients, clinical retrospective studies have shown that most of them could not return to work or deal with the instrumental daily life activities.

Dementia/Higher function disorders: Alzheimer’s disease/mild cognitive impairment P497 The impact of oxidative stress in patients with depression and mild cognitive impairment M. Padurariu, R.I. Ciubotariu, C. Stefanescu, A. Ciobica, A. Cantemir Gr.T.Popa University (Iasi, RO); Alexandru Ioan Cuza University (Iasi, RO) Background: Mild cognitive impairment (MCI) has been defined as a transitional state between regular aging and dementia. However, not all patients with mild cognitive impairment develop dementia. It has been proved that patients with depression and mild cognitive impairment present a doubled risk of developing dementia of Alzheimer type, as those with MCI only. Considering the importance of oxidative stress in MCI and Alzheimer disease, our current objective was to determine the level of oxidative stress in MCI patients with depression, compared with non-depressed MCI patients. Methods: The patients were selected using Petersen criteria for mild cognitive impairment. The cognitive performance was assessed using MMSE (Mini Mental State Examination), ADAS-cog (Alzheimer’s disease Assessment Scale- cognitive subscale), Clock Drawing Test and Verbal Fluency Test. Psychiatric examination for depression was based on Diagnostic and Statistical Manual of Mental Disorder, Fourth Edition criteria. We assessed the levels of some enzymatic antioxidant defences like superoxide dismutase (SOD) and glutathione peroxidase (GPX), as well as lipid oxidation makers like MDA (malondialdehyde), using chemiluminometric and spectrophotometric methods. The results were compared to an aged-matched non-depressed MCI control group.

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Results: A decrease in the specific activity of SOD and GPX was found in MCI patients with depression compared with non-depressed MCI patients. Also, the concentration of serum MDA was increase in MCI patients with depression. Additionally, when we used Pearson’ s correlation coefficient and regression analysis we observed a significant correlation between the cognitive scores (ADAS-Cog and MMSE) and the levels of antioxidant enzymes in depressed patients with MCI. Conclusions: We conclude that patients with MCI and depression have an increased level of oxidative stress, compared with nondepressed MCI patients. This could explain the increased risk of patients with depression and mild cognitive impairment in developing dementia-Alzheimer type.

P498 Methodology for a plural approach of temporality in Alzheimer’s disease T. Rivasseau Jonveaux, M. Sauvee, M. Braun, M. Batt, G. Hossu, G. Barroche, A. Trognon University Hospital of Nancy (Nancy, FR); University of Nancy (Nancy, FR); Institute for National Health and Medical Research (Nancy, FR) Objectives: Temporal orientation disturbances are frequently diagnosed during Alzheimer’s disease (AD) course, but temporality alterations by AD is a more complex notion. To approach the representation of time and perturbations in time perception for daily activities on those patients we create a coherent combination of several specific approaches: neuropsychological, functional imagery and analysis of the results of semi-structured interviews. Methods: Firstly, we develop and valid with control groups: A temporal semantic knowledge clinical scale: hour reading, the using of a clock, temporal segmentation, time duration estimation. A time duration estimation test about daily activities with a visual presentation of scenes describing the action. Then, we used this methodology with a group of 21 patients who suffer from mild to moderate AD. We recorded 6 interviews, which were conducted according to piagetian clinical interviews; the questions were built with Hintikka theory (1976). We ask the patients to talk to us about their daily activities. For each activity, they are asked to say how long it lasts. Results: The temporal semantic knowledge clinical scale shows differential alterations in the explored areas like hour reading and the using of a clock. The time duration estimation test about daily activities provides us with an ecological approach; it has been also used to create a cognitive paradigm to explore brain areas involved in this task with an IRMf. Neuropsychological assessment gives us an opportunity to explore and follow up temporality disturbances. Easy-to-use, they can be used by any clinician. By using a theory, which looks at the social and cognitive aspects of the verbal interactions, Interlocutory Logic (Trognon, Batt 2007), we analysed the interviews: it gave us a deep understanding of how the patient experiences time and the passing of time. Objectively and systematically identifying specified characteristics of the time patient representation is interesting; such an analysis examine and compare the distortions of the two dimensions of time passing: chronological reference points and time duration estimation. Conclusion: These convergent approaches enlarge comprehension of the multiple facets of temporality and their alterations in AD, they have serious impact in daily life of patients and their caregivers. Results will be helpful to elaborate strategies to help the patients and for tutoring interventions for caregivers and professionals.

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P499 Analysis of predictive factors of development of dementia in mild cognitive impairment. A longitudinal, multicentre observational study in Madrid R. Garcia Cobos, B. Frades Payo, M. Valenti Soler, J. Lopez-Arrieta, M. Llanero Luque, J. Olazaran Rodriguez, J. Alvarez Linera, A. Frank Garcia for the DEMCAM Objectives: Mild Cognitive Impairment (MCI) is an entity with a characteristically variable evolution, not necessarily to dementia. This can be explained because many different disorders can cause cognitive disturbances in elderly patients. It could be of great interest to find biomarkers that can detect patients at higher risk of developing dementia. The main objective of this study is to describe demographic and neuropsychological markers capable of predict development of dementia in patients with MCI. We show the initial results of the first visit of a three year period longitudinal study. Methods: 75 patients from different sanitary areas of Madrid underwent neurological and neuropsychological assessment. Demographic and neuropsychological profiles were obtained in all cases. Other causes of dementia different from primary degenerative Alzheimer’s type (vascular, hydrocephalus, brain tumour, movement disorders and others) were excluded. Results: In our cohort, 18 patients were classified as control; 25 as MCI (11 amnestic single domain: aMCI; 14 amnestic multiple domain: mMCI), and 23 as Alzheimer’s disease (AD). There were no age differences between groups. The male:female ratio was almost 1:3 in aMCI and AD groups. AD and aMCI patients had lower educational level than mMCI and control ones. No significant differences in prevalence of vascular risk factors, physical activity, depressive symptoms or family history of dementia among the four groups were found, but this fact could be explained because of the low number of patients included. Memory (MMSE, MIS, T7M), attention (MMSE, T7M, TMT) and executive function (T7M) and global function (Blessed, CDR, FAQ) outcomes were statistically significant worse in AD patients than in the rest of groups. In the subgroup analysis, aMCI group showed a trend to obtain worse outcomes in memory assessment (free recall in MMSE, MIS and T7M), verbal fluency and attention (TMT) versus the mMCI group, but these results did not reach statistical significance, probably because of the small sample size. Prevalence of mood disorders (Yesavage) was similar among the four groups. Conclusions: Neuropsychological assessment and demographical data can help to define a high risk profile to develop dementia in patients with MCI. Evolution of these variables in a longitudinal follow up can be very useful in establishing a prognosis.

P500 Focus on the effect of memantine treatment on specific behavioural symptoms in patients suffering from Alzheimer’s disease P. Beredimas, S. Stamouli, G. Georgakoudas, N. Makris, K. Papadopoulos, E. Papalexi, I. Parashos Psychiatric Hospital Petras Olympou (Katerini, GR); University of Athens Eginition Hospital (Athens, GR); General Hospital of Florina (Florina, GR); Regional General State Hospital of Patras (Patras, GR); Psychiatric Hospital of Tripolis (Tripolis, GR); Lundbeck Hellas (Athens, GR) Objectives: The main objective of the present study was to investigate the effectiveness of memantine treatment in routine clinical practice,

alone or in combination with other anti-dementia drugs, focusing on the behavioural symptoms which are most commonly presented in Alzheimer’s disease (AD). Methods: The 6-month, observational, open-label study was conducted in 110 investigational sites in Greece. Effectiveness of memantine treatment was assessed using Mini Mental State Examination (MMSE) and NeuroPsychiatric Inventory (NPI), as an evaluation of patients’ cognitive functions and frequency / severity of neuropsychiatric symptoms. Statistical analysis was performed in the Intent-To-Treat dataset (ITT) with at least one post-baseline evaluation and the Per-Protocol-Set (PP) with assessments at both 3 and 6 months using repeated measures analysis of variance (Hotelling’s test) and Friedman test for NPI single items. Results: 1,469 patients were included in the study. Mean age of patients was 75.7±6.5, (52.7% women). Mean baseline scores (±SD) were 17.6 (±5.3) and 30.6 (±25.9) for the MMSE and the NPI, respectively. Memantine was the first treatment option for 80.6% of the patients while the rest 19.4% received combination therapy. Both cognitive and behavioral symptoms were improved at the end of the study according to MMSE and NPI scales (Repeated measures analysis of variance, Hotelling’s test, p-value\0.001, both for ITT and PP datasets). Focusing on the single items of the NPI scale in the PP dataset (n=713), memantine treatment presented a statistically significant positive effect during the study compared to baseline scores on delusions, hallucinations, agitation, depression/ dysphoria, anxiety, apathy/ indifference, disinhibition, irritability/ lability, aberrant motor behavior, night-time behavior and appetite changes (Friedman test, p\0.001). More than one third of the patients showed improvement in agitation (37%), depression/dysphoria (46%), anxiety (42%), irritability/ lability (39%) and nighttime behavior (54%), while less than 10% showed any worsening in any of the twelve single NPI items, at the end of the study. Memantine was well tolerated as only 3.5% of patients withdrew from the study and 7.6% of patients reported one adverse event (AE) at least. Conclusion: Memantine treatment resulted in significant improvement of cognitive and specific behavioral symptoms, presenting an excellent tolerability profile. Supported by an unrestricted educational grant from Lundbeck Hellas SA

P501 Retinal nerve fibre layer atrophy in Alzheimer’s disease: a six-months follow-up study S. Pomati, E. Marziani, P. Ramolfo, F. Clerici, G. Staurenghi, C. Mariani Hospital Luigi Sacco (Milan, IT) Objective: in the last few years some studies have reported a reduction of retinal nerve fibre layer (RNFL) thickness in Alzheimer’s disease patients and in a single cross-sectional study such a reduction has been associated with the severity of the disease. So far, to our knowledge, no follow-up study has been reported. Subjects and methods: 20 AD patients and 19 control subjects were assessed with optical coherence tomography (OCT) (RTVue100, Optovue Inc.) at baseline (T0) and after six months (T1). Measures of RNFL thickness were taken at the fovea and in the peri- and parafoveal regions (at 3 and 5 mm from the centre of the macula), in the superior, temporal, nasal and inferior quadrants. All subjects underwent a complete ophthalmologic examination, including assessment of visual acuity, refraction, ocular motility, pupillary reflexes, anterior and posterior segment biomicroscopy, applanation tonometry, and dilated fundus examination. Eyes with

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S164 ocular pathologies such as glaucoma, propionic acidosis, choroidal neovascularization, age-related macular degeneration, retinal vascular diseases, vitreo-retinal diseases, macular hole, or with media opacification such as cataract that prevented ocular and OCT examination were excluded. Results: a two-way analysis of variance for repeated measures (group 9 time) was conducted with time as within-subjects and group as between subjects variables. All measures of RNFL thickness appeared significantly different between groups while no significant difference emerged between T0 and T1 for both groups. Discussion: RNFL atrophy may be a marker of Alzheimer’s disease but changes in retinal thickness seem to take years to reveal; further studies are needed to confirm our data with longer follow-up times to assess the rapidity of retinal changes.

P502 Homer 1a rescues intracellular Ab-mediated suppression of BK channels in neocortical pyramidal neurons K. Yamamoto, Y. Ueta, R. Yamamoto, N. Inoue, K. Inokuchi, N. Kato Utano National Hospital (Kyoto, JP); Kanazawa Medical University (Uchinada, JP); Mitsubishi Kagaku Institute of Life Science (Machida, JP) Objectives and methods: A large number of studies have indicated that intracellular b-amyloid (Ab), prior to accumulating extracellularly, can trigger cognitive defect in the early stage of Alzheimer disease (AD). Moreover, recent studies using APP transgenic mice showed that increasing neuronal activities promote the formation and secretion of Ab. These observations raise the possibilities that intracellular Ab and neuronal excitabilities are interacted each other, which accelerate the progression of AD, which remained to be elucidated. Here we report how intracellular Ab regulates action potential profile by applying Ab protein into rat and mouse neocortical pyramidal neurons through whole-cell patch pipettes, and by using 3xTg AD model mice. Results: Intracellularly applied Ab1-42, but not Ab1-40, broadened spike width and augmented Ca2+ influx via voltage-dependent Ca2+ channel in rat neocortical neurons. However, this class of Ca2+ channel turned out to elude direct modulation by intracellular Ab1-42. On the other hand, charybdotoxin, a blocker of large-conductance Ca2+-activated K+ (BK) channel, mimicked and occluded these effects of Ab1-42. Furthermore, isopimaric acid, a BK channel opener, and electroconvulsive stimulation (ECS), which is shown to facilitate BK channel opening via Homer 1a/Vesl-1S expression, blocked the effects of Ab1-42. Both Ab1-42-injected neurons of wild-type mice and neurons of 4 months old 3xTg mice, which have intraneural Ab42 without extracellular Ab accumulation, showed spike width broadening and attenuation of spike peak amplitude during spike trains. These actions of Ab were mimicked and occluded by charybdotoxin and blocked by ECS. By contrast, Homer 1a knockout mice failed to show the same blocking effects of ECS on Ab. These results were confirmed by single BK channel recording. Conclusion: Since Homer 1a is physiologically expressed by neuronal activities in neurons, intracellular Ab-mediated suppression of BK channels may be rescued by facilitating naturally occurring Homer 1a expression, thereby providing a novel therapy for early dysfunction in the AD brain.

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P503 Determinants of the quality of life in Alzheimer’s disease: perspective of patients, informal carers and professional carers M. Gomez-Gallego, J. Gomez-Amor, J. Gomez-Garcia Catholic University San Antonio (Murcia, ES); University of Murcia (Murcia, ES) Objectives: To determine the main factors related with the quality of life (QOL) of patients with Alzheimer’s disease (AD) as assessed by the individuals, their informal carers and professional carers. Methods: 229 subjects (102 patients with mild-to-moderate AD, 102 informal carers and 25 professional carers) were asked to rate patients’ QOL using QOL-AD scale. Additional measures included the demographic data, Mini-Mental State Examination, Functional Activities Questionnaire (FAQ), Barthel Index (BI), Geriatric Depression Scale (GDS), Neuropsychiatric Inventory (NPI), Cumulative Illness Rating Scale (CIRS) and Caregiver Burden Interview (CBI). The correlations between patient, informal carer and professionalreported QOL-AD scores and variables were evaluated using Spearman’s rank correlation coefficient (r). Multivariate linear regression analyses were carried out separately to determine the main factors influencing the perceptions of QOL by the three groups. A p value \0.05 was regarded as statistically significant. Results: Patients’ ratings about QOL were significantly negatively correlated with GDS (r=-0.71), CIRS (r=-0.20), NPI-depression (r=-0.66), NPI-anxiety (r=-0.21), NPI-apathy (r=-0.40) and NPIagitation (r=-0.23) and positively with BI (r=0.23). Informal carers’ ratings were significantly correlated with the above factors and with FAQ (r=-0.35), NPI-irritability (r=-0.35) and CBI (r=-0.19). The professionals’ ratings were correlated with the same factors as patients’ ratings and with FAQ (r=-0.38), NPI-delusions (r=-0.28) and CBI (r=-0.39). No significant differences were found in QOL between patients receiving cholinesterase inhibitors and those who did not. Similar results were observed between groups of different anxiolytic treatment. Taking psychotropics was associated with reduced QOL according to the professionals. Regression analyses indicated that the main predictors of QOL were BI, GDS and NPIdepression for patients; NPI-depression and NPI-irritability for informal carers; CBI, NPI-depression, BI and psychotropics for professionals. Conclusions: Interventions to improve patients’ QOL should mainly focus on mood and functional abilities. Some kind of therapies targeted at relieving anxiety, apathy and agitation are also likely to increase QOL, but this may not be the case with psychotropics. Clinical trials including QOL measures are necessary to clarify ‘‘real life’’ effects of the drugs currently used for the treatment of AD.

P504 Low body mass index predicts progression of MCI to dementia and Alzheimer’s disease F. Clerici, B. Caracciolo, I. Cova, S. Fusari Imperatori, S. Pomati, V. Cucumo, D. Galimberti, E. Scarpini, C. Mariani, L. Fratiglioni L.Sacco Hospital (Milan, IT); Karolinska Institute (Stockholm, SE); University of Milan (Milan, IT); University of Stockholm (Stockholm, SE) Objective: To examine the relationship between Body Mass Index (BMI) and the risk of progression of mild cognitive impairment (MCI) to dementia and Alzheimer’s Disease (AD).

S165 Methods: Between January 2001 and September 2009, 245 MCI subjects (mean age 74,09±6,92 years, 58,3 % female) were included in the study and followed-up for 2,40 ± 1,58 years at ‘‘Luigi Sacco’’ Hospital. Height and weight were assessed at baseline and used to calculate BMI. The main outcome was progression to dementia (DSM-IV criteria) and AD (NINCDS-ADRDA criteria). Comparisons between groups was performed using the t test and the v2 test. To investigate whether BMI was associated with the risk of progression of MCI to dementia we used Cox Proportional Hazard Models. The covariates (collected at the baseline) in the final model were: age, sex, education, MCI subtypes (amnestic, single non-memory and multiple domains), Mini Mental State Examination (MMSE) score, Instrumental Activities of Daily Living score, Geriatric Depression Scale score, smoking habit, Cumulative Illness Rating Scale Score, hypertension, diabetes, hypercholesterolemia, atrial fibrillation, and history of cerebrovascular and cardiovascular diseases, Hachinski Ischemic Score, APOE genotype and cerebral CT/MRI white matter lesions as assessed by the Age Related White Matter Changes Scale. Results: One-hundred-twenty-nine (52,6%) out of 245 MCI subjects progressed to dementia. Eighty-seven (67%) out of 129 subjects progressed to AD. Subjects who progressed to dementia were older (75,24±5,99 vs. 72,82±7,66 years; p= 0.006) and had lower MMSE score (25,29±2,18 vs. 26,14±2,12; p=0,002) as compared to MCI who did not progress. Subjects with multiple-domain MCI were more likely to progress to dementia as compared to subjects with amnestic and single non-memory domain MCI (p=0.031). People who progressed had lower BMI as compared to people who did not progress (23,81±3,75 vs. 25,47±3,68; p=0,001). The multivariate analysis showed that MCI subjects with lower (\ = 23) BMI had a significant higher risk of progression to dementia (HR=1,68; 95% CI 1,03–2,72) and AD (HR= 1,81; 95% CI 1,09–3,25), as compared to subjects with higher ([24) BMI. Conclusions: Lower BMI is associated with higher risk of progression to dementia and AD in MCI subjects. This relationship suggests that decreased BMI may be an early systemic manifestation of the AD process. Alternatively, body composition may influence the rate of cognitive decline. This study was sponsored by the Associazione per la Ricerca sulle Demenze-ARD Onlus. Funder had no role in study design, data collection and analysis or preparation of the abstract.

P505 Assessing quality of life in Alzheimer’s disease: agreement between patients, informal carers and professional carers M. Gomez-Gallego, J. Gomez-Amor, M. Ato Catholic University San Antonio (Murcia, ES); University of Murcia (Murcia, ES) Objective: To compare the views of patients with Alzheimer’s disease, informal carers and professional carers about patients quality of life (QOL) and to determine possible factors associated with the discrepancy between ratings. Methods: 229 subjects (102 patients with mild-to-moderate Alzheimer’s disease, 102 informal carers, 25 professional carers) were recruited from six day centres. Patients’ QOL was rated with QOLAD scale by the individuals, their informal carers and professionals. Additional measures included the Mini-Mental State Examination, Barthel Index, Geriatric Depression Scale, Neuropsychiatric Inventory (NPI), Clinical insight Rating Scale and Caregiver Burden Interview. Agreement between ratings was examined for both consistency and absolute agreement using the intraclass correlation coefficient(ICC). An individual difference score was calculated for

each dyad by subtracting informal carer report score from the patient report score, and professional report score from patient report score. To evaluate the effect of factors associated with the difference score in each case, stepwise linear regression analysis was carried out. A p value \0.05 was regarded as statistically significant. Results: Patients rated their QOL higher than informal carers and professionals did (p=0.000 in both cases). Agreement between patients’ reports and informal carers’ reports was poor (absolute ICC=0.38; consistency ICC=0.40). 82.35% of the patients rated their QOL higher than their informal carers did. The mean difference for the scores was [15% of the patients average score. Regression analyses indicated that the most important predictors of higher discrepancy were patient irritability and sleep disorders, and carer burden. Patient-professional agreement was also low (absolute ICC=0.35; consistency ICC=0.40). In 66.7% of the dyads, patients rated their QOL higher than professionals did. The mean difference for the scores was [10% of the patient average score. Patient education and NPI-anxiety score, and carer burden significantly predicted higher discrepancy. Conclusions: Patients with mild-to-moderate Alzheimer’s disease should be directly asked when assessing their QOL since agreement with both informal carers and professionals is poor, and significant differences exist between the reports. Assessments by informal carers and professionals should be used with caution, especially in cases with severe neuropsychiatric symptoms or carer burden.

P506 The impact of vascular burden on the progression of MCI to dementia F. Clerici, B. Caracciolo, I. Cova, S. Fusari Imperatori, L. Maggiore, D. Galimberti, E. Scarpini, C. Mariani, L. Fratiglioni L.Sacco Hospital (Milan, IT); Karolinska Institute (Stockholm, SE); University of Milan (Milan, IT); University of Stockholm (Stockholm, SE) Objective: To investigate at which extent vascular burden may contribute to the progression of mild cognitive impairment (MCI) to dementia. Specifically we aimed to investigate whether vascular risk factors (VRF), vascular diseases (VD) and vascular lesions (VL) in the brain were associated with an increased risk of dementia in MCI subjects. Methods: Between January 2001 and September 2009, 245 consecutive subjects were diagnosed as affected by MCI (mean age 74,09±6,92 years, 58,3 % female) at ‘‘Luigi Sacco’’ Hospital and followed up for 2,40 ± 1,58 years to detect their progression to dementia (DSM-IV criteria). Dementia subtypes were defined according to currently established criteria. The following VRF were analyzed: alcohol consumption, smoking habit, obesity, hypertension, diabetes, and hypercholesterolemia. VD includes: atrial fibrillation, carotid atherosclerosis, history of cerebrovascular and other cardiovascular diseases. The following vascular summary scores were considered: Hachinski Ischemic Score and Framingham risk score. VL detected by CT or MRI were assessed using the Age Related White Matter Changes (AR-WMC) Scale. To investigate whether VRF, VD, VL and vascular scores were associated with the risk of progression from MCI to dementia we used Cox Proportional Hazard models. Results: One-hundred-twenty-nine (52,6%) out of 245 subjects at risk converted to dementia. Eighty-seven (67%) out of 129 subjects who progressed to dementia were diagnosed with Alzheimer’s Disease. No association was found between any of the VRF, VD or vascular scores and the development of dementia in this MCI cohort. However we found an association between AR-WMC in the basal

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S166 ganglia (both sides) and the risk of progression from MCI to dementia (left side HR=1,512; 95% CI 1,007–2,269; right side HR=1,410; 95% CI 0,948-2,098). The risk of progression from MCI to dementia was increased when the AR-WMC in the basal ganglia were combined with high vascular risk scores : AR-WMC + Hachinski Ischemic Score C4: HR 3,471; 95% CI 1,626–7,407; and AR-WMC + Framingham risk score C12: HR 1,950; 95% CI 1,139–3,336. Conclusions: Vascular burden contributes substantially to the progression of MCI to dementia, especially when all vascular diseases/risk factors are combined toghether and are severe enough to lead to vascular lesions in the brain. This study was sponsored by the Associazione per la Ricerca sulle Demenze-ARD Onlus. Funder had no role in study design, data collection and analysis or preparation of the abstract.

P507 Cognitive testing and correlation with cerebrospinal fluid Ab, s and Ps levels in subjects with mild cognitive impairment E. Rotondo, D. Galimberti, R. Vimercati, P. Corti, L. Bergamaschini, C. Fenoglio, M. Serpente, C. Cantoni, M. De Riz, N. Bresolin, C. Vergani, E. Scarpini University of Milan (Milan, IT); Ospedale Maggiore Policlinico (Milan, IT) Objective: To correlate neuropsychological testing with cerebrospinal fluid (CSF) Amyloid b (Ab), s and hyperphosphorylated (P)s levels in patients with Mild Cognitive Impairment (MCI). Background: Mini Mental State Examination (MMSE) is currently used to determine global cognitive state in subjects with MCI. However, cognitive domains that better predict progression from amnestic MCI to Alzheimer’s disease (AD) are episodic verbal memory, evaluated with Recall Test (SRT) and Learning of Couples of Words (LCW), and executive functioning, tested by Coloured Progressive Matrices of Raven (CPMR) and Clock Drawing Test (CDT). Methods: Eighteen subjects with amnestic MCI were recruited. All of them underwent neuropsychological testing, including global cognitive assessment by MMSE, episodic verbal memory by SRT and LCW and executive functions by CPMR and CDT. Six out of 18 underwent lumbar puncture at time of diagnosis. Ab, s and Ps were evaluated by ELISA. Statistical analysis was carried out by using t-test and Spearman test for correlations. Results: In the whole population, a significant positive correlation between SRT and MMSE was observed (r=0.577; P=0.012). In addition, a trend towards a positive correlation between CDT and MMSE was found (r=0.444; P=0.064). Considering CSF biomarker levels, three subjects showed an altered pattern and converted to AD after few months, whereas remainders had a normal profile and did not convert. Comparing these two groups, converters exhibited worse scores at LCW and CDT as compared with non-converters (8.66 versus 6.66, and 4.33 versus 3.33, P[0.05). Conclusion: According to these results, SRT and CDT are likely more representative of episodic verbal memory and executive functions, respectively, and reflected more sensitively MMSE score. The same analysis in a small group of subjects in which CSF biomarkers predicted diagnosis, confirmed data obtained on CDT. Nevertheless, LCW, rather than SRT, seemed to be the more specific episodic verbal memory test to predict conversion from MCI to AD.

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P508 Serum levels of homocysteine, vitamin B12, and folic acid in patients with Alzheimer’s disease M. Assefi, A. Amani, A. Mohammadi, M. Taleb Iran University of Medical Sciences (Tehran, IR) Background: Alzheimer’s disease is the most common form of dementia in the elderly. Serum levels of homocysteine have been related to increased cortical and hippocampal atrophy. We aimed to determine the serum levels of homocysteine, folate, and vitamin B12 in patients with Alzheimer’s disease. Methods: Blood levels of homocysteine and its biological determinants, folate, and vitamin B12 were measured in 51 patients who were diagnosed as having Alzheimer’s disease according to DSM-IV criteria and compared with the serum levels obtained from 49 control individuals. Results: The mean serum homocysteine concentration was significantly higher in patients with Alzheimer’s disease than the controls (20.4 ± 16.5 lmol/L v 14.5 ± 5 lmol/L; P= 0.02). There were no statistically significant differences between the mean serum levels of vitamin B12 (P=0.6) and folate (P= 0.3) in the patients and the controls. There was no correlation between age and serum homocysteine concentration in both groups (P= 0.8). Conclusion: Serum homocysteine concentration was significantly higher in the patients with Alzheimer’s disease. This biomarker might be considered as a predictor of cognitive performance.

P509 Biomarkers of Alzheimer’s disease in the CSF of patients with mild cognitive impairment J.A. Monge-Argiles, C. Mun˜oz-Ruiz, A. Pampliega-Perez, M.J. Gomez-Lopez, J. Sanchez-Paya, E. Rodriguez-Borja, M. Ruiz-Vegara, J. Montoya-Gutierrez, C. Leiva-Santana General University Hospital Alicante (Alicante, ES) Introduction: The study of biomarkers in the cerebrospinal fluid (CSF) of patients with mild cognitive impairment (MCI) is a technique used with increasing frequency in the early diagnosis of Alzheimer’s disease (AD). Objective: To gain our own experience while evaluating the reliability, sensitivity, and reproducibilty of this technique. Materials and methods: Thirty seven patients with MCI and twenty four control subjects were studied by means of AD biomarker analysis in CSF. xMAP Luminex and INNO-BIA Alzbio3 reagents of Innogenetics were used. The study variables assessed were levels of Aaˆ 1-42, T-tau and P-tau181p proteins as well as the ratios of T-tau/ Aaˆ1-42 and P-tau/ Aaˆ1-42. Samples from nineteen patients were examined twice. Results: Intra-class correlation coefficients for the three biomarkers used showed values higher than 0.95. We observed significant differences between the control group and the MCI groups. In the six months following lumbar puncture (LP), eleven (29%) patients with MCI developed AD. These patients showed significant differences to those in the same group who remained stable. We obtained similar results to those in the most recent reliable literature with our COR curves, especially with our P-tau181p values and T-tau/ Aaˆ1-42 ratio in order to differentiate between control and AD groups. Conclusion: Our experience showed that the analysis of CSF AD biomarkers in patients with MCI is reliable, sensitive and reproducible.

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P510 Diagnostic value of P300 in mild cognitive impairment V. Silva, A. Carvalho, A. Santos, A. Silva, A. Martins, A. Valverde Portuguese Institute of Oncology (Lisbon, PT); Hospital Prof. Doutor Fernando Fonseca (Amadora, PT) Background: Mild Cognitive Impairment (MCI) has been accepted as a risk factor for Alzheimer’s Disease. Early detection of MCI patients may offer an opportunity for therapy initiation in early stages of the neuropathological process. Some studies have reported a relationship between electrophysiological potentials, including the P300, with cognitive function. This relation can be useful for diagnosis and monitoring of the cognitive decline in patients with MCI. Objectives: To determine the relationship between P300 latency and cognitive state. Methods: Neuropsychological assessment according to Wechsler Memory scale (WMS) and the Reisberg’s Global Deterioration scale (RGDS) of MCI patients and a control group matched for age and education. Identification of P300 potential by electroencephalogram with scalp electrodes in Fz, Cz and Pz positions. Statistical analysis: Fisher’s Exact Test and Mann Whitney U test. Results: We included 21 patients with MCI (12 males, 9 females, mean age 68.8±10.5 years [45–86]) and 22 controls (10 males, 12 females, mean age 68.6±6.9 years [57–81]). All patients were classified stage 3 in RGDS and in the control group 5 patients in stage 2 and 19 in stage 1. The average score in the MWS was QM=87.7 (68– 114) for patients and QM=96.4 (69-128) for controls. The mean latencies of P300 were 372ms (287–437) in patients group and 364ms (268–432) in controls, being normal in 71.4% of patients and 77.3% of controls. No statistically significant association was found between MCI and prolongation of P300 latency (p[0.05). Increase in P300 latency was however more frequent in patients with impairment in immediate memory, working memory and verbal associative memory tests, than in the other memory subtypes assessed. Conclusions: In our study, although the mean latencies of P300 were slightly higher in MCI, it was not possible to establish an association between this latency increase and the diagnosis of MCI, once P300 was normal in most patients. The latency of the P300 seems to be related essentially with immediate memory, working memory and verbal associative memory.

sleep process and of its features (sleep spindles) in people with aMCI, and to trace, via these parameters, a possible progression towards AD. Methods: 5 AD patients (4F, 1M; mini-mental state examination (MMSE) 18± 4.8; Clinical Dementia Rating (CDR) 1; age 76.8 ± 7.9 years), 12 aMCI patients (10F, 2M; MMSE 27 ± 1.9; CDR 0.5; age 75.4 ± 4.5 years) and 9 healthy elderly controls (HE) (4F, 5M; age 72.3 ± 7.2 years), all drug-naı¨ve, underwent 2 consecutive polysomnographic night recordings. Sleep macro- and microstructure features were analyzed. The latter refers to sleep spindle density and distribution (unilateral/bilateral) which were visually analyzed in frontal (F3, F4) and central (C3, C4) EEG channels. This analysis was performed in short time intervals (at least 5 min) of uninterrupted sleep stage 2 in the beginning, middle and end of the second recorded night. Results: Statistical significant differences (Mann-Whitney nonparametric test) were observed between the following sleep macrostructure variables: Sleep stage 1 percentage: AD[aMCI (p\0.027), (AD: 11.6 ± 7.9, aMCI: 5.2 ± 2.5); sleep stage 2 percentage: aMCI[AD (p\0.043), HE[AD (p\0.043), (AD: 24.9 ± 12.0, aMCI: 40.3 ± 7.16, HE: 45.2 ± 9.0); REM sleep percentage: MCI[AD (p\0.047), (AD: 9.1 ± 6.0, aMCI: 17.0 ± 6.9). Conclusions: Our findings suggest that, with the advance of cognitive decline, sleep becomes lighter and with less REM sleep. As dementia progresses, sleep becomes more fragmented, with an increase in sleep stage 1 and a decrease in sleep stage 2. When aMCI worsens, it leads to AD. A decrease of Ach is observed in AD. Since REM sleep is related to the cholinergic system, a decrease in REM sleep following the cognitive decline may also reflect a lowering in brain Ach levels.

Muscle disorders P512 A novel CHRNE gene mutation associated with congenital myasthenia: case report and review of the literature F. Magri, A. Govoni, R. Del Bo, I. Colombo, N. Bresolin, G.P. Comi, S. Corti Ospedale Maggiore Policlinico (Milan, IT); University of Milan (Milan, IT)

P511 From amnestic mild cognitive impairment towards Alzheimer’s disease: a progression based on sleep features N.T. Economou, A. Bonakis, I. Kritikou, T. Paparigopoulos, P. Ktonas, P. Theodoropoulos, T. Kontaxis, A. Kyrozis, N. Kalfakis, G. Papadimitriou, S.G. Papageorgiou Neurocenter of Southern Switzerland (Lugano, CH); University Hospital of Athens (Athens, GR) Objectives: Mild Cognitive Impairment (MCI) is considered to be a transitional stage between normal aging and dementia, usually dementia of the Alzheimer’s Disease (AD) type. MCI could be either amnestic (aMCI) or non-amnestic (naMCI). aMCI presents only memory impairment, and its clinical evolution, when present, is AD. Sleep features of AD have been already described (e.g., reduced total sleep time, frequent arousals/awakenings, increase of light sleep, decrease of deep sleep, sleep-wake rhythm disturbances, compromised phasic EEG components, e.g., sleep spindles, K-complexes). The sleep of aMCI and in general of MCI patients has not been systematically investigated. Our objective was the assessment of the

Objectives: Congenital Myasthenic Syndromes (CMS) are clinically and genetically heterogeneous inherited disorders affecting the neuromuscular transmission.To date, 10 different forms have been described.A precise molecular characterization is fundamental to address a mutation-based therapeutic approach.The most frequent form is the postsynaptic one, caused by mutations in the genes encoding the nicotinic acetylcholine receptor subunits, mostly in the epsilon-subunit gene(CHRNE).We describe a new mutation in CHRNE gene associated with CMS phenotype expanding the spectrum of these disorders. Furthermore, we stress the relevance of detailed clinical data in order to address molecular diagnosis in CMS. Case report: A 11-yr-old girl presented since the age of 4 months with fluctuant bilateral ptosis, ophthalmoparesis and feeble cry. She was the first of 3 children born from apparently non-consanguineous Egyptian parents.Over the years she developed progressive and fixed proximal lower limb weakness, hypophonia and dysphagia with mild improvement after therapy with corticosteroids and pyridostigmine. Myasthenic antibodies and cerebral MRI were normal.Electromyography was normal at age of 1 yr and demonstrated a decremental pattern of transmission at 9 ys.Muscle biopsy showed mild not-specific myopathic changes.Mediastinal MRI showed increased thymus diameters, which extended from aortic root to jugular region. To

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S168 exclude a possible pathogenetic role we performed also mediastinal TC and scintigraphy excluding neoplasm.Molecular analysis of genes involved in CMS was undertaken in the proband and extended to parents. Results: Molecular analysis demonstrated the following homozygous mutation in exon 10 of the gene encoding the subunit epsilon of Ach receptor: c.1181_1187dup (p.Glu396AspfsX2).The parents presented the same mutation in heterozygosis. Conclusions: The 1293insG founder mutation in CHRNE gene is a frequent cause of CMS in North Africa. Our proband showed a phenotype suggestive for CMS. The geographic origin associated to some clinical features, such as the absence of arthrogryposis and respiratory involvement, suggested to investigate CHRNE gene, demonstrating the presence of a homozygous mutation within the coding region. Up to now only few mutations associated to CMS have been found in this gene and p.Glu369AspfsX2 is novel, being not previously reported.Furthermore the finding of mediastinal enlargement can be misleading, but must be considered normal at this age.

P513 A novel intronic DYS gene mutation leading to a pseudoexon insertion in a DMD patient A. Govoni, F. Magri, R. Del Bo, S. Ghezzi, A. Bordoni, F. Fortunato, M.G. D’angelo, S. Tedeschi, V. Lucchini, M. Moggio, G.P. Comi University of Milan (Milan, IT); IRCCS E.Medea (Bosisio Parini, IT) Background and objectives: Duchenne muscular dystrophy (DMD) is caused by mutations along the dystrophin (DYS) gene. The majority of mutations generally consist in deletion and duplications, but in few cases more complex rearrangements have been described. To describe an intronic DYS gene mutation associated with clinical and biochemical data suggestive for DMD phenotype. To better understand the molecular basis underlying this clinical presentation. Case report: We describe a 6-yr-old boy investigated at the age of 4 ys for occasional finding of hyperCKemia. He showed mild calf hypertrophy and frequent fallings and during years he developed mild proximal hyposthenia with Gowers’ sign and running difficulties. He had no cognitive impairment. The patient underwent to an extensive clinical evaluation, comprehensive of a complete cardiac and respiratory assessment. Muscle biopsy was obtained at age of 6 yr from brachial biceps. Dystrophin immunohistochemistry (IHC) and Western blot (WB) analysis were performed using three monoclonal antibodies against mid-rod domain, NH2 and COOH epitopes. The genetic screening was performed through Multiplex PCR and Multiple Ligation Probe Assay, followed by direct sequencing of DYS gene and transcript analysis. Results: Muscle biopsy showed a dystrophic pattern and IHC and WB analysis demonstrated the complete absence of dystrophin on muscle membrane. Genomic DNA analysis excluded the presence of deletions, duplications as far as point mutations within the coding sequence. We further investigated this patient performing the study of the transcript. cDNA analysis showed a ‘‘de novo’’ point mutation in intron IVS65 which is predicted to cause an insertion of 53 base pairs (c.9563_9564ins53bp) leading to the production of an out-of-frame transcript (p.Thr3188Thr_fsX7). Conclusions: Dystrophinopathies are mainly due to deletions and duplications in DYS gene. In recent years major interest is given to the study of point mutations and more complex molecular changes. This data highlight the importance of transcript analysis and can give new insights into the mechanisms that determine molecular

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rearrangements of the Dystrophin gene and their importance in developing new therapeutic molecular approaches.

P514 Differential expression of microRNAs in primary and secondary calpainopathies M. Aguennouz, O. Musumeci, C. Rodolico, A. Garufi, E. Barca, G. Vita, A. Toscano University of Messina (Messina, IT) Objectives: Calpainopathies are a group of muscle disorders due to calpain 3 deficiency. Calpain 3 (CAPN3) is a muscle-specific member of the calcium-activated neutral protease family. Primary calpainopathy or limb-girdle muscular dystrophy (LGMD) 2A is the most frequent form of LGMD in Europe. It is characterized by progressive muscle wasting and weakness. CAPN3 secondary deficiency has been reported in dysferlinopathies, titinopathies, and idiopathic hyperCKemia. The pathomechanism leading to the muscle damage has not been clearly elucidated. MicroRNAs (miRNAs) control different cellular activities such as proliferation, morphogenesis and apoptosis. Recently, their regulatory role in mRNA turnover and translation has been postulated in muscular dystrophies (…). The aim of this study was to identify and differentiate the expression of mature miRNAs in skeletal muscle biopsies of patients with primary and secondary calpainopathies. Methods: We have subdivided the patients with calpainopathies in three groups: (G1) pts with absence of CAPN3 protein in WB analysis, (G2) pts with reduced CAPN3 autocatalytic activity and (G3) pts with altered CAPN3 secondary to dysferlin deficiency. The gene expression of miRNAs was performed using a miRNACHIP containing 360 miRNA normalized with normal controls. Results: Among the 360 genes analyzed, 98 miRNAs were overexpressed in CAPN3 deficiency (G1+G2+G3) vs CTRs; 53 miRNAs were overexpressed in the primary deficit (G1 + G2) vs secondary deficit (G3); 45 miRNAs were overexpressed in the secondary deficit (G3); 18 miRNAs were present only in the primary deficiency with the absence of CAPN3 (G1); 9 miRNAs were present only in the primary deficit shown by autocatalysis (G2); The miRNAs identified were differentially expressed and involved in different cellular functions, including regulation of mRNA targets involved in calcium metabolism. Some miRNAs, involved in inflammatory and proteolytic processes, were identified in CAPN3 secondary deficiency (G3). Conclusions: The calcium family genes are a common target of miRNAs and they are expressed in all 3 groups. The variable expression of miRNAs, evidenced in the 3 groups of patients, suggests different pathogenic patterns in calpainopathies.

P515 Novel FHL1 mutations in fatal and benign reducing body myopathy, rigid spine and myofibrillar myopathy S. Shalaby, C.M. Quinzii, Y.K. Hayashi, K. Goto, I. Nonaka, S. Noguchi, M. Hirano, I. Nishino Ain Shams Medical University (Cairo, EG); Columbia University (Columbia, US); National Institute of Neuroscience (Tokyo, JP) Introduction: Reducing body myopathy (RBM) is a rare myopathy characterized pathologically by the presence of reducing bodies on menadione-nitroblue tetrazolium (NBT) in the absence of substrate, a´-glycerophosphate. RBM has heterogeneous clinical features varying

S169 from fatal congenital, benign childhood or adult onset. FHL1 encoding four-and-a-half LIM domain protein 1 was identified as the causative gene for RBM. FHL1 mutations also cause scapuloperoneal syndrome (SPM) and X-linked myopathy with postural atrophy (XMPMA). Objective: We searched for FHL1 mutations in our patients previously diagnosed as RBM and among other groups of myopathy patients. Patients: We searched for FHL1 mutations in 3 sporadic and 2 familial RBM patients, 18 rigid spine syndrome (RSS) patients and 70 myofibrillar myopathy (MFM) patients. Methods: We directly sequenced FHL1 in all patients selected. Frozen muscle specimens were examined by histochemistry, immunohistochemistry and immunoblotting using standard techniques. Conclusion: We identified FHL1 mutations in all RBM patients, one RSS patient and 4 MFM patirents

P516 Novel CLCN1 gene mutation causing Becker type myotonia congenita: case report Y. Harigaya, S. Sakoda, K. Mizushima, I. Higuchi Maebashi Red Cross Hospital (Gunma, JP); Kagoshima University Graduate School of Medical and Dental Sciences (Kagoshima, JP) Introduction: Myotonia congenita (MC) is an autosomal dominant (Thomsen type) or recessive (Becker type) inherited muscle disorder characterized by impaired muscle relaxation and variable degrees of muscle weakness associated with abnormalities in the muscle currents linked to the chloride channel gene (CLCN1) encoding the human skeletal muscle chloride channel. More than 70 disease-causing mutations have been described. We performed sequence analysis of all coding regions of CLCN1 in a Japanese patient clinically diagnosed with MC, and identified a novel homozygous mutation. Case report: A 37-year-old man came to our hospital for evaluation of impaired muscle relaxation. He complained of difficulty with starting movement, which had begun at the age of 6 years old. The patient also suffered from myotonia, which improved with continued exercise, and worsened with general rest and coldness. There was no particular past or family history of neurological disorders, and his parents were consanguineous. Neurological examination showed grip and percussion myotonia without pain. Muscle hypertrophy was observed especially in the leg and forearm muscles, while muscle strength in all extremities was normal. Mental status was also normal. The levels of serum creatine kinase and thyroid function were within normal limits. A needle electromyography (EMG) examination revealed abundant myotonic discharges in all tested muscles at rest. The degree of decrease in compound muscle action potential (CMAP) amplitude after prolonged exercise lasting for 5 minutes was normal, whereas a significant decrease in CMAP amplitude was observed immediately after short exercise that lasted for 20 seconds. There were no ˜ subunit of the voltage-gated sodium channel mutations in the ƒN gene. Direct sequencing analysis of all 23 exons of the CLCN1 gene demonstrated a G to A transition at position 1262 of the exon 12 in a homozygous state, with replacement of arginine with histidine at codon 421 (R421H). This mutation was also present in a hetrerozygous state in his parents. Normal EMG findings and absence of myotonia in the parents suggested a recessive inheritance pattern. The diagnosis of Becker type MC was made, and mexiletine at 200mg/day was effective in relieving myotonia. Conclusion: We report a novel R421H homozygous mutation in the CLCN1 gene causing a mild form of Becker type MC.

P517 Eletromyographic patterns and clinical characteristics in familial hyperkalemic periodic paralysis with a Met1592Val mutation J.X. Lee, J.H. Kang, S.Y. Kang, J.C. Choi, J.S. Lee National University Hospital of Jeju (Jeju, KR) Background: Hyperkalemic periodic paralysis (HyperPP) is characterized by episodic flaccid paralysis of skeletal muscles exacerbated by administration of potassium-containing foods, fasting or rest following exercise. Although the development of commercially available molecular testing for mutations in channelopathies has introduced, the diagnosis of HyperPP is still made largely on clinical grounds, supported by electrodiagnostic techniques. Methods: 7 patients from three families were assessed by interview and clinical examination. Surface-recorded compound muscle action potential was used to monitor muscle electrical activity. Standardized protocols comprising short and long exercise tests and cooling tests were applied on 8 unaffected control subjects and on 7 patients with familial HyperPP. All patients were asked to complete the age at onset, duration of attacks, precipitants of attacks and presence of myotonia. Creatinine phosphokinase (CPK) and potassium level were checked in all patients. Genetic studies were performed on blood DNA from all patients for SCN4A gene on chromosome 17q. Results: In repeated short exercise, the amplitude of the compound muscle action potentials (CMAP) as a percentage of the pre-exercise value in patients was more increased than that observed in controls (p \ 0.05 for all periods). In long exercise tests, transient increase of CMAP amplitude as a percentage of the pre-exercise value in patients was more marked than that observed in controls immediately after exercise completion (p \ 0.001). The changes of CMAP amplitude were not significantly different during the cooling test compared with that at room temperature (15.96 ± 2.35 mV vs 15.98 ± 2.50 mV, P = 0.98). Precipitants of attacks were vigorous exercise and hunger in all patients and cold and potassium rich foods in 5 of 7 patients. All patients experienced clinical myotonia at eyelids or lips. CPK was high in 5 patients and potassium level was normal range in all patients. Molecular analysis of the SCN4A gene revealed an A-G transition causing the substitution of valine for methionine at codon 1592. Conclusions: We conclude that the exercise tests may be helpful in confirming abnormal excitability of the muscle membrane in patients with hyperPP. We hypothesize that abnormal electromyographic patterns depended on the underlying pathophysiological mechanism. We describe a clinical and electromyographic characteristics in familial hyperPP with a Met1592Val mutation.

P518 Myasthenia gravis associated with etanercept therapy L. Codeluppi, A. Ariatti, S. Meletti, F. Valzania, F. Barbi, G. Galassi Institute of Neurosciences (Modena, IT) Objective: Myasthenia Gravis (MG) is chronic T-cell, complementdependent neuromuscular junction disorder mediated by autoantibodies against nicotinic acetylcholine receptor (AChR) on postsynaptic membrane.Antibodies against AChR receptors and activated complement cascade play crucial role in MG pathogenesis.Various cytokines including tumor necrosis factor-a (TNFa) have shown importance in development of experimental autoimmune MG. Etanercept is drug treating autoimmune diseases by interfering with TNFa as inhibitor. Etanercept is a fusion protein produced through expression of

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S170 recombinant DNA.Human recombinant tumor necrosis factor receptor blocker are used to treat inflammatory disorders, designed to antagonize TNFa function: however, it can cause autoimmunity, initiating CNS demyelination, worsening multiple sclerosis, provoking neuropathy resembling chronic inflammatory demyelinating polyradiculopathy. Methods: We came across a patient who developed generalized MG nine months after starting etarnecept therapy(Enbrel). A 68 year old woman experienced fluctuating fatigability in chewing, swallowing, climbing stairs. Etanercept was administered subcutaneously 50 mg, weekly to treat psoriatic arthritis. On admission (October 2009)patient exhibited bilateral ptosis, slurred speech, proximal,distal extremity weakness graded 2/5, 3/5 respectively on MRC scale. Results: Laboratory results including tumor marker titer,thyroid function, microbiological, viral screenings were negative. Brain MRI was normal.Antibodies to MGT-30 were positive; anti-AChR antibody titer was 76 pmol/ml(normal\0,5). Total body computed tomography excluded malignancies. Low rate repetitive stimulation (3 Hz)of ulnar and spinal accessory nerves showed at rest 12% decrement of compound muscle action potential amplitude; after exercise there was post activation exhaustion. Single-fiber electromyography (SFEMG) of frontalis muscles showed increased jitter,all fiber blocking. Etanercept was halted. Symptomatic treatment with anticholinersterases had benefit. No specific therapy was instituted. At one and three months after drug cessation, patient had no residual fatigability. Conclusion: Rapid resolution of symptoms strongly implicate TNFa blocker in inducing MG. Review of literature discloses a single case of MG associated with etarnecept therapy. As to pathogenesis, role of TNFa blocker might be involved in disequilibrium of immune system, exacerbating pro-inflammatory and tissue damaging activity.

P519 Clinical characteristics of MUSK antibody-positive and -negative myasthenia gravis patients K.K. Kim Asan Medical Center (Seoul, KR) Backgroud: The anti-muscle-specific tyrosine kinase (MuSK) antibody (Ab) in serum is specific for acethylcholine receptor (AChR) Ab-negative myasthenia gravis (MG),and therfore should be useful as diagnostic test in patients who lack AChR Ab. In this study we report the clnical charactersitics of 22 such patients with generalized MG and compare the features of patients with MuSK antibodies to those without such antibodies. Methods: We assayed sera from 22 AChR Ab-negative patients with generalized MG who were followed clinically for MuSK Abs and analyzed and compared their clinical characteristics. Results: Eleven patients with generalized MG had MuSK Abpositive sera, including one man and 10 women (91%).Among the 22 patients with generalized MG but no AChR Abs, MuSK testing was positive in 1 of 5 men (20%) and 10 of 17 (59%).The age of onset in MuSK Ab-positive group ranged from 22 to 52 years (average 36.9 years). The age of onset in MuSK Ab-negative group was not significantly later, ranging from 21 to 55 years (F=0.4652). In MuSK Ab-positive group, the weakness initially involved the extraocular muscles and bulbar muscles in 5 of 11 (45%) patients, each. During the disease progress, the weakness affected the oculo-bulbo-skeletal muscles in 8 of 11(73%). In MuSK Ab-negative group, the weakness initially involved ocular muscles in 7 of 11 (64%), and bulbar muscles in 3 (27%). Repetitive nerve stimulation test (RNST) was normal in 5 MuSK Ab(-) and 4 MuSK Ab(+) patients. At proximal muscles of deltoid or trapezius was positive RNST in 5 MuSK Ab (+) patients. Patients moderately responded to immunosuppressant regardless of whether MuSK Ab was present.Two MuSK Ab(-) patients was completely treated after thymectomy for thymoma without persistent

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immunosuppressant or anticholine-esterase.Hyperthyroidism (4 of 11 patients, 36%) was more prominent in MuSK Ab(-) patients. Conclusion: In a group of female generalized MG patients without AChR-Ab and hyperthyroidsm the probablity of MuSK Ab(+) was prominent, inspite of RNST test and presenting ocular symptoms. The responses of anticholinesterase and immunomodulatory agents to patients in MuSK Ab-positive and -negative groups were similar and generally successful in continuing therapy.

P520 Thymomatous myasthenia gravis among Hong Kong Chinese K.H. Chan, J.W. Tsang, W.W. Mak, H.H. Liu, S.L. Ho, R.T. Cheung The University of Hong Kong (Hong Kong, HK) Background: Myasthenia gravis (MG) is an autoimmune disorder targeting skeletal muscle acetylcholine receptor. Thymoma is associated in some patients with myasthenia gravis, the majority of whom present with symptoms of MG before detection of underlying thymoma. Aim: to study clinical and serological characteristics of Chinese thymomatous MG patients. Methods: Autoimmune MG patients with thymomectomy and histologically confirmed thymoma followed up in our hospital for at least 12 months were studied. Results: Total 37 Chinese MG patients with histology-proven thymoma were retrospectively studied. The mean MG symptom onset age was 48.5 years (range 25–81), 25 (68%) were female. The mean follow-up duration was 4.9 years (range 1–15). MG symptoms preceded detection of thymoma in the majority (31 patients, 84%), in 6 patients thymoma detection preceded MG symptoms onset by 1–8 years. 19 patients (51%) had early onset MG (before 50 years of age). All patients were seropositive for acetylcholine receptor antibodies and 30 patients (81%) seropositive for striated muscle antibodies. Eleven patients (30%) had experienced myasthenic crisis and the worst MGFA clinical severity grade were class I (6 patients), class II (3), class III (8), class IV (9) and class V (11); hence 31 (84%) had generalized MG and 6 (16%) had ocular MG. 27 patients (73%) had history of corticosteroid therapy, 22 (60%) require azathioprine, 2 require other immunosuppressant (1 mycophenolate mofetil, 1 cyclosporin A). All 37 patients had good or satisfactory MG clinical outcome measured by MGFA post-intervention status (2 pharmacological remission, 23 minimal manifestation, 12 improved) though one patient died from metastatic thymoma. Conclusion: Thymoma MG was clinically severe with frequent myasthenic crises, but response to conventional immunosuppressive therapies are satisfactory.

P521 Congenital slow channel myasthenic syndrome responding to fluoxetine treatment A.-K. Peyer, A. Abicht, M. Sinnreich, D. Fischer University Hospital of Basel (Basel, CH); Medizinisch Genetisches Zentrum (Munich, DE) Objective: To describe a patient with a new mutation in the a subunit of acetylcholine receptor (AChR) with clinical and electrophysiological hallmarks of a slow-channel myasthenic syndrome (SCCMS), responsive to fluoxetine treatment. Background: SCCMS is due to a genetically determined kinetic abnormality of the AChR at the neuromuscular junction leading to its

S171 prolonged open state. Fluoxetine has a non-depolarizing blocking activity of nicotinic AChRs and has been used as treatment for SCCMS. Methods: Clinical examination, nerve conduction studies, repetitive nerve stimulation at varied frequencies before and after treatment with fluoxetine were performed on a 44 year old patient with suspected SCCMS. Sequence analysis of the a-subunit of AChR according to standard protocol. Results: A 44 year old woman had progressive muscle weakness, being hypotonic as an infant with delayed acquisition of motor milestones. At age 16 she stopped playing piano due to weakness of finger extensors. Later, upper limb girdle weakness developed. At presentation she had bilateral ptosis, external ophthalmoparesis, a myopathic facies, neck extensor weakness, proximal upper extremity weakness and finger extensor weakness. Motor nerve conductions studies revealed a double compound muscle action potential (repetitive R-CMAP) of the ulnar CMAP. Low frequency repetitive stimulation of ulnar, spinal accessory, and facial nerves showed a CMAP decrement greater than 10% in all nerves analysed, which worsened at higher frequencies (5 Hz, 10 Hz) and also after administration of an acetylcholinesterase inhibitor (Pyridostigmin). The diagnosis of SCCMS was suspected. She had a marked treatment response to fluoxetine, 80 mg/day. After 2 months, she experienced marked improvement of proximal muscle strength, but persistent ptosis and ophthalmoparesis. Repetitive nerve stimulation on fluoxetine showed a normalization of the decrement in ulnar and spinal accessory nerves, and the R-CMAP disappeared. Genetic analysis of AChR revealed a new c.959G[T (GGA[GTA), p.GLy320Val mutation within the a subunit. Analyses of further healthy family members to prove pathogenicity of the mutation are ongoing. Conclusion: We suggest initiating treatment in SCCMS when the clinical and electrophysiological findings are characteristic.

P522 Fatigue and excessive daytime sleepiness in patients with myotonic dystrophy type 1 S. Peric, V. Rakocevic-Stojanovic, I. Basta, Z. Stevic, I. Marjanovic, D. Lavrnic University of Belgrade (Belgrade, RS) Objectives: Myotonic dystrophy type 1 (DM1) is a multisystemic disorder. The main emphasis is usually placed on progressive muscle weakness and mytonia, while central nervous system manifestations have received little attention. Severe fatigue and excessive daytime sleepiness (EDS) can be a major determinant of disability and can influence quality of life (QoL) in neurological patients. The aims of this study were to evaluate the presence of fatigue and EDS in patients with DM1, to determine factors related to fatigue and EDS, as well as to assess if these two symptoms affect quality of life (QoL). Methods: This study included 62 consecutive patients with adult form of DM1 who were seen at the outpatient unit of the Institute of Neurology, Clinical Center of Serbia from October 2009 to January 2010. Severity of muscular involvement was measured by MRC score. Following assessment questionnaires were used: the Fatigue Severity Scale (FSS), the Daytime Sleepiness Scale (DSS), the Hamilton Depression Scale and the SF-36 questionnaire. Results: Our study showed that 58% of DM1 patients were fatigued and 40% were sleepy. Significant correlation between FSS and DSS scores was observed (p\0.01). Fatigue was related to the age of patients (p\0.05), their muscle strength (p\0.01) and the level of depressiveness (p\0.01). However, EDS was related only to the level of depressiveness (p\0.01). SF-36 total score was significantly affected by fatigue (p\0.01), but not by EDS (p[0.05).

Conclusion: EDS was found in 40% of DM1 patients and this is of a major importance because EDS may present a danger to the patients themselves and to the others. Significant fatigue was observed in 58% of DM1 patients and it significantly affected their health-related QoL. Thus, we emphasize the importance of development of compensatory strategies to reduce fatigue and EDS in patients with DM1.

P523 Myotonia congenita: paper work for mexiletine is worthy C. Serrano Munuera, M. Martinez Corral, E. Peral Hospital St.Joan de Deu (Barcelona, ES) Objectives: To report the response to mexiletine, a class IB antiarrhythmic drug, in three patients with myotonia congenita. Methods/patients: Three patients (2 males, 1 female), ages 40yo, 49yo and 29yo, with a diagnosis of myotonia congenita (2 of them Becker, one of them Thompsen type) were put into mexiletine. One patient had been previously treated with this drug successfully, two were naı¨ve. Response to treatment was evaluated clinically (daily tasks improvement, time to relaxation and 10-stairs test). Dose range varied from 400 to 600mg/day in 200mg single doses. Results: The drug was very well tolerated in all three patients. No side effects were reported. All three patients reported a clear improvement in daily tasks. Time to relaxation and 10-stairs test also improved in all three. Conclusions: Myotonia can be a very invalidating symptom generating social and work problems. When stiffness interferes with daily life activities, treatment should be considered. Mexiletine is the drug of choice in this condition. The doses used in myotonia are generally well tolerated. Nevertheless and despite a correct diagnosis early in life, most patients with myotonia congenita are not currently being treated. Presumably, paperwork needed to obtain the drug (in Spain includes compassive use and foreign drug forms that need to be authorized by Health Department) discourages doctors from prescribing such a treatment. In addition, neurologists may feel uncomfortable with a drug that is no commonly used in our field and in the setting of an exclusive clinical and EMG diagnosis, since genetic tests for myotonia congenita are not broadly available either.

P524 Low level of fasting blood glucose should be noted at the early stage of glucose intolerance in myotonic dystrophy type 1 H. Takada, S. Kon, Y. Oyama, T. Gotoh Aomori Hospital (Aomori, JP); Akita Red Cross Hospital (Akita, JP) Objectives: Glucose intolerance is one of principle complications in myotonic dystrophy type 1 (MD1). Hyperinsulinemia (HI) is a characteristic feature of glucose intolerance in MD1. We reported negative correlation between fasting plasma glucose (FPG) and plasma insulin (IRI) at 120 minutes or total summation of IRIs during oral glucose tolerance test (OGTT), and referred to peculiar HI in MD1. It is important to know how glucose intolerance in MD1 progresses. In this study, plasma glucose (PG) and IRI response by OGTT in MD1 with different stages of glucose intolerance were investigated to make it clear the course of glucose intolerance at early stage in MD1 using easy parameters in daily clinical scene. Methods: Twenty-six patients with MD1 (eleven females, the mean age of 52.8 ± 8.7 years) were examined by means of 75g OGTT. PG and IRI values at 0, 120 and 180 minutes during OGTT

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S172 were measured. Eighteen volunteers with non-diabetic pattern of OGTT were participated as controls (CT). Results: Four patients showed normal PG and IRI response (NO). Seven patients had normal PG response with HI. Ten patients were classified into border line pattern of OGTT (BL). Five patients were diagnosed as diabetes pattern (DM). There was no significant difference between FPG in NO and that in CT. FPG in HI or BL was significantly lower than that in CT. FPG in DM was significantly higher compared to that in CT. There was no significant difference between PG at 120 or 180 minutes in NO or HI and CT. PG at 120 or 180 minutes in BL or DM was significantly higher than that in CT. There was no significant difference for fasting IRI among groups. IRI at 120 minutes in HI, BL or DM was significantly higher than that in CT. Conclusion: Our results suggested development of glucose intolerance in MD1 could be as follows. In the earliest stage of glucose intolerance in MD1, lower FPG was a characteristic feature. In the next stage, HI lasting for 120 minutes after glucose intake was observed. Then, postprandial hyperglycemia continued over 120 minutes was manifested. FPG was getting higher along development of glucose intolerance, and finally, DM occurred in MD1. Therefore, low FPG at the early stage should be more paid attention for the management of glucose intolerance in MD1 at bedside.

P525 Juvenile case of myotonic dystrophy type 2 correlates with early spliceopathy: biomolecular evidence for anticipation? G. Meola, R. Cardani, M. Giagnacovo, A. Botta, F. Rinaldi, A. Morgante, V. Sansone, E. Bugiardini, G. Novelli University of Milan (Milan, IT); University of Pavia (Pavia, IT); Tor Vergata University of Rome (Rome, IT); University of Milan (San Donato, IT) Objective: Myotonic dystrophy type 2 (DM2) is a common adult onset muscular dystrophy caused by a dominantly transmitted CCTG expansion in intron 1 of ZNF9 gene. In DM2 there is no obvious evidence for an intergenerational increase of expansion size and no congenital cases have been reported. We describe clinical, histopathological, genetic and molecular analysis in a 14-year-old female with juvenile onset DM2 and her affected mother presenting with a more severe phenotype and a later onset of symptoms. Methods: Biceps brachii muscle biopsy and blood samples were taken from two DM2 patients. Muscle tissue was fresh-frozen in isopentane cooled in liquid nitrogen for routine histological or histochemical stainings, fast and slow myosin isoforms and CLC1 immunohistochemical stainings and FISH in combination with MBNL1-immunofluorescence. Genetic characterization of the DM2 mutation has been obtained by a combination of long-PCR and Southern blot analyses on DNA extracted either from peripheral blood and muscle. The RT-PCR splicing assays for the IR, MBNL1 and CLCN1 genes have been carried out on muscle samples. Results: Histological and immunohistochemical analysis do not correlate with disease severity or age at onset in both patients. Only a small increase in the CCTG repeat number through maternal transmission. FISH in combination with MBNL1-immunofluorescence on muscle sections shows the presence of mutant-mRNA and MBNL1 nuclear foci whose fluorescence intensity and area appear to be similar in the two patients. Splicing analysis of the IR, ClCN1 and MBNL1 genes in muscle tissue demonstrates that the level of aberrant splicing isoforms is lower in the daughter than in the mother. No

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mutations of the CLCN1 gene have been found excluding a second genetic mutation in this ion channel gene responsible for myotonia in the young DM2 patient. Conclusion: Juvenile onset with early abnormal expression of splicing products should be also considered in DM2. These findings might be the basis for biomolecular anticipation in DM2. Alternative mechanisms should be to show clinical and biomolecular differences in comparison to DM1.

P526 The analysis of corrected QT interval in patients with myotonic dystrophy type 1 K.J. Shin Hanmaeum Hospital (Jeju, KR) Sudden cardiac arrest is one of the leading causes of death in patients with myotonic dystrophy type 1 (DM1). It has been proposed that prolonged QT interval is associated with sudden cardiac death in several diseases such as primary autonomic failure, diabetic autonomic neuropathy, multiple systemic atrophy and idiopathic Parkinson’s disease. The purposes of this study are 1) to determine the association between the QT interval and DM1 and 2) to analyze the factors affecting QT interval in patients with DM1. Sixty-eight patients diagnosed with DM1 through genetic test were included in this study. Age, sex, age of onset, disease duration, associated diseases, ECG findings, CTG repeat sizes and the QTc interval (corrected QT interval calculated by Bazett’s formula, QTc=QT/rootRR33) of 68 patients were assessed by reviewing their medical records. The QTc intervals of 68 patients and 68 normal sex-age matched healthy control group were compared. The clinical and laboratory factors affecting the QTc interval in patients group were investigated. The QTc interval of DM1 group (413.8 ± 45.3 msec) was significantly higher than normal control group (355.6 ± 20.6msec). Thirteen among the 68 DM1 patients showed abnormal prolonged QTc interval ([440 msec in male, [450 msec in female). The female sex, abnormal EKG findings, disease duration and age were significantly associated with prolonged QTc interval in patients group. The advantages of QTc interval in assessing the cardiovascular autonomic nervous system (ANS) are its safety, simplicity, costeffectiveness and reproducibility. Therefore, the QTc interval can be used as a good screening test in assessing the cardiovascular ANS in patients with DM1. And the analysis of QTc interval by using surface ECG could be important in expecting prognosis of the patients with DM1.

P527 MERRF: clinical features, muscle biopsy and molecular genetics P.J. Lorenzoni, R.H. Scola, C.S. Kay, R.C. Arndt, C.E. Silvado, L.C. Werneck Federal University of Parana´ (Curitiba, BR) Objectives: MERRF is one of occurring mitochondrial diseases and is characterized by myoclonic epilepsy with ragged red fibers. Since its first description, few patients with this disease have been identified in Brazil. In this study we analyze the clinical and laboratory manifestations, brain images, interictal electroencephalogram, histological and molecular findings in Brazilian patients suffering from MERRF. The aim of the study was to analyze a series of Brazilian patients suffering from MERRF.

S173 Methods: Six patients with MERRF were studied with correlation between clinical findings, laboratorial data, electrophysiology, histochemical and molecular features. Results: The sample consisted of 6 patients (2 female and 4 male) aged 27 to 54 years. The mean time of the progression of the disease was 8.5 months. All patients had other family members with possible mitochondrial disorders. Myoclonus and epilepsy were present in all cases; other symptoms reported included cerebellar ataxia, weakness, peripheral neuropathy, multiple lipomas, headache, vomiting, dementia, ocular ptosis, ophthalmoparesis and exercise intolerance. Blood lactate was increased in four patients. Interictal EEG showed background activity with diffuse slowing and generalized epileptiform discharges in five patients. Photic stimulation revealed photosensitivity response in two patients. Brain image study observed a diffuse cerebral and cerebellar atrophy in four patients. Muscle biopsy showed RRF in all patients on modified Gomori-trichrome and succinate dehydrogenase stains. Cytochrome c oxidase (COX) stain analysis indicated deficient activity in five patient and subsarcolemmal accumulation in one patient. Strongly succinate dehydrogenase-reactive blood vessels (SSV) did not occur. The molecular analysis of tRNALys(UUR) gene by PCR/RLFP and direct sequencing showed the 8344 mutation on mtDNA in five patients. Conclusions: The muscle biopsy often confirmed the MELAS diagnosis by presence of RRF and COX deficiency. Molecular analysis of tRNALys(UUR) gene is an important diagnostic criteria for MERRF. Supported by Fundac¸a˜o Arauca´ria, CAPES and CNPq.

P528 Non-specific mitochondrial encephalomyopathy: towards diagnosis M. Gawel, B. Kierdaszuk, J. Zajaczkowska, K. Tonska, M. Kaliszewska, Z. Jamrozik, E. Bartnik, H. Kwiecinski Medical University of Warsaw (Warsaw, PL); University of Warsaw (Warsaw, PL) Mitochondrial diseases may cause a wide range of central nervous system, peripheral nervous system as well as muscle disorders. The diagnostic process routinely includes electrophysiological, morphological, neuroimaging and genetic studies. In some cases, however, only when mitochondrial DNA (mtDNA) examination in muscle is performed the diagnosis may be ascertained. We report on a case of a 24 years old woman, with 7 years history of tremor of hands and slurred and scanned speech, and with unremarkable family history. The neurological examination showed slowly progressive cerebellar syndrome and bilateral ptosis. There was no significant cognitive impairment. Laboratory studies revealed an elevated level of protein in cerebrospinal fluid (155 mg/dl) with normal level of glucose and normal cytosis. Audiological tests demonstrated significant sensorineural hearing loss in the right ear. Magnetic resonance imaging (MRI) of the brain showed diffuse involvement of the white matter so initially leukoencephalopathy was suspected. Metachromatic leucodystrophy, adrenoleukodystrophy and Krabbe disease were, however, excluded by appropriate blood tests. MRI spectroscopy revealed a high lactate concentration in brain tissues. Electrophysiological studies revealed normal conduction in peripheral nerves and normal electromyography pattern in muscles. As the diagnosis of mitochondrial disease was considered, a skeletal muscle biopsy was performed. It revealed minor nonspecific myopathic changes in light microscopy. In electron microscopy small

collections of abnormal mitochondria with irregular cristae were detected in some fibers. Blood leukocyte and muscle mtDNA analysis were performed. Common point mutation screen for 3243A[G, 8344A[G, 8993T[G and 8993T[C gave negative results as did a PCR test for the so-called common deletion of 4977 bp. Southern analysis for mitochondrial rearrangements was negative for the blood sample but revealed the existence of a large mtDNA deletion in muscle with 24% of mutated mtDNA. Deletion mapping by RFLP and sequencing of its borders showed that it covered nucleotides: 7815-14804 with an indirect border repeat of 12 nucleotides. This case emphasizes the role of mtDNA studies in muscle in nonspecific multisystem mitochondrial disorders, even without clear clinical muscle involvement.

P529 Role of the autophagic process in adult-onset patients with Pompe disease O. Musumeci, M. Aguennouz, T. Mongini, L. Palmucci, E. Barca, G. Vita, A. Toscano University of Messina (Messina, IT); University of Turin (Turin, IT) Objectives: Pompe disease or glycogenosis type II (GSD II) is an autosomal recessive disorder due to deficiency of the lysosomal enzyme alpha-glucosidase (GAA). The adult form is clinically heterogeneous, and may present as a slowly progressive limb-girdle syndrome with or without respiratory distress. Asymptomatic subjects can be incidentally diagnosed because of elevated creatine kinase levels. GSD II muscle biopsies showed great morphological variability ranging from a vacuolar myopathy with high glycogen content to minimal unspecific changes. So far more than 200 mutations in GAA gene have been reported but there are no clear phenotypegenotype correlations. It is conceivable that other conditions such as non-genetic factors and/or modifying genes may determine GSD II clinical pattern. The main purpose of this study was to investigate muscle gene expression in patients with late-onset Pompe disease with different morphological features. Methods: Muscle specimens from 10 GSD II patients and from 5 normal controls were studied. We divided muscle samples in two groups according to main pathological features: the first group (G1) characterized by a vacuolar myopathy with increased glycogen content and a second group (G2) with minimal or absent changes and no glycogen storage. Microarray experiments were performed using amplified RNA isolated from muscle specimens hybridized in a GeneChip microarrays panel of the whole human Genome containing approximately 44000 genes. Results: Gene expression analysis revealed an upregulation of transcripts for calcium binding proteins and myosin light-chain kinase in G1. Ion channels family was downregulated in G1, whereas voltage-gated cation channels such as potassium channel were upregulated in G2. Folding, sorting and degradation protein family genes, such as ubiquitin and proteasomes, were overexpressed in G1. Several genes, involved in the autophagic pathway, resulted also overexpressed (ATG8, LC3, FOXO3 etc.). The upregulation of ATG8, LC3 e FOXO3 was validated by RealTime PCR and Western Blot analysis Conclusions: Our data support the hypothesis that additional genetic factors strictly linked to autophagy and protein catabolism pathways play a role in the pathogenesis of GSD II.

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P530 Clinical characteristics, biochemical features and electrophysiological findings in Korean patients with thyrotoxic periodic paralysis S.B. Kwon, M.K. Park, S.S. Hong, S.Y. Kang, S. Jung, S.H. Hwang, K.H. Kwon Hallym University College of Medicine (Seoul, KR); SoonChunHyang University College of Medicine (Seoul, KR) Background and objectives: Thyrotoxic periodic paralysis (TPP) has a much higher prevalence in Asian than in all the other populations studied so far. It is also increasingly being seen at the emergency departments, hence, it is important to stress the importance of recognizing it. However, there were few studies about Korean TPP patients. We undertook this study to analyze the clinical and electrophysiological characteristics of hypokalemic TPP in Korean patients. Methods: We retrospectively evaluated clinical characteristics, biochemical features, and electrophysiological findings of consecutive TPP patients who were admitted from Jan 2003 through Jun 2009. We also compared patients with and without recurrent paralytic attacks in order to identify predictors of recurrent paralytic attacks before achieving the euthyroid status. Results: A total of 16 TPP patients were enrolled during the study period. All but one were male (93.8%, 15/16). The mean onset age was 33.2 years (range: 23–53 years). The main cause of thyrotoxicosis was Graves’ Disease (13/16, 81.3%). Only 18.7% had a known history of thyrotoxicosis before their first presentation with periodic paralysis. Duration of attacks varied from 12 to 48 hours. Most attacks occurred in the late evening or early morning and developed in late summer and early autumn (62% and 50%, respectively). Precipitating factors were rest/sleep at night, carbohydrate rich diet, upper respiratory tract infections (URIs), fatigue, and excessive physical activities, etc. Upper and lower extremity weakness was observed in 7 (43.8%, 7/16) patients and lower extremity weakness was found in all patients. Most patients (14/16, 87.5%) were found to have hypokalemia (mean 2.29 mmol/l, ranged from 1.8 to 4.4 mmol/l) during attacks. Prolonged exercise test during the period between attacks were performed in 10 patients, and the sensitivity of the test was 40% (4/10). Before treatment of thyrotoxicosis, the rate of recurrent attacks was as high as 43.8% (7/16). There were no predictors to determine the possibility of recurrent attacks before achieving euthyroid state. Conclusion: Even though this study was analyzed with small portion of all Korean TPP patients, it may give help to comprehend clinical characteristics, biochemical features, and electrophysiological findings in Korean patients with TPP.

P531 Dysferlin interacts with a-tubulin in skeletal muscle B. Azakir, S. DiFulvio, C. Therrien, B. Erne, M. Sinnreich University Hospital Basel (Basel, CH) Objective: To identify novel dysferlin binding partners in skeletal muscle. Background: Mutations in the dysferlin gene lead to Limb girdle muscular dystrophy type 2B (LGMD2B), Miyoshi Myopathy (MM) and distal anterior compartment myopathy. Dysferlin is a type II transmembrane protein containing seven C2 domains and two Dysf domains, and is an integral part of the skeletal muscle surface membrane repair process. In muscle cells dysferlin is localized to the sarcolemma, the t-tubule system and to cytoplasmic vesicles. Dysferlin’s role in skeletal muscle membrane repair, its intracellular trafficking and signalling pathways are still poorly characterized.

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Identifying dysferlin protein binding partners and understanding their implication in dysferlin mediated membrane repair should shed light on the membrane repair mechanism and should be important for the development of therapeutic strategies for dysferlinopathies and other muscular dystrophies. Methods: We used affinity purification followed by liquid chromatography/mass spectrometry on dysferlin pull down from mouse skeletal muscle tissue, and have identified a number of proteins in mouse skeletal muscle, which showed association with dysferlin. One of these proteins was a-tubulin. To confirm the interaction between dysferlin and a-tubulin, we used protein overlay assays, immunoprecipitation assays, microtubule sedimentation assays and confocal microscopy. Finally, we mapped dysferlin’s tubulin binding domains through pulldown assays with recombinantly generated GST-dysferlin C2 domains. Results: We have identified a large number of novel potential dysferlin protein binding partners. We were able to identify the few proteins that were previously shown to interact with dysferlin demonstrating the validity of the chosen approach. We show by biochemical and localization studies that dysferlin interacts with one of the identified partners, namely a-tubulin in vitro and in vivo. Dysferlin co-localized with a-tubulin close to perinuclear region in myoblasts and along microtubules in myotubes. This interaction is mediated by dysferlin’s C2A and C2B domain and is calcium independent. Conclusion: Our studies identified novel protein binding partners of dysferlin. Here we characterized the interaction between dysferlin and a-tubulin. We suggest that microtubules are implicated in dysferlin trafficking to the sarcolemma, a pathway that is currently poorly characterized for dysferlin.

P532 A sarcolemmal wounding assay to study membrane resealing in cultured myotubes B. Azakir, B. Erne, M. Sinnreich University Hospital Basel (Basel, CH) Objective: To establish a sarcolemmal resealing assay in cultured human dysferlin deficient myotubes suitable for testing therapeutic compounds for muscular dystrophy caused by dysferlin deficiency. Background: The pathogenic basis for many muscular dystrophies is the inability of the muscle cell to maintain its sarcolemmal integrity, due to defective or deficient membrane associated structural proteins or components of the membrane repair machinery. An important protein implicated in surface membrane repair in muscle is dysferlin. Mutations in dysferlin are a frequent cause for the recessively inherited limb girdle muscular dystrophies (LGMD), defining the common subtype of LGMD2B. Dysferlin is a large protein containing seven C2 domains, 2 DYSF domains and a transmembrane domain. To understand the molecular basis of dysferlin’s function we wish to study recombinantly generated C2 domain deletion mutants of dysferlin. We also generated small recombinant micro-dysferlin molecules suitable for Adenovirus Associated Virus (AAV) mediated gene transfer as a treatment strategy for muscular dystrophies caused by dysferlin deficiency. In order to test the resealing capabilities of the recombinantly generated proteins we wished to develop an in vitro sarcolemmal resealing assay. Method: Differentiated myotubes from the cell line C2C12 and from primary myoblast cultures of dysferlin deficient patients, transformed with E6 and E7 from HPV16, were used as the assay system. Sarcolemmal resealing kinetics were determined by measuring fluorescent dye uptake at defined, laser induced wound sites. C2C12 cells were obtained from ATCC. Primary myoblast cultures were obtained from EuroBioBank.

S175 Results: We found a significant difference of resealing kinetics of laser induced sarcolemmal wounds in the presence versus the absence of calcium in C2C12 myotubes, reflecting the known calcium dependency of the resealing process. In cultured dysferlin deficient human myotubes, resealing did not occur, regardless of the presence or absence of calcium, confirming the membrane resealing deficiency demonstrated previously in mouse myofibers. Conclusion: The dysferlin deficient myotubes used here are easily cultured and the developed assay system should allow to test the membrane resealing capabilities of small molecular compounds or of recombinantly generated micro-dysferlin proteins in an attempt to develop therapies for dysferlin deficiency.

P533 Generalized weakness after focal injection of botulin toxin type A (BTA) G. Galassi, C. Orlandi, F. Valzania, G. Albertini, A. Ariatti, A. Barbieri Institute of Neurosciences (Modena, IT); Intensive Care Unit (Modena, IT) Objective: Botulinum toxin type A (BTA) is established treatment for muscle, autonomic nerve terminal overactivity.BTA is primarily presynaptic neuromuscular blocking agent inducing selective, reversible muscle weakness lasting several months when injected intramuscularly.The toxin in therapeutic doses is safe.Generalized weakness of distant muscles is seldom reported. BTA is digested in gastrointestinal tract as it forms complex with proteins that protect and stabilize neurotoxin;it considered treatment option for gastrointestinal achalasia. Methods: A75 year old diabetic woman developed functional obstructive gastrointestinal symptoms due to esophageal achalasia. She received endoscopically epicardial BTA injection (Botox Allergan 100 U).By day 3 patient developed shortness of breath, dysarthria, dysphagia, nasal regurgitation.By day 7 she exhibited respiratory distress.When admitted to ICU (day 8) patient was alert; eye movements were full with normally reactive pupils. There was neck flexor, upper, lower limb weakness graded 2/5-3/5 respectively (MRC scale).Deep jerks were brisk throughout. Results: Blood tests showed anemia; tumor marker titer, autoimmune screenings, antibody search of muscle tyrosin kinase, acetilcholine receptors, voltage gated calcium channels were negative.Brain,total body computed tomography was inconclusive. Three Hz repetitive nerve stimulation(RS)on day 8 showed 25 % decrement of ulnar compound muscle action potential(CMAP). Repeated low rate RS(day 12) revealed up to18% CMAP decrement before and after activation.No increment was recorded at 20 Hz whereas initial CMAPs were low in amplitude(1–2.0 mV). Overall findings suggested severe neuromuscular transmission defect.Needle electromyography (day 12, 45) showed widespread denervation, increased brief duration polyphasia. Oral pyridostigmine bromide(60 mg every 4 hour)was commenced on day 8. Four courses of plasma exchanges (PEX) were given from day 21.By day 48,patient was able to protrude her tongue,to bend upper, lower limbs. By day 51, she developed respiratory failure due to superimposed pneumonia from which she recovered. Conclusions:Our patient exhibited neuromuscular junction (nmj) disorder chronologically related to BTA injection.Electrophysiology suggested transmitter release block.The disorder partially responded to oral anticholinesterases and PEX. In our view,pathogenesis was related either to distant effect of BTA or to uncover underlying nmj disorder.

P534 An apparently isolated case of recessive oculopharyngeal muscular dystrophy–the first Portuguese report H.P. Grebe, M. Milheiro, A. Ferreira, P. Coutinho Hospital Sa˜o Sebastia˜o (Santa Maria da Feira, PT) Introduction: Oculopharyngeal muscular dystrophy (OPMD) is a late onset myopathy with progressive ptosis, dysphagia and proximal muscle weakness, usually dominantly inherited. A rare recessive form has also been described, yet documentation of such cases in the literature is very sparse. Here we report an apparently isolated case with genetically confirmed recessive OPMD. Case report: A 74 year-old male patient presented with recent onset diplopia. According to the family he had been developing eyelid drooping, slurred and hypophonic speech, swallowing difficulties and gait difficulties since approximately three months. Information on fatigability was vague. He had no family history of consanguinity, or of symptoms suggestive of muscular disorders. His neurological exam revealed bilateral ptosis, incomplete adduction of the left eye and limited upward movements of both eyes, poor gag reflex, hypophonia, slurred speech, weak facial muscles, slight proximal paresis of the legs and wasting of thigh muscles. The Simpson test showed no fatigability. There was no fasciculation or pyramidal signs. The Tensilon test was negative. Muscle enzymes were normal, acetylcholine receptor antibodies were negative. Electrophysiological studies were inconclusive, namely there were no anomalies in repetitive stimulation. Magnetic resonance imaging (MRI) of the right thigh showed myopathic changes, especially in the great adductor muscle. Genetic testing revealed homozygous (GCG)7 expansion of the poly-(A) binding protein nuclear 1 (PABPN1) gene on chromosome 14q11, compatible with recessive oculopharyngeal muscular dystrophy. The patient has been clinically stable. Discussion: OPMD is a late onset myopathy usually presenting in the 5th or 6th decade of life with progressive ptosis, dysphagia and proximal muscle weakness. It is usually transmitted as an autosomal-dominant trait and characterized by an expansion of 8 or more GCG/GCA repeats in the PABPN1 gene on chromosome 14q11. Autosomal-recessive OPMD with a homozygous (GCG)7 expansion of PABPN1, like in our patient, has been described in a few patients only and has been generally associated with a comparably mild phenotype and later onset. This and the possibility that OPMD may be masked by symptoms of other diseases of the elderly may account for the paucity of cases of recessive OPMD reported in the literature despite an estimated 1-2% prevalence of the GCG7 allele. To our knowledge, this is the first case reported from Portugal.

P535 Oculopharyngeal muscular dystrophy among Bulgarian Jews. A new cluster? S.C. Blumen, A. Kesler, N. Blumen, V.E. Drory, M. Gurevich, S. Shalev, I. Braverman, R.L. Carasso, P. Nisipeanu, B. Brais Hillel Yaffe Medical Center (Hadera, IL); Tel Aviv Souraski Medical Center (Tel Aviv, IL); Sheba Medical Center (Tel Hashomer, IL); Haemek Medical Center (Afula, IL); University of Montreal (Montreal, CA) Background and objective: Oculopharyngeal Muscular Dystrophy (OPMD) produced by the (GCG)13 expansion mutation in the

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S176 PABPN1 gene is frequent among Uzbek Jews (UJ) in Israel. Here we report the phenotypic and genotypic features in five Bulgarian Jewish (BJ) patients with autosomal dominant OPMD. Methods: Clinical follow-up, electrodiagnostic tests and mutation detection; blood samples were obtained after informed consent and DNA was extracted; measurement of the sizes and sequencing of OPMD mutations was performed according to standard techniques. Results: We identified 5 patients (4 females), aged 58 to 69 years, with family histories suggesting autosomal dominant inheritance, with bilateral ptosis, dysphagia, dysphonia (3 patients) and myopathic motor units by EMG. In all patients we noticed proximal weakness of upper limbs with marked winging scapulae in three of them. All shared the (GCG)13-(GCG)10 PABPN1 genotype. Conclusions: 1. OPMD among BJ is produced by a (GCG)13 expansion, identical to the UJ and French Canadian mutations. 2. In addition to the classical neurological and neuro-ophthalmological features, early shoulder girdle weakness is a common denominator in BJ patients; this is a very unusual feature during the early stages of OPMD produced by the same mutation in other populations. We suggest that besides the disease producing GCG expansion, additional, ethnicity related, genetic factors may influence the OPMD phenotype 3. OPMD is a rare disease; the identification of five affected families in the rather small BJ community in Israel, probably, represents a new cluster; future haplotype studies will elucidate whether a founder effect took place.

Epilepsy P536 Lateralization of upper limb automatisms in temporal lobe epilepsy: a quantitative movement analysis Z. Mirzadjanova, A. Peters, C. Bilgin, J. Silva Cunha, S. Noachtar Tashkent Medical Academy (Tashkent, UZ); Ludwig-MaximiliansUniversity (Munich, DE); University of Aveiro (Aveiro, PT) Purpose: To evaluate the significance of lateralization of ictal upper limb automatisms in patients with temporal lobe epilepsy (TLE). Methods: Ictal upper limb automatisms of 28 patients with temporal lobe epilepsy were quantified. Duration of automatisms in relation to total seizure duration, movement speed, extent, length and predominant frequencies of the movements were analyzed for both upper extremities separately and compared to the lateralization of the epileptogenic temporal lobe. Results: Predominantly ipsilateral upper limb automatisms were more common (n = 19) than predominantly contralateral automatisms (n = 9). The duration of ictal ipsilateral upper limb automatisms was significantly longer than the duration of contralateral automatisms (ipsilateral automatisms: 29 s of 86 s total seizure duration; contralateral automatisms: 19 s of 110s total seizure duration; p = 0.048). Patients with ipsilateral upper limb automatisms had more often exclusively unitemporal interictal epileptiform discharges (IED) (84.2%) than patients with contralateral automatisms (11.1%; p \ 0.001). The positive predictive value (PPV) of the combination of these parameters is 84.2%. Excellent surgical seizure outcome was better in patients with ipsilateral upper limb automatisms (77.8%) compared to those with contralateral automatisms (20%) (p = 0.09). The quantitative analysis of movement extent, average speed, maximum speed and repetition rate of ipsilateral and contralateral upper limb automatisms did not show any statistically significant difference in this patient sample.

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Conclusion: The lateralization of upper limb automatisms in TLE has a good lateralizing value if the lateralization of IED were also taken into consideration.

P537 Psychogenic non-epileptic seizures: clinical classification based on the video-EEG analysis of 145 seizures C. Hubsch, C. Baumann, L. Maillard Central Hospital (Nancy, FR) The ‘‘psychogenic non-epileptic seizures (PNES), paroxysmal behavioral changes that resemble an epileptic seizure but are not associated with electrophysiological epileptic changes seem to be caused by a psychological process. They still are misdiagnosed. The video-EEG allows their direct observation. After studying the characteristics of the affected population of Lorraine, we are interested in the semiological aspect of PNES and have sought to demonstrate inter and intra-individuals reproducibility who attest to common ‘‘laws’’ and would look a neurological substrate for these events. Methods: We analyzed the symptomatology of 145 PNES, recorded by video-EEG in 52 patients. Statistical analysis of data consisted first, to describe all the characteristics of seizures and patients. Secondly, we conducted a multiple correspondence analysis and hierarchical clustering. The SAS  v9.1 was used. 5 subtypes of PNES emerged from the statistical analysis showing reproducibility of seizures in 61.54% of patients: – – – – –

brief crisis with automatisms and dystonia ‘‘pauci-kinetic’’, sensitive crisis with preserved contact brief and brutal crisis with break contact and clonic jerks ’’major crisis’’ with extended axial spasms prolonged, fluctuating with hyperventilation preceded prodrome.

by

The identification of a typology can move from a clinical based diagnosis to a real positive diagnosis. The reproducibility of the crisis allow to make common pathophysiological hypotheses. The history of psychological trauma query on a relationship between the management of neuro-psychological affects and PNES ‘‘dysfunction’’ of connections between the frontal lobe, the limbic system and the basal ganglia. Beyond the positive diagnosis, the fundamental and therapeutic perspectives are many.

P538 Sex hormone levels in women with epilepsy on antiepileptic therapy T. Afrantou, R. Lagoudaki, I. Mavromatis, E. Konstantinopoulou, G. Stamatopoulou, A. Tsiligiris, M. Paschalidou, N. Tascos Aristotle University of Thessaloniki (Thessaloniki, GR); General Hospital of Xanthi (Xanthi, GR) Objective: Women with epilepsy manifest endocrine problems such as polycystic ovary syndrome, hyperadrogenemia, infertility, menstrual irregularities and premature menopause. Also, in catamenial epilepsy seizures are presented at the beginning of menstrual cycle when estrogens are higher than progesterone levels. Methods: FSH, LH, prolactin (PRL), estadiol (E2), progesterone (Pg) and testosterone (T) levels were measured in 30 women with epilepsy, 21–67 years old, with disease duration 1–55 years

S177 (mean=21.5), with symptomatic (n= 12) and cryptogenic (n=18) epilepsy, on antiepileptic treatment with enzyme-inducers (EI) (n=10), valproic acid (VA) (n=10) and new generation (NG) drugs (n=10). The patients were compared to 20 healthy controls. Hormonal data were correlated with the antiepileptic drugs. Results: The epileptic women at reproductive age (RA) have similar results in their hormones alterations during both luteral and follicular phases. We identified decreased levels of FSH, LH and PRL, increased E2 and T, and unaltered levels of Pg compared to controls. At menopause we identified similar levels of LH, PRL, T and Pg, increased FSH and decreased E2 compared to controls. At the subgroup on EI at the RA there was a decrease in FSH, LH and a milder decrease in T levels, whereas increased E2 and PRL. At menopause we mentioned similar levels in FSH, LH, E2 and Pg increased prolactin and decreased T. At the subgroup on VA at the RA there was decreased FSH, mildly decreased LH,PRL, E2, Pg and unaltered levels of T compared to controls. At menopause, a mild increase FSH, unaltered levels of LH,T and Pg, decreased levels of PRL and E2 were found. On NG drugs patients, at the RA, FSH, PRL and T were decreased, LH and Pg were unaltered and E2 was increased. Conclusions: On EI patients we observed decrease of T in all age subgroups. Additionally it was mentioned that RA patients had a more diverse hormone profile alteration than women in menopause. On VA patients, characteristic finding has been the decrease of FSH and milder fluctuations at the rest hormones at the RA. The diverse hormone alterations which were found at the NG drugs treated patients was attributed to the severity of the disease as well as to the polytherapy used in this subgroup. Regular monitoring of ovarian function helps in the early characterization of reproductive abnormalities in epileptic patients and could be a useful tool for the choise of the antiepileptic drugs.

P539 Reproductive hormone levels in men with focal epilepsy T. Afrantou, R. Lagoudaki, I. Mavromatis, D. Nikiforidis, G. Stamatopoulou, A. Tsiligiris, N. Tascos Aristotle University of Thessaloniki (Thessaloniki, GR); General Hospital of Xanthi (Xanthi, GR) Objective: Male epilepsy patients experience sexual dysfunction in increased frequency compared to healthy men. Hypothalamus regulates the release of gonadotropins, the pituitary gland releases LH, FSH and Prolactin (PRL) which stimulate the gonads to produce Estradiol (E2), Progesterone (Pg) and testosterone (T). Anti-epileptic drugs play a key role in altering sex hormone levels both directly by influencing their metabolism and indirectly by affecting the hypothalamus-pituitary-gonadal axis (HPG). Method: FSH, LH, PRL, E2, Pg and T levels were measured in 31 men with epilepsy, 21-69 years old, with disease duration from 2 to 54 years (mean=19.3), with different epilepsy syndromes (symptomatic n=15 from which 13 temporal, cryptogenic n=16), on antiepileptic treatment with enzyme-inducers (EI), enzyme-inhibitors(EIH) and new generation (NG) drugs. The patients were compared with 10 healthy men. Hormonal data were correlated with the antiepileptic drugs, epilepsy syndrome and seizure frequency. Results: In the epilepsy patients LH and E2 levels were increased whereas PRL and T levels were decreased compared to controls. FSH and Pg levels showed an increasing tendency. At the subgroup on valproic acid (n=8), it was demonstrated decreased FSH and PRL, and increased E2 and LH compared to controls. The subgroup on EI (n=12) showed an increased expression of FSH, LH and E2, whereas a marked decreased of PRL and T, and Pg

being at the upper levels of the control group. At the subgroup on NG drugs (n=11) the pattern of hormone expression was similar to the one of enzyme-inducers subgroup but in milder levels. At the temporal epilepsy subgroup (n=13) it was demonstrated an increased tendency of FSH,LH, E2, T and decreased PRL compared to controls. When the hormone levels of seizure free patients were compared with those of patients with increased seizure frequency, there was not a detectable difference. Conclusions: There is a marked disturbance in the hormone levels of epilepsy patients compared to controls. We demonstrated that valproic acid decreases FSH and increases E2 whereas EI increase E2 and total testosterone. The similarity between the hormone levels of EI and NG drugs subgroups was attributed to the fact that patients on NG drugs were mainly on 3 drugs and had severe forms of epilepsy. Finally it was mentioned that the seizure frequency is not a factor that can act independently at the hormone levels.

P540 Coexistence of epilepsy and poliomyelitis: assessment of the clinical and pathophysiological relationship C. Demir, M.S. Berilgen, B. Mungen, S. Bulut Firat University (Elazig, TR) Neuronal destruction which caused by poliovirus infection is accompanied by an inflammatory infiltrate of polymorphonuclear leukocytes, lymphocytes, and macrophages. These lesions involves not only at the gray matter of the anterior horn of the spinal cord, but also neurons in several regions of the neuraxis, including the cerebral cortex, mesencephalon, cerebellum, brain stem, hypothalamus, dorsal root ganglia, muscles and nerves. Material and methods: This study was carried out on 53 patients who were admitted to the neurology clinic and EMG laboratory those belongs to Firat University Faculty of Medicine. The history, physical examination and electrophysiological findings of these patients were compatible with poliomyelitis sequelae. We have reviewed the frequency of epilepsy among these 53 patients. Results: The patients were consisted of 4 female and 49 male and mean age was 25.7±3.34 years (range 18–46). Acute paralytic poliomyelitis had been appeared in 1–13 years. The motor unit abnormalities which observed in atrophic muscles with EMG, were also shown in clinically unaffected muscles in 47 patients who has polio sequelae. Active denervation potentials were observed in one patient. Nine of these patients were receieving antiepileptic therapy with the diagnosis of epilepsy. Beginning of epileptic seizures was ranged between the ages of 1–23 years. Discussion: There are indications that long-term, even mild, over production of cytokines in central nervous system can directly or indirectly cause damage, including neurodegeneration. IL1 and TNF-a also have neurotoxic potential and may enhance neurodegeneration. Ehrengut and Ehrengut reviewed the findings of 59 cases of convulsions after oral polio vaccine and reported that in 44 cases occurred within 8 days after the vaccination, and eight patients suffered later from a convulsive disorder. Our results are based on a small number of cases, nevertheless our findings suggest that the patients who had had poliomyelitis are in a high-risk group in terms of epilepsy. We think that this association is more common in clinical practice but wider studies are needed to recognize the patients who had had poliovirus infection without sequelae of poliomyelitis. Understanding the mechanisms of seizure development, and of host susceptibility factors will aid in identification and validation of therapeutic strategies.

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P541 Long-term antiepileptic treatment with histone deacetylase-inhibitors may reduce the risk of prostate cancer M. Stettner, G. Kra¨mer, A. Strauss, S. Ohle, B.C. Kieseier, P. Thelen Heinrich-Heine-University (Du¨sseldorf, DE); Swiss Epilepsy Center (Zurich, CH); Georg-August-University (Go¨ttingen, DE) Objectives: Various antiepileptic drugs are known to exhibit histone deacetylase inhibitory (HDACi) properties. Treatment is commonly administered for the long-term. Valproic acid (VPA), carbamazepine (CBM), oxcarbazepine (OCX), lamotrigine (LMT) and levetiracetam (LEV), as HDACi alter gene expression aberrantly silenced by histone deacetylation. In prostate cancer (PC), the parameter values due to an aberrant androgen axis e.g. prostate specific antigen (PSA) act as a hallmark in the early detection and its levels may predict an invasive PC in subsequent years. Since the average age of diagnosis is 70, more moderate and less wearing anticancer therapies such as those based on HDACis are of interest. Methods: The PSA levels of epilepsy patients under long-term treatment with HDACi were examined. Over 100 patients were studied in this retrospective analysis: patients with PC, with other malignancies, acute or chronic prostatits, those having undergone prostate surgery, steroid treatment, or suffering from alcohol abuse were excluded. For in vitro experiments, the representative LNCaP cell line model was treated with antiepileptic HDACis and PSA was assessed on the RNA as well as protein level using RT-PCR and ELISA analyses. Results: Treatments with HDACi decreases the PSA-levels in vivo compared to patients who were not exposed to HDACi. The ranking for the age corrected PSA decrease is VPA [ LEV [ CBM/OXC [ LTG. Generally, the age-correlated PSA levels in the HDACi-treated patients were lower, compared to untreated controls. Furthermore, there was a correlation between PSA-reduction and the number of HDACis within the medication, lending credence to the idea that a synergistic effect might be possible. Moreover, in vitro, HDACi decreases PSA on RNA and protein levels and exhibits further oncoprotective properties. Conclusion: HDACis are known to render anti-proliferative effects on neoplastic cells, which are paralleled by expression alterations of aberrantly regulated genes, e.g. decrease of PSA levels. The PSA level at a younger age may predict the likelihood of PC in later years. In this study, HDACi significantly decreased PSA levels in an age correlated fashion for men over 50 years. In vitro observations support our findings. These data suggest that long-term HDACi treatment can positively influence the transformation of tumour precursor cells in the prostate during its characteristic slow progression and may, thus, reduce a patient’s risk of developing PC.

P542 Electroencephalography after a first seizure A.C. Fonseca, R. Peralta, C. Bentes Hospital Santa Maria (Lisbon, PT) Objective: To determine the amount of patients referred to our department which underwent electroencephalography (EEG) after a first suspected seizure which had electroencephalographic changes, namely epileptiform activity, and to determine associated clinical variables. Method: Retrospective analysis of a consecutive cohort of 2274 patients ([15 years) which underwent EEG in your department from

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2007–2008. Patients referred with the clinical hypothesis of a first seizure were included. Registered variables included: age, sex, motor/ non-motor symptoms, medical history, antiepileptic medication, imaging exams, EEG with or without sleep deprivation, background activity and background activity interferences including epileptiform activity. A logistic regression analysis was performed to attempt to identify clinical variables associated to the presence of epileptiform activity. Results: 168 patients were included (mean age 55 years; 58,3% men). 114 (67,9%) patients had motor symptoms. Median and mean time to EEG was 4 and 38,7 days respectively. 33 EEGs (19,6%) were done with sleep deprivation. 62 (39,6%) of patients were under antiepileptic medication. 118 patients had already preformed one imaging exam – 50 (42,4%) had a cortical lesion. 38,7% of patients had changes in the EEG background activity and 64,3% had interferences in the background activity. Epileptiform activity was detected in 12 patients (7,1%). No clinical variable was associated to the presence of epileptiform activity. Conclusion: There is a great variation in the literature concerning the percentage of epileptiform activity detected after a first seizure. In our series, the majority of patients did not have epileptiform activity. It is possible that the kind of referred patients, the way how patients were referred, the time till EEG and the small number of EEGs with sleep deprivation might have contributed to the final result.

P543 Bone turnover markers in epileptic patients under chronic valproate therapy in Isfahan, central Iran M. Zare, M. Najafi, M. Aghaghazvini, M. Dashti Alzahra University Hospital (Isfahan, IR) Objectives: The effects of chronic valproic acid administration on bone health have been a matter of concern and controversy. In this study, the situation of bone status following valproate intake was assessed by using several bone related biochemical markers. Methods: This cross-sectional study enrolled 67 female epileptic patients and 44 age-matched controls. The patients had been under chronic valproate therapy (322 ± 99 mg/day) for at least the past six months. Serum markers of bone turnover carboxyterminal telopeptide of type I collagen (CTX) and Bone specific alkaline phosphatase (BALP), calcium, phosphorus, total alkaline phosphatase PTH and valproate level were measured in both groups. Results: The markers of bone turnover as well as other measured bone biochemical parameters, did not statistically differed between the two groups. Conclusion: In contrast to some of the previous publications, valproate therapy does not seem to change bone turnover in epileptic patients.

P544 Bone marrow mononuclear stem cells transplant as treatment of refractory temporal lobe epilepsy M.J. Carrion, D.I. Costa, L.P. Schilling, C.M. Torres, D. Marinovic, B. Garicochea, E.F. Raupp, D.C. Machado, M.W. Portuguez, J.C. da Costa Pontifical Catholic University of Rio Grande do Sul (Porto Alegre, BR) The aim of this study is to verify feasibiity-safety and therapeutic potential of bne marrow mononuclear stem cells (BMMSC) transplant

S179 in seizure control and memory outcome in patients with temporal lobe epilepsy (TLE). Methods: Eight patients were diagnosed as medically refractory TLE by neurological evaluation, MRI study, Video EEG and neuropsychological (NPS) examination. After informed consent and fulfilling all criteria patients underwent BMMSC transplant by selective posterior cerebral artery catheterization. They were observed during a follow period in which, seizure frequency, EEG, MRI and NPS tests were evaluated. Results: MG, 43 years old, female, with, 4 to 12 seizures/month. She received 3,2 x 108 cells. After a 12 month follow up she presented only 3 slight crisis No structural changes were seen at MRI. Memory tests showed increased scores.NA, 53 years old, female, MRI, 4 seizures/month. Received 1,9 x 108 cells No seizure was documented during a 12 month follow up period. Memory tests showed increased scores.JR, 38 years old, male, 4 seizures/month plus 4 auras/month. Story of depression, using fluoxetin..Received 3,59 X108 cells. No improve,ment in seizure frequency was observed. Contrasting results regarding memory tests: some have increased and others have decreased scores. AB, 40 years old, male, up to 5 seizures/month. Received 3,12 x 108 cells. No Changes in seizure frequency were noticed. Memory tests showed increased scores.;JR, 51 years old, male, 2-3 seizures/month. Received 3,9X108 cell.. No seizures was verified since then.; JB, 48 years old, female, TLE, 10/ month. Received 4,41X108 cells. No changes in seizure frequency were noticed. Memory tests showed increased scores. VK, 46 years old, female, 12 seizures/month. Received 5,59X108 cells. Brief auras were Kept, but no seizures in six months follow up period. Increased scores were observed in the most memory functions applied tests; RB, 26 years old, male 20 seizures/month. Received 4,2 x 108. No seizure was documented during the 6 month follow up period. Memory tests showed increased scores. No adverse event was documented in any of these patients so far. Conclusion: Given the patient’s favorable outcome, BMSC transplant seems feasible and safe so far. The seizure control achieved brings promising perspectives in TLE treatment. Moreover, new perspectives in memory dysfunctions patients rehabilitation may be considered.

P545 Mosaicism for a missense SCN1A mutation and borderline Dravet syndrome in a Roma/Gypsy family S. Zhelyazkova, D. Azmanov, P. Dimova, M. Radionova, V. Bojinova, L. Florez, S. Smith, I. Tournev, A. Jablensky, J. Mulley, I. Scheffer, L. Kalaydjieva, J. Sander Medical University (Sofia, BG); University of Western Australia (Perth, AU); University College of London (London, UK); Women’s and Children’s Hospital (Adelaide, AU); University of Melbourne (Melbourne, AU); Epilepsy Institute of the Netherlands Foundation (Heemstede, NL) Objectives: SCN1A mutations account for a large proportion of Dravet syndrome patients, and some genetic epilepsy with febrile seizures plus (GEFS+) syndrome families. While most Dravet syndrome cases are caused by de novo mutations, 5% inherit a mutation from a mildly affected or symptom-free parent. We describe a Roma/ Gypsy family, where the child was affected with borderline Dravet syndrome while his father had a mild GEFS+ phenotype. Methods: Clinical data and EEG of the proband and his family. SCN1A mutation analysis in the proband involved a whole-gene

coding sequence dHPLC screen and subsequent exon 4 DNA sequencing. Analysis of the remaining members of the family was done by direct sequencing. Results: Our proband was diagnosed as borderline Dravet syndrome, with atypical features including the lack of evidence of normal early development and of myoclonic seizures. His father had a phenotype compatible with GEFS+. SCN1A analysis in the proband identified the missense mutation c.580 G[A leading to a substitution of asparagine for the conserved aspartic acid residue at position 194 (p.D194N) in the S3 segment of the DI protein domain. Mutaton analysis showed that the p.D194N mutation was present in 60–70% of the paternal cells but not in the paternal grandparents or in other relatives. Conclusion: Parental mosaicism is a rare exception, where phenotypic variation can be attributed to a specific mechanism, thus facilitating prognosis and genetic counselling. Our finding of a missense mutation transmitted by a mosaic parent implies that the mechanism is likely to be more common than currently recognised. The study was funded by grant 458736 of the National Health and Medical Research Council of Australia

P546 Cognitive profile in newly diagnosed Egyptian temporal lobe epileptics, and impact on lateralization N. Kitchener, S. Samy, N. Nagy, A. AbdelKader General Organization for Teaching Hospitals (Cairo, EG); Ain Shams University (Cairo, EG); Cairo University (Cairo, EG) Objectives: Epilepsy is associated with difficulties in cognition and behavior in children. These problems have been attributed to many causes, like ongoing seizures, or underlying abnormality of the brain. We investigated the baseline functions with respect to learning, attention, and memory and lateralizing ability of intelligence scores, in newly diagnosed temporal lobe epilepsy (TLE) patients according to the distribution of interictal epileptiform discharges (IEDs). Methods: This study enrolled 94 TLE patients. All patients had aged 5 to 11 years, with new onset TLE epilepsy, using tests of cognitive function reflective of learning, memory, and attention. Patients were categorized as having unitemporal or bitemporal IEDs, right and left. Results: Attention and visual motor speed tests were particular area of weakness across all patients. In patients with unitemporal IEDs, performance IQ (PIQ) was significantly lower in the right than in the left subgroup (p \0.05). Verbal IQ (VIQ) - PIQ discrepancy scores differed significantly between the left and right subgroups, being negative in the left and positive in the right subgroup. Based on multivariate analyses, two variables, right TLE (p \ 0.05) and the unitemporal distribution of IEDs (p \ 0.05), were independently related to the VIQ - PIQ discrepancy of more than 10 points. About 49% of those with unitemporal IEDs had VIQ - PIQ discrepancies of greater than 10 points and the rate for correct lateralization was 68.6%. In patients with bitemporal IEDs, however, none of the intelligence individual subtests showed evidence of correct lateralization. In patients with bitemporal IEDs, Full-scale IQ and PIQ were significantly lower than that in the left unitemporal subgroup. Conclusions: These findings suggest intrinsic abnormalities in Egyptian patients with new-onset temporal lobe epilepsy at baseline. Intelligence scores had some lateralizing ability, but only in TLE patients with unitemporal IEDs.

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P547 Clinical characteristics of mesial temporal lobe epilepsy with hippocampal sclerosis depending on nocturnal predominance S. Park, Y.H. Kim, J. Hong, K.H. Cho Yonsei University (Seoul, KR) Objectives: Seizure with nocturnal predominance (NP) was more common in generalized seizure with idiopathic origin rather than partial seizure. Among partial seizure, NP was one of the clinical characteristic of the frontal lobe seizure, not temporal lobe seizure, which was much more unlikely in mesial temporal lobe epilepsy (MTLE) with hippocampal sclerosis (HS). We tried to compare the clinical profiles between the MTLE with NP and MTLE without NP. Methods: The patient with past history of central nervous system infection and dual lesions such as cerebromalacia, focal atrophy, and tumor in brain MRI were excluded. Nocturnal predominance was defined as more than 90 % of seizure attack occurred during sleep. 25 patients with pure nocturnal seizure were recruited among the total 158 patients with MTLE-HS. Demographic features, antecedents related to seizure, ictal semiology, and prognosis through Engel’s classification of at least 2 years follow-up were compared between two groups. (MTLE with NP; Group A, MTLE without NP: Group B) Results: 15.8 % among the MTLE showed NP. Onset age of seizure was 18.4 in group A which was later than 14.4 in group B. All the antecedents including febrile convulsion were not significantly different between two groups. All patients with NP experienced 2’ GTC, compared to 76.7 % in group B. The proportion of patients with seizure clustering was higher in group B (23.3 %) than in group A (16 %). Aura and automatism was more common in group B (88.7 % and 81.2 %) compared to group A (76 % and 56 %) respectively. Limbic nature aura was also predominant in group A. The proportion of good prognosis which meant class I and II was 47.8 % in group A. In contrast, those of poor prognosis which meant class IV and V was 46.1 % in group B with statistical significance. Conclusion: This study suggested there was a possibility of subgroups within MTLE-HS, depending on the clinical characteristics especially such as nocturnal predominance. Nocturnal predominance was a good prognostic factor in patients with MTLE-HS.

P548 Neuropsychological assessment of patients with different epileptic syndromes during the course of the disease T. Afrantou, E. Konstantinopoulou, R. Lagoudaki, I. Mavromatis, N. Tascos Aristotle University of Thessaloniki (Thessaloniki, GR) Objective: Neuropsychological testing in epileptic patients is a useful tool in the global assessment of the disease. The most important application of it, is the presurgical evaluation of the drug-resistant epileptic patients. However, the psychometric tests can present further information for the nature of the epilepsy especially when the epileptic syndrome of the patient is vague based on the clinical and paraclinical data. Methods: We studied 39 patients with chronic epilepsy. Specifically 19 women and 20 men with mean age 41.1, with temporal (n=11), frontal (n=5), idiopathic generalized (n=5), cryptogenic (n=12) and cryptogenic probably of temporal aetiology (n=6) epilepsy. All patients were treated with antiepileptic drugs either as

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monotherapy or as polytherapy. We evaluated verbal memory, visuospatial memory and executive functions with the following tests: Rey-Osterrieth Complex Figure Test, Digit Span, Stroop Test, Verbal Fluency and Trail Making Test. The above tests took place in two different timepoints (1 year) during the follow-up of the patients. Results: The duration of the disease (1–55 years) and the seizure frequency (seizure free [4 seizures/month) influences the performance in verbal memory, selective attention, executive functions. A significant correlation between the duration of the disease and performance on verbal memory test was found only in patients with temporal epilepsy. There was no significant difference in the test performance between temporal epilepsy and cryptogenic epilepsy probably of temporal aetiology. Between the two time-points of psychometric testing it was observed higher scoring to the seizurefree patients. It was finally observed higher performances in patients on monotherapy compared to patients on polytherapy in tests of selective attention and verbal memory. Conclusion: The severity of the disease (prolonged disease duration and increased number of seizures) seems to affect globally the cognitive functions. Patients with temporal epilepsy are affected over time-course in their verbal memory in increased rate. The similar results of performances on tests by patients with temporal and cryptogenic (probably of temporal-being) suggest that the psychometric assessment can be used as an extra tool for the enhancement of the diagnosis, during the follow-up of the patients. As far as therapy is concerned, our results agree with the existing knowledge that polytherapy affects significantly the cognitive functions.

P549 Cognitive improvement after bilateral chronic stimulation of anterior thalamic nucleus in patients with intractable epilepsy Y.S. Oh, Y.M. Shon, K.J. Lee, Y.I. Kim The Catholic University of Korea (Seoul, KR) Objectives and background: It is unknown over the cognitive and behavioral effects after deep brain stimulation (DBS) on the deep cerebral nuclei for epilepsy treatment. We investigated the cognitive outcome at least 6 months after DBS on bilateral anterior thalamic nucleus (ATN) for controlling intractable epilepsy. Methods: Nine, intractable epilepsy patients who are not candidates for resective surgery treated by bilateral ATN DBS underwent cognitive and behavioural assessments before implantation and around 1 year after DBS surgery. Postoperative cognitive assessments were carried out under continuous stimulation mode. Results: Mean seizure reduction rate of our patients after ATN DBS was 71.8% (28.5 * 99.3%). There was a favorable results on verbal fluency tasks (letter and category, p \ 0.05) and a significant improvement on immediate and delayed verbal memory (p = 0.017). But, there were no significant changes in general abilities (IQ, MMSE), information processing (digit forward & backward, trail-A, and digit symbol) or executive function (train-B and WCST). Interestingly, we could not observe any significant cognitive decline during ATN DBS for around 1 year (mean, 15.8 months). Also, no patient developed acute or severe cognitive decline after surgery. Conclusions: Our findings showed that ATN DBS resulted in not only an excellant clinical efficacy but additional improvement of both a verbal recall and oral information processing, which may be related to the bilateral activation of fronto-limbic circuit following DBS surgery. Further controlled, long-term studies with larger population for elucidating clinical effects of ATN DBS should be warranted.

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P550 The diffusion of neuroactive substances in the extracellular space is altered in focal cortical dysplasias J. Zamecnik, L. Vargova´, A. Homola, P. Marusic, P. Krsek, E. Sykova´ Charles University Prague (Prague, CZ) Objectives: Focal cortical dysplasia (FCD) of the brain represents a prominent cause of intractable epilepsy. The epileptogenesis in FCD is supposed to result from the alteration of the synaptic transmission; however, neurons themselves also communicate by extrasynaptic transmission mediated by the diffusion of neuroactive substances in the extracellular space (ECS). Therefore, changes in ECS size and geometry might contribute to the epileptogenicity of FCD. Methods: The diffusion parameters of the ECS (i.e. its size and geometry) were studied by the real time iontophoretic method using ion-selective microelectrodes in acute brain cortex slices of 25 patients surgically treated for intractable epilepsy, including samples of 9 patients with FCD type I and of 6 patients with FCD type II. The diffusion measurements revealed the ECS volume fraction (ECS volume/total tissue volume) and the geometrical factor ‘‘tortuosity’’, reflecting various ECS diffusion barriers. The results were correlated with the histopathology. Results: In control non-malformed cortex, ECS volume fraction = 0.22 ± 0.01, tortuosity = 1.46 ± 0.01 (mean ± S.E.M.). In both FCD type I and FCD type II, the tortuosity was significantly increased (1.53 ± 0.01 and 1.62 ± 0.02, respectively). ECS volume fraction was not significantly changed in FCD. Conclusion: Despite the unchanged size, the ECS of FCD has increased tortuosity reflecting the increase of diffusion barriers in the ECS. We propose that disturbed extrasynaptic transmission through the ECS of such cortex, along with altered diffusion parameters, represents another factor contributing to the epileptogenicity of FCD. This study was supported by the Grants of Ministry of Health of the Czech Republic No. IGA MZCR NS9915-4 and MZOFNM2005.

P551 MR volumetry of the entorhinal cortex and fornix in temporal lobe epilepsy Y.I. Kim, Y.D. Kim, J.H. Cho, H.J. Kim, Y.M. Shon, Y.I. Kim, K.S. Lee The Catholic University of Korea (Seoul, KR) Object and background: Patients with temporal lobe epilepsy (TLE) often have hippocampal sclerosis. Hippocampus adjoins many other near structures and is closely related to each others. We measured not only the volume of hippocampus but also those of structures adjacent to it, specially entorhinal corticeal and forniceal volume, in order to investigate the relationship between the pathological change of hippocampus and other structural volume changes. Method: We performed high resolution MRI and measured volume of the both hippocampi, entorhinal cortices and fornices by MRI volumetry program in patients with left TLE (n=22), right TLE (n=26) and control (n=18). We corrected each volume by intracranial volume (ICV). We divided TLE patients into TLE with hippocampal sclerosis (TLE+HS) and TLE without hippocampal sclerosis (TLE-HS). We defined TLE+HS as those with hippocampal volume (HV) below -2SD of normal controls and TLE-HS as HV above -2SD. In addition, we reviewed retrospectively the clinical history of 46 TLE patients.

Result: We compared ipsilateral (lesion site) and comtralateral (normal site) hippocampal volume (IHV, CHV), forniceal volume (IFV, CFV) and entorhinal coticeal volume (IEV, CEV) of three groups (TLE+HS, TLE-HS, control) by ANOVA. In TLE+HS group, IHV, CHV, IEV, and CEV were significantly decreased than that of TLE-HS and control groups. In TLE-HS group, IHV, CHV, IEV and CEV were significantly decreased than that of control group. But. IFV and CFV were not significantly different among three groups. In regression analysis, IHV was most significantly associated with IEV (IEV[[CHV), and IEV was most significantly associated with CEV (CEV[IHV[CHV). Conclusion: In TLE patients group, the entorhinal cortical atrophy is related to hippocampal sclerosis but forniceal atrophy is not. Entorhinal cortical atrophy may be more sensitive marker manifesting pathological changes in temporal lobe epilepsy rather than hippocampal atrophy as well as forniceal atrophy.

P552 Epilepsy due to infectious diseases in Africa-Malaria, human immunodeficiency virus and herpes simplex virus J. Yahaya, S. Shorvon University College Hospital (London, UK) Introduction: The association between epilepsy and CNS infections, especially in Africa, is poorly studied, due to constraints in epidemiological, and microbial and epileptological techniques. Seizures commonly occur during acute viral encephalitis and are most common with (Herpes Simplex Virus) HSV. Objective: This study is to systematically review the literature since 1990 pertaining to the epidemiology of the three most common infectious causes of epilepsy (malaria, HIV/AIDS and Herpes Simplex Encephalitis) in Africa, to focus on the identified potential causes and mechanisms of seizures, the seizure types and the frequency of the seizure as well as the risk of development of chronic epilepsy. The gaps in knowledge will be identified. Based on these findings, recommendations are made in relation to the treatment and prevention of these diseases to reduce the burden of epilepsy on the African continent. Methods: Literature was obtained from Pubmed, using specific search strategy and limiting the articles to only those in English Language and a time limit of not later than 20 years. Data was also sought from standard textbooks of Neurology. Results and conclusion: In this review, there are limited numbers of well-controlled aetiological studies for infectious causes of epilepsy in the resource poor countries south of the Sahara. All the three infections studied - malaria, HIV/AIDS and Herpes Simplex Encephalitis (HSE) - are commonly associated with epilepsy, have multiple potential epileptogenic mechanisms and in all the treatment is complex. Amongst the recommendations made are fundamental and desirable recommendations to meet the immediate and long term health care needs respectively due to limited resources available in this region; to intensify control/preventive strategies to reduce spread of these infections such as widespread use of insecticide treated nets in malaria control programmes, provision of robust diagnostic services such as PCR analysis, imaging facilities as CT and MRI scans and EEG machines to improve care and outcome of subsequent epilepsy associated with these infectious diseases, well controlled clinical trials of treatment protocols would go a long way in assessing all preventative strategies for effective reduction of frequency of epilepsy in sub-Saharan Africa.

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Peripheral neuropathy P553 Laser-evoked potentials and nerve markers in skin biopsies provide diagnostic and prognostic information regarding regenerating nerve fibres M. Rage´, N. Van Acker, P. Facer, M. Timmers, T. Meert, P. Anand, L. Plaghki Catholic University of Louvain (Bruxelles, BE); Histogenex (Antwerp, BE); Imperial College London (London, UK); Johnson&Johnson PRD (Beerse, BE) Objectives: To study, in an experimental model of reversible chemical axotomy (topical capsaicin), the temporal relationship between functional changes (CO2 laser evoked potentials, LEPs) and morphological changes in dermal and intra-epidermal nerve fibre (IENF) density using 3 different immunostaining markers. Methods: Capsaicin (0.075%) was applied to the lateral calf for three consecutive days in 12 healthy volunteers. LEPs and skin biopsies were performed at baseline and time intervals up to 54 days post-capsaicin treatment (Day +1, +5, +12, +26 and +54). Biopsies were immunostained with antibodies for PGP9.5 (panaxonal marker), TRPV1 (heat/capsaicin receptor), and GAP-43 (marker of regenerating nerve fibres), and analysed for IENFs and dermal innervation (for GAP-43). Results: At baseline (Day 0), a linear correlation between LEP amplitude of the N2-P2 complex (mean 26 ± 11.4 lV) and IENF density using PGP9.5 immunostaining (13.8 ± 7.02/mm) was observed. At 1 day post-capsaicin, PGP9.5, TRPV1 and GAP-43immunoreactive nerve fibres and LEPs were almost completely absent. By day 12, LEPs had fully recovered, although PGP9.5 and TRPV1 IENF density continued to be significantly decreased even at 54 days post-capsaicin. In contrast, dermal GAP-43-immunoreactivity closely matched recovery of LEPs. Conclusion: In the regenerating phase, a close correlation was observed between LEPs and GAP-43 staining, in contrast to PGP9.5 and TRPV1. Assessing skin biopsies by the more conventional PGP9.5 immunostaining alone may miss potential significant diagnostic and prognostic information regarding regenerating nerve fibres, if other approaches are neglected e.g. LEPs or GAP-43 immunostaining. MR supported by a Johnson & Johnson PRD Funding Grant

P554 Microneurographic study of sympathetic activity in somatic and autonomic small fibre neuropathies R. Liguori, M. Giannoccaro, V. Di Stasi, V. Donadio University of Bologna (Bologna, IT) Objectives: small fiber neuropathy may involve somatic and autonomic fibers. Microneurography allows to evaluate directly peripheral sympathetic nerve outflow. Here we analyze peripheral sympathetic activity involvement by microneurography in small fiber neuropathies with and without autonomic symptoms. Methods: we studied 48 patients (32 males and 16 females; mean age±SD: 58±15 years) with small fiber neuropathy diagnosed by skin biopsy. All patients complained burning paresthesia whereas 18

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patients (14 males and 6 females; mean age±SD: 56±16 years) reported associated autonomic symptoms. Patients underwent to motor and sensory conduction studies to evaluate large myelinated peripheral nerve fiber and microneurographic record of muscle sympathetic nerve activity (MSNA) and skin sympathetic nerve activity (SSNA) from peroneal nerve. Thirty age-matched subjects (18 males and 12 females; 53±15 years) without clinical signs of neurological dysfunction were used as controls. Results: autonomic symptoms included sweating disorders (67%), chronic constipation (28%), urinary incontinence or genital dysfunction (11%) and orthostatic hypotension (11%). Microneurographic failure to record sympathetic activity characterized 48% of patients with autonomic symptoms whereas MSNA and/or SSNA were always recorded in patients without autonomic symptoms and controls (p \ 0.001). Conclusion: microneurographic failure to record sympathetic activity was significantly higher in patients with small fiber neuropathy and autonomic symptoms. Microneurographic evaluation may help to diagnose autonomic nerve fibers involvement in small fiber neuropathy.

P555 Sympathetic innervation in peripheral autonomic neuropathy V. Donadio, M. Giannoccaro, V. Di Stasi, R. Liguori University of Bologna (Bologna, IT) Objectives: several autonomic tests to evaluate dysautonomia are available in the clinical setting but they usually provide indirect findings by reporting target organ changes. Here we report the first direct evaluation of muscle and skin sympathetic innervation in peripheral autonomic neuropathy. Methods: we studied 30 patients (21 males and 9 females; mean age±SD: 58±14 years) with signs and/or symptoms of peripheral autonomic neuropathy caused by diabetes mellitus (3), immunemediated (8) or paraneoplastic (1) neuropathy, primary amyloidosis (1), hereditary autonomic neuropathy (3), pure autonomic failure (9) or undetermined aetiology (5). Patients underwent to motor and sensory conduction studies to evaluate large myelinated peripheral nerve fiber, microneurographic record of muscle sympathetic nerve activity (MSNA) and skin sympathetic nerve activity (SSNA) from peroneal nerve and punch skin biopsy from finger, thigh and leg to evaluate cholinergic and adrenergic autonomic innervation of dermal annexes graded by a semiquantitative score showing an high intervariability and intravariability correlation. Twenty sex and agematched subjects without clinical signs of neurological dysfunction were used as controls. Results: sympathetic symptoms were prevalent in 25 patients whereas parasympathetic failure was the main symptom in 5 patients. Conduction studies disclosed normal large myelinated nerve fiber in the majority of patients. Skin autonomic innervation was abnormal in all patients whereas extensive microneurographic search procedures usually failed to identify sympathetic bursts in 63% of patients. Microneurographic failure was more often in patients with sympathetic symptoms such as orthostatic hypotension. Conclusion: sympathetic innervation study of skin annexes is a reliable and sensitive method helping to diagnosing peripheral autonomic neuropathy. Microneurography could contribute to this diagnosis but with less sensitivity.

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P556 Antibodies against ganglioside complexes in polyneuropathy associated with monoclonal gammopathy A.C. Stork, B.C. Jacobs, A.P. Tio, L.H. van den Berg, N.C. Notermans, W.L. van der Pol University Medical Centre (Utrecht, NL); Erasmus Medical Centre (Rotterdam, NL) Objective: Antibodies against ganglioside complexes are target antigens in Guillain-Barre syndrome and several other immune-mediated neuropathies. We investigated whether antibodies against ganglioside complexes play a role in polyneuropathy associated with monoclonal gammopathy. Methods: Antibody titers against asialo-GM1, GM1, GM2, GD1a, GD1b and GQ1b and their complexes were measured by enzyme linked immunosorbent assay (ELISA), as was light chain usage of antibodies against these targets. Results: Antibodies against gangliosides were found in 19 out of 54 (35%) patients with polyneuropathy and IgM monoclonal gammopathy without antibodies against myelin-associated glycoprotein (MAG). Two out of 19 (11%) had antibodies against GM2-GD1a and GM2-GD1b complexes, respectively, but not against GM2, GD1a or GD1b individually. Five (26%) additional patients had a significantly higher titre and optical density for ganglioside complexes than for the constituent gangliosides of the complex, even though activity against both was found. Eight (42%) patients had anti-ganglioside antibodies exclusively using kappa light chains, suggesting mono- or oligoclonality of the antibody response. These patients also had an IgM-kappa M protein. Interestingly, two patients had a mixed lambda/kappa chain usage in antibodies against gangliosides, but an exclusively kappa respons against ganglioside complexes. This suggests that the abnormal monoclonal antibodies might be targeted at ganglioside complexes, with a concomitant polyclonal antibody response against individual gangliosides. Conclusion: Ganglioside complexes are target antigens in patients with polyneuropathy associated with IgM monoclonal gammopathy. Light chain analysis suggests mono- or oligoclonality of anti-ganglioside complex antibodies in these patients.

P557 Clinical progression in Charcot-Marie-Tooth disease type 1A duplication: clinico-electrophysiological and MRI longitudinal study of a family J. Berciano, E. Gallardo, A. Garcı´a, C. Ramo´n, J. Infante, O. Combarros University Hospital Marque´s Valdecilla (Santander, ES) Objective: Long-term follow-up studies in Charcot-Marie-Tooth disease type 1 duplication (CMT1A) are scanty. Here we describe a longitudinal study in a CMT1A pedigree. Methods: Our CMT1A pedigree comprised 11 examined patients, aged between 13 and 83 (median, 36) years, serially evaluated for up to 26 years. In all 11 patients we carried out electrophysiological evaluation, and in three of them magnetic resonance imaging (MRI) of lower-limb musculature. Results: The 54-year-old proband patient, yearly examined as of age 28, developed at age 48 gradual and progressive distal lower-leg weakness ascending to thigh musculature. His serial electrophysiological studies showed diffuse slowing of motor conduction velocity, absence or severe attenuation of distal compound muscle action potentials, and spontaneous muscle activity in tibialis anterior and

rectus femoris. Two MRI studies of lower limbs, at ages 51 and 54, showed extensive fatty atrophy of lower-leg musculature, and progressive and distally accentuated fatty atrophy of anterior and posterior femoral muscles. Outstanding finding in the first MRI was the presence of marked edema of anterior femoral musculature, which to a great degree was replaced by fatty atrophy in the second study. Muscle edema was also noted in lower-leg and posterior femoral musculature. There was minimal fatty atrophy of gluteus maximus, the remaining pelvic muscles being preserved. The other 10 patients showed mild or moderate phenotype, which remained quiescent over the period of observation. Electrophysiological studies disclosed diffuse and uniform slowing of nerve conduction velocities; in no case was spontaneous muscle activity recorded. MRI showed the CMT1A characteristic pattern of distally accentuated fatty atrophy involving foot and lower-leg musculature with preservation of thigh musculature. Conclusion: A small proportion of patients with CMT1A develop a late progression of disease manifested with accentuated distal leg weakness ascending to involve thigh musculature and that long-term follow-up is essential for its detection. Supported by CIBERNED and FIS Grant PI07/132E.

P558 Prognostic factors of local steroid injection in carpal tunnel syndrome S. Thissen, V. Meys, R. Beekman, C. Rozeman Atrium Medical Centre Heerlen (Heerlen, NL) Objectives: most studies that investigate predictive factors for a successful outcome in carpal tunnel syndrome (CTS) patients focus on the surgical treatment options. There has been little research into which prognostic factors determine a successful outcome after steroid injection in CTS patients. The aim of this study is to identify which clinical, electrodiagnostic and sonographic parameters are correlated with a successful long term outcome after steroid injection as a treatment for CTS. Methods: we prospectively included 113 patients (40 men and 73 women) with a clinical diagnosis of CTS. All patients underwent clinical, electrophysiological and sonographical investigations. Patients with electrodiagnostic confirmation of the diagnosis of CTS received a steroid injection. Follow-up visits were planned at 1, 3, 6 and 12 months after the injection (t=0). Primary outcome measures were surgery within one year, a second steroid injection or any other additional treatment within one year. Second outcome measures were the number of nights that the patient awoke due to the symptoms during the past week, functional outcome measurements on a fivepoint scale, patient based improvement on a six-point scale and symptom outcome measurement on an eleven-point scale. Results: At one month follow up 1.8% of all patients had neurolysis, at three months follow up 23.9%, at six months follow up 38.1% and at twelve months follow up 53.1%. During the study, 22 patients were lost-to-follow up. The mean cross sectional nerve area at the os pisiforme in patients with a successful outcome was 11.00 mm2 and 12.08 mm2 in patients with an unsuccessful outcome (p=0.024). Furthermore patients with a successful outcome had a significantly lower symptom severity scale (p=0.021). None of the other tested variables showed an association with outcome at followup. Conclusion: local steroid injection in patients with carpal tunnel syndrome has a significant successful short term effect. The results suggest that a lower sonographical cross sectional nerve area at the os pisiforme is more prone to a successful outcome after steroid injection.

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P559 Pain-related evoked potentials in mixed fibre neuropathy N. Hansen, N. U¨ceyler, A.K. Kahn, D. Zeller, Z. Katsarava, K.V. Toyka, C. Sommer University of Wu¨rzburg (Wu¨rzburg, DE); University of EssenDuisburg (Essen, DE) Objectives: To evaluate the usefulness of pain related evoked potentials (PREP) to detect small fibre involvement in mixed fibre neuropathies (MFN). Methods: We analyzed data from 33 prospectively recruited patients with MFN and 18 healthy controls from an ongoing study. Six patients had chronic inflammatory demyelinating polyneuropathy (CIDP), 8 had vasculitic neuropathy, 3 had hereditary neuropathy, 6 had other aetiologies, and in 10 cases the aetiology remained unknown. Patients underwent standardized clinical, psychophysical and neurophysiological evaluation including neuropathy scales, quantitative sensory testing, nerve conduction studies, pain questionnaires and skin biopsy. PREP were elicited at the face, arms and legs bilaterally and recorded with an electrode placed at Cz referenced to linked earlobes. Twenty blocks of triple-pulse stimulation were applied via a concentric electrode [stimulation intensity twofold of the individual pain threshold (face: 1.5 ± 0.6 mA, hand: 2 ± 0.4 mA and leg: 2.1 ± 0.4 mA), duration: 0.5 ms, triple-pulse interval: 5ms, interstimulus interval: 12-18 seconds]. Data are expressed as mean ± SD. Results: PREP upon trigeminal stimulation were detectable in 21/ 33 patients (64%) and in 13/18 controls (72%; p\0.05). PREP to stimulation of the hand were detectable in 22/33 of patients (67%) and in 15/18 controls (84%; p\0.05). PREP from the leg were detectable in 16/33 patients (49%) and in 10/18 controls (56%; p=0.22). The N1/P1 latencies [face N1 (P1) latency: 138 ± 17 (195 ± 35) ms, hand N1 (P1) latency: 154 ± 27 (220 ± 40) ms, and leg N1 (P1) latency: 182 ± 37 (259 ± 53) ms] and NP peak-to-peak amplitudes (PPA) (face: 20 ±11 microV, hand: 21 ± 11 microV and leg: 17 ± 11 microV) of PREP from all investigated subjects were comparable to previously published data. We found no significant differences in N1/P1 latencies and PPA between MFN patients and controls in all stimulation conditions. Stimulation intensities to reach twice the individual pain threshold for hand and leg were significantly higher in patients than in controls (p\0.05). Furthermore, patients rated the stimulation-induced pain during PREP recording lower than controls. Conclusion: The higher rate of absent PREP in MFN patients indicates damage to nociceptive fibers. This assumption is supported by the finding of reduced pain sensitivity in patients with MFN. Future large-scale studies may allow to assess the diagnostic validity in patients with complex neuropathies.

P560 Clinical, electrophysiological, and immunological study of peripheral nerves in Egyptian patients with monoclonal gammopathy H. Marouf, M. El-Difrawy, N. Zaki, M. Ayad, A. Farrag Alexandria University (Alexandria, EG) Background: Monoclonal antibodies are found in approximately 10% of patients with peripheral neuropathy of unknown etiology. Several autoantibodies,including anti-MAG (Myelin associated glycoprotein) antibodies, have been reported to induce neuropathy in experimental animals.

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Objective: The aim of the present work is to study the prevalence and characteristics of peripheral neuropathy in Egyptian patients with monoclonal gammopathy, and to estimate the serum level of antiMAG antibodies and its relationship to peripheral nerves dysfunction. Methods: Forty patients with monoclonal gammopathies were inclued in the present study. Their mean age was 56.65. All patients were subjected to full history taking and thorough clinical examination, Laboratory investigations including CBC, liver and renal function tests, serum uric acid, ESR, C-reactive protein, serum LDH, serum aˆ2 microglobulin, serum protein electrophoresis, urinary Bence-Jones protein, Bone marrow aspiration and/or trephine biopsy, quantitative estimation of serum IgM and IgG by nephelometry, AntiMAG antibodies by indirect serum immunofluorescence, Radiological assessment and nerve conduction study of both upper and lower limbs. Results: Clinical and electrophysiological evidences of peripheral neuropathy were found in 32 out of the 40 patients with monoclonal gammopathies (80%). 25 patients (62.5%) had distal symmetrical polyneuropathy and seven (17.5%) had mononeuritis or mononeuritis multiplex. The majority of patients (65%) had sensory or predominantly sensori-motor polyneuropathy. The neuropathy was mainly demyelinating in 22 patients (55%), and axonal in the other 10 (25%) patients. Anti-MAG antibodies were positive in only nine patients (22.5%), six of them (66.6%) had peripheral neuropathy. The neuropathy in the six patients with anti-MAG antibodies was predominantly demyelinating motor neuropathy in 4 and axonal in the remaining 2. However, the relationship between the presence of antiMAG antibodies and the development and type of polyneuropathy was not statistically significant. Conclusion: The present study showed high frequency (more than 60%) of distal symmetrical polyneuropathy in patients with monoclonal gammopathies. The neuropathy is predominantly sensory and demyeinating. Anti-MAG antibodies were detected only in 22.5% of the patients and were associated with more motor and demyelinating neuropathy, although the relationship did not reach a statistically significant level.

P561 Predicting inflammatory neuropathies – the diagnostic value of endoneurial oedema in sural nerve biopsies G. Necula, N. U¨c¸eyler, E. Hueber, C. Sommer, K.V. Toyka University Emergency Hospital Bucharest (Bucharest, RO); University of Wu¨rzburg (Wu¨rzburg, DE) Objectives: The aim of this study was to evaluate the diagnostic value of additional pathological markers such as endoneurial oedema in sural nerve biopsies of patients with inflammatory neuropathies. Materials and methods: Sural nerve biopsies of 70 patients with clinically, electrophysiologically, and histologically proven neuropathy of the following types were investigated: vasculitic neuropathy (n=10), chronic inflammatory demyelinating polyneuropathy (CIDP, n=20), mixed axonal and demyelinating neuritis (n=10), and non-inflammatory chronic neuropathy (n=30). Endoneurial oedema was assessed on hematoxylin-eosin (H&E) stained frozen and paraffin sections and on methylene-blue/azure-two stained semithin sections. The area of oedema was determined manually on digitized images using SPOTTM advanced software. For each case, three fascicles per nerve section were investigated, and the mean area of oedema was related to the entire endoneurial area of the investigated fascicles. The results were analyzed as percentage of oedema per lm2 endoneurial area. All assessments were performed by an investigator not aware of the underlying diagnoses.

S185 Results: On H&E frozen and paraffin sections quantification of oedema did not reliably differentiate between inflammatory and noninflammatory neuropathies. However, on semithin sections, oedema more frequently occupied more than 10 % of the entire endoneurial area of patients with CIDP than in patients with non-inflammatory neuropathy (v2-test: p\0.001). Oedema in cases with vasculitis was not significantly different from non-inflammatory neuropathy. Conclusion: The assessment of endoneurial oedema on semithin sections may be used as an easily applicable additional method for the differentiation of inflammatory from non-inflammatory neuropathies. The findings are consistent with a predominantly endoneurial pathology in CIDP and an epineurial pathology in vasculitic neuropathy. Additional inflammatory markers are currently under investigation. This study was supported by a fellowship of the European Neurological Society (ENS) to Gina Necula

P562 Cerebrospinal fluid oligoclonal IgM bands in GuillainBarre´ syndrome A.M. Simone, D. Ferraro, M.G. Venneri, J. Mandrioli, G. Galassi, R. Bedin, P.F. Nichelli, P. Sola University Hospital of Modena (Modena, IT) Objectives: Aim of the study was to examine the cerebrospinal fluid (CSF) and serum of a group of patients with Guillain-Barre´ Syndrome (GBS) for the presence of oligoclonal IgM bands (IgMOB) and to investigate their relation to clinical and laboratory data. Methods: We examined the clinical records of 19 patients who were diagnosed with GBS between January 2007 and March 2009 and collected clinical, laboratory and electrophysiologic data pertaining both to the hospital stay and to follow-up evaluations. CSF and serum samples, which had been stored at -80C, were examined for the presence of IgMOB by means of agarose gel isoelectric focusing followed by immunoblotting with polyclonal specific anti-human IgM antibodies (using a modified version of the procedure proposed by Villar et al, 2001). We then compared the group of patients who had a ‘‘mirror’’ IgM pattern (i.e. identical OB in CSF and serum) or who had CSF-restricted IgMOB to the remaining patients, with respect to numerous clinical and laboratory variables. Results: Of the 19 patients (14 males, 5 females; mean age 52,8 years, range: 22-79 years), 11 (58%) showed a mirror IgG pattern. A total of 6 patients (32%) showed a mirror IgM pattern; of these, 3 also showed a mirror IgG pattern. A total of 4 patients (21%) had IgMOB which were visible only in the CSF; of these, 2 showed a mirror IgM pattern, in addition. Patients with a mirror IgM pattern had a significantly higher CSF/ serum albumin ratio (p\0,03), indicating a greater degree of bloodbrain barrier damage. Patients with CSF-restricted IgMOB showed higher amounts of CSF proteins (p\0,03) and were more likely to have had upper respiratory tract infections as a prodrome (p\0,05). Conclusion: This study indicates that IgMOB are detectable in the CSF of patients with GBS. We found an IgM mirror pattern in 32% of our patients, which was not necessarily associated with the presence of a mirror IgG pattern. A mirror pattern indicates a passive transfer from serum to CSF of oligoclonal Ig from a systemic B-cell response and it is typically seen in GBS. Interestingly, we also detected CSF-restricted IgMOB, which normally indicate a central nervous system-only B-cell response, and which were associated with upper respiratory tract infections as a prodrome.

P563 Telephone call reminders and attendance in an electromyography laboratory S.B. Kwon, S.S. Hong, S.Y. Kang, S. Jung, S.H. Hwang Hallym University College of Medicine (Seoul, KR); SoonChunHyang University College of Medicine (Seoul, KR) Background: Non-attendance at outpatient appointments (appointment failures or failure to attend, ‘no shows’, and broken appointments) is an important obstacle to providing effective and efficient health care. For the individual, nonattendance results in delay of effective therapy, increased morbidity, and greater hospitalization. Clinic reminders, including both telephone (personal and computer-generated) and written reminders, have been shown to significantly increase attendance rates. Objectives: We undertook this study 1) to measure the effect of telephone reminders on electrodiagnostic laboratory attendance, 2) to identify factors associated with poor attendance, and 3) to determine whether reminder strategies are used universally or targeted at particular groups. Methods: A randomized controlled trial took place during a 8month period from May 2005 to December 2005. Electrodiagnostic laboratory bookings of patients were randomly assigned to either a telephone reminder one day prior to their appointment, or a routine booking (no reminder). Attendance was recorded. Non-attendance was the primary outcome measure, defined as non-attendance without prior notification. We also evaluated demographic and clinical data, and compared those between attendance and non-attendance group. Results: There were 404 clinic appointments made during the study period of 8 months. Of these, 223 (55.2%) were randomized to receive telephone reminders and 181 (44.8%) were randomized to the control group. The non-attendance rate for the reminded group was 9.0%. This was not significantly lower than that in the control group, which was 11.6% (OR 0.698; 95% CI 0.362, 1.346; P=0.283). For appointments of the particular test such as electromyography (EMG), the non-attendance rate for the reminded group was 2.4%. This was significantly lower than that in the unreminded group, which was 24.1% (OR 0.068; 95% CI 0.008, 0.605; P=0.016). Conclusion: Although the effect of telephone reminders was not significant on attendance at overall appointment of electrodiagnostic laboratory, telephone reminders greatly improved attendance at EMG tests. The background non-attendance rate and the effectiveness of telephone reminders for attendance at EMG test will determine whether reminders are more efficiently targeted at specific bookings than used routinely.

P564 Multifocal motor neuropathy: clinical, neurophysiological, immunological and MRI findings in seven patients A.P. Sousa, E. Aldeia, F. Carvalho, P. Alves, L. Medeiros Central Lisbon Hospital Centre (Lisbon, PT) Objective: To describe the clinical presentation, immunological and imagiological findings, clinical and neurophysiological evolution and effectiveness of intravenous immunoglobulin (IVIg) in patients with clinically typical multifocal motor neuropathy (MMN). Methods: A retrospective analysis of patients with MMN from our Clinical Neurophysiology Unit, between January 1997 and December 2009, was carried out. We studied the distribution of electrophysiological abnormalities and its correlation with weak muscle groups and evaluated the clinical and neurophysiologic progression of the disease. A very proximal conduction block was demonstrated by magnetic stimulation.

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S186 Results: Out of a total 6864 patients, 7 had MMN. Four were female. The median age at onset was 43,4 years (33–55). The mean symptom duration prior to diagnosis was 10,4 years (5–17). The mean follow-up duration was 8 years (1–17). In all patients the disease presented with progressive, distal and asymmetric weakness without sensory impairment. 2 patients had lower limb onset. At diagnosis all patients had an upper limb affected and 5 had both upper and lower limb involvement. Only one patient didn’t have bilateral symptoms. The most affected nerves, in descending order, were ulnar, median, peroneal, radial and tibial. None had hematologic disorders. GM1 ganglioside antibodies were present in 3 patients. Moderately increased serum creatine kinase levels were observed in 4 patients. All patients improved with IVIg but the length of benefit was variable, lasting from 2 to 6 weeks. The dose and frequency of the subsequent treatment was based on individual patient response. 2 patients became unresponsive after 7 years. Conclusions: Patients with probable conduction block (CB) were clinically and immunologically indistinguishable from those with definitive CB, without differences in response to IVIg. During followup, even when dosage or frequency of the treatment was increased, in some patients, news nerves became affected. Antibody status wasn’t a reliable predictor of treatment responsiveness.

P565 Bell’s palsy associated with herpes infection in 33-year old pregnant woman: a case report A. Kaprelyan, N. Deleva, A. Tzoukeva Medical University Prof. Dr. P. Stoyanov (Varna, BG) Background: Bell’s palsy is a unilateral, peripheral facial paresis or paralysis that has a sudden onset. Its occurrence during pregnancy is about three times higher. Although the early description of the syndrome in 1821, the recognition of etiologies and successful management of patients still present a great challenge. High blood pressure, diabetes, pre-eclampsia, vascular, infectious, genetic, and immunological causes are most likely thought to be associated with this neurological disorder. Case report: A 33-years old woman presented to our hospital with sudden onset of inability to close the right eye, excessive tearing, asymmetrical appearance of the mouth, facial twitching, and impaired sense of taste. The patient was pregnant in the third trimester. Medical history revealed an occurrence of herpetic rash around the upper lip one week ago. Checking of facial nerves function recognized unilateral right-sided paralysis. The diagnosis was based on patient’s history, physical and neurological examination, as well as laboratory tests. Conclusion: Although the etiology of Bell’s palsy often remains unclear and several causes have been proposed, this case confirms that the development of peripheral facial nerve paralysis during pregnancy might be associated with the increased susceptibility to herpes simplex viral infection.

Multiple sclerosis: cognition / neuro-psychology / treatment adherence P566 Cognitive impairment in multiple sclerosis Y. Wang, Y.M. Zhang Beijing Tiantan Hospital (Beijing, CN) Objective: Cognitive impairment is increasingly being recognized as a common and disabling symptom of Multiple sclerosis (MS).

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However, cognitive function is not assessed routinely in clinical practice or in clinical trials. In this study, we tried to reveal cognitive impairment of MS in order that doctors can pay more attention to cognitive disorders for MS patients and give them some instructs. Methods: We involved 90 cases of MS from March 2007 to Aug, 2008 admitted by Neurology department, Beijing Tiantan Hospital, and selected 90 old-aged people from community of Beijing as control group (CG), the two group had no remarkably different in sex, age and history diseases. All subjects participated in the observation voluntarily and their cognitive status were assessed with Montreal Cognitive Assessment (MoCA), If the score was greater than or equal to 26, the case would be diagnosed as normal, on the other hand, if the score was smaller than 26, the case would be think of having cognitive impairment, then, we used clinical Dementia Rating (CDR) to estimate the degree of cognitive impairment. Results: All the MS cases and healthy control cases entered results analysis. There were 12 MS cases and 35 CG cases had no cognitive disorders respectively, 38 MS cases and 18 CG cases were probable cognitive impairment respectively, and there were 46 MS and 51 GC were mild cognitive impairment, MS and CG had significant difference in the number of moderate cognitive disorders while had no difference in severe cognitive impairment.. Conclusion: MS have high prevalence of cognitive impairment compared with old-aged normal people. And how to manage cognitive decline in MS also requires further study.

P567 Cognitive dysfunction in multiple sclerosis in a Turkish cohort A. Bingo¨l, S. Yidiz, M. Tu¨tu¨ncu¨, N.O Demirci, N. Ahi, B. Topc¸ular, S. Saip, A. Siva Mayis Pschology Institute (Istanbul, TR); Istanbul University (Istanbul, TR); Bakirkoy Hospital for Psychiatric and Nervous Diseases (Istanbul, TR) Objective: Cognitive dysfunction is commonly seen multiple sclerosis (MS) in patients, with a frequency reported between %20 to %60 in different cohorts. Studies also report conflicting findings on correlation of cognitive dysfunction with quality of life. Therefore we investigated a cohort of 184 Turkish MS patients selected randomly from our MS Clinic to study demographic features, physical disability, quality of life and cognitive dysfunction. Methods: We instituted Functional Assessment of Mutiple Sclerosis (FAMS) instrument for quality of life and The Brief Repeatable Battery of Neuropsychological Tests to assess cognitive functions together with EDSS for physical disability. We excluded patients with concommittant diseases or treatments that could affect quality of life or cognitive functions. Results: 184 patients were included in the analysis. Relapsing remitting course was the most frequent disease course(62,13%) followed by primary progressive course (21,89%), secondary progressive (15,38%) and clinically isolated syndromes(0,59%). Female to male ratio was 1,67. Cognitive dysfunction existed in %30.5(n=56) of the patients. Patients performed worst on PASAT(n=55, mean 64,99%, SD 24,26), followed by 10/36 test(n= 49, mean 64%, SD 2,18) and selective reminding test (n=47, mean 54,6%, SD 2,73) referring to sustained attention, spatial immediate and delayed recall memory and verbal immediate and delayed recall memory respectively. Patients who performed under 50% in more than one test were considered as cognitively impaired. Introducing quality of life data to the statistical model showed good correlation between FAMS scores and cognitive dysfunction detected by BRB

S187 (p= 0.01) as well as selective reminding test, word list generation test, and symbol digit modalities, p= 0.0004; p=0.02; p=0.01 respectively. Conclusions: Cognitive dysfunction is an essential feature of multiple sclerosis and it plays a significant role in quality of life. Logistic regression analysis showed no correlation between disease course and cognitive dysfunction, nor between gender and cognitive dysfunction. However patients with secondary progressive or primary progressive MS had worse BRB scores (p\0.05).

P568 Premenstrual worsening in multiple sclerosis: physical disability and cognitive decline Y. Guven Yorgun, S. Ozakbas, E. Idiman Dokuz Eylul University (Izmir, TR) Objective: Premenstrual worsening of symptoms, which may be caused by hormonal influences on inflammatory pathways, has been reported in multiple sclerosis (MS). In the present study, we aimed to recognize the effect on physical and cognitive functions of premenstrual period of premenopausal MS patients. Method: 29 female patients were included in the study. Mean age was 33.55, mean disease duration was 7.09. All patients were normally menstruated. They were evaluated for cognitive functions in premenstrual and ovulation phase for two consecutive cycles. Premenstrual phase was compared to ovulation phase on the basis of physical disability and cognitive functions. Evaluation was made by expanded disability status scale (EDSS) and multiple sclerosis functional composite (MSFC) which is consisted of 9 hole peg test (9HPT), 25 foot timed walk test (TWT) and paced auditory serial addition test (PASAT), and auditory consonant trigram (ACT). Results: There was no significant difference in EDSS scores between premenstrual phase and ovulation. But MSFC was significantly decline in premenstrual period (p=0.042). 9-HPT did not found to be differed. Duration of 25-TWT significantly prolonged in premenstrual phase which meant worsening in walking (p=0.048). PASAT score was 48.71 in ovulation period. It decreased to 45. 64 in premenstrual phase (p=0.006). ACT score was also decreased from 49.07 (ovulation period) to 46.29 (premenstrual phase) which was statistically significant (p=0.005). PASAT and ACT were significantly correlated in both premenstrual phase (r=0.623, p=0.004) and ovulation (r=0.579, p=0.03). 25 There was a significant negative correlation between TWT and ACT in the premenstrual period (r= -591, p=0.03). Conclusions: In conclusion, the present study is the first one demonstrated transient decline of cognitive functions in premenstrual period in patients with MS. It is also shown significant decline in MSFC, which has been known to be more sensitive to demonstrate clinical worsening than EDSS.

P569 Cognitive performance in early multiple sclerosis: 2-year longitudinal data from CogniMS, a multinational study D. Langdon, E.M. Wicklein, K.K. Kim, N. Prayoonwiwat, K. Beckmann, P. Scherer, S. Fredrikson Royal Holloway (Egham, UK); Bayer Schering Pharma AG (Berlin, DE); Asan Medical Center (Seoul, KR); Siriraj Hospital (Bangkok, TH); Private practice (Berlin, DE); Karolinska Institute (Stockholm, SE) Objective: Cognitive function in patients with early multiple sclerosis (MS) is rarely documented longitudinally, and there is little

data from multinational studies. Our aim was to measure cognitive function in patients with early MS in a global, longitudinal study. Methods: Cognition in MS (CogniMS) is an observational study involving 33 countries. A total of 1349 patients with early MS were treated with interferon b-1b (IFNB-1b) and assessed every 6 months for 2 years. Demographics and neurological findings were recorded. Cognitive testing included the Paced Auditory Serial Addition Test (PASAT, 3-second version) and Faces Symbol Test (FST). Results: The 2-year data will be presented. Baseline results in cohorts from Canada, Australia, the Middle East, and Asian and European countries showed that 67.6% of patients were female. Median age at study entry was 34.0 years (Europe, 34.0; Middle East, 26.0; Asia, 34.0; Canada and Australia, 36.0); median time since first clinical symptoms was 19.2 months; and median time since MS diagnosis was 6.5 months. Median Expanded Disability Status Scale score at baseline was 2.0 (Europe, 2.0; Middle East, 1.0; Asia, 2.0; New World, 1.5). Median PASAT score was 49.0 (Europe, 49.0; Middle East, 56.5; Asia, 49.0; New World, 47.0), with 9.7% scoring below available normal controls. Median FST score was 2.6 (Europe, 2.6; Middle East, 3.2; Asia, 3.4; Canada and Australia, 2.3), with 35.8% scoring below available normal controls. Conclusion: The 2-year longitudinal data will provide information on cognitive function over time in patients with early MS, from different geographic/cultural settings. This study suggests that the prevalence of cognitive impairment in early MS is similar across different geographic regions. This study was sponsored by Bayer Schering Pharma, Berlin, Germany

P570 Cognitive impairment assessment in patients with clinically isolated syndrome suggestive of multiple sclerosis R. Romano, R.G. Viterbo, P. Iaffaldano, P. Taurisano, L. Fazio, C. Tortorella, D. Paolicelli, G. Blasi, A. Bertolino, M. Trojano University of Bari (Bari, IT) Objectives: The prevalence of cognitive impairment (CI) approaches 40–60% in definite Multiple Sclerosis (MS) and 20–30% in Clinically Isolated Syndrome (CIS). In the present study we used an extended neuropsychological battery to evaluate frequency, type and severity of cognitive domains impaired in CIS relative to normal controls (NC). Methods: Forty-nine CIS patients (16M; age 29,32±8,44 years; EDSS 1,89±0,88) and 43 healthy control participants (17M; age 27,04±7,19 years) were assessed with the Brief Repeatable Battery of Neuropsychological Tests (BRBN). Subjects also underwent a set of neuropsychological tests assessing Working Memory (N-back), sustained attention (Continuous Performance Test, CPT), attentional control (Variable Attentional Control, VAC), executive function (Wisconsin Card Sorting Test, WCST), cognitive flexibility (Trail Making Test A-B), and short-term memory (Wechsler Memory Scale, WMS). Parental socioeconomic status (Hollingshead Scale), and handedness (Edinburgh Scale) were also assessed. The Nback and VAC task were used to elicit increasing demands of working memory and attentional control processing. Results: The two groups were age and sex matched and they did not differ for socioeconomic variables (all p[0.1). At BRBN assessment of CIS patients 24.5% failed at list two tests and 10.2%

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S188 were cognitively impaired (scored abnormally on three tests). The most frequently failed tests were Word List Generation (32.7%), Stroop Test (20.4%) and PASAT 3 (10.2%). Patients also had reduced working memory (p=.007) and short–term memory (WMS p=00166) performance relative to NC. We found, also, a diagnosis by load interaction in working memory (Nback; p=,01787) and attentional control (VAC; p=,01871). Other tests did not show statistical differences between the two groups. Conclusion: The present study confirms cognitive dysfunction in patients with CIS and suggests that functional integration between different brain areas is affected even at early stages of demyelinating disorders. More specifically, the results seems to indicate a greater impairment of functional integration between prefrontal and hippocampal areas, mainly involved when cognitive load is increased.

P571 Cognitive performance in clinically isolated syndrome suggestive of multiple sclerosis: 2-year data from CogniCIS, a multinational longitudinal study D. Langdon, E.M. Wicklein, N. Prayoonwiwat, K. Beckmann, P. Scherer, S. Fredrikson Royal Holloway (Egham, UK); Bayer Schering Pharma AG (Berlin, DE); Siriraj Hospital (Bangkok, TH); Privat practice (Berlin, DE); Karolinska Institute (Stockholm, SE) Objective: Knowledge on cognition in patients with clinically isolated syndrome (CIS) is limited due to the lack of large or longitudinal studies. We aimed to assess the pattern and development of cognitive deficits in CIS, longitudinally, in a multinational study. Methods: Cognition in CIS (CogniCIS) is a noninterventional study across 18 countries. A total of 380 patients with CIS without previous disease-modifying treatment (DMT) use underwent assessments every 6 months over 2 years. Once patients started a DMT, they were transferred to a parallel study (Cognition in Multiple Sclerosis [CogniMS]). Patient demographics were recorded, and neurological and neuropsychological assessments including relapse rate, Expanded Disability Status Scale (EDSS) score, Paced Auditory Serial Addition Test (PASAT, 3-second version) and Faces Symbol Test (FST) were performed. Results: The 2-year data on the total cohort will be presented. Baseline analyses revealed that 76.7% were female and mean (SD) age was 33.2 (9.7) years (Europe, 32.1 [9.4]; Asia, 38.1 [9.6]; Canada and Brazil, 35.8 [9.7]). Mean time since disease onset was 8.45 months; mean EDSS score was 1.0 (Europe, 1.0; Asia, 2.0; Canada and Brazil, 1.0). At baseline, mean PASAT score was 45.0 (12.4) (Europe, 48.0 [10.5]); Asia, 31.6 [15.0]); New World, 38.6 [12.4]), with poor performance in 11.6% of patients. Mean FST score was 2.65 (1.34) (Europe, 2.29 [0.87]; Asia, 4.88 [3.01]; Canada and Brazil, 2.84 [1.24]). Conclusion: This exploratory multinational study confirms that cognitive impairment is present at the CIS stage. Change over time will be described by the 2-year longitudinal data. This study was sponsored by Bayer Schering Pharma, Berlin, Germany

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P572 ITACA Study: final data. Cognitive and affective 24-month follow-up of multiple sclerosis patients treated with glatiramer acetate or b-interferon: the ‘immunomodulating treatments affective and cognitive aspects’ S. Canale, M. Falautano, V. Martinelli, A. Solari, F. Mattioli, M.P. Amato, I. Simone, C. Pozzilli, F. Patti, C. Di Serio, M. Radaelli, E. Leopizzi, G. Comi Scientific Institute San Raffaele (Milan, IT); Neuological Institute C. Besta (Milan, IT); Salvatore Maugeri Foundation (Brescia, IT); University of Florence (Florence, IT); University of Bari (Bari, IT); La Sapienza University (Rome, IT); University of Catania (Catania, IT) Background: Cognitive dysfunction is a common and disabling symptom of MS that contributes to the poor quality of life in affected patients. Aims: to evaluate the changes of cognitive performances (particularly of memory and executive functions) and of affective and clinical variables over a 24-month period in RRMS patients, treated with Glatiramer Acetate (GA) or B-Interferon (IFN). Method: Observational, longitudinal, multicentre, Italian study. 752 patients were enrolled by 79 Italian MS Centres. All patients underwent a comprehensive Neuropsychological evaluation including Rao’s Brief Repeatable Battery of Neuropsychological Test (BRB-N), Stroop Colour Word Test and Short Intelligence Test. At baseline and 24 months, patients were assessed with the BRB-N-version A, at 12 months whith BRB-N-version B. The MS Quality of life/54 items (MSQoL/54) and the Montgomery Asberg Depression Rating Scale (MADRS) were used to assess QoL and the depression index. The Fatigue Severity Scale (FSS) and neurological disability (EDSS) were also evaluated in all patients. The patients were divided into three subgroups (absent, mild or severe cognitive impairment) according to number of test failed. Moreover it was evaluated for each patient an index of Cognitive Impairment (CI) based on the number of standard deviations from the normative average. Results: In 619 patients who completed the study a significant decrease in cognitive dysfunctions was observed at 24 months whereas no significant differences were observed between the two treatments group (Wilcoxon non parametric test: P\0.001). A worse cognitive performance was observed at 12 months in both groups for BRB-N and for memory and executive functions. This result it was not related neither to an increase of disability or depression index. Only the performance on the Stroop test increased at 12 month fup for both groups of treatment. At baseline GA patients showed significantly higher EDSS, FSS and MADRS scores than IFN patients (P\0.005); this level of statistic significance was not observed at 24 month-fup for FSS only. Finally, both groups showed a decrease of depressive symptoms. Conclusion: Our study showed an improvement of cognitive functions and a reduction of the depressive index in patients who have maintained the immunomodulatory treatment for two years. The decline observed at 12 months could be due to the two different forms of BRB-N (A and B) used. Received fee for consulting service from Sanofi-Aventis

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P573 Screening for cognitive impairment in patients with multiple sclerosis: a study with the Spanish Brief Neuropsychological Battery C. Oreja-Guevara, G. Lubrini, L. Gabaldo´n Torres, M.L. Martı´n-Barriga, B. Manzano, E. Diez-Tejedor University Hospital La Paz (Madrid, ES); University Hospital Gregorio Maran˜o´n (Madrid, ES) Introduction: Cognitive impairment is increasingly being recognized as a common and disabling symptom of multiple sclerosis (MS) that contributes to poor quality of life in affected patients. Therefore, brief screening tests to identify these are needed. Objectives: To study cognitive alterations in MS patients with a new validated spanish brief neuropsychological battery and to determine the relationship between age, gender, disease duration, disability level and depression and the presence of cognitive impairment. Methods: It is a cross-sectional study. A new validated spanish brief neuropsychological battery called BNB was used by the neurologist as a quick screen to assess cognitive dysfunction in patients with relapsing-remitting MS (RRMS). The BNB can be administered and scored in about 20 minutes and includes a spanish version of the Free and Cued Selective Recall Test (FCSRT), the Symbol Digit Modality Test (SDMT), a test of verbal fluency and a modified version of Paced Auditory Serial Addition Test (PASAT). The Beck Depression Inventory (BDI) was also used to screen depressive symptoms. Results: Eighty RRMS patients participated in the study. Mean age was 42 years and mean education duration was 12.96 years. Median EDSS score was 2.5 (range: 0-6.5) and mean disease duration was 132 months. 78 % of patients were under different immunomodulatory treatments. 40 % of the patients were affected by some degree of cognitive deficit as in previous studies using other neuropsychological batteries. In particular 24% had mild, 11% moderate and 5% had severe impairment. Deficits in speed of information processing (39%) and verbal fluency (32%) were the commonest abnormalities. Significant correlations were found between cognitive alterations, disability (EDSS) and disease duration. No significant association was found between depression and any cognitive deficits. Conclusion: These results suggest the effectiveness of the BNB as a fast screen for cognitive impairment in MS in the daily clinical practice. The study confirms the sensibility of the SDMT to detect cognitive impairment in MS, in particular the impairment of speed of information processing. We conclude that the BNB, similar to other proposed screening methods, has potential use in the clinical setting.

P574 Psychopathology of multiple sclerosis: influence of the perception of the disease on the disorders of mood and the emotions S. Roy Bellina, G. Benes, W. Camu, B. Carlander, E. Thouvenot, N. Landragin, M. Cherif, C. Geny, M.C. Ge´ly-Nargeot University Hospital (Montpellier, FR); University Paul Vale´ry (Montpellier, FR) Background: The uncertainty about the future, a frequently weak family circle and understanding way induce an erroneous perception of the disease in multiple sclerosis (MS) patients and some disorders of the mood and the emotions.

Objectives: This study aims at bringing to light the links which exist between the disorders of the mood and the emotions, and the perception of the disease according to its evolution. Methods: 32 MS patients, 26 women and 6 men, old from 16 to 62 years (mean age = 40 uears ± 12.5) with an average EDSS score of 3.54 (± 2.23), were evaluated with 5 questionnaires : illness perception questionnaire revised (IPQ-R), Hamilton anxiety scale (HAMA), Beck depression inventory (BDI), Toronto alexithymia scale at 20 items (TAS-20) and apathy inventory (IA). Patients with dementia were excluded (MMSE [ 24). Results: There was a positive correlation between ‘‘The number of symptoms inherent to the disease’’ and the disorders of the mood (depression : r =-0.39, p=0.02; anxiety : r=0.59, p=0.0004), as well as with alexithymy (r =-0.36, p=0.04). ‘‘The consequences of the disease’’ were positively correlated with depression (r=0.37, p=0.03). There was a negative correlation between ‘‘the coherent character of the disease’’, apathy (r =-0.35, p=0.04) and the loss of initiative (r =-0.37, p=0.03). ‘‘The cyclic character’’ was positively correlated with alexithymy (r=0.49, p=0.004) and apathy (r=0.36, p=0.04). Discussion: The more MS patients associate symptoms with their disease the more they present a depressive and anxious tendency, and alexithymic profile. Besides, the more the perception of the disease is inconsistent, the more MS patients are apathic. The uncertainty as for the evolution of the episodes of relapses and forgiveness pull a loss of initiative, a lack of general interest, with for consequence a progressive isolation of patients. Conclusion: The perception of the disease plays a role of mediator on the disorders of the mood and the emotions. Better to inform, can contribute to the improvement of the psychic state of MS patients.

P575 Depression in early relapsing-remitting Multiple Sclerosis (RRMS) patients with higher risk of progression S. Cihelkova´, Z. Baranı´kova´, M. Jung, M. Bojar Motol Hospital (Prague, CZ) Background: Aim of this study was to assess relationship between recognized and unrecognized depressive disorders to Kurtzke Expanded disability status scale (EDSS), fatigue and anxiety of patients in RRMS’s early stages stabilized on immunomodulating therapy and in higher risk of disease progression. Patients and methods: 65 consecutive unselected patients with RRMS, without relapse, more than 1 year on immunomodulating therapy, disease duration to 7 years, EDSS to 4.5, more than 2 relapse in first two years of illness and lession mainly in brain entered to study. Patients were scored by Beck’s Depression inventory II. (BDI II), Beck Anxiety inventory II (BAI II), Derogatis scale 90 (SCL 90), EDSS, MS disability scale, MS fatigue scale, Mini Mental Status Exam (MMSE), Eyseck personality test II A or B (EOD II.A,B). In patients with anxiety without depression a psychiatric interview was done. Differences between patients with and without depression in EDSS, fatigue, anxiety and between patients treated for depression before study and patients depression recognized in study was statistically evaluated. Results: Patients with depressive disorders had higher EDSS (n 27) than patients without (n 29) p= 0,05 and had higher fatigue score p\0.001. 9 patients were excluded due to other psychiatric symptoms or because of noncompliance with possible psychiatric diagnosis. 21 patients with depression had also anxiety. Another 6 patients without depression symptom had anxiety and only 2 non-depressive patients had anxiety. No differences between patients with clinically unrecognized depressive disorders (15 detected in study) and with clinically recognized depressive disorders (12 detected before study) were found in EDSS, fatigue, EOD II A or B, depression or anxiety score.

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S190 Conclusion: Patients with early RRMS and with higher risk of disease progression with depressive disorders had higher EDSS, but patients with depressive disorders suffer mostly also from anxiety. Depressive disorders are also associated with higher fatigue. Any specific comorbid symptoms of unrecognized depression wasn’s found. Futhermore, comorbidity of anxiety and depression may suggest that patients suffered from mixed depressive-anxiety disorder, not only depression. This study was supported by Jan Hus Educational Foundation, Czech Republic

P576 Quality of life in patients with high-risk clinically isolated syndrome treated with AvonexÒ: Interim results of the AREMIN study O. Sa´nchez-Solin˜o, C. Grau, J.C. Parra, E. Arroyo on behalf of the AREMIN Group Objectives: Clinically isolated syndrome (CIS) is defined as a first demyelinating event that affects the central nervous system and that may indicate the onset of multiple sclerosis. The AREMIN study evaluated long-term Quality of Life (QoL)outcomes of patients who started treatment with intramuscular interferon-b 1a (Avonex) after a first event. Here we present a descriptive analysis of the QoL of patients with clinically isolated syndrome (CIS) treated with Avonex. Methods: This was a multicenter, phase IV, post-marketing, observational, prospective, longitudinal 4-year study. The present interim analysis covers the baseline visit through to the 24-month visit. Patients filled out the following validated QoL questionnaires: Functional Assessment of Multiple Sclerosis (FAMS) and EuroQoL 5D (European Quality of Life). Results: Thirty-four patients were included in the study. The mean score on the FAMS questionnaire was 60.9 points, 63.1 points, 61.0 points, 63.9 points, and 63.8 points at the baseline visit and at visit 2, visit 3, visit 4 and visit 5, respectively. There were no statistically significant differences between visits. The scores on the different dimensions of the EuroQoL 5D questionnaire on quality of life for the baseline visit and visit 5 were: no mobility problems 86.2% vs 85.7%; no self-care problems 96.6% vs 100%; no problems with usual activities 79.3% vs 61.9%; no pain/discomfort 69% vs 57.1% and no anxiety/depression 72.4% vs 57.1%, respectively. The mean score on the Visual Analogue Scale (VAS) that assesses the state of health of the patients was 84.4% at baseline and 83.2% at visit 5. No statistically significant differences were found between any of the visits (p[0.05). Conclusion: The AREMIN study is the first to prospectively collect data on health-related quality of life in clinical practice in patients with high-risk CIS in treatment with Avonex. The overall quality of life of the patients was good. The total mean score on the FAMS, EuroQol 5D and VAS questionnaire was very similar over the 2-year analysis period; quality of life remained stable over the observation period.

P577 Therapeutic compliance to disease-modifying drugs in patients with multiple sclerosis: a hospital-based multivariate analysis of influencing factors L. De Santi, G. Polimeni, E. Palella, F. La Fauci Belponer, E. Sessa, P. Bramanti, L. Gitto IRCCS Centro Neurolesi ‘‘Bonino-Pulejo’’ (Messina, IT) Objectives: Disease-modifying drugs (DMDs) for multiple sclerosis (MS), interferon-b and glatiramer acetate, changed the natural history

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of the disease by reducing the frequency of relapses and the progression of disability. However, a poor patient compliance to the treatment may carry relevant medical and economic implications. Aims of the study: 1)

2)

to identify the factors related to patient perception and awareness of the disease and of the potential benefit of treatment impacting on the decision to start a DMD. to identify potential indicators of poor patient compliance to DMDs.

Methods: The first phase of the study was retrospective. We analyzed data from medical records of 567 MS patients visited at the IRCCS Centro Neurolesi ‘‘Bonino-Pulejo’’ (Italy) between 20012008. Factors influencing patient decision to start a treatment with a DMD, in agreement with the neurologist suggestion, were evaluated by applying a multinomial logit model. The second phase of the study was cross-sectional. We analyzed the data obtained through a questionnaire administered to consecutive outpatients between March and May 2009 (n = 143). The probability to continue the treatment or to drop out was estimated through a probit model. Results: Young age (p \ 0.0001), symptomatology (cerebellar dysfunctions p = 0.001, sensitive symptoms p = 0.004, pyramidal symptoms p = 0.001) and anxiety (p = 0.007) positively impact on the patient decision to start the DMD treatment, suggested by the neurologist, within three months from the first visit (23.1% probability). The probability that a DMD treatment was started was considered an index of patient awareness of the risks associated with the disease. The greatest negative impact on patient compliance is represented by the need of symptomatic drugs for side effects associated to DMD treatment (p = 0.001). On the other hand, a positive self-evaluation of DMD treatment effectiveness correlates with the probability to carry on with the treatment (p = 0.022). Conclusion: A better knowledge of factors associated to lack of compliance to DMD drugs may help to allocate resources and to reduce costs related to MS management. We suggest also an improved patient-doctor communication to minimize the number of patients dropping-out from DMDs.

P578 Maintaining treatment adherence during immunomodulatory therapy in multiple sclerosis patients – results of a multicentre survey R. Hozejowski, B. Kozlowska-Boszko Bayer Schering Pharma (Warszawa, PL) Objectives: Treatment adherence has been identified to be a major issue during the long-term use of disease modifying therapies (DMT) of multiple sclerosis (MS). We assessed routine practice addressing patient noncompliance and evaluated doctors’ perception of the impact of various patient-, disease- and medication-related factors on treatment adherence. Methods: With a structured questionnaire we collected data on the treatment initiation process and commonly employed measures to control compliance. Perception of risk of nonadherence was assessed by evaluating the impact of predefined risk factors using a categorical scale from 1 (very negative) to 5 (very positive). Results: Out of 35 sites investigated, 8 were academic centres and 27 tertiary hospitals. Specialised MS team was in place in 30 centres (86%). The team included neurologist (100%), MS nurse (97%), physiotherapist (80%) and psychologist (74%). Patient’s contribution (%) to the decision of initiating DMT varied from 5 to 70% (median

S191 30%) depending on site. Median duration of patient’s visit was 30 minutes (range 20–60 min). Training on self-injections was conducted either by MS nurse alone (80% of sites), nurse and physician (17.4% of sites) or solely by physician (2.8% of sites) and lasted from 5 to 120 min (median 30 min). Patients compliance to DMT was monitored on a monthly basis in 82.6% of sites and was under the responsibility of a neurologist (97.1% of sites) and also involved MS nurses and family members (82.7% and 60.0% of sites respectively). Only 12 sites (34%) used regular active nurse phone contact to control compliance. Dedicated monitoring programme was in place at 3 sites (8.6%) only. The major factors perceived as challenging treatment adherence were ‘‘lack of information or misinformation about treatment’’, ‘‘depression’’ and ‘‘unrealistic expectations’’ (by rank order, Friedman ANOVA). Steps most commonly taken when patients reported intention to stop treatment included assessment of adverse events (87.9% sites), depression symptoms (84.9% sites), scheduling additional visits (45.5% sites) and modifying drug dosage (36.7% sites). Conclusions: 1. Despite declared importance of ‘‘understanding of the disease by patients’’ for treatment adherence (95% responders rated ‘‘very important’’), actual time spent per visit to communicate treatment strategy was quite limited. 2. Phone contact was too rarely used to monitor adherence to therapy. 3. More active role of MS nurse should be considered. This study was supported by Bayer Schering Pharma, Warsaw, Poland.

P579 Factors-related to adherence in Spanish patients with multiple sclerosis: 2-year results of the GAP study O. Sa´nchez-Solin˜o, E. Arroyo, C. Grau, J.C. Parra on behalf of the Spanish GAP Study group Objectives: Treatment efficacy may be substantially impacted by nonadherence. Treatment, Health Care Providers (HCP) and sociocultural factors have been identified as related factors to non adherence. In Spain a 5-year follow-up study is in progress to evaluate long-term adherence. Here we assess factors related to lack of adherence from the first 2 years of the GAP study in Spain. Methods: Secondary objectives evaluate factors related to adherence. A questionnaire assessing adherence to DMTs, is distributed annually to patients with MS and their treating neurologists. Patients signed informed consent for follow-up and Ethics Committees approved follow-up in 15 out of 18 centers. Results: 254 patients at baseline (V0) visit, 142 after one year of follow-up (V1) and 131 after two years of follow-up (V2) were included. The lack of adherence related to: 1. Treatment: At V0, most common reasons were forgetting to inject and injection-related reactions (70.3%, 43.2%) versus 42.1%, 89.5% at V1 and 32%, 72% at V2 respectively. 2. HCP: neurologists and nurses of adherent patients saw the patients more often and more regularly both at V0 (89.1% and 25.7%) and at 2 years (99% and 31%), respectively.3. Sociocultural factors; There were little differences between adherence and non adherence patients. Comparing V0 to V2, % patients working full-time decreased (36% to 32%), while % patients retired or receiving assistance increased (16% to 26.3%). The main sources of patient support at V0 and V2 were by importance: family, partner, physician and nurse, friends, other healthcare workers, and religious beliefs.

Conclusion: At V2 injection-related factors was the most common reason for lack of adherence. The therapeutic option may directly affect adherence of an MS patient to DMT. Although all these are dynamic factors, if they are managed effectively, there would be greater emphasis on patient education and long-term adherence would be enhanced. The Global Adherence Project was financed by Biogen Idec

P580 Assessment of adherence to subcutaneous interferon b-1a treatment in daily practice among patients with relapsing multiple sclerosis using an electronic self-injection device F. Baldinetti, L. Ghazi-Visser Merck Serono S.A. (Geneva, CH); Merck Serono (Schiphol-Rijk, NL) Background: Poor adherence to medication may impact on efficacy outcomes. Data that are available for patients with multiple sclerosis (MS) suggest that treatment adherence is sub-optimal, although this is mainly based on indirect measures. The ongoing SMART study will provide the first large-scale, accurate, objective assessment of patient adherence to disease-modifying drug therapy in MS. Objective: To assess adherence to subcutaneous (sc) interferon (IFN) b-1a treatment among patients with relapsing MS (RMS) using an electronic self-injection device. Methods: This 12-month, observational, multicentre study is being carried out across 18 countries. It includes patients with RMS (McDonald criteria), a baseline Expanded Disability Status Scale score of 6 or less and who are either naı¨ve to treatment or currently treated with sc IFN b-1a injected by the electronic device (RebiSmartTM) but for less than 6 weeks. Included patients will receive IFN b-1a, 22 or 44 mcg sc three times weekly, via self-injection using this electronic injection device. Compliance and persistence with therapy will then be calculated using data collected by the device (date and time of injections). The primary endpoint is the proportion of expected injections completed during 12 months’ treatment. Secondary endpoints include the reasons for missed injections, relapse outcomes, and an overall assessment of the device based on both patient and physician assessment. Results: Enrolment commenced in October 2009 with the intention of recruiting 1100 patients to the study across 300 centres in 18 European countries. As of January 2010, 16 patients have been recruited across 50 centres in 3 countries. Study supported by Merck Serono S.A. – Geneva, Switzerland, an affiliate of Merck KGaA, Darmstadt, Germany

General neurology P581 Pure adrenomyeloneuropathy with changes in magnetic resonance spectroscopy A. Dolgan, J. Chojdak-Lukasiewicz, M. Koszewicz, R. Podemski, A. Krupinska-Dulemba, S. Budrewicz, A. Szczepanska Medical University of Wroclaw (Wroclaw, PL) Introduction: Adrenomieloneuropathy (AMN) is an adult variant of Xlinked adrenoleukodystrophy, caused by defects in the ABCD1 gene. In the clinical picture spastic paresis of lower limbs, cerebellar ataxia,

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S192 sphincteral disturbances and polyneuropathy predominate, emotional lability, mania, psychosis and endocrinological disturbances occur rarely. There are two types of AMN: pure (limited to spinal cord and peripheral nerves) and cerebral (brain, spinal cord and peripheral nerves are affected). The incidence of AMN is about 2.5 per 1 000 000, in 8% of them the family history is negative. Case report: 30 year old man, without any past medical history, has suffered from gait difficulties with lower limbs’ stiffness and weakness since 4 years. The family history was negative. On admission to the Neurological Department of Medical University in Wroc3aw he presented right facial nerve palsy and spastic tetraparesis, predominantly in the lower extremities and the left side, bilaterally pyramidal signs without sphincter disturbances. Conventional brain magnetic resonance imaging (MRI) was normal, MRI imaging of the spinal cord revealed atrophy limited to the thoracic spinal cord. Magnetic Resonance Spectroscopy (MRS) of the brain detected biochemical abnormalities suggesting axonal damage (nonspecific diffuse white matter damage). Nerve conduction velocities showed mixed polyneuropathy. Auditory brain-stem response revealed elongated III-V interval. Very Long Chains Fatty Acids (VLCFA) level was increased and the diagnosis of adrenomyeloneuropathy (AMN) was confirmed. There were no endocrinological abnormalities. Discussion: We report a rare case of a 30-year-old man with adrenomyeloneuropathy. The diagnosis was based on a clinical picture and wide range of standard diagnostic procedures, which allowed us to recognized ‘‘pure’’ AMN. According to MRS results, brain changes were confirmed additionally in our patient. We suggested that spinal changes in MRI might be secondary to white matter impairment revealed in MRS. MRS allowed- to recognition of more diffuse changes even in ‘‘pure’’ AMN. This radiological procedure should be done in such, cases of AMN.

P582 Intramedullary cryptococcal abscess with normal serological antigen tests A. Efthymiou, E. Meidani, A. Toskas, M. Siakantari, N. Evangelatos, K. Karydakis Laiko General Hospital (Athens, GR) Introduction: Cryptococcal infection is caused by variants of the cryptococcus neoformans species complex. Immunocompromised individuals are more often affected, especially patients with AIDS, hematological malignancies, diabetes mellitus, sarcoidosis, and patients treated with corticosteroids. Involvement of the central nervous system (CNS) has been found in 80% which is usually manifested as sub acute or chronic meningoengefalitis and rarely as cryptococcoma or abscess. Spinal cryptococcosis is exceptionally rare. We present a case of spinal intramedullary cryptococcal abscess with concurrent multiple intracranial involvement and normal serological antigen tests. Case report: A 78-year old woman, immunocompromised, admitted with acute paraplegia, bilateral Babinski’s sings and sensory level at T7-T8. `Iagnetic resonance imaging (MRI) of the thoracic spinal cord revealed intramedullary lesion with a smooth border at the T9 vertebral level. MRI of brain scans showed small-ring contrast enhancing lesions with surrounding perifocal edema in both cerebral hemispheres suggesting abscess or malignancies Laboratory and imaging testing for the presence of malignancy or systemic disease proved negative. Cerebrospinal fluid (CSF) examination revealed: cells 2/mm3, leucoma 52mg/dl, Gl. 90 mg/dl (serum 189mg/dl). Serological CSF tests, India inEˆ, fungal cultivations and the detection

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of Cryptococcus antigen were negative. The spinal intramedullary lesion was surgically removed and the histological examination was indicative of cryptococcal abcess. The patient received antifungal therapy but died 1 month later due to septicemia. Conclusion: Although the spinal intramedullary cryptococcal abscess is extremely rare, it should be included in the differential diagnosis of mass lesions of the spinal cord particularly in immunocompromised patients.

P583 Evaluation of quality of life parameters in Syringomyelia patients F. Roser, C. Sixt, B.E. Will, M. Tatagiba University of Tu¨bingen (Tu¨bingen, DE) Objective: Syringomyelia, the formation and expansion of a cyst or syrinx within the spinal cord, is a centromedullary syndrome accompanied by pain, numbness, and dissociative symptoms. The majority of patients undergo a steady progression and escalation of neurological symptoms. Although various forms of conservative and neurosurgical treatments exist, it remains unclear how neurosurgical intervention affects quality of life and what syringomyelia patient subgroups profit by such an intervention. Methods: Physical and mental quality of life was assessed in 142 patients with syringomyelia via the standardized SF-36 questionnaire (physical and mental component scores [PCS/MCS]), a Syringomyelia-Disability-Index (SDI) to determine functional disability, and an individualized questionnaire to summarize clinical history. Results: Underlying syringomyelia pathologoys varied, including prevalent Chiari-Malformations, as well as spinal trauma, spinal tumors, and others. Syringomyelia patient SF-36 component scores (PCS/MCS) were significant lower compared to the general German population as well as patients suffering from other chronic diseases. Scores from surgically treated patients did not differ significantly from those treated conservatively, nor were scores dependent upon underlying syrinx pathology. Cluster analysis revealed four patient groups based on quality of life patterns, displaying characteristics of clinical presentation and history. Conclusion: Syringomyelia is a chronic and progressive disorder. As confirmed by cluster analysis, clinical deterioration can be avoided and a high quality of life can be maintained provided that experts employing appropriate diagnostic tools intervene promptly. As the syrinx itself appears to be the source of symptoms, it is necessary to treat the pathology that preserves the syrinx cavity.

P584 Liber Pantegni: transmission of Greek knowledge of neurological diseases to the Latin West in Constantine, the African translation from Arabic A.L. Guerrero, V. Frutos-Gonza´lez University Hospital (Valladolid, ES); University of Valladolid (Valladolid, ES) Objectives: Medical school of Salerno was founded around nine and tenth century thanks to the collaboration between Greek, Jewish, Latin and Arab physicians. Classic Greek medical texts, compilated by roman authors, were translated into Syriac language by nestorians heretics and, after that, into Arabic. Constantine the African studied medicine in Baghdad and extensively travelled, acquiring Arabic medical texts. He joined School of Salerno and his translations from

S193 Arabic to Latin helped to reintroduce Greek medicine into Medieval Europe, influencing medical teaching for centuries. Methods: Kamil as-sina’a at-tibbiya (complete book of medical art), written by the Persian physician Ali ibn Abbas was Constantine’s first translation to Latin, Liber Pantegni. It was the first medical treatise in Latin language. We have carried out a descriptive review of Henricum Petrum’s Latin edition, year 1539. Liber Pantegni contains ten books, each of them divided in numerous chapters. After a few generalities considered in the first book, second and third ones enumerate the different simple and compound members, according to galenism. Fourth book considers sense organs functions, and fifth the galenic sex res non naturales. After reviewing sense organs diseases, pulses, digestion and skin pathologies in sixth to eighth books, ninth one is a therapeutic treatise a capite ad calcem (from head to toe), and last one completes natural history of some diseases. Results: Pantegni proposes an explanation for the origin of both central and peripheral nervous system. Nerves are defined as simple members, with sensitive and motor function, and brain is considered a moving member in which memory and intelligence lie. 7 cranial and 31 spinal nerves are considered; spinal nerves diseases lead to weakness, epilepsy, spasms and tremor. Regarding headache, text classifies them in cephalea, holocranial pain due to systemic diseases or harmful foods, and hemicrania produce by meningeal disturbances. Both apoplexy and epilepsy are produced by cerebral ventricles obstruction. Obesity, excessive alcohol intake and cold weather favour epilepsy or apoplexy. Epilepsy is considered a milder state of apoplexy, and this conduct to death of the patient or to paralysis and epilepsy as remaining sequelae. Conclusion: Liber Pantegni contains lots of references to neurological diseases. It is considered as a pivotal text in the early development of European medicine.

P585 Neurology in Byzantine medicine. Insights into Alexander of Tralles’ Medici Libri Duodecim V. Frutos-Gonza´lez, A.L. Guerrero GIR Speculum Medicinae (Valladolid, ES); University Hospital (Valladolid, ES) Objectives: Following destruction of Western Roman Empire, Byzantium continued Greek and Roman habit of texts compilation, and so, preserved medical knowledge. In addition, and assimilating the influence of the monastic and Arabic medicine, Byzantine physicians transmitted original contributions including interesting references to neurological diseases. Alexander of Tralles practiced and wrote during 6 th century and is one of major exponents of Byzantine medicine. Born in a distinguished family he received his early medical training with his father, and then undertook extensive travels, gathering medical knowledge and experience. Methods: Medici libri duodecim (MLD) is a treatise on the pathology and therapeutics of internal diseases, in twelve books. First eleven books contain material gathered for lectures or teaching, whilst twelfth one was probably written toward the end of Alexander’s life and comprises in supplementary matter, his views from observation of different diseases. Its influence was prolonged and was translated and edited until Renaissance. We review grecolatin edition by Henricum Petrum in 1556 with special interest in neurological disease citations. Results: First of twelve books is dedicated to head and brain diseases. Regarding head, Alexander proposes therapies against baldness, grey hair, or dandruff. When considering headache, he classifies them, following Aretaeus of Cappadocia theories, in cephalalgia, cephalea and hemicrania, suggesting different pathogenic mechanisms and therapies for each one. Headache is included among symptoms conducting, as well as memory or sleep disturbances, to delirium. MLD

considers memory complaints among systemic diseases, mainly with cardiac involvement. Alexander distinguishes between paralysis, a privation of sensibility and mobility concerning half of the body, and apoplexy, affecting whole body and including main soul functions loss, even conducting to death. Regarding epilepsy, MLD considers that its origin can be outside the head, mainly in the stomach, and offers us an interesting description suggesting an epileptic aura. Conclusion: Analysis of Alexander of Tralles’s MLD gives us an interesting view of how byzantine physicians understood neurological diseases. Therapeutics was based on venesection, medicinal plants and avoidance of noxious substances.

P586 Murdock free recall data: the initial recall search identifies the context by the location of the least remembered item and memory activity level may be sensed by glial cells E. Tarnow Private practice (Fair Lawn, US) The curious free recall data of Murdock (1962) shows an additional surprise that seems to have gone undetected until now: the probability of guessing an item in the initial recall is not identical to the overall free recall curve. Initial recall of an item is well correlated with the total recall of that item using a straight line but with an unexpected offset. The offset varies with the presentation rate and the total number of list items but in each case it is the same as the total recall probability of the least recalled item. Thus for the initial ‘‘freest’’ of recalls the location of the least remembered item is identified, in effect identifying the context, and from there the items recalled are those better remembered items, in proportion to the probability of total recall. Within the tagging/retagging model (Tarnow, 2008, 2009) the free recall starts by an identification of a discontinuity in the activity level and produces an item with a probability according to the relative activity level. I speculate that the activation level and its discontinuity is detected by glial cells assisting in rebuilding post-activation empty presynaptic neurotransmitter vesicles.

P587 Combination of tissue-plasminogen activator with erythropoietin induces blood-brain barrier permeability, extracellular matrix disaggregation and DNA fragmentation after focal cerebral ischaemia in mice A. Zechariah, A. El Ali, D.M. Hermann University Klinik Essen (Essen, DE) Background: Following one clinical study, in which recombinant erythropoietin (Epo) protected against ischemic stroke and improved clinical outcome, the German multicenter Epo trial recently reported increased mortality in stroke patients receiving Epo after tissueplasminogen activator (t-PA)-induced thrombolysis. The reasons for Epo’s adverse effects in t-PA-treated patients are unknown. Methods: Mice were submitted to 90 minutes middle cerebral artery occlusion. Immediately after reperfusion, animals were treated with normal saline or t-PA (10 mg/kg). Animals subsequently received injections of normal saline or Epo that were administered after reperfusion and 12 hours later (2500 IU/kg each). Ischemic injury and brain edema were analyzed at 24 hours after reperfusion by cresyl violet staining and terminal transferase biotinylated-dUTP nick

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S194 end labelling. Blood-brain barrier integrity was assessed by histochemistry for extravasated serum IgG. Matrix metalloproteinase activity was evaluated by gelatinase zymography. Results: Epo did not influence ischemic infarct size, but reduced brain swelling. This effect was abolished by t-PA, which exacerbated serum IgG extravasation in ischemic tissue. Gelatinase zymographies revealed that Epo promoted matrix metalloproteinase (MMP)-9 activity that was markedly elevated by t-PA. Add-on treatment with tPA increased the density of DNA-fragmented cells in ischemic tissue of Epo-treated, but not vehicle treated mice. Conclusions: Our data demonstrate a hitherto unknown interaction of t-PA with Epo at the blood-brain interface, i.e., promotion of vascular permeability and extracellular matrix breakdown, which may account for Epo’s unfavourable actions in t-PA-treated patients. Following t-PAinduced thrombolysis, Epo may not be suitable as stroke treatment.

P588 Influence of STEAM and PRESS sequences on absolute quantitation of 1H MR spectroscopy and comparison of three post-processing technologies X.Q. Guo, Y. Xiao, Z.W. Shen, Z. Xu, L. Pang, K. You, L. Ning, R.H. Wu Shantou University Medical College (Shantou, CN) Objective: To compare the differences on absolute quantitation in anterior central gyrus between the PRESS and STEAM sequences in 1H MR spectroscopy. To compare the differences of 3 post-processing softwares: LCModel, Functool, and SAGE. Methods: Eight healthy volunteers, of whom the average age was 26.1 years old, were selected for this study. All the metabolites were detected by the PRESS and STEAM sequences with the same experimental parameters (TE=30ms and TR=300ms). Results: The differences between concentrations of Cr by PRESS and STEAM sequences were significant (P\0.05), which were related with characteristics of the sequences and the influence was come from nearby metabolite peaks. There were significant differences among NAA, Cho, MI and NAA/Cr analyzed by Functool, however, this significant difference can not been found in the other metabolites (P\0.05). With an external standard, the absolute concentration analyzed by SAGE was acquired by transformed metabolite peak area to the concentration. There was also significant difference among the metabolites except for MI (P\0.05). Conclusion: To detect the metabolites with short T2, such as Glx and MI, STEAM sequence is more valuable. Nevertheless, the result of Cr is instable, which is easier to be affected by metabolite peaks nearby in the condition of short TE. Compared with Functool and SAGE, LCModel showed an advantage for the absolute quantitation with short TE sequences. Supported in part by the grant from National Natural Science Foundation of China (NSFC key project 30930027)

P589 Myasthenic crisis in ICU – a 10-year review J.E. Spillane, N. Hirsch, D.M. Kullmann, C. Taylor, U. Reddy, R. Howard Institute of Neurology (London, UK) Introduction: The prognosis of autoimmune myasthenia gravis (MG) has improved with a reduction in mortality from 75% to a current rate of less than 5%. However, approximately 20% of MG patients will experience a myasthenic crisis requiring intensive care admission during the course of their illness.

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Aim: To perform a 10 year audit on cases of myasthenic crisis admitted to a neurological intensive care unit. Methods: Cases of myasthenic crisis were identified from the ICU register and case notes were retrospectively reviewed Results: 36 patients were admitted in myasthenic crisis. 4 patients had multiple admissions. The average age at admission was 55.5. 24 were female. 12 were male. Average disease duration at ICU admission was 2.7 years. 82.5% of patients were acetylcyholine receptor antibody positive. 7.5% tested positive for MuSK antibodies and 10% were seronegative. 27.5% of patients had a history of thymectomy. All patients were admitted in respiratory failure. 15 patients had a precipitating systemic infection. 2 patients had an associated myocardial infarction. 62.5% required invasive mechanical ventilation. 83% received IVIG and 12.5% were treated with plasma exchange. The average duration of ICU stay was 11.5 days. There were 3 deaths all due to respiratory failure. Conclusion: MG continues to be a serious disease with a considerable morbidity and mortality. Management of myasthenic crisis requires specialised neuro-intensive care facilities.

P590 Drop attacks in Creutzfeldt-Jakob disease S. Bek, T. Kasikci, G. Koc, Y. Kutukcu, Z. Odabasi Gulhane Medical Faculty (Ankara, TR) Introduction: A great variety of neurological symptoms and signs can be seen in Creutzfeldt–Jakob disease (CJD) but no association between CJD and drop attacks has been reported in literature. Case report: A 75 year-old woman had been admitted to another hospital 6 months ago because of drop attacks lasting for over 4 months. Then her neurologic examination, carotid-vertebral artery doppler ultrasonography, brain magnetic resonance imaging (MRI) and cervical MRI and cardiovascular examination were normal and had been applied b histine therapy. 6 months after she was admitted to our hospital because of no response to the treatment. Her family mentioned that her drop attacks were lost one month ago but myoclonic jerks of the right arm had occured in sleep for 2–3 weeks. Neurological examination revealed orientation and cognitive dysfunction (MMSE 21/30), resting tremor and rigidity in right upper limb, right Babinski sign and gait ataxia. Because of ataxia, pyramidal/extrapyramidal signs and myoclonic jerks we planned laboratory investigations for probable CJD. Brain MRI (especially in FLAIR and Diffusion weighted (DW) sequences) revealed signal hyperintensity in striatum, insula and cingular gyrus. Electroencephalography (EEG) showed generalized slow activity in theta frequency. Protein 14-3-3 analysis in cerebrospinal fluid (CSF) was positive. Our diagnosis fulfilled the WHO criteria for probable CJD. Conclusion: The cause and effect relationship between CJD and drop attacks cannot be explained exactly but it may be likely related to neurodegeneration in early stage of the disease.

P591 Lower extremity weakness and dysesthesias associated with zinc deficiency S. Iyadurai, T. Bear, G. Lopate Washington University (St. Louis, US) Objective: To describe a rare case of zinc deficiency associated with lower extremity weakness and dysesthesias. Background/Significance: Several vitamin and micronutrient deficiencies (significantly B12 and copper deficiencies) have been

S195 well documented. However, there are no reported cases of neurological dysfunction in the setting of zinc deficiency. Design/Methods: Case Report. Case Report: A 45-year old obese woman presented with dysesthesias, lower extremity weakness and unsteady walking requiring a walker, approximately 2 months following gastric bypass surgery. Post-surgically, the patient had been placed on ‘‘replenishment vitamins’’, but not on minerals. In addition, the patient took up a self-prescribed ‘‘bread- and-soup’’ diet. Neurologic examination was significant for lower extremity weakness, proximally and distally at 4/5. Sensory examination was significant for absent position sense and decreased vibration sense, dysesthesias in a patchy fashion in thighs, legs and feet, and a sensory level at T12. Reflexes were unobtainable in the lower extremities. Gait ataxia was present. Toes were mute bilaterally. Serological/CSF evaluation did not reveal rheumatological, infectious/inflammatory abnormalities or vitamin deficiencies. Serum copper, B12, and folate levels were normal. The patient changed her diet to include meat and green vegetables. A serum zinc level, one month after her change in diet was found to be 0.57 mcg/ml (normal 0.66-1.2 mcg/ml). EMG/NCS revealed a symmetric, length-dependent axonal sensorimotor polyneuropathy. After zinc supplementation, the zinc levels normalized, and a follow-up 12 months later showed the patient walking unassisted. EMG/NCS was normal except for mild sensory abnormalities. Conclusion: Given the normal levels of copper and other vitamins, low serum zinc, with improvement (physical and electrodiagnostic) after replenishment, we believe that patient’s symptoms are most likely due to her zinc-deficiency state. Zinc deficiency, similar to copper and B12 deficiencies, may also cause a myeloneuropathy. Post-gastric bypass patients are at risk for not only vitamin-, but also mineral- deficiencies, and should be supplemented with minerals, in addition to vitamins. To our knowledge, this is the first report of zinc deficiency in humans.

__________________________________ Poster session 5 Cerebrovascular disorders: thrombolises/ treatment P592 Can we safely base the decision to thrombolyse stroke patients with unclear time of onset on MRI criteria? C.H. Nolte, M. Wendt, G.J. Jungehu¨lsing, H. Audebert, J. Fiebach Charite´ (Berlin, DE) Objective: Standard selection criteria for thrombolysis typically exclude patients with acute ischemic stroke and unclear time of onset. This applies to approximately one fourth of patients with acute ischemic stroke. However, thrombolysis may be safely applied in patients with unclear-onset-stroke if certain magnetic resonance imaging (MRI) specific eligibility criteria are fulfilled. We assessed outcome and bleeding complications after thrombolysis in stroke patients with unclear-onset-stroke.

Methods: Patients who received thrombolysis with unclear-onsetstroke were identified from a prospectively operating database. Patients received thrombolysis if MRI showed acute vessel obstruction and diffusion-perfusion mismatch and did not show fluidattenuated-inversion-recovery (FLAIR) changes of acute diffusion lesions. Safety was assessed by rate of neurological deterioration (NIHSS on day 1 and 7) and intracranial bleeding (follow-up MRI on day 1 and day 7). Functional outcome was measured by modified Rankin Scale (mRS) after 3 months. Results: Eleven patients were identified (median age=80 [58–89] years, median NIHSS=15 [7–21], 45% female, 82% with hypertension, 45% with atrial fibrillation). Vessel occlusion was located as follows: M1-Segment=64%, M2-Segment=18%, P1-Segment=18%. No neurological deterioration was seen during hospital stay. On day 1 median NIHSS was 9 (range 2-20). On day 7, median NIHSS was 7 (range 0–20). There was no symptomatic intracranial bleeding (MRI detected 2 asymptomatic hemorrhagic transformations). At 3 months, 27% were independent in activities of daily living (mRS=0-2). None of the patients had died. Conclusions: Thrombolytic therapy should be considered in patients with unclear-onset-stroke if certain MRI criteria are fulfilled as symptomatic bleeding risk is presumably low.

P593 Shall we deny thrombolytic therapy to acute stroke patients with mild symptoms? M. Wendt, L.M. Gerischer, G.J. Jungehu¨lsing, J. Fiebach, H. Audebert, C.H. Nolte Charite (Berlin, DE); Centre for Stroke Research (Berlin, DE) Objectives: Many acute stroke patients do not receive thrombolytic therapy (rTPA) because symptoms are considered as mild, a good functional outcome is expected and bleeding complications are feared. Subsequent neurological deterioration happens in a substantial portion of these patients leading to poor neurological and functional outcome. Whether mild symptoms should be considered as an absolute contraindication to thrombolysis constitutes a therapeutic dilemma. We assessed outcome and bleeding complications after thrombolysis in stroke patients with mild symptoms. Methods: Patients who received rTPA and had stroke symptoms considered as disabling but mild (B4 on the NIHSS) in 2008 and 2009 were identified in a prospectively operating database. Safety was assessed by rate of neurological deterioration, intracranial bleeding and functional outcome measured by modified Rankin Scale (mRS) on day 7 and after 3 months. Results: Twenty-nine patients were identified (median age=67 [39– 92] years, median NIHSS=4 [1–4], 33% female, 86% with hypertension, 31% with atrial fibrillation, median onset-to-treatment time: 145 [80-280] min). All patients had proven infarction on follow-up imaging. The left hemisphere was affected in 52% of patients (right hemisphere=21%, other=27%). No neurological deterioration was seen during hospital stay. There was no symptomatic intracerebral bleeding (MRI detected 3 asymptomatic hemorrhagic transformations). On day 7, median NIHSS was 0 (range 0–3) and median mRS was 1 (range 0–2). At 3 months, 41% of patients had no persisting symptoms (mRS=0) and 82% had favourable outcome (mRS=0–1). Conclusions: Thrombolytic therapy should be considered in patients with mild symptoms as symptomatic bleeding risk is presumably low and outcome considerably favourable in treated patients.

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P594 Successful combined intraarterial and intravenous thrombolysis for cerebral venous and dural sinus thrombosis thirteen days after symptoms onset G. Matias, T. Lampreia, P. Soares, I. Carvalho, J. Reis, S. Calado, P. Alegria, J. Vale West Lisbon Hospital Centre (Lisbon, PT) Introduction: Cerebral venous and dural sinus thrombosis (CVDST) is a rare, but not uncommon life-threatning disease, accounting for less than 1% stroke. Heparin remains as the first line treatment. Thrombolysis has been widely used in CVDST patients who fail to improve despite adequate anticoagulation, with great benefit. There are no randomized controlled trials assessing its safety and efficacy. Case report: A 35-year-old woman presented with a four day history of severe headache, vomiting and right-sided hemiparesis. She had a history of migraine and was taking low-estrogen oral contraceptives. CT scan showed a mild right parietal hemorrhage and hyperdense right transverse sinus. She deteriorated in the next 24 hours, becoming drowsy and confused, followed by the appearence of papilloedema and seizures. CT venography showed thrombosis of the sagittal, straight and right transverse sinus and cortical veins. Heparin was started with some benefit, but by the end of the seventh day there was a marked deterioration. A new CT scan showed diffuse cerebral edema and CVDST extension. Combined intraarterial and intravenous thrombolysis was performed thirteen days after symptoms onset, followed by complete recanalization of the occluded sinus and veins. She was discharged with mild disability 10 days after procedure. During the sequent 3 months followup, she recovered completely. Conclusions: Thrombolysis appears to be a reasonably safe treatment in selected CVDST patients with rapid clinical deterioration despite adequate anticoagulation. Timing of intervention remains unclear, but delayed treatment may be beneficial, as seen in our patient and previous reports. A complete recovery was achieved after combined intraarterial and intravenous thrombolysis, despite the presence of several predictors of poor outcome. A large randomized controlled trial is needed to assess thrombolysis efficacy in CVDST patients.

P595 Results of combined intravenous and intra-arterial thrombolysis based on MR angiography during intravenous recombinant tissue plasminogen activator infusion – single-centre experiences from acute ischaemic stroke thrombolysis registry C.K. Suh, Y.W. Kim, Y.H. Hwang, S.P. Park, D.H. Kang, Y.S. Kim Kyungpook National University Hospital (Daegu, KR) Objectives: Recanalization of target vessel with intravenous (IV) recombinant tissue plasminogen activator (rtPA) and/or intra-arterial thrombolysis (IAT) has been of prime importance on the outcome in acute ischemic stroke (AIS) patients with intracranial arterial occlusions. The aim of this study was to show the efficacy and safety of the combined IV and IA thrombolysis in AIS patients with intracranial arterial occlusions despite the use of IV rtPA and to find the effects of early recanalization before IAT in cases showing target vessel occlusion on MR angiography (MRA). Methods: For more than 3 years, 86 consecutive AIS patients were enrolled for analysis. Inclusion criteria for enrollment was as follows: 1) AIS patients showing target vessel occlusion on MRA during IV

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rtPA infusion, and 2) patients who underwent transfemoral cerebral angiography (TFCA) for IAT. The factors affecting the good functional outcome (defined as modified Rankin scale score 0–2) were analyzed, and the characteristics between cases of early recanalization before IAT and of combined thrombolysis were also compared. Results: The mean age, male sex, and mean baseline NIHSS score were 67.7 years, 65%, and 13.7. The mean interval from the needle time of IV rtPA to the puncture time of TFCA was 102.2±56.5 minutes. The favorable functional outcome and symptomatic intracranial hemorrhage was 53.5% (46/86) and 11.6% (10/86). The persistent target vessel occlusion during TFCA was found 59 of 86 patients (68.6%). In cases of combined thrombolysis, target vessel recanalization (defined as thrombolysis in cerebral infarction (TICI) grade [2) was achieved 72.9% (43/59). The recanalization itself (spontaneous or by IAT) was the only predictive of the good outcome by multivariate analysis [odds ratio 4.64 (1.10-19.59)]. Patients with early recanalization before IAT had a more favorable outcome (74.1% vs. 44.1%) and lower baseline NIHSS score (11.4 vs. 14.7) than patients of combined thrombolysis (p=0.01 and 0.005). Conclusion: In this study, the good outcome and recanalization rate was comparable to the historical combined thrombolysis registries. In 31.4% of IV rtPA cases who had target vessel occlusion on MRA, the occluded vessels were spontaneously recanalized before IAT and the functional outcome was more favorable than the cases of persistent angiographic occlusions on TFCA. However, the recanalization itself was the most predictive of the favorable outcome irrespective of IAT.

P596 Thrombolysis with alteplase in ischaemic stroke: 126 case reports, Joinville/ Brazil A.P. Miranda, A.F. Volkman, M.C. Silva, G.L.C. Costa, M.V. Gonc¸alves, A.L. Longo, C.H. Amaral, C.H. Moro Hospital Municipal Sa˜o Jose´ (Joinville, BR) Objective: To demonstrate the experience of 126 cases of intravenous thrombolysis at the HMSJ and compare with results from other series. Method: Report of 126 cases of acute ischemic stroke undergoing intravenous thrombolytic therapy, according to NINDS protocol, within the period of October 2004 to May 2009 at the Hospital Municipal Sa˜o Jose´, Joinville/Brazil. Results: The average age was 64 years old (35-89). 63 (50%) patients were women. The time between the beginning of symptoms and the medication was 0 to 90 min in 19% of the patients; 90 to 180 min in 61.1%; and above 180 min in 19.8%. The average score of the NIHSS (National Institute of Health Stroke Scale) to admission was 15. There was a decrease of 5 or more points in the score of the NIHSS in the first 24 hours for 43.6% of the patients. According to the modified Rankin scale (Rm) after 90 days of the event 39.7% had Rm 0-1, 15.9% had Rm 2-3, 19 % Rm 4-5, 25.4% Rankin 6. The rate of symptomatic intracranial hemorrhage (ICH), which is defined as parenchymal haematomas type 2 associated with an increase of 4 points or more in the NIHSS, was 2.38%. Conclusion: We extrapolated when comparing our results to the SITS-MOST observational study, despite of the last one having a thrombolysis time of up to 3 hours from the ictus. We observed slightly higher rates of symptomatic ICH (2,38% vs. 1,7%), however, there was an improvement regarding complete healing after 3 months, Rm 0-1 (40% vs. 39%). It is important to remember that in the SITS-MOST patients over 80 years old were excluded from the study. Despite the fact that these patients have worse prognosis it doesn’t mean there is no benefits from the treatment. These restrictions are good for a lower symptomatic ICH rate in the SITSMOST.

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P597 Intravenous thrombolysis in the treatment of ischaemic stroke due to the spontaneous craniocervical artery dissection M.S. Budimkic, D.R. Jovanovic, L.J. Beslac Bumbasirevic, I. Berisavac, P. Stanarcevic, O. Savic, V. Bogosavljevic, M. Ercegovac Clinical Centre of Serbia (Belgrade, RS) Objectives: Intravenous thrombolysis (IVT) is a standard treatment for patients with acute ischemic stroke. However, there are potential hazards in dissection, including extension of the intramural haematoma, dislocation of the luminal thrombus leading to distal embolisation, pseudoaneurysm formation and subarachnoidal haemorrhage. The aim of this study was to compare the efficacy and safety of IVT in the patients with ischemic stroke due to spontaneous craniocervical artery dissection (AD) compared to the patients with AD who have not received IVT. Methods: Main outcome and measures of complication rate were: favourable outcome (Modified Rankin Scale (mRS) score B2), occurrence of intracranial cerebral haemorrhage (ICH) and local signs of intramural haematoma extension, recurrent ischemic stroke, recurrent AD and death. The median follow-up period was two years. Results: Fourteen patients out of 42 patients with ischemic stroke due to the spontaneous craniocervical AD were treated with IVT within 3 h of stroke onset. The mean age was 42.9± 11.1 years (range 18–57) in thrombolysed patients, and 44.5 ± 10.6 years (range 21–68) in the group of patients who have not received IVT. Two patients treated with IVT had intracranial propagation of cervical AD and another four had isolated intracranial AD. The mean initial NIHSS (National Institutes of Health Stroke Scale) score in thrombolysed group was 11.6±4.2 (range 6–22) and in non-thrombolysed group 8.1±3.1 (range 0–19). No worsening of local signs was present. Delayed CT imaging has showed ICH in one patient treated with aspirin and in none treated with IVT. Two patients treated with IVT had recurrent ischemic event during hospitalization, one had recurrent cerebral ischemia, and other had retinal ischemia. There was no death, recurrent ischemic events and recurrent AD in both groups of patients during the period of follow-up. Favourable outcome had 93% of patients treated with IVT and 83% not treated with IVT (OR 2.6, 95% CI 0.27-24.64, P=0.65). Conclusion: Patients treated with IVT had nonsignificant better outcome than those not treated with IVT. The complication rate was low. In particular, there was no worsening of local signs. Those results suggest that IVT should not be excluded in patients who may have craniocervical AD.

P598 Early recurrence of ischaemic stroke in a young woman: two i.v. thrombolytic treatments in three months E. Puca, A. Correnti, S. Lorenzano, M. De Michele, A. Falcou, D. Toni Policlinic Umberto I (Rome, IT) Introduction: I.v. alteplase is recommended in ischaemic stroke patients up to 4.5 hours from the onset of symptoms. Few patients were treated two times in a short period. Methods and results: A 48 year-old patient presented to our emergency room 90 minutes after onset of left weakness, dysarthria,

gaze deviation toward right, slight neglect (NIHSS score = 8). Brain CT showed an hyperdense right MCA. After 2.5 hours she received i.v. thrombolysis (0.9 mg/kg). At the end of treatment MR showed an ischemic right capsular lesion, while PW/DW showed an important mismatch in 2/3 of right MCA territory. Angio-MR showed a pre-occlusion of right MCA. Four days after stroke onset she underwent TEE which detected PFO with atrial septum aneurysm. At discharge NIHSS was normal and control MRA showed complete MCA reopening. Two months later the patient underwent PFO closure. A week after she presented a new ischemic stroke in the same territory with left weakness and hypoesthesia (NIHSS 5). CT showed again hyperdensity of right MCA. Hence she underwent again i.v. thrombolisys with alteplase (0.9 mg/kg). MR immediately after the end of treatment showed a new ischemic lesion in the right putamen and nucleus pallidum, and M1 MCA occlusion. After 6 days from treatment she had NIHSS 2 and control MR showed MCA reopening. Conclusion: This case report demonstrates that i.v. thrombolysis is possible even within less than three months after a previous stroke, suggesting that this protocol violation is feasible in selected patients.

P599 Case report: cerebral venous sinus thrombosis possibly associated with human papilloma virus vaccination E. Kyriazopoulou, C. Bouziani, G. Tsigos, G. Deretzi, J. Rudolf, I. Tsiptsios Papageorgiou General Hospital (Thessaloniki, GR) Objectives: Cerebral venous sinus thrombosis (CVST) is a rare but dangerous condition with 85% of patients presenting with at least one predisposing risk factor. We report the first published and third reported case of sagittal venous thrombosis associated with Human Papilloma-Virus (HPV) vaccination. Methods: A 14 year-old female patient presented with headache, nausea, vomiting and a brief episode of loss of consciousness without focal neurological deficit. History and clinical findings were suspicious for CVST and the diagnosis was confirmed with brain computer tomography and magnetic resonance imaging and venography. No predisposing risk factors for deep venous thrombosis (DVT) were identified from the clinical and laboratory investigation (hypercoagulability, contraceptives intake, malignancy, thrombophilia). She had been vaccinated with the second dose of HPV vaccine one month prior to the onset of her symptoms. The patient was initially treated with low-molecular weight heparin in therapeutic doses and late, replaced by oral warfarin with a target INR between 2-3. The patient and her parents were advised to cancel the scheduled administration of the third dose of the vaccine. The event was reported to the Greek National Drug Administration immediately after the confirmation of the diagnosis. Results: According to the Postlicensure Safety Surveillance for Quadrivalent Human Pappilomavirus Recombinant Vaccine, among the 31 thromboembolic events reported with sufficient information for clinical review, 2 cases involved sagittal sinus venous thrombosis. Most of the cases reported (90%) had a known risk factor for venous thrombosis events. Conclusions: CVST may be a rare, but important complication of HPV vaccination. Our report highlights the importance of a rigorous history taking from a patient with CVST, in order to identify also rare predisposing risk factors.

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P600 Aspirin non-responder status and early neurological deterioration in ischaemic stroke: a prospective study J.M. Bugnicourt, P.Y. Garcia, B. Roussel, S. Canaple, C. Lamy, O. Godefroy

P603 Prehospital notification from EMS enhances the shortening of transfer and intra-hospital processing times for acute stroke patients J.K. Cha, S.Y. Lee

Amiens University Hospital (Amiens, FR)

Dong-A University Hospital (Busan, KR)

Objectives: We tested the hypothesis that initial biological aspirin non responder status (ANRS) helps predict early neurological deterioration (END) in acute ischemic stroke patients. Methods: A total of 85 patients with acute ischemic stroke on 160 mg aspirin daily were prospectively included. END was defined as an increase in the National Institutes of Health Stroke Scale (NIHSS) C 4 points in the first 72 hours after admission. Platelet responsiveness to aspirin was assessed using the PFA-100 system, and ANRS was defined as a collagen/epinephrine closure time \ 1.65 ms. Results: END was observed in 10 patients (11.8%). Initial altered consciousness (30% vs. 3%), visual disturbance (60% vs. 23%) and ANRS (60% vs. 20%) were observed more frequently in patients with END. In multivariate analysis, impaired consciousness (OR: 17.3; 95%CI: 2.0–149.5; p=0.01) and ANRS (OR: 6.4; 95%CI: 1.4–29.6; p=0.017) were found to be independently associated with END. Conclusions: ANRS is common in acute ischemic stroke patients and is predictive of END. The clinical significance of these findings requires further evaluation

Little information is available about the effects of EMS hospital notification on transfer and intrahospital processing times in acute ischemic stroke. In this study, we retrospectively investigated the real transfer and imaging processing times for suspect acute stroke (AS) patients with EMS notification of needing intravenous tissue type plasminogen activatior (IV t-PA) and those without. Also compared between patients with and without notification were intrahospital processing times for receiving t-PA. From December 2008 to August 2009, EMS transported 102 patients with suspected AS to our stroke centre. During the same period, 33 patients received IV t-PA without prehospital notification from EMS. Mean real transfer time after EMS calls was 56.0±32.0 min. Patients with a transfer distance of more than 40 km could not arrive at our centre within 60 min. Among the 102 patients, 55 transferred via EMS to our ER for IV t-PA. The positive predictive value for stroke (90.9% vs 68.1%, p=0.005) was much higher and real transfer time was much faster in patients with an EMS t-PA call (47.7±23.1 min, p=0.004) compared to those without one (56.3±32.4 min). The 18 patients with prehospital notification who ultimately received t-PA had a significantly reduced door-to-imaging (17.8±11.0 min vs 26.9±11.5 min, p=0.01) and door-to-needle time (29.7 ± 9.6 vs 42.1 ± 18.1 min, p=0.01). Our results indicate that prehospital notification could enable rapid dispatch of AS patients needing IV t-PA to a stroke centre. In addition, it could reduce intrahospital delays, particularly, imaging processing times.

P601 Stroke units avoid off-hour effect in stroke care and outcome M. Martinez Martinez, J. Fernandez-Travieso, L. Rodriguez de Antonio, J. Oliva-Navarro, B. Fuentes, E. Diez-Tejedor University Hospital La Paz (Madrid, ES) Background: Previous studies report that patients with acute stroke arriving to the Emergency Room (ER) on off-hour and weekends have worse outcome and poorer stroke care process compared with those who present on regular workdays. Stroke Units (SU) offer continous specialized care that could avoid the differences in management and outcome associated with time of admission. We present our experience in a Spanish University Hospital. Methods: Observational study with analysis of a random sample of prospectively collected data in a Stroke Data bank covering all the stroke patients admitted to the Department of Neurology, including the SU, of a University Hospital during 2008. Two groups of patients were separated according to their arrival time at the ER. Off-hour presentation was defined as arrival to the ER on weekends and on anytime outside 8:00 am to 3:00 pm on weekdays. Differences on time delays to diagnostic and therapeutic procedures and on stroke outcome (modified Rankin Scale, mRS) at discharge were analized. Results: Data from 454 patients are analyzed, 284 (63%) presented during off-hours. No differences in demographic data or stroke severity on admission were found comparing off-hour patients and those who presented on regular workdays. Mean time (minutes) to diagnostic tests were similar in the two groups: blood tests 92,74 vs. 83,45; p 0,35; CT: 132,91 vs. 113,99, p 0,50; SU admission time 453,65 vs. 416,64; p 0,48. No differences in stroke outcome at discharge were found with 74,72% of patients with mRS\3 in the group presenting on regular workdays and 80,18% in the off-hours group (p=0.283). Conclusions: SU care avoid the diferences in management and in outcome associated with time of admission and guarantee a continue and equal attention to stroke patients.

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P604 Do outcomes vary in elderly patients with acute stroke according to treatment modality? P. Bhattacharya, A. Majjhoo, S. Narayanan, G. Norris, A. Xavier, W. Coplin, R. Madhavan, K. Rajamani, S. Chaturvedi Wayne State University (Detroit, US) Background: Previous studies have found that elderly patients (age [80 years) can safely receive intravenous (IV) thrombolysis for acute stroke. A recent analysis identified elderly status as a predictor of poor functional outcome following intra-arterial (IA) intervention for acute stroke. We sought to investigate whether treatment modality affected patient outcome in our Comprehensive Stroke Center. Methods: A prospectively maintained database of acute ischemic stroke patients treated with either IV or IA therapy was reviewed. We collected information on demographic data, baseline stroke severity, status at hospital discharge, and hospital length of stay. A good outcome was defined as discharge to home or inpatient rehabilitation. Treatment modality was tested with likelihood of a good outcome using univariate and logistic regression methods. Results: 34 patients above age 70 were enrolled. 23 patients received IV tissue plasminogen activator and 11 were treated with IA intervention. The mean age of these groups was 81.1 years and 77.6 years. The mean age of the NIH stroke scale (NIHSS) was 10.4 in the IV group and 17.8 in the IA group. Mean length of stay was 9.7 days in the IV group and 9 days in the IA group. Overall mortality was 32.4%. In univariate testing, IV treatment was associated with a

S199 greater likelihood of a good outcome (p=0.017). After controlling for baseline NIHSS, treatment modality was no longer associated with the likelihood of a good outcome (p=0.15). Baseline NIHSS was a predictor of hospital length of stay (p=0.036) whereas treatment modality did not predict length of stay (p=0.41). Conclusions: In our center, IA treatment was given to patients with more severe baseline deficits. Likelihood of a good outcome did not differ between elderly patients treated with IV or IA therapy. Baseline stroke severity predicted longer hospital length of stay. Larger studies with long-term outcome are needed to confirm these findings.

P605 Clinical predictors in patients with acute stroke for requiring mechanical ventilation P. Gupta, P. Srivastava, R. Bhatia, M. Tripathi, M. Singh, K. Prasad All India Institute of Medical Sciences (New Delhi, IN) Endotrachael intubation and mechanical ventilation (MV) in stroke may be warranted to prevent hypoxia and potential worsening of neurological injury. Many health centers in India do not have facility for mechanical ventilation. Early identification of patients who potentially require ventilatory support may help in referring them to hospitals where such facilities exist thereby reducing mortality and morbidity. Present study was undertaken to identify factors predicting requirement of MV and evaluate the clinical outcome. A prospective cohort study with consecutive patients with acute stroke was done over one year. Outcome measures were death or disability (modified Barthel Index [ BI], modified Rankin Score [mRS]) at discharge. Clinical & radiological parameters, cause for intubation, complications during hospital stay and interventions were recorded. Statistical analysis was done with SPSS (version 16). Of 193 patients, 60 (31.08%), (19/118 [16%] of ischemic stroke; 38/68 patients with ICH [55.9%]), were intubated due to various reasons. Multivariate analysis showed, an overall predictor accuracy of requirement of MV of 90% if there is history of progression of symptoms (p \ 0.0005), loss of consciousness at onset (p = 0.011), and Glasgow Coma Scale (GCS) \ 5 (p \ 0.0005). In patients with ICH, history of loss of sensorium (p = 0.001) and large hematoma volume (p = 0.023) had 88% predictor accuracy for requirement of MV. Findings show poor sensorium, low motor GCS and progression of symptoms as independent predictors for requirement of MV in patients with stroke.

P606 Dysphagia in acute stroke programme investigation and its implication to clinical outcome H.Y. Sung, J.S. Kim on behalf of the DAS Investigators Group Background: Dysphagia is a common problem in patients with acute ischemic stroke which leads to aspiration. The aim of this study was to evaluate the dysphagia in acute stroke (DAS) program and its application for diet plan. Methods: During 7 months, consecutive patients with acute stroke were enrolled. DAS was comprised of three steps. The first step was to stratify stroke patients into three sub groups through oropharyngeal neurological evaluation; high risk (unable to swallow due to mental, articulatory, general and neurological conditions), moderate risk (oropharyngeal neurologic deficit) and low risk group (absence of oropharyngeal deficits). The low risk group was allowed to start

normal diet and the high risk group was recommended to have Levine tube feeding. The intermediate risk group underwent second step screening; water swallowing tests (indirect and direct tests). In the third step, high resolution manometry (HRM) was performed on patients who tolerated 2nd step. Diet plans were decided based on the results of second and third steps. Results: 294 patients were enrolled and stratified into 3 groups (low risk group: 169 patients, intermediate: 96 and high risk: 29). Four of 96 intermediate risk patients have failed second step; and thereby recommended tube feeding. In the third step, HRM was performed to 91 patients except for one who dropped out due to discomfort. Among 91 patients, 55 patients revealed normal swallowing pattern and 36 revealed abnormal swallowing pattern which included frequent chocking, bolus retention on UES, abnormality on UES opening and double swallow pattern. The abnormal swallowing pattern group showed shorter UES opening duration, lower pharyngeal contractile integral and longer transition zone length than those from the normal swallowing pattern group. Fifty-five patients with normal swallowing pattern were started with normal diet and tolerated well. Thirty-six patients with abnormal swallowing pattern were recommended swallowing rehabilitation and stepwise dysphagia diet of which 97.2% successfully adapted to oral diet. Only one of them failed to oral diet and received tube feeding instead. During the admission, all patients with low and intermediate group had no aspiration pneumonia. However, aspiration pneumonia frequently occurred in 18 patients in high risk group. Conclusion: In acute ischemic infarct, DAS was safe and effective in assessing swallowing function and determining appropriate diet plan.

P607 Evolution and explanatory factors of nutritional status in the few years post-stroke J. Paquereau, M. Romon, E. Allard, W. Daveluy, M. Rousseaux Reginoal University Hospital Swynghedauw (Lille, FR); Regional University Hospital Huriez (Lille, FR) Objectives: In patients with stroke, the risk of denutrition is especially frequent, and is recognized as a main factor of poor outcome. However this risk has been addressed in the short-term, i.e. in the first few weeks or months post-stroke. Here, we analysed the 1-5 year evolution of nutritional status, and its explanatory factors. Methods: We prospectively included 50 patients followed in the outpatient rehabilitation clinic (M: 27; mean age=62.8), with a poststroke delay of 1-5 years (mean=2.7; SD=1.5). We examined: 1. the evolution of weight and BMI: before stroke (BS), at 3 weeks (W3), at discharge from the inpatient rehabilitation unit (discharge), and at late examination (LE); 2. the possible explanatory factors: previous medical history (diabetes) general factors (age, gender, education), stroke severity (Rankin score at 3 weeks, swallowing disorders), severity of sequellae (Rankin, swallowing disorders, physical activities), modifications of food intake preferences, and actual socio-economic status (site of living, presence of family, resources). Denutrition was defined according to the criteria of the French ‘‘Haute Autorite´ de Sante´’’. Results: Weight decreased from BS to W3 (-3.6 ±5.6 kg), remained stable until discharge (-0.2 ±4.4 kg), then increased at LE (+3.2 ±9.9 kg), with huge variability. At LE, 18 patients showed significant ([4%) weight loss in comparison with BS status, 19 showed increase ([4%), and 13 remain stable. Prevalence of denutrition was 42% at LE. Most important explanatory factors of weight evolution at LE stage (LE-BS) were (p\0.01) preceding weight (-),

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S200 sugar (+), salt (+) and fat (+) preferences, and diabetes (-). We did not find any effect of post-stroke delay, age, education, mood disorders, level of physical activities and other possible factors. Similar results were found for BMI. Denutrition was associated with gender (male), preceding weight (-), actual Rankin score (+), presence of family (-) and institutionalization (+). Conclusion: In the long term, nutritional status varies considerably after stroke, even after discharge from inpatient rehabilitation unit. The prevalence of denutrition is high. Follow-up and prevention are clearly insufficient, especially for patients living in institution.

P608 Intravenous infusion of autologous marrow stem cells promote recovery in chronic stroke A. Bhasin, P. Srivastava, S. Mohanty, S. Kumaram, R. Bhatia All India Institute of Medical Sciences (New Delhi, IN) Introduction: Stem cell transplantation is hoped to restore function in experimental models as well in clinical trials of ischemic stroke. This study evaluates the safety, feasibility and efficacy of autologous mesenchymal (MSC) and mononuclear(MNC) stem cell transplantation in promoting recovery in chronic stroke. Methods: Ten chronic ischemic stroke patients (mean age =53, SD = 12.1), (3 months-2 years of onset) were recruited from the stroke clinic. Fugel meyer, brunnstrom, Barthel Index (BI) and MRC grade of strength of hand muscles was used to assess the patients pre and post treatment. Intervention: Subjects were grouped equally into experimental (stem cells and physiotherapy) and control group (physiotherapy only). 50-60 ml of bone marrow aspiration was done under aseptic condition. The ex vivo culture of cells took around 21 + 5days. Two patients (pat. id 1,2) were administered with 5x 108 mesenchymal and patient id (3,4,5) were administered with mononuclear stem cells intravenously followed by 6 weeks of physiotherapy. Safety tests at day 1, 3, 7, and at 6 weeks were performed. Intense exercise regimen was administered to all the patients for 5 days a week for 6 weeks. Results: The pre & post treatment (paired t test) fugel meyer scores were significant in all the patients (t= -9.770 & p =0.001). The intergroup analysis could not be done as the data was less. The experimental group patients did not report any adverse events which indicates safety and feasibility. More studies are needed to validate efficacy of stem cells.

P609 Standardization of diagnostic and therapeutic procedures for neurogenic oropharyngeal dysphagia – prediction of outcome with a new NOD step-wise concept G. Bra¨uer, A. Riecker, C. Ho¨hlig, M. Prosiegel, U. Becker, R. Mu¨ller, H. Reichmann, G.W. Ickenstein HELIOS General Hospital Aue (Aue, DE); University Clinic of Rehabilitation (Ulm, DE); Technical University Dresden (Dresden, DE); m&i Special Clinic (Bad Heilbrunn, DE); University Clinic Carl Gustav Carus (Dresden, DE) Introduction: Strokes are the most frequent cause of neurogenic oropharyngeal dysphagia (NOD). In the acute phase following a

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stroke, the frequency of NOD is greater than 50% and, in the case of a lesion of the brainstem, more than 60%, with the danger of silent aspirations. Methods: Within the framework of complex treatment in the stroke unit, a standardized screening for dysphagia (MSA) was carried out by trained nursing staff followed by a standardized clinical swallowing examination (CSE) carried out by a swallowing therapist. Subsequently, in those patients who showed conspicuous characteristics, more detailed equipment–based diagnostics with a flexible–transnasal swallowing endoscopy (FTS) were carried out, in order to initiate a pathophysiologically oriented, functional swallowing therapy. At day 90 after neurorehabilitation a telefone interview assessing the functional communication measure (FCM) swallowing was carried out with the study endpoint ‘‘tube feeding dependency (FCM 1–3)’’. Results: In a multivariate analysis an evaluation of the NOD stepwise concept with 114 dysphagic stroke patients revealed a model with four variables: functional communication measure (FCM), penetrationaspiration scale (PAS), swallowing disability scale (SDS) and NOD grade. This model showed a predictive probability of 72.8% (OR 11.83) for the outcome prediction ‘‘tube feeding dependency’’ (FCM 1–3) on day 90. In comparison, this prediction applied to the clinical parameters ‘‘neurological deficit’’ measured with the National Institute Stroke Scale (NIHSS) and ‘‘pneumonia’’ revealed only a probability of 46%. Discussion: The combination of specific NOD scales in the overall assessment of dysphagic stroke patients represents a clear advantage in the outcome prediction in order to differentiate between transient and chronic dysphagia. The recording of penetration or aspiration is one of the most important criteria for a pathophysiological–oriented NOD grading system and provides a direction for the type of swallowing therapy to be implemented. The aim of our research was to evaluate a new step-wise concept for the assessment of neurogenic oropharyngeal dysphagia (NOD) that could be used by nursing stuff, swallowing therapists, as well as physicians, to identify patients with this disorder, so that feeding and therapy could begin as soon as possible avoiding malnutrition and complications such as aspiration pneumonia.

Neuro-epidemiology P610 Stroke awareness and vascular risk factors in youngsters: an observational study of the Italian Association against Stroke A. Consoli, L. Zeppilli, M.T. Di Mascio, G. Carbotta, G. Barilaro, P. Lucchetti, G. Causarano, D. Toni, M.L. Sacchetti, S. Vidale on behalf of A.L.I.Ce. Italia Introduction: Although stroke is a leading cause of death and the first cause of disability in adulthood, only few studies describe this condition and risk factors (RF) in young. Incidence, RFs and etiology of stroke are also quite different concerning young people (\35 years) than adults. Aim of the study was to evaluate vascular RFs and awareness about stroke in a young population. Materials and methods: 818 undergraduates of Como and Rome Universities (mean age: 23 ± 5 yrs, M/F: 1/1.4) participated to a screening day organized by the Italian Association against Stroke. Variables recorded: blood pressure, glycemia and anthropometric measures (weight, height and BMI); main vascular RFs and stroke awareness level were registered using a standardized questionnaire. Statistical analysis was performed using chi-square test and anal-

S201 ysis of variance (ANOVA). Results: Overweight was prevalent in males (p \ 0.01). Smoke was the main RF (51.7%), overall in younger population (ANOVA; p \ 0.01). Headache was prevalent in females (p \ 0.001), while alcohol abuse in males (p \ 0.001). 28.3% of population had more than 2 RFs. 93.6% of people knew what is stroke, but only one third was aware about warning signs and emergency action at onset, in association with a previous family history of stroke (p \ 0.01). People with less RFs knew what is stroke (p \ 0.01) Conclusions: Main vascular RFs are quite present in young people, while wrong lifestyles (i.e. smoke and excessive alcohol consumption) are prevalent in this population. These results underline the need of preventive campaign in young people.

P611 The associations of brain atrophy and cerebrovascular pathology with late-life depression and cognitive impairment. The SMART-Medea study A.M. Grool, Y. Van der Graaf, W.P. Mali, M.I. Geerlings on behalf of the SMART Study Group Objectives: Late-life depression (LLD) and cognitive impairment are highly prevalent in elderly and frequently co-occur. Shared pathologies, including cerebrovascular changes and brain atrophy, might underlie both conditions. It is however unclear whether vascular changes, including large- and small-vessel disease, and brain atrophy are equally important in LLD and cognitive impairment. We examined associations of presence and location of infarcts, white matter lesions (WML) and brain atrophy on magnetic resonance imaging with LLD and cognition in patients with symptomatic atherosclerotic disease. Methods: Within the Second Manifestations of ARTerial diseaseMemory, depression and aging (SMART-Medea) study, cross-sectional analyses were performed in 455 patients (mean age 63±9 years, 84% male) with no history of depression before age 50 years. WML volume and atrophy measures were calculated by an automated segmentation programme and corrected for intracranial volume. Infarcts were rated visually and categorized anatomically. LLD was defined as a score of 6 or higher on the Patient Health Questionnaire-9. Neuropsychological tests assessed executive functioning, memory performance and processing speed and composite z-scores were calculated. Regression analyses were used with infarcts, WML and atrophy as independent and LLD (yes/no) and cognition (z-score) as dependent variables, adjusted for age, sex, intelligence, education and vascular risk factors. Results: Subcortical infarcts (OR 5.82, 95% CI 1.37–24.77) and infarcts in the frontal lobe (OR 2.34, 95% CI 1.14–4.81) increased the risk for LLD. No associations of LLD with lacunar infarcts, WML or brain atrophy were found. Brain atrophy and left sided infarcts were associated with worse performance in all cognitive domains, whereas frontal and cortical infarcts were associated with decreased executive functioning and processing speed, but not with memory. Infarcts in the parietal lobe were associated with decreased processing speed (B= -0.10, 95% CI -0.56 to -0.07). Lacunar infarcts and WML were associated with decreased executive functioning and memory, but not with processing speed. Conclusion: In this study, late-life depression and cognitive impairment were both related to underlying infarcts in the frontal lobe, possibly by the disruption of emotion-regulating pathways. The etiology of cognitive impairment seems more diverse, and was influenced by both cerebrovascular changes and brain atrophy. This study was supported by a program grant from the Netherlands Heart Foundation (NHF: project no. 2007B027)

P612 Sex differences in hospitalization and case-fatality in individuals with stroke in Aragon, Spain, 1998 to 2008 A. Gime´nez-Mun˜oz, J.R. Ara, J.M. Abad, J. Marta, J.I. Lo´pez-Gasto´n, L. Torne´ Hospital Royo Villanova (Zaragoza, ES); Hospital Universitario Miguel Servet (Zaragoza, ES); Health and Consumer Affairs (Zaragoza, ES); Hospital Virgen del Camino (Pamplona, ES) Objectives: The aim of this study was to examine the effect of sex across different age groups and over time for stroke hospitalization and 28-day case fatality in a Spanish region (Aragon). Methods: All hospitlizations for stroke in Aragon (1998 to 2008) were identified through the minimum basic data set from the Health Service of Arago´n. Age-specific rate ratios (RRs) for compring women with men for hospitalization were modeled with adjustement for study year. Regression models were performed for trends analysis. Results: Women had a lower incidence of hospitalization than men and size of effect varied with age (55 to 64 years, RR=0.56, 95% CI 0.51 to 0.61; C85 years, RR=0.80, 95% CI 0.76 to 0.86). Adjusted risk of death within 28 days was significantly higher in women than men aged 55 to 64 years (OR 1,31, 95% CI 1,01 to 1,69), and 65 to 74 years (OR 1,16, 95% CI 1,01 to 1,35), and this difference increased in all age groups. Case-fatality shows a significant declining trend from 1998 to 2008 in individuals aged C65, and the size of the effect is higher in men. Conclusion: We observed lower rates of hospitalization in women than men. Short-term case-fatality is significantly greater in women aged 55 to 74 years, and these differences increased from 1998 to 2008 due to the strongest declining trend in case-fatality among men than among women.

P613 Seasonal variation in intracerebral haemorrhage hospitalizations in Nis (Serbia): a time-series analysis approach V. Milosevic, M. Zivkovic, S. Djuric, V. Vasic, D. Kisic Tepavcevic, T. Pekmezovic Clinical Centre Nis (Nis, RS); University of Belgrade (Belgrade, RS) Objectives: The study of seasonal variability of intracerebral hemorraghe (ICH) occurence may contribute to a better understanding of the nature of this disease and open up new perspectives in its prevention. The aim of this study was to test seasonal patterns in the number of admissions of ICH patients and determine which months have maximal and minimal number of admissions. Methods: The main data source for this study was a hospital-based registry at the Clinic of Neurology in Nis, Serbia. During the studied period (1997- 2007) a total of 1,569 ICH patients were registered (806 male, 763 female; mean age was 63.9±11.4 years). Time series, consisting of the monthly number of hospitalized patients, for the 128 months of the study duration, has been successfully modeled using the multiplicative Auto Regressive Integrated Moving Average (ARIMA) model. Results of ARIMA analysis have been compared with the results obtained by the procedure of the ratio to moving average, which is used in the seasonal decomposition analysis of time series Results: Using the maximum likelihood method, utilizing Melrad’s algorithm, the parameters of this ARIMA model have been calculated: constant (estimate 12.068, p\0.001), auto regressiveAR(1) (estimate 0.866, p\0.001), moving average-MA(1) (estimate 0.775, p\0.001), seasonal moving average-SMA(12) (estimate -0.198, p=0.036). The analysis of Huber’s M estimations of the average number of the estimated values from the given ICH series

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S202 shows that the maximal number of admissions occur in March (Huber’s robust average equals 13.01), and the minimal number occurs in August (Huber’s robust average is 11.35). Results obtained through ARIMA modeling have been controlled through the use of the statistical method of seasonal time series decomposition. By isolating the seasonal component from the given series, it has been noted that three months have a seasonal factor 20% higher than the seasonal factor average (and is the highest in March, 124.8%), while three months also have a seasonal factor 20% lower than the seasonal factor average (and is the lowest in August, 75.9%). Conclusion: ARIMA modeling has been successful and showed that there is a clear seasonal pattern in the data analyzed. Based on the seasonal multiplicative ARIMA model and the seasonal time series decomposition, we showed that, in the period covered by the study, the peak of admissions occurred in March, and the trough of admissions was found in August.

P614 Differences of men and women in linear correlation of multi-factors to carotid intima-media thickness and carotid artery plaque formation: a study of 2840 asymptomatic persons from Taiwan S.Y. Lee, S.M. Ma, C.C. Wang West Garden Hospital (Taipei City, TW); Ming Chi of Technology (Taipei City, TW) Objectives: The main goals are to establish regression equation of common carotid intima-media thickness (CIMT) to the most important factors in men, women, left (Lt), and right (Rt) and of carotid artery plaque (CAP) to the most important factors in men and women. Methods: From Feb. 12, 2003 to Oct. 24, 2008, 2840 asymptomatic persons, age 35–75, went to Eonway Healthy Maintenance Center for thorough healthy check up. Multiple factors were used for CIMT and CAP analysis. All data analyzed after calculated as grouping of same year of age. Those of age 65 and above were excluded for excellent linear correlation results of CIMT. Both CAP and CIMT analysis were made to different sex, while CIMT analysis was made further into Lt and Rt side. The four groups of CIMT analysis are CIMTML (men’s Lt), CIMTMR (men’s Rt), CIMTWL (women’s Lt), CIMTWR (women’s Rt). Regression equation was used in determination of significance of all factors affecting CIMT. Binary logistic regression was used for CAP formation to all factors. Results: CIMT analysis results in order of number, mean, standard deviation were CIMTML: 1346, 0.77623, 0.10961; CIMTMR: 1345, 0.76833, 0.09899; CIMTWL: 1082, 0.72616, 0.08799; CIMTWR: 1082, 0.7207, 0.08729. Multiple factors analysis for linear regression will be shown later. CAP was detected in 22.23% (347/1561, 33 missing value) of men and 16.38% (190/1160, 86 missing value) of women. The equation for CAP analysis in men is ln(CAP)yes/no = 0.0594824 X age + 0.0225273 X systolic blood pressure (SBP) + 2.48556 X ankle-brachial index(ABI) (Lt) and the odds ratio is 1.06, 1.02 and 12.01, accordingly. The equation for CAP analysis in women is ln(CAP)yes/no = 4.62989 X LtCIMT + 5.48385 X RtCIMT + 0.0015698 X LDH and the odds ratio is 102.5, 240.77 and 1.0016, accordingly. Conclusion: Aging alone has excellent linear correlation to CIMT in both sex and related to steady 6% increasing of CAP yearly in men. Good control of SBP is more important in men (CAP each 2 mmHg up and important in CIMT also). ABI are even more important (20.1% increasing of CAP each 0.1 up) and highly recommended to add than just routine blood pressure, especially for men. Preventing CIMT thickening and anti-inflammation are more important in women (9.23 and 23.077 fold for 0.1 mm increasing in Lt and Rt

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CIMT). LDH level is a weak but significant factor and needs attention for women’s CAP. Obesity/metabolic problems are same important in men and women. Emphasis of prevention of carotid atherosclerosis for men and women is same in obesity/metabolic problems and different in blood pressure for men and intima thickness and LDH for women.

P615 Industrial food production in countries of the European Union and the prevalence of multiple sclerosis: an ecological analysis K. Lauer Epidemiologist (Griesheim, DE) Objective: In the orchestra of environmental risk factors for multiple sclerosis (MS), beside infectious agents, vitamin D deficiency and tobacco smoking, also food is an important issue. Predominant risk factors were meat, or pork, or processed meat, whereas fish and seafood were protective. Other variables, so far, were inconsistent. Data on industrial food production from the early 1970s now were analyzed in a small number of countries of the European Union (EU) for a possible correlation with the MS prevalence. Methods: Data of seven EU countries were evaluated. The MS prevalence 1990-2001 was taken from Pugliatti and Rosati (2008) and dichotomized into MS prevalence rates \70, and [70, per 100,000. Data from food industry originated from the Statistical Office of the European Communities 1971–1973, but only data from 1971 and/or 1972 were available for a minor number of food items and countries, respectively. Population data originated from 1969. The rank order correlation of Spearman was used throughout. The low number of countries precluded the usage of multivariate regression analysis. Results: The following industrially produced food items (by population) were significantly (p\0.05) correlated with the MS prevalence: ‘‘margarine’’; ‘‘canned meat’’; ‘‘jam and marmalade’’; ‘‘chocolate and chocolate confectionary’’; ‘‘sugar confectionary’’; and ‘‘beer’’. A negative association was observed for ‘‘canned fish’’ and ‘‘macaroni, spaghetti and similar products’’. No correlation was found for: ‘‘crude vegetable oils and fats’’; ‘‘butter’’; ‘‘cheese’’; ‘‘condensed and evaporated milk’’; ‘‘canned vegetables’’; ‘‘canned and bottled fruit’’; ‘‘wheat flour’’; ‘‘biscuits’’; ‘‘beet sugar’’; ‘‘cocoa powder’’; ‘‘ice cream’’; and ‘‘smoking and chewing tobacco, snuff’’. Conclusions: The food pattern repeatedly reported to be correlated with different measures of MS frequency, in particular a high intake of processed meat and low ingestion of fish, was confirmed also in a small number of EU countries in an appropriate time interval. Other foods were highly controversial and, thus, unlikely to be related to MS.

P616 Increasing incidence, anticipation and prophylaxis of genetic Creutzfeldt-Jakob disease E.J. Mitrova´ Slovak Medical University (Bratislava, SK) Objectives: Creutzfeldt-Jakob disease (CJD) is the most important human prion disease.Mutations of the prion gene (PRNP)are decisive for the development of genetic CJD (gCJD). Most frequent CJDspecific mutation is E200K, found in unique accumulation in Slovakia (1,2). The high annual incidence of gCJD, observed in years 19752008 never exceeded 1,66 /1 mill., therefore the increase to 3,2/1 mill. in year 2009 was alarming and signalized a need for detailed analysis.

S203 Methods: Genetic testing was performed in 234 definite CJD patients and their 426 relatives. Epidemiological, genealogical data and CJD risk factors were analyzed in families affected by gCJD. For statistical evaluation MannWhitney tes,T-test and v2 in conting. tables were used. Results: Mutation E200K was found in 158 (67,5%) of patients and 151 (35,5%) relatives. Increased value of annual incidence of gCJD was statistically significant (p = 0,006). 10 out of 17 gCJD in year 2009 were familial cases, 8 of them belonged to a 2nd affected generation, 6 were metionine homozygous in the PRNP codon 129. The mean age difference at CJD onset in patients from different generations was 17.12 years (p= 0,034). The mean number of surgical interventions in analysed 17 patients (year 2009)and in 21 patients (years 2006-2008) was not significantly different(ccc2 = 0,504). Conclusion: During our studies on CJD (years 1975–2009) the incidence of gCJD increased slowly and the highest number of cases was 9. In the year 2009 we observed for the 1st time a dramatic, highly significant change. The suddenly increased number of gCJD cases was strongly influenced by anticipation, i.e. by the earlier onset of the disease in E200K carriers in the 2nd affected generation. Interesting is that in the same families, in the 1st affected generation healthy asymptomatic carriers of the mutation at age 85 – 88 years were found. Described effect of anticipation was most striking in Slovakia, because of high incidence of gCJD, but its influence could be expected world wide where gCJD occurs, even if in a less conspicuous form. Genetic CJD represent a human prion disease with advantage of preclinical identification of persons at CJD risk. Presented, warning increase of gCJD suggests a re evaluation of prophylactic Doxicycline administration to asymptomatic carriers of CJD-specific mutation E200K. 1. Mitrova´ E. and Belay G.:Acta Virol 2002,46:31 2. Mitrova´ E. et al.: Europ J neurol 2005,12:1 Supported by the EC project "PRIORITY"

P617 Angiostrongylus cantonensis meningoencephalitis: differences of immunoglobulins intrathecal synthesis patterns in Cuba and Ecuador A.J. Dorta, B. Padilla-Docal, R. Bu-Coifiu-Fanego, J.M. Moreira, L. Martini-Robles Superior Institute of Medicine (Ciudad de la Habana, CU); Ministry of Public Health (Quito, EC); National Institute for Hygene Dr. Leopoldo Izquieta Pe´rez (Guayaquil, EC) Introduction: Angiostrongylus cantonensis meningoencephalitis was first reported in Cuba in 1981 and recently in South America. The aim of this paper is to present a neuroinmmunological comparison study between the first report of two outbreaks in subtropical regions from Ecuador and from Cuba Materials and methods: Eight young adults from two different outbreaks in Ecuador and 27 patients from Cuba were studied. Simultaneous blood and cerebrospinal fluid (CSF) simples were taken. IgA, IgM, IgG and albumin were quantified by radial immunodiffusion. Corresponding reibergrams or CSF/serum quotient graphs were employed. The diagnosis of A. cantonensis meningoencephalitis was based on a previous antecedent of raw snail consumption or food contamination, its symptoms and the cerebrospinal fluid characteristics. Results: The immunoglobulins intrathecal patterns from Cuba patients were different from Ecuador’s. Three immunoglobulins synthesis pattern was the most frequent one in general in both populations but in Ecuadorians, IgM was presented in all the different

patterns and in the Cuban patterns IgA+ IgG was present in all the different patterns. Conclusions: The different intrathecal patterns can help to characterize epidemiologically both populations. These neuroimmunological findings contribute to improve and confirm the diagnosis of this disease now spreading over South America.

Neuro-genetics P618 Neurodegeneration with brain iron accumulation caused by phospholipase A2 gene mutations: identification of a new mutation T. Lampreia, J. Vale Hospital Egas Moniz (Lisbon, PT) Objectives: To report a case of Neurodegeneration with Brain Iron Accumulation (NBIA) caused by compound mutation in phospholipase A2 (PLA2G6) gene. Methods: Clinical evaluation and an extensive investigation including brain MRI and genetic studies for Huntington Disease and PANK2 mutations. The axon of PLA2G6 was amplified by polymerase chain reaction (PCR) and analyzed for mutations by SSCP and DNA sequencing. Results: A 21-year old Afro-American female developed cognitive deterioration since the age of 11, initially accompanied by focal dystonia of the left upper limb. Her clinical state slowly progressed and at present she has a frontal syndrome, generalized dystonia, action-induced myoclonus, parkinsonism, bilateral pyramidal signs and slowed vertical eye movements. Her oldest brother died at the age of 17, after 10 years of psychiatric disorders and difficulties in motor coordination and gait; her parents were not consanguineous. The MRI showed bilateral symmetrical T2 hypointense lesions in the pallida and mild cerebellar atrophy. We detected the already described heterozygous mutation c.2370T[ G (p.Tyr790X) in exon 17 of the PLA2G6 gene and a transition of cytosine to thymidine in exon 14 resulting in the substitution of arginine by cystine in codon 649. Conclusion: Mutations in PLA2G6, which encodes a phospholipase A2, are responsible for 80% of cases of Infantile Neuroaxonal Dystrophy (INAD), Karak syndrome and some cases of NBIA PANK2-negative. The genotype-phenotype correlation for PANK2 and PLA2G6 genes is still difficult to establish but the association of hypointensity lesion in the pallida without ‘‘eye-of-the-tiger’’ and with cerebellar atrophy, as in our case, seems characteristic of PLA2G6. The change found in exon 14 has not yet been described, extending the spectrum of PLA2G6 mutations.

P619 PICALM and APOE polymorphisms in Italian patients with Alzheimer’s disease B. Nacmias, I. Piaceri, S. Bagnoli, A. Tedde, V. Bessi, L. Bracco, B. Guarnieri, S. Sorbi University of Florence (Florence, IT) Objectives: A common polymorphism (rs3851179) in the PICALM (phosphatidylinositol-binding clathrin assembly protein) gene has been recently associated with the risk of developing Alzheimer’s disease (AD).

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S204 To study a possible implication for PICALM as a susceptibility genetic factor for AD and whether or not such effects are dependent on the Apolipoprotein E (ApoE) epsilon4 allele. Methods: We studied the genotype and allele distributions of the PICALM rs3851179 polymorphism in 374 Italian subjects recruited at the Department of Neurological Sciences at the University of Florence: 258 sporadic LOAD patients (165 females and 93 males, mean age 75.72 ± 4.77, age at onset 72.25 ±5.19, mean ± SD years defined as the onset of the first cognitive changes) and 116 healthy controls (66 females and 50 males, mean age 66.57 ±5.28). The analysis of the SNP rs3851179 was performed using PCR and high resolution melting analysis (HRMA); the three genotypes were identified with sequencing (ABI PRISM 310, Applied Biosystem). The ApoE genotype was determined using PCR RFLP method. The study protocol was approved by the local ethics committee and informed consent for genetic screening was obtained from study participants or, where appropriate, legal representative. Results: The A allele frequency was overrepresented in AD patients compared to controls (44.2 % versus 37.5%), although not statistically significant. After stratification for APOE epsilon4 carrier status, we observed that the association was confined to ApoE epsilon4 carriers (p=0.004) with an OR =3.89 for the A allele. Conclusion: The genetic effect of PICALM is relevant in predisposing to AD only in ApoE epsilon4 allele carrier thus suggesting a possible epigenetic effect. Our data support a possible implication of the genetic variation in the PICALM gene as a modest risk factor for LOAD, thus providing further contribution toward new opportunities to investigate AD pathogenesis, treatment and prevention.

P620 Genotype-phenotype relationships in Bulgarian Alzheimer’s patients S. Mehrabian, A. Jordanova, M. Raycheva, M. Cruts, C. Van Broeckhoven, L. Traykov University Hospital Alexandrovska (Sofia, BG); Laboratory of Molecular Pathology (Sofia, BG); University of Antwerp (Antwerpen, BE) Objectives: The main objective of this study is to clarify genotypephenotype relationships in Bulgarian patients with Alzheimer’s disease (AD). Methods: Our clinical, genealogical, neuroimaging and neuropsychological examinations in 23 Bulgarian families with early onset AD (EOAD) resulted in revelation of 4 molecular-genetic verified mutations in PSEN1 and PSEN2 genes. We also analyzed the ApoE genotype in patients with AD (n=131), EOAD (n=63), late onset AD (LOAD) (n=68) and healthy elderly (n=43). Results: In PSEN1 gene is found 3 different mutations in 3 Bulgarian families with autosomal dominant pattern of inheritance. The (L381V) PSEN1 mutation leaded to the phenotype of very EOAD and atypical clinical manifestations. The (L250V) PSEN1 mutation resulted in the phenotype of EOAD with the behavior changes and myoclonus. The (L424P) PSEN1 mutation brought about the phenotype of EOAD and atypical clinical picture. A novel sporadic mutation (C319A) is identified in PSEN2 gene and resulted in EOAD. The results indicated significant association of ApoE-e4 allele with LOAD in comparison with EOAD and clinically healthy elderly. We revealed that the indices of short-term, long-term memory and executive functions show significant decline in patients bearing e4allele (p\0.05). We also found that e4-bearing AD patients would exhibit an increased frequency of delusion and aggression/agitation. Conclusion: We have clarified the genotype-phenotype relationships revealing variable clinical manifestations in different mutations

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in PSEN1 and PSEN2 genes. The results support the hypothesis of ApoE-e4 being associated with more severe pathologic changes of AD and leads to a specific cognitive and behavioral pattern for bearing e4-allele patients.

P621 Impact of caffeine intake on Huntington’s disease course C. Duru, C. Simonin, F. Richard, P. Hincker, J. Salleron, P. Charles, K. Youssov, S. Burnouf, J.P. Azulay, C. Verny, C. Tranchant, C. Goizet, L. Defebvre, B. Sablonnie`re, M. Romon, L. Bue´e, P. Amouyel, O. Godefroy, A. Du¨rr, A.-C. Bachoud-Le´vi, D. Blum, P. Krystkowiak on behalf the Huntington French Speaking Network Objectives: To determine whether in Huntington’s disease (HD), the age at onset (AAO) (primary endpoint) and the rates of functional, motor and cognitive decline (secondary endpoints) are influenced by caffeine intake. Methods: 62 HD patients were included from 8 Huntington French Speaking Network sites over a six-month period. Information about caffeine consumption was collected with one validated self-questionnaire. All patients were evaluated twice a year (at least one year between two assessments) using the Unified Huntington’s Disease Rating Scale. Factors influencing AAO were examined using a stepwise regression analysis. Results: The comparable rates of functional decline and demographic characteristics with other published studies suggest that our limited population was representative of HD patients. The mean daily caffeine intake from all sources for the period of the last ten years was 226 mg/day. We found a significant correlation between AAO and caffeine intake (R2= 0,041, p=0,016), so high caffeine intake was associated with earlier AAO. However, we failed to demonstrate a relation between caffeine intake and the rate of the functional, motor and cognitive decline. Conclusion: Our findings could have a great therapeutic impact because they suggest that caffeine could be the first environmental modifier of AAO in HD. Consequently,the modulation of A2A receptors may represent new therapeutic approaches of HD.

P622 The FGB –455G/A polymorphism and a risk of brain haemorrhage in two different populations: Polish and Greek J. Jagiella, E. Dardiotis, M. Wnuk, W. Turaj, K. Fountas, G. Hadjigeorgiou, A. Slowik Jagiellonian University Medical College (Krakow, PL); University Hospital of Larissa (Larissa, GR) Objectives: Elevated fibrinogen level is associated with an increased risk of intracerebral haemorrhage (ICH). Moreover, there is a significant correlation between elevated fibrinogen level and early neurological deterioration, clinical outcome and hematoma enlargement in these patients. Several allelic variants of the fibrinogen b chain (FGB) gene are reported to have a possible connection with plasma fibrinogen level. Since the FGB -455 G/A polymorphism strongly affects fibrinogen level, we aimed, for the first time, to determine a possible association between the FGB –455 G/A polymorphism and a risk of ICH in the Polish and Greek populations. Methods: A total of 238 patients with ICH from the Polish and 216 of the Greek populations as well as 501 controls in the Polish and 198

S205 controls in the Greek populations were analysed for the FGB –455G/ A polymorphism. The diagnoses of ICH were confirmed by cranial computed tomography and vascular malformations were excluded by vascular imaging. The FGB –455G/A polymorphism was detected by gel electrophoresis and TaqMan RT-PCR assay. Results: The analysis did not show a significant difference between the distribution of the studied polymorphism in all patients with ICH both in the Polish cases (patients: n=238, GG-112 (47%), CG-99 (42%), CC-27 (11%)), controls: (n=501; GG-282 (56%), GC170 (34%), CC-49 (10%)) v2=5,565, p=0,0619 and the Greek cases (patients: n=216; GG-118 (55%),CG-82 (38%), CC-16 (7%)), controls: (n=198; GG-110 (56%), CG-66 (33%), CC-22 (11%)), v2=2,179, p=0,336. The distribution of the studied polymorphism was similar in males (Polish cases: v2=4,133, p=0,126; Greek cases: v2=0,528; p=0,768) or females (Polish cases: v2=2,041, p=0,360; Greek cases: v2=2,900; p=0,235). A significant difference was observed, however, when Polish cases with non-lobar ICH (patients: n=140, GG-58 (41%), CG-64 (46%), CC-18 (13%)) were considered separately (OR=1.82; 95%CI: 1.25-2.66, v2=9,707; p=0,0078). This correlation was not present in the Greek cases with non-lobar ICH (patients: n=144, GG-77 (53%), CG-57 (40%), CC-10 (7%)) (v2=2,516; p=0,284). Conclusions: The genotypes with the C allele of the –455G/A polymorphism of the FGB gene shows a different significance in different phenotypes of ICH in the Polish, but not the Greek population. These data suggest a need for further studies of the polymorhism significance in a different population and a subsequent meta-analysis of the obtained results. Supported financially by the KBN State Committee for Scientific Research (Grant Number: K/PBW/000343)

P623 ACE tagging SNPs in patients with intracerebral haemorrhage E. Dardiotis, J. Jagiella, G. Xiromerisiou, C. Vogiatzi, G. Patramani, P. Kountra, A. Komnos, K. Paterakis, K. Fountas, A. Papadimitriou, A. Slowik, G. Hadjigeorgiou University Hospital of Larissa (Larissa, GR); Jagiellonian University Medical College (Krakow, PL) Objectives: Genetic loci along with other well known epidemiological factors have been implicated in the development of ICH. ACE I/D polymorphism has been was associated with non-lobar ICH in Polish patients. This was the first study involving genetic factors in hypertensive ICH. In the present study we further investigate the role of ACE gene by genotyping 5 tagging polymorphisms along ACE gene in two independent populations. Methods: We included in the study 250 Greek and 193 Polish ICH patients and 250 Greek and 322 Polish normal controls. To cover most of the genetic variability across ACE gene 5 tagging SNPs (rs4343, rs4461142, rs7221780, rs8066276, rs8066114) were identified using tagger genetic software that capture 83.3% of the ACE gene variability in the Hapmap database. All SNPs were genotyped with TaqMan allele-specific amplification method (Applied Biosystems). Hardy-Weinberg equilibrium was tested by the 72 test. Case-control association testing of single SNPs was performed by logistic regression analyzed under dominant, recessive, and additive inheritance models. The level of significance after correction for multiple comparisons was equal to 0.01. Haplotype estimation was performed by an expectation-maximization algorithm. The relation between haplotypes and ICH was examined by haplotype-based conditional logistic regression analysis.

Results: A trend for association was found with the intronic rs4461142 polymorphism (12Kb far from ACE I/D polymorphism) in the Polish group (p=0.03). No significant association was detected with the other polymorphisms. Haplotype analysis also didn’t reveal any significant association. No significant association was found in the non-lobar subgroups. Conclusion: Our results are inconclusive for the role of ACE gene in the development of ICH.

P624 A splicing site OPA1 mutation associated with autosomal dominant optic atrophy in an Italian family M. Ranieri, R. Del Bo, S. Corti, A. Bordoni, G. Mancarella, N. Bresolin, G.P. Comi University of Milan (Milan, IT); Valduce Hospital (Como, IT) Objective: Autosomal dominant optic atrophy (ADOA) is due in about 60-70% of cases to mutations in the nuclear gene encoding for the OPA1 protein, a dynamin-like GTPase involved in mitochondrial network structure and in control of apoptosis through the compartimentalization of cytochrome c. ADOA shows great variability in phenotypic expression. even within the same family carrying the same molecular defect. We report the association of a OPA1 gene mutation with an Italian family affected by classical ADOA. Methods: The proband is a 15-year old female affected by a slow progressive visual loss at the age of 11 with a current visual acuity (7/ 10 right; 6/10 left). Ophthalmologic examination discloses mild temporal pallor of the optic disc bilaterally; pattern visual evoked potentials(PVEPs) show increased latencies of cortical responses with a moderate signal dispersion. Her brother (11-years old) developed a progressive visual loss at the age of 10 and his current visual acuity is 4/10 bilaterally. No other pathological signs were found at their neurological examination, in particular no muscular involvement (MRC:5).Their mother suffered from poor vision and died at age of 38 for breast cancer. Their 41-year old aunt shows a deterioration of visual acuity since childhood; current visual acuity is 2/10 bilaterally; a mild sensor neural hearing loss was observed in the last years. Results: No mtDNA mutation was observed. Sequence analysis of OPA1 showed in affected members the heterozygous mutation c.9852A[G. It was associated with the in-frame-skipping of exon10, as detected by mRNA analysis, resulting in the loss of 27 amino acids within the GTPase domain. Conclusions: We examined an Italian family with clinically diagnosed ADOA and a splicing defect within OPA1. The same mutation has been previously identified in only one Chinese pedigree showing an incomplete penetrance in this family. In the Italian genetic background it is associated with an early-onset and complete penetrance. The exon10 of OPA1 gene is critical for GTPase activity, and exon10 splice acceptor site may be a mutation hot spot. We highlight the value of mRNA analysis in the characterization of OPA1 mutations.

P625 Wolfram syndrome: report of a genetically confirmed, late diagnosed case A. Bisecco, A. Gallo, R. Sacco, M. Ciccolella, F. Santorelli, G. Tedeschi Second University of Naples (Naples, IT); IRCCS Bambino Gesu` (Rome, IT) Background: Wolfram syndrome (WS) is an uncommon genetic disease defined by the association of early onset (\15 years) optic

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S206 atrophy and diabetes mellitus. The disease is inherited as an autosomal recessive trait with an estimated prevalence of 1 in 770,000. WS is caused by homozygous mutations in WFS1, a gene located at 4p16.1 and composed of seven coding exons. To date, approximately 130 distinct mutations in WFS1 have been identified in WS individuals from different ethnic backgrounds, and these include a variety of missense, nonsense, and frameshift insertion/deletion mutations. Case report: we report the case of a 31-years-old woman, who was given a diagnosis of diabetes mellitus type 1 when she was 3 years old and who developed progressive optic atrophy during the first decade of life, with complete visual loss when she reached 18 years old. Her parents were not relatives. In the third decade of life she developed ataxia with unsteady gait and falls, objective vertigo in supine position, constipation, neuropathic bladder, dysarthria, dysphagia, compulsive and self-damaging behaviour. On neurological examination the patient was poorly collaborative and presented with Romberg test positive, unsteady gait, loss of smell, amaurosis in OO with bilateral optic atrophy and mydriasis withouth pupillary constriction to light stimuli, bilateral sensorineural hearing loss, dysarthria, areflexia, loss of pain, temperature and vibration sensation distal on the legs, dysmetria, dysdiadochokinesia, urinary incontinence and constipation. On blood test she had a hyperglycemia and raised HbA1c. Electrophysiological studies showed a symmetric sensori-motor axonal and demyelinating neuropathy at the level of the lower limbs. Audiometry findings were consistent with a bilateral sensorineural hearing loss. A brain MRI showed brainstem atrophy. Mutation screening for WS1 gene revealed a compound heterozygous mutation: c.1456C[T(p.Q486X) + c.1523_1524delAT. Conclusions: in this case reports we have described a case of late diagnosed WS. WS should be suspected in any individual presenting with diabetes mellitus and progressive optic atrophy in the first 15 years of life. The avaiability of a genetic test offer the opportunity to confirm diagnosis. An early diagnosis of WS followed by an adequate treatment may avoids serious medical complications and allows to optimize the management of the patient, including psychological support.

P626 Examination of cognitive function in Friedreich’s ataxia using the Simon task L.A. Corben, H. Akhalghi, N. Georgiou-Karistianis, J.L.B. Bradshaw, G.F. Egan, E. Storey, A.J. Churchyard, M.B. Delatycki Monash University (Melbourne, AU); University of Melbourne (Parkville, AU); Monash University (Clayton, AU); Monash University (Prahan, AU); Monash Medical Centre (Clayton, AU); Bruce Lefroy Centre for Genetic Health Research (Melbourne, AU) Objectives: Friedreich ataxia (FRDA) is the commonest genetic cause of ataxia. The limited literature available on the cognitive components of FRDA suggests reduced information processing speed in the setting of intact executive function. Recently we proposed FRDA may also impair cognitive capacity either because of direct pathology affecting the cerebrum or pathology affecting the projections from the cerebellum to the cortex. However, the exact nature and underlying pathogenesis of cognitive changes in FRDA remains poorly understood. We utilised a well-known conflict resolution task (Simon task) to further address these issues. Methods: Thirteen right-handed individuals homozygous for a GAA expansion in intron 1 of the FXN gene and fourteen matched controls participated. Participants were instructed to press a button corresponding with the direction of an arrow on a computer screen. The task involved congruent stimuli (e.g. right pointing arrow on right

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side of screen) or incongruent stimuli (e.g. right pointing arrow on left side of screen). Response times to stimuli were recorded. Reaction time data were submitted to a two-way ANOVA. Results: Not surprisingly people with FRDA (M = 811ms, SD = 32ms) were 289ms slower than control participants (M = 529ms, SD = 31ms). The data also demonstrated the ‘‘Simon effect’’, that is, incongruent stimuli (M = 779ms, SD = 240ms) returned overall a 218ms longer reaction time than congruent stimuli (M = 561ms, SD = 134ms). There was a significant [F(1,26) = 6.68, p\0.05] and disproportionally greater difference between reaction time to congruent and incongruent stimuli in people with FRDA (275ms) compared to control participants (162ms). There was no significant difference between the two groups in the total number of errors, indicating an absence of any speed/accuracy tradeoff or difference in response set between the groups. Conclusion: People with FRDA were disproportionally slower to respond to incongruent stimuli requiring inhibition of a prepotent response. We propose that such ‘dysmetria of thought’ results not simply from cerebellar compromise, but also from deficits in cerebroponto-cerebello-thalamo-cerebral loops accessing critical cortical areas, in particular the dorsolateral prefrontal cortex and the anterior cingulate cortex. Use of imaging methods in tasks such as the Simon task will provide a more comprehensive understanding of the neurobehavioural profile and neuropathology associated with FRDA.

P627 Description of a four-generation family with autosomal dominant cerebellar ataxia: clinical and genetic analysis D. Italiano, F. Annesi, A. Lagana`, G. Provenzano, P. Tarantino, A. Gambardella, G. Annesi, A. Quattrone, P. Bramanti IRCCS Centro Neurolesi ‘‘Bonino-Pulejo’’ (Messina, IT); National Research Council (Mangone, IT); University Polyclinic of Messina (Messina, IT); University Magna Graecia (Catanzaro, IT) Objectives: Autosomal dominant cerebellar ataxias (SCAs) are a heterogeneous group of neurodegenerative disorders, characterized by imbalance, dysarthria, and progressive gait and limb ataxia, which are variably associated with other neurological signs. To date, about 28 genetic loci associated to Mendelian forms of SCA are known, and several SCA genes have been identified. Nevertheless, about 30–60% of clinically identified SCA families remain genetically unassigned. We performed a genetic analysis of a four-generation family from southern Italy, with a form of slowly progressive SCA. Patients and methods: Fourteen subjects (seven affected) in a family with fifteen affected members have been evaluated. The disease seems to display an autosomal dominant pattern of inheritance with elevated penetrance. The mean age at onset was 34 years with a strong evidence of anticipation across generations. The first symptoms were invariably ‘‘legs heaviness’’, imbalance, or dysartria. Neurological examination in the advanced state of disease showed in all patients unbalanced standing, gait and limb ataxia and dysmetria. None of them presented sensory loss, cognitive impairment, nystagmus, or dysfunctions of ocular movement. We performed mutational analysis by PCR searching for the most common SCA mutations. Two-point linkage analysis for known SCA genetic loci was calculated with the LINKAGE program package under the assumption of autosomal dominant inheritance and a disease frequency of 1 to 100.000. Five age-dependent penetrance classes were defined based on the cumulative age at onset profile of the family. Results: Mutational analysis excluded pathological repeat expansions in the SCA 1, 2, 3, 6, 7, 8, 12, 17 and DRPLA genes. Linkage

S207 exclusion tests showed no evidence of association with most of known mapped SCA loci (SCA4, SCA5, SCA13-16, SCA19-22, SCA25 and SCA27-29). Conclusion: SCA prevalence in Italy significantly differs from European countries because of the very low prevalence of SCA 3 and SCA 6. Forty-five percent of the Italian families are associated with SCA1 and SCA2 genotypes, and only a small percentage of cases exhibits expansions in SCA3, SCA6, SCA7, SCA17 and DRPLA genes. In this large family, mutational analysis excluded the presence of all the main common SCA gene mutations, and linkage analysis ruled out the association with most of the so far reported SCA genetic loci. This could suggests a genetically distinct form of SCA.

P628 Association of Charcot-Marie-Tooth type 2a and motor neuron disease C. Marchesi, C. Ciano, E. Salsano, L. Nanetti, M. Milani, C. Gellera, F. Taroni, G. Fabrizi, A. Uncini, D. Pareyson C.Besta Neurological Institute (Milan, IT) Objectives: To report the association of Charcot-Marie-Tooth (CMT) and motor neuron disease (MND) in a 62-year-old woman with genetically confirmed CMT2A, who subsequently developed rapidly progressive form of MND. CMT2A is caused by mutations in Mitofusin 2 gene (MFN2) that account for up to 20% of CMT2 cases and can be associated with complex phenotypes including optic atrophy, hearing loss, pyramidal signs and cerebral whitematter abnormalities. Methods: We evaluated the patient clinically, neurophysiologically and neuroradiologically and sequenced the Super-Oxide Dismutase-1 (SOD1) and MFN2 genes. Results: Our patient had bilateral pes cavus since childhood. At age 14 she developed mild gait difficulties and then she showed slow disease progression with mild-to-moderate hand and foot muscle atrophy and weakness, steppage gait and distal sensory loss. However, CMT neuropathy was diagnosed only at age 43, after CMT diagnosis in her 17-year-old daughter. Twelve years later, both of them were found to carry the same H165L mutation in MFN2 gene. After age 60 years, she developed rapidly progressive generalized weakness, dysarthria and dysphagia. At age 62, examination showed: tongue weakness and fasciculations, pharyngeal weakness, severe muscle atrophy, especially of the first interosseus, thenar and hypothenar muscles bilaterally, and weakness in upper and lower limbs. She also had increased upper limb and patellar deep tendon reflexes. Neurophysiological data confirmed a severe sensory-motor axonal neuropathy with reduced amplitude of motor and sensory potentials but EMG examination revealed also diffuse acute denervation with widespread fibrillations, and fasciculation potentials. Motor evoked potentials derived from tongue and upper limbs did not detect clear abnormalities of central motor pathways. Brain MRI and CT scan were normal. Haematologic work-up was unremarkable, including thyroid hormones, auto-antibodies, and paraneoplastic antibodies. Molecular test for SOD1 mutations was negative. At the beginning involvement of vocal cord in the setting of CMT2A was suggested, but the rapid deterioration and diffusion of wasting weakness and fasciculation was typical of a MND. Conclusion: Our CMT2A patient had clinical features, EMG findings, and disease progression consistent with amyotrophic lateral sclerosis, showing the co-occurrence of two rare disorders. To our knowledge, MND has never been previously reported in association with CMT.

P629 A3243T, a new mutation of mtDNA with variable phenotypic expression T. Lampreia, J. Vale, L. Vilarinho, P. Alegria Hospital Egas Moniz (Lisbon, PT); Centro de Gene´tica Me´dica Dr. Jacinto Magalheˆs (Porto, PT) Objectives: To report a case of non-syndromic mitochondrial disease caused by the A3243T mutation. Methods: The patient was assessed by a Neurologist, an Ophthalmologist and an Otorhinolaryngologist. She was submitted to neuropsychological examination. The ancillary exams included lipid profile, vitamin E, phytanic acid and b-hexosaminidase quantification, lipoprotein electrophoresis, serum a-fetoprotein, serum piruvate and lactate, electromyogram (EMG), electroencephalogram (EEG), brain MRI, muscle biopsy, respiratory chain studies and sequencing of the mtDNA. Results: A 33-year old Caucasian woman, with normal development milestones, complained of gait difficulties and cognitive deterioration for the last 5 years. She had a mild gait ataxia, four limb ataxia of cerebellar type and occasional myoclonous. Her medical story was significant for sensorineural bilateral hearing loss starting at the age of 18, myoclonic seizures and bilateral cataract and retinitis pigmentosa diagnosed when she was 25 years-old. Neuropsychological assessment showed diffuse deficits (RAVEN \5th percentile). A Brain MRI showed olivopontocerebellar atrophy and extensive calcification of the lenticular and caudate; the EEG showed diffuse spike-wave and polyspike-wave discharges and the EMG was normal. Serum lactate and piruvate were normal, as well as the muscle biopsy and the respiratory chain enzymes studies, but the sequencing of mtDNA showed the mutation A3243T with 70% heteroplasmy. Her family history was irrelevant. We excluded other causes of recessive ataxia. Conclusions: We describe a case of mitochondrial disease with cerebellar ataxia has its main symptom. Although non-syndromic, the systems involved in this case are very suggestive of this type of diseases. The pathogenicity of this mutation is supported by the absence of other changes in mtDNA, its degree of heteroplasmy and the high phylogenetic conservation of this nucleotid. Two paediatric patients with this mutation and a phenotype characterized by severe metabolic acidosis and encephalomyopathy have been described. The severity may have been influenced by different degrees of heteroplasmy. We emphasize the normal respiratory chain enzymes studies, as well as the fact that this mutation could not be detected by testing for the A3243G mutation. In some cases, a high level of clinical suspicion is needed to establish a diagnosis of mithochondrial citopathy, sometimes being necessary a whole mtDNA sequenciation.

P630 Dominant cardiomyopathy and very distal myopathy with rod, myofibrillar and AVSF myopathology S. Iyadurai, C. Weihl, A. Pestronk Washington University (St. Louis, US) Objective: To describe a family with a distinctive syndrome of cardiomyopathy with conduction defects, very distal weakness and muscle with rods, myofibrillar changes and autophagic vacuoles with sarcolemmal features (AVSF). Background: Myopathies with predominantly distal weakness include at least 16 genetically distinct disorders. We describe a multigenerational family with a distal myopathy with unusual features.

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S208 Design: Retrospective study of eight affected members of a four generation Missouri family. Results: The syndrome segregated by history as a dominantlyinherited disorder with affected family members of both sexes. Symptomatic weakness often dated to the second decade manifest by clumsy gait. Most family members presented in their 4th decade with sudden death or cardiomyopathy and severe cardiac conduction deficits requiring a pacemaker. Four affected patients without cardiac pacing died before age 40. Two affected patients with cardiac pacing were examined in their fifth decade. Symmetric weakness was most severe in intrinsic muscles of the hands and feet, averaging less than 10% of normal. Intrinsic muscles of the hands and feet were severely atrophic. Proximal muscle strength was 80% to 100% of normal. Tendon reflexes and sensation were normal. Serum CK was less than 250. Electromyography revealed a distal predominant, irritable myopathy. Nerve conduction studies were normal. EKG showed left anterior, and then complete, heart block. Muscle ultrasound showed a distal myopathy involving the hands and legs. Muscle biopsy showed varied fiber size, splitting, rods, desmin aggregates, and vacuoles containing granular debris with rims staining for sarcolemmal proteins, including dystrophin, sarcoglycans and caveolin. Conclusion: Our family differs from previously reported myopathies with AVSFs. Distinctive features include very distal weakness and wasting, early sudden death, cardiomyopathy with conduction block and myopathology with rods, myofibrillar changes in addition to AVSFs. Genotyping will be required to further define the identity of this distal myopathy syndrome.

P631 Autoimmune MuSK-positive myasthenia gravis in two sisters S. Iyadurai, M. Al-lozi Washington University (St. Louis, US) Objective: To describe two sisters with Muscle-Specific Kinase (MuSK)-positive myasthenia gravis (MG). Background/Significance: MG is an immune disorder with antibodies commonly directed against acetylcholine receptors (AChR), but rarely against MuSK. Twin studies have shown discordance for the myasthenia gravis phenotype. Although HLA locus DQ5 has been implicated in MuSK-positive MG, multiple affected siblings have been described in AChR-associated, but not in MuSK-associated MG. We report 2 sisters with MuSK-positive MG. Design/Methods: Case Series. Case Report: Patient 1 presented at age 32 with double vision, difficulty swallowing, shortness of breath, fatigue and weakness. Examination revealed bilateral lateral rectus weakness, facial weakness, dysarthria, mild proximal limb weakness, and markedly reduced vital capacity. Work up showed significant decrement of compound muscle action potential (CMAP) with repetitive nerve stimulation at low frequency and positive anti-MuSK antibodies. Patient 2, a biological sister of patient 1, presented at age 36, following the delivery of her 3rd child, with symptoms similar to her sister. Examination showed bilateral lateral rectus weakness, facial weakness, dysarthria, respiratory muscle weakness, and proximal limb weakness. Both patients were treated with cholinesterase inhibitors, steroids, Intravenous Immunoglobulins (IVIG), and other immunosuppressive medications with poor response. Rituximab was given to patient 1 with excellent response, and recently initiated in patient 2. Conclusions: The occurrence of MuSK-positive MG in biological sisters suggests a genetic predisposition to this disease.

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Infection P632 A case of progressive multifocal leukoencephalopathy after autologous bone marrow transplantation successfully treated with mirtazapine and cidofovir P. Ripellino, C. Varrasi, C. Comi, M. Mula, A. Stecco, D. Brustia, N. Nasuelli, K. Savio, E. Marotta, F. Monaco, R. Cantello University of Eastern Piedmont (Novara, IT) Objectives: We report on the first case of Progressive Multifocal Leukoencephalopathy (PML) after Autologous Bone Marrow Transplantation (ABMT) in Multiple Myeloma (MM), successfully treated with Cidofovir and Mirtazapine. Methods: A 63 years old woman, who developed MM in 2006, was treated with high-dose chemotherapy followed by two ABMTs. Nine months after the last ABMT she was admitted to our Department complaining of severe left hemiparesis, hemiparesthesia and homonymous hemianopsia, gait ataxia, apathy, nausea and vomiting. Those symptoms were consistent with the diagnosis of PML, as confirmed by the Magnetic Resonance Imaging (MRI) scan and by the discovery of JCV DNA in the Cerebrospinal Fluid (CSF) on Polymerase Chain Reaction (PCR). The analysis of JC virus DNA documented a mutation (Arg75Lys) in the region coding for the surface loops of the major capsid protein (VP1). As the autoimmunity panel, the HIV test and all other viral infections were negative, the disease appears linked to a prolonged state of immunosuppression. Since the patient started worsening and there is currently no effective therapy for PML, we begun an off-label treatment with Cidofovir 5 mg/kg fortnightly and Mirtazapine 30 mg nightly. Results: Six months later the clinical benefit was evident. On neurological examination the patient showed mild left spastic hemiparesis, left homonymous hemianopsia and normal sensory function. At that time, the JC virus DNA became undetectable in the CSF. Repeated MRI scans demonstrated the reduction in demyelinating lesions volume; cerebral biopsy was not performed, but MRI spectroscopy confirmed the pattern typical in PML. At follow-up consults (12 and 18 months) her neurological examination did not show significant variations. She is currently on Mirtazapine 30 mg nightly. Our patient has shown an unexpected long term–survival (more than 18 months), a clear clinical and radiological improvement and early disappearance of JC virus from the CSF. The prompt start of Mirtazapine could explain the benign course of PML, but it is difficult to quantify his role because of the combination with Cidofovir and the variability in PML natural history, depending also on the JC virus adaptive mutations. Conclusion: To restore the immune system function is the first aim in PML cases. In AIDS–negative patients early discontinuation of exogenous immunosuppressants is recommended. We suggest to consider adding Mirtazapine to first line treatment of PML.

P633 Progressive multifocal leukoencephalopathy – a series of Service of Infectious Diseases, 2008–2009 M. Shamasna Hospital Centre of Coimbra (Coimbra, PT) Introduction: The Progressive multifocal leukoencephalopathy is a rare disease caused by the JC virus, associated with immunosuppression, particularly HIV infection.

S209 Objectives: Characterize a group of cases progressive multifocal leukoencephalopathy, in respect of the underlying pathologic condition, and clinical manifestations. Material and methods: We reviewed the medical files of patients diagnosed with PML, admitted at the Infectious Diseases of HCC between January 2008 and December 2009. Just consider the cases in which there was confirmation of JC virus in CSF by PCR technique. Results: We identified 7 cases of PML, all in patients with HIV infection. The mean age was 43.3 years (minimum 33, maximum 59) and mostly men (6 cases). Point of view of HIV infection these patients had CD4 cell counts of 79.7 cells/mm3 (minimum 2, maximum 333). All patients had HIV RNA detectable with a mean value of 571,285 cp / ml. In two cases the neurological manifestations associated with PML were the first manifestation of HIV infection. The initial clinical manifestations: 4 patients had neurological deficit engine, 3 and 4 had ataxia also had dysarthria associated with one of the other events. The cytochemical examination of CSF was normal in 6 patients and in 1 case occurred cellularity at the expense of mononuclear cells. All patients had imaging changes at the CNS. In all patients were advised combination antiretroviral therapy (TARVc). Two patients died - a 1 and a half and another 6 months after diagnosis. Two patients have clinical situation Stationary, 1 for 32 months and another 3 years. These patients meet TARVc, with both CD4[ 200ce´l/mm3 (average 302.5) and HIV RNA undetectable. In 3 other cases, there has been a worsening neurological slow but progressive. In the latter group of patients, the diagnosis was made between 5 and 7 months ago, and all under TARVc with CD4 cell counts of 69.7 cells/mm3 (minimum 30, maximum 114) and HIV RNA ranging from 43 to 110 cp / ml. Conclusions: – The manifestations of PML are varied and nonspecific. – The cytochemical examination of CSF may not reveal changes. – In the context of HIV infection, although this entity is more common in situations of severe immune depression, a CD4 count above 200 cells/mm3 does not exclude the diagnosis. – Although the prognosis is very reserved, in some cases there is a stabilization of disease associated with the institution TARVc, together with immune recovery.

P634 A case of subacute sclerosing panencephalitis with 14 years of evolution J.M. Roriz, D. Alves Hospital Pedro Hispano (Matosinhos, PT) Introduction: SSPE is a persistent infection of the CNS caused by an abnormally replicating measles virus, years after the original infection. Increasingly rare after the generalization of vaccine, it usually leads to death in 1–3 years, with 5–10% of patients surviving over 5 years, and only very few over 10 years. Clinical case: Female patient vaccinated for measles as a child and with no known history of measles. She began having learning and relational difficulties by her 6 years. Over 2 months, she developed a progressing picture of dysphasia, urinary incontinence, tremor, ataxia, coreoathetosic movements and episodic absences. She was investigated with EEG (6/minute periodic complexes of generalized slowwaves and frequent anterior 2Hz sharp-wave activity), MRI (bilateral diffuse white matter T2 hyperintense areas), CSF (innocent cytochemical profile with elevated IgG index) and positive antibodies for measles in blood and CSF. Over the following 2 months she displayed increasing cognitive deterioration, startle myoclonus and extensor posturing with brisk reflexes, remaining bedridden with scarce social

interaction. By her 8 years, she presented unexpected spontaneous improvement, with remission of myoclonus, spastic and ataxic gait, directed ocular gaze, purposeful manipulation of objects end emotional resonance. She stayed stable up to her 18 years, at witch time she resumed insidious deterioration, with loss of autonomous gait and environmental interaction, cortical blindness, ocular roving, marked spasticity and occasional tonic focal seizures. She maintained positive blood and CSF oligoclonal bands and measles IgG, 3-7Hz EEG background activity with multiregional epileptogenic capacity and no periodic activity, and exuberant global encephalic atrophy with diffuse T2 hypersignal of supratentorial white matter. Discussion: Reports of SSPE cases with long survival are rare in literature. Female gender, older age, periodic complex remission and measles-specific IgG persistence were variably associated with a better prognosis. Ultimately, however, even the cases of prolonged remission are known to eventually recur and progress to death.

P635 Voltage-gated potassium-channel antibody-mediated limbic encephalitis in association with mycobacterial infection G.Z. Hassan, D. Siddique, A.H.A. Grubneac University Hospital (Coventry, UK) Objectives: To highlight a case of voltage-gated potassium-channel antibody-mediated limbic encephalitis, in association with mycobacterial infection. Methods: Presenting history: A 30 year old South Indian chemical engineer, previously fit and well, presented with a 6 week history of lower back and leg pains, night sweats, anorexia and weight loss. Three days prior to presentation, he developed visual hallucinations and became increasingly disorientated in time and place. He had last travelled to India in 2006. Examination: His speech was rambling with some flight of ideas, and he had periods of agitation alternating with hypersomnolence. He was hyperhidrotic, and was salivating profusely. He displayed myokymias in the frontalis muscle, and showed a degree of dysautonomia, with labile blood pressure recordings and temperature readings ranging from 35.5C to 37.4C. Results: Blood chemistry revealed syndrome of inappropriate ADH secretion (SIADH) with marked hyponatraemia. No malarial parasites were detected, and T-spot test was negative. Vasculitic, autoimmune, paraneoplastic and porphyrin screens were negative, as were tumour markers. Serum and urine heavy metal and toxicology screens were negative. MRI brain and whole spine was normal. CSF analysis was unremarkable, including viral PCR, acid/alcohol-fast bacilli (AAFB) analysis and cytology. EEG showed generalized slowing consistent with encephalopathy. Voltage-gated potassium channel antibodies (VGKC) were elevated at 196 pM. NMDA receptor antibodies were negative. The only abnormality on CT chest, abdomen and pelvis was mild concentric wall thickening and mucosal enhancement just above the ileo-caecal junction. Ileal tissue biopsy on colonoscopy showed ulcerative ileitis with no evidence of AAFB. We diagnosed limbic encephalitis with positive VGKC, and treated him with 1g IV methylprednisolone per day for 3 days, followed by a reducing course of oral prednisolone. He made a full neurological recovery including reversal of SIADH. Two months later the patient was readmitted, having developed a caecal abscess secondary to perforation, which was drained under ultrasound guidance. Analysis of the fluid isolated mycobacterium tuberculosis. He has remained clinically very well, currently on anti-tuberculous therapy. Conclusion: To our knowledge, this is the first reported case of VGKC-mediated limbic encephalitis associated with mycobacterial infection.

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P636 Massive intraventricular cysticercosis, unusual presentation and neuroendoscopic management G. Ca´rdenas, A. Bahena, J. Soto-Hernandez, A. Fleury National Institute of Neurology (Mexico City, MX) Introduction: Neurocysticercosis (NC) is the most frequent parasitic disease of the central nervous system (CNS). Intraventricular parasites affects between 7–33% of patients with NC. In most of the cases parasites in this location are not sensible to pharmacological treatment with cysticidal drugs and require surgical intervention for either cysts removal or CSF shunting. Objective: To describe a case of patient with subarachnoid NC resistant to pharmacological treatment that developed massive intraventricular NC. Case report: A 77 year old with a history of fourth months of severe headache, vomiting disorientation and gaze apraxia. Neurological examination revealed papilledema. On CT scan, hydrocephalus and multiple vesicular lesions at subarachnoidal space were observed. A CSF shunt was placed, patient showed clinical improvement. Two months later a cycle of albendazole (ABZ) (30mg/ kg) was administered. Patient did not continue his clinical follow-up during 2 years. He returned to emergency room with severe headache and papilledema. Asymmetric hydrocephalus and subarachnoidal parasites were observed. Patient received a total of four cycles of cysticidal drugs during 2 years of clinical follow-up and no radiological changes were observed. Finally, patient received neuroendoscopic management. A lot of parasites (more than 30) were removed from lateral ventricles despite this intervention no clinical improvement was observed and patient died two months later. Discusion and conclusions: Partial response to cysticidal treatment had been described before. It is also possible that some resistance of the parasite to ABZ may exist, as it was reported in other species. The severity of this case is particularly due to parasites location at the basal SA space and IV, there was not cysticidal drugs response and patient developed an unusual massive ventricular infection.. Whatever the reasons are, this case illustrate the importance of developing new therapeutic approaches that associate more specific anti-inflammatory drugs and more efficient cysticidal drugs. Although endoscopic surgery have shown to be efficient in IV NC it is not available to all the population of endemic countries. In conclusion, cysticidal resistance is a problem still exist in the management of some severe cases of this disease. It must impulse the continuation of efforts that permit its better understanding and resolution.

P637 Strongiloides stercoralis brain abscesses in a HTLV-1 positive patient G. Matias, N. Canas, C. Veringer, M. Chora˜o, J. Vale Hospital Center (Lisbon, PT) Introduction: Strongyloidiasis is a human intestinal infection caused by Strongiloides stercoralis (Ss). Because the Ss chronic infection is mildly symptomatic, the onset of gastro-intestinal and systemic manifestations is usually associated with hyperinfection (increase in the number of larvae) due to immunosuppression. The involvement of the CNS, usually meningeal, is rare and often fatal, resulting from the Ss itself or bacterial superinfection. Case report: Brazilian, 44 years old man, admitted due to abdominal pain, diarrhea, vomiting and weight loss with three weeks of development. The patient had been medicated with methylprednisolone in the last two months (after vitrectomy). Blood tests revealed abnormalities consistent with malnutrition and infection,

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without eosinophilia. Larvae of Ss were demonstrated in the faeces and gastro-intestinal biopsies. Ss and HTLV-1 serologies were positive; HIV 1 and 2 were negative. During the hospitalization, the patient developed intense headache and delirium, which was associated with sepsis by Serratia marcescens. MRI revealed multiple brain abscesses. He was treated with albendazole and imipenem, with complete regression of the clinical and laboratory abnormalities after 20 days. Two months later, the neurological examination, CSF studies (including serology for Ss), cerebral MRI and gastrointestinal biopsies were normal. Conclusions: The presence of brain abscesses in the Ss hyperinfection is an exceptional occurrence, and was only reported twice. As in our case, the vast majority of patients with neurological compromise had bacterial superinfections, making impossible to determine a specific etiology. The diagnosis of Strongyloidiasis should be suspected in patients from endemic areas who are immunocompromised.

P638 Cerebral schistosomiasis mansoni. A report of three cases and a review of the literature L. Guilloton, A. De Carvalho, F. Dufour Gaume, J.L. Lambolay, L. Quesnel, A. Drouet Army Instruction Hospital Desgenettes (Lyon, FR) Objectives: Schistosoma mansoni (SM) is a parasitic disease common usually revealed by urogenital or gastrointestinal manifestations; neurological presentation is possible, medullar and sometimes cerebral. Methods: We report 3 cases of cerebral SM: one encephalitis with focal neurologic deficits occurring during the acute phase and 2 tumorous forms are described. Discussion : A review of the literature is proposed with the description of 28 cases. Acute encephalitis is described for 5 patients with ischemic lesion secondary to vasculitis. The events occur on average 3 weeks after bathing in freshwater infested. At this stage treatment is based mainly on the steroids. 23 cases were described in a later stage. The clinical presentation is usually pseudo-tumor with intracranial hypertension, focal signs and epilepsy. The main pathophysiological mechanism differs from the acute phase, with an immune reaction around eggs present in brain tissue and the formation of a granuloma. The lack of specificity of the imagery can sometimes make a differential diagnosis of brain tumor and frequently lead to a gesture neurosurgical diagnostic. The development of biological techniques for this diagnosis is a new diagnostic approach: thus, the serology, in Elisa or Western Blot in cerebrospinal fluid, may support clinical diagnosis and may prevent a potentially invasive neurosurgical intervention. The treatment use an antihelmintic drug with corticosteroids for short-term, over a period that remains to be defined. Conclusion: Cerebral localization with schistosomiasis is possible, not only with S japonicum but also with SM with manifestation at the earlier or the later stage.

P639 Meningovascular syphilis with left thalamic infarction H. Nicolae, R. Gurgu, M. Comanescu, A. Dragomir, C. Panea Elias University Hospital of Emergency (Bucharest, RO) Case report: We present the case of a 38-years old right-handed man, without any relevant medical history and without known vascular risk

S211 factors, referred to our hospital for loss of consciousness preceded by intense cephalalgia and paresthesia of right limbs. Neurological examination revealed an alert patient, presenting dysarthria, right hemiparesis, ataxia of right limbs, right hemihipoesthesia. Cerebral MRI showed acute left lenticulo-thalamic infarct. Doppler examination of extra and intracranial blood vessels, ECG, echocardiography and EEG were all normal. Biological assessment excluded dyslipidemia, vasculitis and prothrombotic status. CSF examination (cell count, protein and glucose levels) was normal. CSF VDRL was negative and TPHA positive, but TPHA, VDRL and RPR were positive in serum, with negative HIV antibodies. Evolution was favorable under treatment with aspirin and statin. The patient was treated with penicillin and will be reassessed after 3 months. Discussion: The particularity of our case is a neurological lesion typical for meningovascular syphilis (single small-caliber artery infarction), with positive serology for tardiv syphilis, but with minimal CSF abnormalities in a young patient with no vascular risk factor. Meningovascular syphilis should always be considered in case of stroke in an young patient, especially in the absence of vascular risk factors. This form of neurosyphilis is currently the most common and occurs usually 6-7 years after the original infection. The diagnosis is based on clinical grounds: neurological manifestations (infarctions in the distal territories of medium- and small-caliber arteries), CSF findings (biochemical and imune changes) and serologic conversion.

P640 Neurosyphilis in an 18-year-old female patient: case report T. Afrantou, D. Nikiforidis, R. Lagoudaki, E. Sidiropoulou, I. Mavromatis, N. Tascos Aristotle University of Thessaloniki (Thessaloniki, GR); General Hospital of Xanthi (Xanthi, GR) Objective: In the current era neurosyphilis occur mostly in HIV affected patients. The accurate diagnosis of the disease remains problematic because the manifestations of syphilis have changed with the wide use of antibiotics. Case report presentation: 18 years old female patient presented with generalized muscular weakness, gait disturbance, behavioral changes and repetitive generalized tonic-clonic seizures during a period of 1 year. The neurological evaluation showed disturbance of cognitive functions, emotional instability, increased reflexes of upper and lower limbs without Babinski sign and mild tremor of the upper limbs. Brain CT revealed cortical atrophy with extensive hydrocephalus. The CSF pressure was within normal limits. CSF examination showed 5 lymphocytes/microlit, protein 83.9mg%, glucose 85mg/dl. The EEG was severely encephalopathic. Immunological screening was normal. Antibodies against viruses such as hepatitis, HIV, HSV, CMV, toxoplasma and rubella were negative. Thyroid function, Vitamin B12 and folic acid were normal. However the antibodies against syphilis were positive in non treponemal (VDRL and RPR) and treponemal (FTA-Abs) tests, at the serum. After the first diagnosis of syphilis we tested the CSF for Abs which turned positive in all three methods (RPR, VDRL, FTA-Abs). Additionally: Brain MRI revealed cortical brain atrophy and hydrocephalus, ophthalmologic examination was normal, gynecological examination without syphilitic ulcers and thorax CT scan without aortal abnormalities. Serological testing for syphilis at the immediate family members showed seropositivity of the mother. The father has previously been affected and treated for syphilis. Course and treatment: The patient has been treated for neurosyphilis with i.v. penicillin G (5,000,000 units x 4) for 20 days,

followed by i.m. penicillin G for 3 months. The patient at the third month of treatment deceased due to the rapid deterioration of the neurological and pathological status. Conclusion: Our patient according to clinical and paraclinical examination had late-congenital syphilis. This diagnosis was based at the family history and neurological manifestations such as general paresis, dementia, epileptic seizures, and finally positive CSF syphilis antibodies, which are diagnostic criteria for this type of syphilis.

P641 Case report: association between HIV and spontaneous carotid artery dissection M. Galovic, B. Tettenborn, A. Felbecker Kantonsspital St. Gallen (St. Gallen, CH) Objectives: Stroke is a common complication in HIV infected patients, autopsy series showed a prevalence of cerebral infarctions between 4% to 29%. There is evidence of cerebral vasculopathy associated with HIV infection. We describe a case of spontaneous artery dissection in an HIV-infected patient as a possible manifestation of HIV associated vasculopathy. Methods: We admitted a 39-year-old man with a 7 day history of right-frontal headache and a right-sided Horner’s syndrome. He had HIV diagnosed in 07/2007 and was incompliant for antiretroviral medication intake. The patient showed a history of arterial hypertension and hypercholesterolemia. There was no other evidence of risk factors including trauma or chiropractic manipulation. We evaluated our patient using CT and MRI scans, MRI angiography, extraand transcranial Doppler. We performed extensive laboratory tests and CSF analysis including an autoantibody screening, serologies for syphilis, VZV, HSV, EBV, CMV, B and C hepatitis viruses, toxoplasmosis, borreliosis and cryptococcal infection as well as a CSF gram stain and CSF cytology. Results: The MRI-angiography as well as the ultrasound studies showed a long-segment extracranial dissection of the right internal carotid artery, without proof of acute cerebral infarctions. Blood testing showed an HIV-RNA load of 3.7 log/ml, a CD4/CD8 ratio of 0.62 with a total CD4 lymphocyte count of 0.49 G/l. All other blood and CSF values were without pathological significance. There was no evidence of a cerebral vasculitis or connective-tissuedisorders. Conclusion: While pathophysiology remains unclear, HIV is known to cause cerebral vasculopathy which leads primarily to the formation of cerebral aneurysms. We propose dissection of an extracranial artery as a new manifestation of HIV associated vasculopathy, although a causal link between HIV infection in our patient and the carotid artery dissection cannot be established definitely. Our findings may play an important role for clinical practice since arterial dissection can lead to stroke in HIV-infected patients. On the other hand diagnostic work-up of young patients with cervical artery dissection should probably include HIV testing.

P642 Acute encephalitis as initial presentation of primary HIV infection H. Nzwalo, P. Rosa´rio, M. Aguas Faro Hospital (Faro, PT); Garcia de Orta Hospital (Almada, PT) Background: Acute encephalitis is an uncommon and life threatening presentation form of primary HIV infection. There is a growing evidence that Highly Active Antiretroviral Therapy (HAART)

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S212 reduces systemic viral spread in HIV primary infection and can be life saving in cases like this one. Case report: We report a case of a previously healthy 51-year-old woman, admitted to the emergency department with fever, disorientation, altered state of consciousness and signs of meningeal irritation. Because of HSV encephalitis suspicion, she started acyclovir. Her clinical condition progressed unfavorably, with deterioration of consciousness (Glasgow Coma Scale 7), generalized hypertonia, and oral candidiasis. Brain MRI was unremarkable. Cerebrospinal fluid revealed a discrete mononuclear pleocytosis and was negative for CMV, VZV, HSV, EBV, Sifilis, Toxoplasma, Mycobacteria. Serology for Bartonella, Enteroviruses, and Mycoplasma where also negative. The EEG showed generalized diffuse slowing activity. The initial HIV Enzyme-linked immunosorbent assay (ELISA) was slightly positive, with negative HIV Western Blot and HIV-p24 antiginemia. Because of the possibility of HIV acute encephalitis the patient started a scheme of antiretroviral drugs with good central nervous penetration, ‘‘neuro-HAART’’, including zidovudine, lamivudine, lopinavir and ritonavir. Her condition improved in the following week, and at the end of the second week she was asymptomatic. Seroconversion to HIV I occurred four weeks later (ELISA, Western Blot), viral load was 6654 copies/ml, CD4 + lymphocyte count 537 cell/ml and CD8+ lymphocyte 1113 cell/ml. Conclusion: This case reinforces the need of considering acute HIV infection as an etiology of encephalitis. Although not completely established, initiating neuro-HAART can avoid fatal evolution in similar cases.

P643 Propagation of herpes simplex virus in a case of brainstem encephalitis via pontine fibre T. Ahn Kyung Hee University (Seoul, KR) Brainstem encephalitis can be a rare manifestation of herpes simplex virus (HSV). The route of entry was suggested as trigeminal nerve. However, the way of viral dissemination in the brainstem remains uncertain. Herein we report a case of HSV brainstem encephalitis in which the mode of viral propagation in the brainstem could be inferred. A 39-year old man was presented with gait ataxia. He had no history of other medical illness. Neurologic examination showed dysmetria, lateropulsion, and positive Babinski sign on the left side. Brain magnetic resonance imaging (MRI) showed gadoliniumenhanced (Gd+) lesions in the lower brainstem and middle cerebellar peduncle. Serum IgM antibody to HSV increased with pleocytosis in the cerebrospinal fluid (CSF). Acyclovir was effective to improve neurologic symptoms. However, about two weeks after acyclovir treatment, he had new cerebellar symptoms on the right side. Followup MRI showed new Gd+ lesions in the dorsal portion of the pons abutting on the pre-existing lesions and a solitary Gd-enhanced lesion in the right pontine base. Repeated CSF study was abnormal requiring another cycle of acyclovir. His neurologic symptoms gradually improved. Third brain MRI showed no Gd+ lesions. He was discharged with mild ataxia. Although the route of entry was uncertain in the first MRI due to the extensive lesions, the new lesions in the second MRI suggested a possible way of viral propagation. As the solitary lesion in the right pontine base was apart from the left pontine lesions, direct invasion was less likely to occur than propagation of virus via horizontal pontine fiber from contralateral pontine base. It was not reported any human case suggesting HSV propagation via neural connection in the central nervous system.

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P644 Human herpesvirus-6: an emerging pathogen of encephalitis in immunocompetent patients J. Rallis, N. Andronas, K. Pontikis, D. Kavatha, N. Oikonomopoulos, A. Tsakris, L. Stefanis Attikon University Hospital of Athens (Athens, GR); University of Athens (Athens, GR) Viral encephalitis is a syndrome characterized by acute inflammation of the brain parenchyma cause by a viral vector. In the past Human Herpesvirus-6 (HHV-6) was considered a rare cause of encephalitis that usually affected transplant recipients. Recently it is being increasingly recognized as an important cause of viral encephalitis in immunocompetent patients. We report the case of a 27 year-old previously healthy male patient that presented a febrile illness with gradually deteriorating mental status and complex partial seizures with secondary generalization that led to convulsive status. Routine CSF examination demonstrated lymphocytic pleocytosis with normal protein and glucose levels. Brain MRI on T2-weighted and FLAIR images revealed high-signal intensity in the hippocampal regions. Serum IgG antibodies as well as CSF polymerase chain reaction was positive for HHV-6. Testing for other bacterial and viral pathogens including HSV-1 was negative for acute infection. The patient received ganciclovir intravenously for 21 days. After the completion of therapy CSF pleocytosis normalized and PCR for HHV-6 was negative. On discharge his neurologic examination was normal, except for mild retrograde amnesia and rare brief complex partial seizures. Viral encephalitis is a potentially fatal disease and in many cases the causative agent remains undiagnosed. Recent reports have shown that HHV-6 could be a possible cause in a large subset of patients. However clinical characteristics, prognosis and natural course have not been well defined. The current case report demonstrates that HHV-6 encephalitis can lead to status epilepticus but prognosis can be favorable following proper treatment. Future research will determine if HHV-6 should be included in routine investigation of viral encephalitis in immunocompetent patients.

P645 Infections in neurological intensive care unit P. Stanarcevic, I. Berisavac, D.R. Jovanovic, L.J. Beslac Bumbasirevic Clinical Centre of Serbia (Belgrade, RS) Background: Severe stroke, accompanied with intracranial hemorrhage is the leading cause for admission in Neurological Intensive Care Unit (NICU) worldwide. Stroke patients, particularly those requiring mechanical ventilation are considered more prone to various complications, especially different kinds of infections. Our primary objective was to determine occurrence of various infectious complications in stroke patients, and to compare to general population of NICU patients hospitalized in one year period. Secondary objective was to compare overall and stroke related mortality and prognosis, and the presence of other selected neurological and systemic complications in stroke and non-stroke subgroups of patients. Methods: We included 318 consecutive patients, 87 of which had acute stroke (65 patients) or intracranial hemorrhage and subarachnoid hemorrhage (12 and 7 patients, respectively). Subgroup of patients requiring mechanical ventilation was analyzed, in general NICU population, so as in group of stroke patients. All data were retrospectively reviewed and statistically analyzed. Results: There were no statistically significant differences between two groups of patients in duration of hospitalization or gender

S213 distribution. However, extent of stay was longer in patients requiring mechanical ventilation in general NICU population then in stroke subgroup. Bronchopneumonia was most frequent infectious complication in NICU patients, occurring in 25,5%, comparing to 22% in non-stroke patients and 29 stroke patients (33%), raising to 52% in ventilated patients, but with major differences in stroke and non-stroke subgroups. Need for ventilatory support was registered in 73 patients, including 30 stroke patients. Respiratory failure was in correlation with more frequent onset of pulmonary complications, and strongly associated with higher mortality rate and longer hospitalization time in all patients. When it comes to onset op sepsis comparing stroke patients to subgroup of non-stroke, as well as to all NICU patients no statistically significant difference was found. Mortality rate was 19.8% for all patients included, rising up to 37% in group of patients with stroke. Conclusion: Except for bronchopneumonia, there were no statistically significant differences in frequency of infectious complications between analyzed subgroups. Mortality was much higher in stroke patients and short term prognosis and recovery was significantly poorer in stroke patients

Extrapyramidal disorders: Parkinson P646 A case-control study of restless legs syndrome in de novo previously untreated patients with Parkinson’s disease. Preliminary results S. Calzetti, A. Negrotti, M. Angelini, E. Marchesi, G. Bonavina University of Parma (Parma, IT) The co-morbid association between Parkinson’s disease (PD) and restless legs syndrome (RLS)is currently a controversial issue. The major criticism of the studies providing negative results concerns the inclusion of PD patients on dopamine(DA)ergic therapy, which could have masked a mild preexistent RLS or prevented its possible emergence following the onset of the neurodegenerative disease. The aim of this study is to assess the prevalence of ‘‘primary’’ RLS in de novo PD patients previously untreated with DAergic drugs. 55 cognitively unimpaired outpatients with PD(34M/21F, mean age 67.5 yrs ± 9.9 SD), attending the Movement Disorders clinic at the Department of Neurosciences, University of Parma, were included in the study. The mean duration of PD was 16.9 months ± 9.9 SD and the median H&Y stage was II (range I–III). All patients underwent careful interview in order to assess the occurrence of RLS in their lifetime, according to the current criteria established by the IRLS Study Group. 71 age and gender matched subjects (43M/28F, mean age 66.2 yrs ± 9.0 SD) were taken as controls and likewise interviewed. Known causes of secondary forms of RLS were subsequently ascertained in both patients and controls by history or by laboratory and/or EMG examination. No significant difference was found (chi-squared test)in the frequency of life-time RLS (both primary and secondary forms pooled together) between PD patients (4 out of 55, 7.27%) and controls (4 out of 71, 5.63%) and of life-time primary RLS between the two above populations (3 out of 55, 5.45% and 4 out of 71, 5.63%, respectively). The preliminary results of this survey, which is still ongoing, support the view of lack of significant co-morbid association between PD and RLS, either primary or secondary, in patients previously untreated with DAergic drugs. This finding confirms the results of our

previous study carried out on a larger population of PD patients, the majority of which were under DAergic therapy. The significant comorbidity of PD and RLS reported in several studies could be ascribed, in our opinion, to a number of factors, such as lack of exclusion of all known secondary causes of RLS in patients turned out positive for the sensory-motor disorder and the possible misdiagnosis due to occurrence of ‘‘mimics’’ of RLS in patients with l-dopa related motor fluctuation, the proportion of which has been only rarely reported in the populations studied.

P647 Complications of levodopa continuous infusion L. Planellas, V. Puente, M. Lo´pez, J. Jime´nez, M. Sepu´lveda, E. Giralt, R.M. Vivanco, E. Cuadrado, A. Seoane, J. Roquer Hospital del Mar (Barcelona, ES) Objectives: To report secondary complications of levodopa continuous infusion (LCI) in a series of 20 patients from our institution. Methods: We reviewed the register of advanced Parkinson disease (APD) patients who were treated with duodopa from February 2006 till February 2010 in Hospital del Mar (Barcelona). We used Hoehn and Yahr (H-Y), Schaw&England (S&E) and Unified Parkinson’s Disease Rating Scale (UPDRS) scales to evaluate all patients before and during the treatment. The ‘‘off’’ time was recorded by the participants daily, in a personal diary. Complications were stratified in 3 groups relating to: gastrostomy, tube and medication. Results: 20 patients (9 males and 11 females; mean age 68’45), with APD has been included. Firstly, LCI was tested by nasoduodenal tube and, afterwards, administrated by percutaneous endoscopic gastrostomy (PEG) tube. The range of follow-up was from 2 to 47 months (average 25’16). The ‘‘off’’ time decreased from an average of 58’71% to 7’44%. We only registered 3 withdrawals (0’15): 1 death, 1 who did not respond at nasoduodenal test and 1 due to severe biphasic dyskinesias. Regarding PEG complications, there were 2 duodenal ulcers (0’1), 11 granulomas (0’55), 4 abdominal pains (0’2), 6 stoma infections (0’3), 7. PEG irritations (0’35) and 14 PEG replacements (0’7). Regarding tube complications, there were 14 tube migrations (0’7), 9 obstructions (0’45), lost of weight in 8 patients (0’4), 21 connector replacements (1’05), 6 pump replacements (0’3) and 17 tube repositioning by fibrogastroscopy (0’85). There were 1 case of buried bumper syndrome and 1 of tube impaction on intestinal mucous that could not be solved by endoscopy and required surgical treatment. As newly secondary effects of levodopa, we registered 1 case of confusion (0’05), 2 hallucinations (0’1), 2 lack of impulse control (0’1) and 7 developed or increased dyskinesias (0’35) which responded to levodopa dosage modifications. Conclusions: The LCI complications were, in our experience, mild and mostly related to the infusion system. There was a satisfying treatment adherence with long term efficacy.

P648 The effect of pramipexole therapy on balance disorder and fall risk in Parkinson’s disease at early stage: clinical and posturographic assessment S. Gu¨ler, L.S. Bir, B. Akdag, F. Ardic¸ Pamukkale University (Denizli, TR) Objectives: The aims of this study were to define balance and postural instability level and ratio, to evaluate fall risk clinically and posturographically and to examine the effect of pramipexole on these

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S214 symptoms in newly diagnosed, early stage Parkinson’s patients who didn’t have any antiparkinson treatment before. Methods: 31 newly diagnosed, early-middle stage Parkinson’s patients who didn’t have any antiparkinson treatment before and 31 voluntary subjects without any neurological disorder, totally 62 subjects were included into the study. Pramipexole therapy was started at very low level doses and was increased gradually up to 3 mg. All the assessments were done before drug therapy, at 1,5 mg dose and 3 mg dose stages of pramipexole therapy. The patients were assessed with Hoehn&Yahr scale and Unified Parkinson Disease Rating Scale, whereas both patients and the control group were assessed with Berg Balance Scale. Detailed posturographic assessments which involved central vestibular, visual, peripheral vestibular, somatosensory field tests were applied to both patient and control subjects and fall risk was defined. The tests were applied 3 times to patients and 2 times to control subjects. Results: All clinic scales applied to patients including Berg Balance Scale, revealed the positive effects of pramipexole therapy. There wasn’t any statistically significant difference between patients and control subjects before and after drug therapy on fall risk defined by posturographic assessment and also no meaningful effect of drug on global fall index was found. However, in the analysis of subsystems, it was found that the involvement in central vestibular field was more severe and could appear at all positions in Parkinson’s patients and pramipexole was partially effective on this finding. Conclusion: Mild balance problems probably related with the involvement of central vestibular field can be seen in early stage of Parkinson’s disease. Pramipexole has positive effect on it.

P649 Are Parkinson’s disease patients taking dopamine agonists counselled and monitored for impulse control disorders? J. Cosgrove, C. Gilmore Nottingham University Hospitals NHS Trust (Nottingham, UK) Objectives: Dopamine agonist-induced impulse control disorders (ICD) are well recognised and can have a profound impact on patient and family quality of life. The study objectives were (i) to establish whether Parkinson’s disease patients commenced on dopamine agonists are counselled on the risk of developing ICD including compulsive gambling and (ii) to establish whether these patients are subsequently monitored for evidence of ICD. Method: A retrospective case-note review of Parkinson’s disease patients attending neurology outpatients in a large teaching hospital. Case-notes of patients receiving dopamine agonists (ropinerole, pramipexole or rotigotine) were assessed for documented evidence of (i) counselling at initiation of medication and (ii) monitoring for the subsequent development of ICD. Results: Of the 54 patients sampled, only 5 (9%) had documented evidence of counselling before initiation of the dopamine agonist. The year of commencement on dopamine agonist medication varied between 2001 and 2009 and in total the 54 patients were followed up over 228 outpatient appointments. Monitoring for evidence of ICD was documented in 51 (22%) of the 228 outpatient appointments. 31 (57%) of the 54 patients had no documented evidence of post prescription monitoring at any clinic visit. ICD were documented to have occurred in 8 (15%) of the 54 patients (7 impulse gambling, one hypersexuality). Conclusion: It is essential that patients – and their relatives – are aware of the potential for ICD on the initiation of dopamine agonists so that intervention can be made in a timely fashion. However, this study suggests that many Parkinson’s disease patients taking

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dopamine agonists are inadequately counselled and monitored for ICD in our centre and has led to the introduction of ICD patientinformation sheets to increase patient and relative education and awareness.

P650 Multi-segmental (eye-to-foot) coordination during gaze transfers in standing parkinsonian patients D. Anastasopoulos, E. Savvidou, N. Ziavra, A. Bronstein University of Athens (Athens, GR); Technological Educational Institute of Epirus (Ioannina, GR); Imperial College (London, UK) Multi-segmental coordination during horizontal gaze transfers was investigated in mildly affected, standing parkinsonian (PD) patients. Subjects (Ss) voluntarily re-orientated eyes and body to targets of eccentricities up to ±1808. We have asked which derangements in the pattern of this complex, clinically relevant motor behaviour compromise task performance. Ss stood upright and when a central LED at eye level was turned off, they had to locate and reorient themselves to a second LED which was lit at one of seven, different positions, either right or left. When this second LED was then extinguished, they had to turn back to the initial LED. As in the second occasion Ss knew where the target was, the movement was for eccentricities larger or equal to 90 deg memory driven. The experimental design allowed thus evaluation of the effect of target visibility and predictability on the resulting movement parameters. Comparisons of kinematic parameters were made by repeated measures ANOVA. The covariation pattern of eye-in-orbit, head-on-trunk and trunk-in-space horizontal angular displacement was quantified by means of principal components (PC) analysis. Patients’ movement initiation latencies were normal. In most trials to initially non-visible targets, the primary gaze shift fell short of the target and more than 50% of the visual angle was covered by the sum of nystagmic fast phases and head-in-space displacement. While normal Ss frequently acquired targets with a single large gaze shift during predictable trials, patients were unable to do so. In both normal and PD Ss, the combined movement was stereotyped such that the first two PCs accounted for the whole data variance of combined gaze transfers up to about 330 ms, suggesting that the three mechanical degrees of freedom (eye-head-trunk) are reduced to two kinematic degrees of freedom. However, in patients the eye contributed overall more and the trunk less to the gaze shift as compared with normal Ss. Peak trunk velocity and as a consequence of that peak head in space velocity were significantly decreased in patients. Acquisition time was significantly prolonged. Foot rotations, though of reduced amplitude and velocity, showed normal stepping frequency and coordination The overall pattern of movement during a whole body gaze re-orientations is preserved in PD. However, slowness in trunk rotation compromises target acquisition on average by more than 0.5s during the course of 180 deg pivot turns.

P651 Electrophysiological analysis of Myerson sign in Parkinson’s disease E. Uematsu, H. Kishida, T. Nakano, Y. Iwahashi, N. Ueda, S. Koyano, Y. Suzuki, Y. Kuroiwa Yokohama City University Hospital (Yokohama, JP) Objectives: The correlation between the Myerson sign, also called the glabella tap sign, and Parkinson’s disease (PD) has previously been

S215 reported. The present study consists of a quantitative electrophysiological examination of the characteristics of the Myerson sign in patients with PD. Methods: The study was performed on 10 patients with PD and 6 patients as a disease control group, all of whom visited the Neurology Department of Yokohama City University Hospital between 11/19/ 2009 and 12/9/2009 and gave informed consent. In order to determine a positive or negative Myerson sign in the subjects, we tapped the glabella with a light-weight hammer with an electric trigger and examined the evoked potential while the subject was blinking. The stimulation frequency was 2 Hz, repeated 20 times. The evoked potential was evaluated, and subjects with a positive or negative Myerson sign were compared. Results: Using a hammer, the R1 and R2 phases were observed in the same way as with the blink reflex procedure. This is different from the blink reflex that is observed bilaterally in the R1 phase, but in the present study only right-side blinks were examined. Subjects with a negative Myerson sign exhibited less than 10 blink reactions, and the R2 phase was observed at the same time. Subjects with a positive Myerson sign exhibited more blink reactions; eight of the 10 PD patients blinked over 20 times. Conclusion: The mechanism of the Myerson sign and its relation to the regions of the brain have not yet been clarified. It is believed that PD patients do not easily become habituated to glabella tapping. The present study demonstrated that habituation to blinking caused by glabella tapping can be evaluated electrophysiologically by using a special hammer.

P652 Investigation of mirror movements with transcranial magnetic stimulation in patients with Parkinson’s disease and effects of dopaminergic treatments M. Yucel, Y. Kutukcu, S. Bek, T. Kasikci, Z. Odabasi

P653 The earliest cognitive deficit in patients with Parkinson’s disease M. Petrova, M. Raycheva, L. Traykov Medical University (Sofia, BG) Parkinson’s disease (PD) is often associated with mild cognitive impairment (MCI) and dementia. Several recent studies have also noticed that even ‘‘cognitive intact’’ PD patients who do not cover the MCI criteria show some neuropsychological features similar to PD group with MCI. However, these early cognitive changes in PD patients are still unclear and appear as a subject of considerable controversy. Objectives: To determine the earliest cognitive deficit in nondemented PD patients without MCI. Methods: We investigated 52 PD patients and 56 normal controls. All subjects underwent a comprehensive neuropsychological assessment, as well as quantitative ratings of motor symptom severity and functional status. PD group included nondemented PD patients who had not covered modified Petersen’s criteria for MCI. Results: Compared to controls, PD patients demonstrated significantly lower scores on Modified Card Sorting Test (p\0.005), Trail Making Test part B (p\0.009)and Stroop test part 3 (p=0.05). However, there was not a significant difference between controls and PD group in digit span backward and forward, TMT part A, Stroop test part 1 and 2, Free and Cued Selective Reminding Test, semantic and phonemic verbal fluency, Boston naming test, Clock drawing test and copy of complex designs. Conclusion: The earliest cognitive deficit in PD is mainly related to cognitive flexibility, concept-formation and inhibitor control. More prospective studies are needed to understand the longitudinal course of these early cognitive changes in PD and to determine which of them represent a precursor to MCI and eventually dementia. This work is supported by a grant from the Medical UniversitySofia, Bulgaria.

Gulhane Medical Faculty (Ankara, TR) Objective: Mirror movements (MM) are unintended movements accompanying voluntary activity in homologous muscles on the opposite side of the body, particularly in distal arm muscles. Despite several mechanisms were proposed to explain congenital MM, pathophysiology of MMs in Parkinson’s disease (PD) is still unclear and there is not much study to explain it. In our study we aimed to explore MMs in early and advanced stage patients with PD before and after treatment with electrophysiologically and explain the mirror movements mechanism. Methods: 52 patients with PD and 15 voluntary healthy people were included. Without any treatment and new diagnosed patients were studied one month later again. Patients currently under treatment and the control group were examined once with TMS. Patients were neurologically examined before TMS application, and UPDRS scoring was performed and noted. Results: As a result electrophysiologically MMs were more common in patients with PD when compared with healthy people. Electrophysiologically MMs incidence was increasing parallel to UPDRS scores in patients with PD. Treatment did not affect the frequency of MMs in patients. When comparing motor threshold in patients with PD, motor threshold of motor cortex controlateral to clinical dominancy was significantly lower. Conclusion: Electrophysiological MMs are more often in correlation with the severity of PD. Relatively increased cortical motor hemisphere activity contralateral to clinically dominancy might be responsible.

P654 Parkinson’s disease – do patients with parkin gene mutations share a common phenotype? F. Moreira, R. Almeida, C. Janua´rio University Hospital of Coimbra (Coimbra, PT) Background: Parkin mutations are the most common known cause of early-onset parkinsonism particularly when the family history is compatible with autossomal recessive inheritance. More than 100 mutations have been described in the parkin gene and a large number of studies reported a similar phenotipic spectrum between carriers. It is still controversial whether heterozygous mutations in the parkin gene can cause parkinsonism or can confer an increased susceptibility for typical late-onset Parkinson Disease (PD). Objective: Descriptive analysis of a population of PD patients with parkin gene mutations. Methods: A total of 296 PD patients consecutively selected from the Movement Disorders department of Coimbra University Hospital underwent an extensive genetic screening including point mutations, exon deletions and duplications in the Parkin gene. In total, 13 patients with at least one parkin gene mutation were found and each proband performed an identical evaluation that included demographic and clinical features. Genotype-phenotype correlations were tentatively established. Results: In the overall sample (n=13) a total of 6 different mutations were found. In 3 patients mutations were found in the

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S216 homozigous state, 1 patient in the heterozygous compound state and 9 patients in the heterozygous state. In these patients, the mean age of onset of PD was 36.8±11.6 and the mean UPDRS motor scores (on state) was 30.9±10.6. Disease progression (HY nine years after diagnosis-HY at diagnosis)showed that 31% (n=4) of patients didn’t progress, 38% (n=5) progressed one stage and 31% (n=4) progressed 2 stages. Only one patient developed dementia (MMSE\15). A good initial response to levodopa was found in 92% (n=12) of all patients and 77% (n=10) had dyskinesias with low doses of dopa. The mean time of dyskinesias development was 3 years after levodopa onset. A family history of parkinsonism was found in 54% (n=7). Conclusions: Despite the small number of patients, there is a broad range of clinical phenotypes in our sample, some share the common features previously reported, but others are atypical, particularly in illness severity and disease progression. We discuss the influence of the number and nature of the mutations on the phenotype of the patients.

P655 Videoendoscopic characteristics of swallowing disorders in patients with Parkinson’s disease W. Roessy Sankt Rochus Clinics (Bad Schoenborn, DE) Objectives: Swallowing disorders are a common finding in Parkinson’s disease (PD) occuring in the late states and leading to aspiration and pneumonia. The videoendoscopic pharyngolaryngoscopy provides an efficient method for diagnosing penetration or aspiration of different media (liquid, puree, bread) and for measuring the velocity of the food-transit. The aim of the present study was to determine the specific particularities of swallowing problems in PD. Methods: Twenty Parkinson-patients with clinically probable swallowing disorders underwent a videoendoscopic pharyngolaryngoscopy. The duration of the oral phase, of the pharyngeal swallowing and of the epiglottic occlusion was quantified by time measurement. Results: The oral phase and the pharyngeal swallowing were extended in most of the patients, whereas the length of the epiglottic occlusion was normal in all patients, compared to 10 healthy controls. 5 patients with a normal duration of the oral phase showed an untimely crossing (‘‘leaking’’) of the food into the pharynx. Conclusion: There usually is a prolonged oral and pharyngeal transit-time of food in Parkinson-patients with swallowing disorders compared to healthy controls. Unexpectedly, patients with a normal length of the oral phase bear the risk of aspiration due to a possible leaking of food.

P656 Dysautonomia – symptoms of Parkinson’s disease? D.K. Pokharel, L.V. Chichanovskaya Tver State Medical Academy (Tver, RU) Background: In fact, Parkinson’s disease is diagnosed only when the first signs and symptoms of motor Parkinsonism become overt. Sometimes, Symptoms of dysautonomia can even precede the motor symptoms, can occur in all disease stages of PD or can occur as Dopamine dysregulation syndrome. Dysautonomic symptoms can easily be missed as there is a tendency to concentrate on the motor aspects of PD.

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Objectives: To disclose dysautonomic symptoms in PD. Methods: 63 patients with PD were observed with age of 55 – 75. Disease course -3.1± 2.5 years, dopaminergic therapy -2.8 ± 2.4 years. Analysis of anamnesis, neurologic exam, UPDRS tool, modified Hoehn Yahr Staging of PD, Schwab and England Activities of Daily Living and PD Non-Motor Group (PD-NMG) - NMS questionnaire was performed to each patient. Results: Symptoms of dysautonomia was found in 37(58.7%) patients. These symptoms were as follows: orthostatic hypotension- in 50% of them, bladder dysfunction-in 70%, gastrointestinal dysfunction (particularly, constipation – 71%, hypersalivation – 70%), sexual dysfunction (reduced and increased sex drive)- in 40%, and others (in 35% of them)-thermoregulatory dysfunctions, papillary abnormalities, respiratory disorders and hyperhidrosis. 25 (67.5%) of them, reported that these symptoms became prominent after dopaminergic therapy(Dopamine dysregulation syndrome). Conclusion: During the pre motor and motor course of Parkinson’s disease, Non Motor Symptoms consisting of light to serious autonomic crisis were observed; delayed detection of which may lead to disability and poor quality of life. Early recognition of these dysautonomic features is therefore essential for the successful management of PD.

P657 Parkinsonism rates in elderly hip fracture patients compared with age- and gender-matched controls K. Yiannopoulou, E. Meidani, I. Anastasiou, D. Kaklamanis, T. Ganetsos, K. Karydakis Laiko General Hospital of Athens (Athens, GR); Athens University Medical School (Athens, GR); Technological Educational Institute (Lamia, GR) Objectives: Parkinson Disease (PD) and Parkinsonism are associated with increased fractures and mortality. Patients with hip fracture (HF) and diagnosed PD have more difficult functional recovery and a higher risk of suffering a second hip fracture. In an attempt to estimate the prevalence of Parkinsonism in HF elderly patients, we assessed patients who had suffered HF and controls. Methods: We randomly assigned patients aged 68 and older admitted in our hospital for HF repair during last year. We compared them with age- and gender matched patients attending other surgical departments. All of the participants (80 HF patients and 80 controls) were examined by two neurologists to determine those who had the cardinal motor features of Parkinsonism. Previous Parkinsonism diagnosis was also assessed. The mean age of patients was 80,563 years and that of controls 80,138 years. Result: Parkinsonism was significantly more common in the HF group than the control group (HF 76,25%, controls 37.5%; p=0.000\ 0,05 with 95% CI=66,9249- 85,5751%). Only 6,25% of HF patients were diagnosed and treated for PD (p = 0,000 \ 0,05 with 95% CI= 2,0603 – 13,9857%). The prevalence of Parkinsonism in HF elderly patients is significantly higher than in control group. Most of them are not aware of their Parkinsonism. Conclusion: Our study indicates the necessity of routine neurological examination of every HF patient, because of the increased possibility of undiagnosed PD or other cause of Parkinsonism coexistence at the time of fracture. It is also a chance for these patients to start receiving a treatment that will improve their quality of life in the future by avoiding the rapid progression of their undiagnosed parkinsonian syndrome and help them to have a better recovery and to avoid a second hip fracture.

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P658 Effects of spinal cord stimulation in a patient with Parkinson’s disease and chronic back pain D. Weise, D. Winkler, J. Meixensberger, J. Classen University of Leipzig (Leipzig, DE) Objectives: Gait disturbances and postural instability are frequent causes of disability in advanced Parkinson’s disease (PD), and are known to respond poorly to levodopa and stimulation of the subthalamic nucleus. Recently, Fuentes and colleagues observed improvement of locomotion after epidural electrical stimulation of the dorsal columns of the spinal cord in two animal models of PD (Fuentes et al., 2009). Electrical spinal cord stimulation (SCS) is used in humans to treat persisting back pain after lumbar spinal surgery. Here, we investigated the effect of SCS on locomotion in a patient with PD who was surgically treated for medically untractable severe chronic back pain. Methods: We report a 72-year old female patient with the coexistence of advanced PD of mixed type (Hoehn and Yahr stage IV, disease duration 17 years), who had been treated with bilateral deep brain stimulation of the STN (DBS) for 2 years (with good effect on the limb-related parkinsonian signs but with persistent gait disorder including freezing) and chronic back pain which was refractory to pain medication. SCS was performed with electrodes placed epidurally above the dorsal columns at the cervicothoracic level. The effect of electric stimulation on a pain score (numerous analogue scale, NAS), UPDRS III (with quantification of bradykinesia of the extremities) and the ‘‘up & go’’ test in the DBS-on and –off state were evaluated prospectively. Results: SCS led to a distinct reduction of pain (NAS from 5-6/10 to 1-2/10). However, despite extensive testing of stimulation parameters (e.g., stimulus intensity, duration and frequency) no clear improvement of the UPDRS III, the subscores for bradykinesia, or locomotion could be observed after SCS with DBS either ‘‘on’’ or ‘‘off’’. Independently of SCS, UPDRS III remained responsive to DBS (off 50, on 27). Conclusion: SCS in this singular patient with advanced PD did not improve locomotion and motor scores. Further studies are needed to assess the effect of SCS prospectively in PD patients. Fuentes R et al., Spinal cord stimulation restores locomotion in animal models of Parkinson’s disease, Science, 2009, 323(5921): 1578–82.

P659 A possible role for antigranulocyte immunoscintigraphy in the approach of skin infection following deep brain stimulation surgery R. Real, P. Linhares, H. Fernandes, M.J. Rosas, J. Pereira, R. Vaz Hospital S. Joa˜o (Porto, PT) Introduction: Deep brain stimulation (DBS) of the subthalamic nucleus is an effective therapy for advanced Parkinson’s disease (PD) that is, nevertheless, subject to complications. Skin infection constitutes a serious adverse event as it often leads to stimulation system removal. To address the issue of infection management following DBS surgery, we set to evaluate the potential role of immunoscintigraphy with 99mTc-labelled antigranulocyte antibodies (Sulesomab) in the development of a rational therapeutic approach of postoperative infection in PD patients. This technique has been used in different clinical settings to detect infectious foci, but its application following DBS surgery has not yet been reported.

Methods: Five consecutive PD patients with clinical evidence of skin erosion or infection were submitted to immunoscintigraphy with 99mTc-Sulesomab and, depending on its results, were further submitted to wound debridement alone or in combination with either partial or complete stimulation system removal. Results: Patients were divided into two groups according to the location of wound dehiscence. The first group comprised four patients that had chronic retroauricular wound dehiscence while the second group included the one patient with subclavicular wound dehiscence. Among the first group of patients, one had a normal distribution of radiolabeled leukocytes and was offered wound debridement alone. Other two patients with retroauricular wound dehiscence were shown to have an abnormal localized radiolabeled leukocyte activity underlying the retroauricular wound and were subjected to partial stimulation system removal that spared only the electrodes. The last patient on this group presented with diffuse 99mTc-leukocyte activity that included the retroauricular and right frontal wounds, as well as along the extracranial trajectory of the corresponding electrode, which resulted in a complete stimulation system removal. Among the second group of patients, a localized distribution of the 99mTc-labeled leukocyte could be observed underlying the subclavicular wound, and the patient was subjected to partial stimulation system removal. Discussion: These preliminary data suggest that immunoscintigraphy with 99mTc-Sulesomab may assist in planning the surgical treatment strategy of skin infections following DBS surgery, by assessing the subcutaneous extension of the infectious process and consequently the extent of stimulation system removal necessity.

P660 Safety of intraoperative microelectrodes multiple recording tracks in deep disease S. Zambito Marsala, M. Moro, F. Ferracci, P. Lauricella, F. Moro, G. Guseo, M. Gentile, M. Gioulis, R. Candeago, C. Marchini Hospital San Martino (Belluno, IT); Medtronic (Milan, IT) Objective: to evaluate safety of five intraoperative microelectrodes multirecording tracks during deep brain stimulation (DBS) of subthalamic nucleus (STN) in Parkinson’s Disease (PD). Background: Currently most groups who perform DBS of STN in PD patients usually utilize microelectrodes recordings and then microstimulation of the better trajectory. However there is no general agreement regard the number of tracks to explore. Methods: We have studied 10 patients (7 males, 3 females) with advanced PD, mean age 63,4 years treated with DBS of bilateral STN. For neuroradiological targeting of the nucleus we used a TCMRI fusion algorithm. We used five parallel trajectories (central, lateral, medial, anterior, posterior) to recognize STN. The criteria adopted to select the better trajectories were 1) the length of an individual track displaying typical STN activity 2) the bursting pattern activity. Then we performed microelectrode stimulation evaluating side effects and motor improvement of rigidity, bradykinesia and tremor. Results: in 7 patients we utilized five recording tracks while in 3 cases we needed to exclude lateral trajectory in respect to cerebral sulcus in two cases and sulcal artery in one patient. Considering both sides central trajectory was selected in 12 records and it was chosen as definitive track where implant the final electrode in 9 situations. Posterior track was selected in 3 registrations and it was chosen as final implant in 2 patients. Anterior tracks was selected in 4 records and it was chosen for final implant

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S218 in 3 patients. Lateral track was selected in 4 studies but it was not considered useful for final implant in our series because the selective stimulation was responsible of transitory side effects (dyplopia anf facial hemispasm). We observed only one major side effects consisting in mild frontal haemorrhage along the trajectory of the definitive electrode in one patient with spontaneous recovery. The duration of the surgery was about 4-5 hours including the final placement of the stimulator in the chest. All 10 patients showed a marked clinical improvement after one year of chronic stimulation with great reduction of dopaminergic therapy. Conclusions: our experience with five intraoperative microelectrodes recording tracks allows to establish that this procedure is safe, fast and useful to define the best site where implant the definitive electrode.

P661 Neuropsychological effects of deep brain stimulation of the subthalamic nucleus in advanced Parkinson’s Disease: a clinical, neuropsychological and neurophysiological study S. Zambito Marsala, C. Lo Cascio, F. Ferracci, M. Moro, F. De Biasi, F. Fabris, A. Fornasier, M. Gioulis, M. Gentile, R. Candeago, C. Marchini Hospital San Martino (Belluno, IT) Objective: to investigate the possible neuropsychological abnormalities in patients with advanced Parkinson’s Disease (PD) after deep brain stimulation (DBS) of subthalamic nucleus (STN) evaluating neuropsychological and neurophysiological tests. Background: neuropsychological impairment may be observed in PD patients after DBS especially in elderly; nevertheless the definite extent of this condition still raises different opinions. Methods: we studied 9 patients (7 males 2 females) mean age of 63.88 years treated with DBS of STN (the mean duration DBS treatment is 3.5 years; range 1–7 years) with great improvement of motor functions. They all underwent to a complete neuropsychological assessment prior surgery, and then a regular follow up of cognitive functions was established at 1,3,6,12,24,36,72 months. We also performed cognitive event-related potentials (P300) after DBS. In three patients P300 was evaluated before and after DBS. We also studied the difference of P300 latency and morphology with DBS-ON (in bipolar setting to reduce the artifact signal) and DBS-OFF, in all patients. We investigated also the Mini Mental State Examination (MMSE) with DBS-ON immediately before P300 execution. Results: Mean MMSE immediately before P300 with DBS-ON was 24.31. The mean latency of P300 after surgery with DBS-ON was 385.3 msec instead with DBS OFF was 401.7 msec. In the three subjects we could study P300 before and after surgery, the mean latency of P300 was 422 msec before DBS and after surgery with DBS-ON the mean latency was 366 msec and with DBS-OFF 388 msec. The amplitude of P300 in DBS-OFF was slightly reduced in respect ON stimulation. Neuropsychological tests before and after DBS disclosed a moderate worsening of fonemic fluency, but not as a selective variable and mild general cognitive profile decline. Conclusions: Our survey displays a slight improvement of attention and discriminatory abilities after surgery. On the contrary neuropsychological evaluation figured out a moderate decline of general cognitive abilities with reduction of verbal fluency. We may hypothesize that a selective frontostriatal pathway may be involved. We are trying to extend our population and create new set of neurophysiological and neuropsychological approach.

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P662 Improvement of time estimation after subthalamic deep brain stimulation in Parkinson’s disease P. Dusek, R. Jech, T. Serranova´, T. Sieger, J. Wackermann, E. Ruzicka Charles University (Prague, CZ); Czech Technical University (Prague, CZ); Institute for Frontier Areas of Psychology (Freiburg, DE) Objectives: Parkinson’s disease (PD) patients fail in time estimation. It has been shown that impaired performance in time reproduction task (TRT) improves after bilateral deep brain stimulation of subthalamic nucleus (STN DBS). It remains unclear whether timing deficit in PD patients and effect of STN DBS is constrained to TRT in particular or reflects more widespread timing dysfunction. It is also unclear, whether DBS of the right or left STN is responsible for this improvement. The aim of this study was to compare performance in TRT, time production task (TPT) and preferred motor tempo task (PTT) in PD patients during DBS of the right, left and bilateral STN, in the DBS OFF condition and in age matched controls. Methods: Twelve PD patients (all male, age 57.4 (mean) ± 6 (SD) years, PD duration 14.4 ± 4 years, 2.5 ± 2 years after the DBS implantation) and twelve age matched healthy volunteers have undergone PTT, TRT with intervals 5 and 16 seconds and TPT with intervals 5, 7, 13 and 16 seconds, each interval repeated several times in a pseudorandom order. TRT consisted of an encoding phase, during which visual stimuli of various durations were presented and a reproduction phase, during which durations were reproduced by button pressing. TPT consisted of a button press after a given duration, which was written on a screen. PTT as a measure of internal tempo was assessed by instructing the subjects to tap regularly at their preferred rate. Each patient was tested after a 12 hour withdrawal of dopaminergic medication in four conditions in a counterbalanced order: STN DBS OFF, DBS of the right STN, DBS of the left STN and bilateral STN DBS. Patients were tested at least 1 hour after switching into a particular DBS condition. Results: No differences were observed in PTT or TPT between PD patients and controls in any of the DBS conditions, while in TRT, PD patients significantly overestimated the 5 second interval in the DBS OFF condition compared to controls (P\0.037). This was not observed for any other condition. Conclusions: Results of this study suggest a specific timing deficit in PD patients. Impaired performance in the TRT might be caused by working memory dysfunction causing distortion of the remembered duration. This dysfunction is improved by STN DBS of any brain hemisphere, which might be due to hemispheric indifference in this task or bilateral effect of unilateral STN DBS. Supported by grants IGAMZ1A8629-5 and GACR309/09/1145 and by the research program MSM0021620849.

Multiples sclerosis: neuro-immunology/ experimental P663 Modulation of interleukin-16 by interferon b-1a treatment in patients with multiple sclerosis S. Nischwitz, P.G. Sa¨mann, M. Knop, F. Mu¨ller-Sarnowski, H. Faber, A. Yassouridis, F. Weber Max Planck Institute of Psychiatry (Munich, DE) Objectives: Interleukin-16 (IL-16) is a chemoatractant for a variety of CD4+ cells (T-lymphocytes, eosinophils, monocytes and dendritic

S219 cells) and is produced by immune cells like T-cells, eosinophils and dendritic cells, but also by neuronal cells, fibroblasts and epithelial cells. There is convergent evidence that IL-16 may play an important role in the pathogenesis of multiple sclerosis (MS): IL-16 levels in brain were found to correlate with CD4+ T cell infiltration, and downregulation of IL-16 mRNA in PBMCs during the first three months of therapy with interferon-b 1a (IFN-b1a) has been reported. In animal models, an increase of IL-16 levels in brain and particularly in microglia has been shown after induction of EAE, and paralysis was reversible by treatment with an anti-IL-16 antibody. In addition, marked upregulation of IL-16 was measured in the spleen and lymph nodes of EAE mice during relapses and in chronic disease. Methods: We determined IL-16 in serum of 16 RRMS patients before and at months 6 and 12 during IFN-b1a therapy by a commercially available ELISA and compared these to 18 age and gender matched healthy subjects. Samples were collected 12 hours after the last injection of IFN-b1a. Magnetic resonance imaging (MRI) was performed before therapy and at month 12 to screen for new T2 lesions and contrast enhancing T1 lesions. Results: At baseline MS patients showed significant higher IL-16 levels compared with controls (Bonferroni corrected post-hoc tests in one-way ANOVA, p\0.05). During 12 months of IFN-b1a treatment IL-16 levels decreased significantly (contrast tests in repeated measures ANOVA, p \ 0.05). At month 12 there was no significant difference between patients and controls, although the patients still had higher mean IL-16 levels. Relapses defined by Gadolinium enhancing T1 lesions in the MRI had no significant effect on IL-16 levels. Conclusion: First, these data suggest, that elevated IL-16 serum levels normalise in MS patients during the first year of IFN-b1a treatment. This reduction may be of relevance for the therapeutic effect of IFN-b1a, as there is evidence from the EAE model that a neutralising antibody directed against IL-16 has the capability to reduce disease activity. Second, IL-16 serum levels were not influenced by relapses. The project was supported in part by Merck Serono GmbH.

P664 Expression levels of cell surface bound interferonreceptor remain stable during short- and long-term interferon b-1b treatment K. Oppermann, P. Wipfler, G. Pilz, A. Harrer, E.-M. Duerr, W. Koczi, C. Sulzer, S. Afazel, E. Haschke-Becher, G. Ladurner, J. Kraus Paracelsus Medical University (Salzburg, AT); Salzburger Landesklinken (Salzburg, AT) Objectives: To investigate the cell surface bound expression of IFN-a/ b receptor (cIFNAR) on peripheral blood mononuclear cells (MNC) subsets during IFN-b-1b treatment in relapsing remitting multiple sclerosis (RR-MS). Background: Interferon-b-1b (IFN-b-1b; BferonTM) treatment is both effective and safe in the treatment of multiple sclerosis (MS). Several different immunomodulatory effects of IFN-b-1b have been described such as modulation of the cytokine network. However, the expression of cIFNAR on MNC during IFN-b treatment has only sparsely been investigated. Methods: Quantitative expression levels of cIFNAR on MNC subsets (CD3+, CD4+, CD8+, CD 14+, CD 19+, CD45RA+, CD16/ CD56+) in the peripheral blood of 19 RR-MS patients were measured by five-colour flow cytometry (Beckman Coulter) in 3 different RRMS patient groups (group 1: at baseline and after two months of IFN-

b-1b treatment (n=8); group 2: IFN-b-1b treatment for 2 to 5 years (n=4); group 3: IFN-b-1b treatment for more than 5 years (n=7)). Results: We found consistently stable results for all investigated MNC subsets at all time points: After two months of IFN-b-1b treatment cIFNAR levels were not significantly increased in most of the investigated MNC subsets as compared to baseline. Four patients from group 1 were also examined after 8 months and cIFNAR remained unchanged. Moreover, cIFNAR expression levels were at the same levels after 2 to 5 years and after more than 5 years of IFNb-1b treatment as compared to expression levels at the onset of IFNb-1b treatment. Conclusions: We obtained impressively stable results for cIFNAR expression on peripheral blood MNC subsets after short-, intermediate- and long-term treatment with IFN-b-1b. These findings suggest a lack of attenuation mechanisms at the level of cIFNAR expression after intermediate and long-term treatment with IFN-b-1b in MS. This lack of regulatory effects on cIFNAR might be a molecular key mechanism of long-term IFN-b-1b efficacy in MS treatment. This study was supported by Bayer Schering Pharma, Austria.

P665 Detection and quantification of IFNB-1b-induced NAbs using various assays and laboratories H.P. Hartung, B.C. Kieseier, D.S. Goodin, B. Arnason, G. Comi, S. Cook, M. Filippi, D. Jeffery, L. Kappos, P. O’Connor, T. Bogumil, V. Knappertz, C. Pohl, R. Sandbrink, B. Stemper, S. Lehr, J. Reischl Heinrich-Heine-University (Du¨sseldorf, DE); University Hospital (Du¨sseldorf, DE); University of California (San Francisco, US); Surgery Brain Research Institutes (Chicago, US); University Hospital San Raffaele (Milan, IT); University of Medicine and Dentistry of New Jersey (Newark, US); Wake Forest University (Winston-Salem, US); University Hospital (Basel, CH); St. Michael’s Hospital (Ontario, CA); Bayer HealthCare Pharmaceuticals (Montville, US); Bayer Schering Pharma AG (Berlin, DE) Background: The development of neutralizing antibodies (NAbs) during use of interferon b (IFNB) for the treatment of multiple sclerosis (MS) is well known. A number of testing procedures have been implemented, but there is no single universally accepted method for evaluating the presence or titer of NAbs. Objective: The objective of this study was to compare detection of IFNB-1b (Bferon)-induced NAbs and quantification of NAb titers using various assays and laboratories and to determine the degree of agreement between results. Methods: In a clinical study of RRMS patients, 125 serum samples were collected from IFNB-1b treated patients. Based on the MxA induction assay, 42 samples were found to be NAb-negative and 83 were NAb-positive, with titers above the lower limit of quantification. These samples were re-analyzed in the same laboratory using the same MxA induction assay and three other laboratories using a luciferase induction assay (one laboratory) and the cytopathic effect assay (CPE, two laboratories). The co-efficient j was used to measure agreement between laboratories (NAb-positive/negative status), with agreement ranging from 0–1 (0 indicates agreement by chance, 1 indicates complete agreement). Results: NAb-negative/NAb-positive agreement was very high for the intra-laboratory comparison of the MxA induction assay (j=0.86). There was also very high agreement between the MxA induction assay and one CPE assay (j=0.87). All other comparisons were lower with a j of 0.65 between the two CPE assays, 0.68 between the second CPE assay and MxA, 0.63 between the luciferase assay and MxA, and 0.6 and 0.57 between the luciferase assay and each of the

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S220 two CPE assays. There was good correlation in titer levels for the intra-laboratory comparison of the MxA induction assay, as well as between the MxA induction assay and one CPE assay. Discordance in titer quantification occurred for all other comparisons. Conclusions: There are substantial differences between laboratories and assays in the detection and quantification of IFNB-1binduced NAbs. These need to be considered when interpreting NAb results and in any recommendation on using NAb titers in general clinical practice. Supported by Bayer Schering Pharma AG, Berlin, Germany

P666 Systematic assessment of JC virus in multiple sclerosis patients treated with natalizumab I. Slesari, O. Heinzlef, J.-D. Poveda Poissy Hospital (Poissy, FR); Pasteur Cerba Laboratory (Paris, FR) JC virus (JCV) is a human polyomavirus that establishes life-long latency in kidney and lymphoid organs. JCV is known for its capability of inducing progressive multifocal leucoencephalopathy (PML). In a clinical trial with b-1a interferon and natalizumab, 2 multiple sclerosis (MS) patients developed PML. 23 other patients developed PML since natalizumab approval. We monitored monthly during 27 months 31 patients with RRMS treated with natalizumab for a mean of 20 months (2-28), for reactivation of JCV/BKV in blood. Peripheral blood was collected monthly from all 31 patients, and DNA was analyzed using standardized JC/BK Consensus kit according to standard procedure. Polyomavirus screen including JCV and BKV PCR, performed on blood samples as enrolment, and monthly thereafter. Among 614 blood samples, we have found transitory presence of JCV in the serum of one MS patients treated with natalizumab for 2 months. The patient did not have unusual symptoms, MRI was not modified and natalizumab was not interrupted. She received in October 2009 the tenth infusion of natalizumab. Our test and the majority of 120 laboratories worldwide registered for the 2009 QCMD EQA distribution for detection and quantification of BK and JC virus1 is able to detect JCV at a consensus concentration of 171 copies/ml (JC.BK09-09). Specificity, as judged by the falsepositivity rate on the true negative specimen (JC.BK09-04), was good for both JCV and BKV specific assays (0.9%). Over 90% of laboratories detected BKV at a consensus concentration of 367 copies/ml. JC virus detection in blood samples of MS patients under natalizumab therapy is a rare event and is not associated with duration of treatment when using the standard detection kit. This is different from recent published results with a more sensitive test ([25 copies/ml) showing frequent JCV reactivation2. However the clinical signification of positivity of JCV detection whatever the sensitivity remains undetermined in MS patients under natalizumab therapy.

P667 Short- and long-term decrease of soluble adhesion molecules (sICAM-1, -2, -3 and sVCAM-1) during natalizumab treatment K. Oppermann, G. Pilz, P. Wipfler, A. Harrer, C. Sulzer, S. Afazel, E. Haschke-Becher, G. Ladurner, J. Kraus Paracelsus Medical University (Salzburg, AT); Salzburger Landesklinken (Salzburg, AT) Objectives: Natalizumab (Tysabri) is a monoclonal antibody used in the treatment of multiple sclerosis (MS). This humanized antibody

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binds directly at the a4-integrin subunit of the adhesion molecule (AM) very late activation antigen-4 (VLA-4) and, thus leads to an inhibition of immune cell extravasation across the blood-brain barrier. This consecutively results in a reduced inflammation of the central nervous system. Our objective was to study the short and long-term effects of Natalizumab treatment on soluble cell AMs in peripheral blood of MS patients. Methods: We determined serum concentration levels of 4 different AMs (soluble intercellular adhesion molecule-1, -2, -3 (sICAM-1, -2, -3) and vascular cell adhesion molecule-1 (sVCAM-1)) by using fluorescent bead immunoassay and enzyme linked immunosorbent assay (ELISA). Blood was sampled from MS patients before, three and twelve months after onset of Natalizumab treatment (short-term: n=20; longterm: n=14). Results: A significant decrease was found in all patients for sICAM-3 serum concentration levels (before therapy: 95ng/ml; after three months: 61ng/ml; p \ 0,001) and sVCAM-1 (before therapy: 617ng/ml; after three months: 217ng/ml; p \ 0,001) levels three months after onset of natalizumab treatment. The decreases of sICAM-3 and sVCAM-1 levels were also seen after twelve months of Natalizumab treatment (sICAM-3: before therapy: 102ng/ml; after twelve months: 45ng/ml; p \ 0,001; sVCAM-1: before therapy: 543ng/ml; after twelve months: 245ng/ml; p \ 0,001). In contrast, serum levels of sICAM-1 and sICAM-2 remained unchanged. Conclusion: We were able to show a significant decrease of serum levels after three and twelve months of Natalizumab treatment in two (sICAM-3 and sVCAM-1) of the four investigated soluble AMs. VCAM-1 is the ligand of VLA-4. We therefore conclude that the decrease of sVCAM-1 might be a result of Natalizumab mediated blocking of VLA-4. Alternatively, the decrease of sVCAM-1 in conjunction with the decrease of sICAM-3 might also be due to the anti-inflammatory effects of natalizumab. This study was supported by Biogen-Idec Austria.

P668 A study of cytokines (Th1/Th2) in relapsing remitting multiple sclerosis patients treated with natalizumab and glatiramer acetate C. Oreja-Guevara, J. Ramos Cejudo, L. Stark, G. Lubrini, L. Gabaldo´n Torres, M.L. Martı´n-Barriga, E. Diez-Tejedor University Hospital La Paz (Madrid, ES); Hospital Gregorio Maran˜on (Madrid, ES) Background: Multiple sclerosis (MS) is an inflammatory disease of nervous system in which cytokines play an important role. While increasing levels of Th2 cytokines are associated with inflammation reduction and improvement in patient’s symptoms, the Th1 cytokines are related with increasing inflammation, disease progression and worsening symptoms. Th2 and Th1 cytokines have antagonist effect and the progression of disease may depend on the balance between both types of cytokines. Objectives: To evaluate the effect of an immunosuppressive treatment for MS, natalizumab, and the effect of an immunomodulatory treatment, glatiramer acetate, in the serum levels of cytokines in relapsing-remitting multiple sclerosis (RRMS) patients and to determine the relationship between disease duration and disability with the levels of cytokines. Methods: Serum from both groups matched in sex and age and treated for 9 to 12 month were collected and store at -808c. The levels of 14 cytokines (IL1a, IL1b, IL2, IL4, IL5, IL6, IL8, IL10, IL12p70,

S221 IL13, MCP-1, TNF-a, IFN-g and GM-CSF) were determined by flow cytometry (FacsCalibur, BD Biosciense, CA, USA) using CBA flex set (BD Bioscience) according to manufacture instructions. MannWhitney U test was performed using a SPSS16 for MAC in order to analyse the results.Patients underwent a complete neurological examination (EDSS). Results: We studied serum of 14 patients with RRMS. In general, patients treated with natalizumab presented higher levels of serum cytokines than patients treated with glatiramer acetate. Natalizumab treated patients presented significantly higher levels of IL6 (p=0,005), MCP-1 (p=0,001), and GM-CSF (p=0,035) than glatiramer acetate treated patients. In addition, the levels of IL12p70, IL1b, TNF-a and IFN-g showed a clear tendency to be higher in patients treated with natalizumab. No significant associations were found between disability (EDSS), disease duration and levels of cytokines. Conclusion: Taken together the results demonstrate that patients treated with natalizumab have higher levels of circulating proinflammatory cytokines than those treated with glatiramer acetate. The significance of this observation is still unclear, but it may have a relation with undesirable side effect of treatment with natalizumab.

P669 Functional relevance of haematopoietic stem cell mobilization following therapeutic a 4-integrin blockade in multiple sclerosis: preliminary data M. Mattoscio, R. Nicholas, O. Malik, C. Mc Guigan, F. Dazzi, P.A. Muraro Imperial College London (London, UK) This single-centre, non-interventional, laboratory-based research study on blood obtained from Relapsing Remitting Multiple Sclerosis (RR-MS) patients receiving Natalizumab (TYSABRI) and healthy subjects (HS) wants to address whether Natalizumab(N)-induced increase of peripheral hematopoietic stem cells (HSC) is the result of true mobilization from the bone marrow to the blood or of impaired HSC migration to organs and tissues. OBJECTIVES: (1) To evaluate circulating HSC frequency and cell cycle status in N-treated MS patients and HS. (2) To detect potentially augmented thymopoiesis and increased diversity of the T cell repertoire. METHODS: HSC frequency was measured by FACS (fluorocytometric) enumeration of side scatter-low/CD34+cells after nucleic acid dye/CD34/CD45 staining on whole peripheral blood. Cell cycle was analysed on purified sorted CD45low-CD34+HSC by FITC/propidium iodine staining. Surrogate markers of thymopoiesis at pre- and post-treatment time points were acquired by FACS enumeration of Recent Thymic Emigrant CD4 and CD8 T cells. Study population: 15 crosssectional (C) group patients (single blood collection), 5 prospectively followed (A) patients (serial blood collection before the first infusion and at 1, 2, 6 and 12 months on treatment) and 22 HS. RESULTS:Higher mean value of CD34+HSC percentage and absolute number (AN) in RR-MS patient C population compared with HS. Significantly higher variance at F test on HSC AN in the whole patients C population (p=0.0003) and in C patients who received more than 3 infusions (p=0.0002) when compared with HS. Trend of progressive increase in CD34+HSC AN correlating with treatment duration in MS C patients. Different variance at F test on G0 (p=0.0091) and G2/M (p=0.0008) cell cycle phase analysis in patients C HSC compared with HS HSC. Trend to a progressive increase in CD4 naive and decrease in CD4 memory T cells count correlating with treatment duration in MS patients C. Increase of 46.68% after 2 N infusions in CD34+HSC AN on the only group A patient sample analyzed so far. CONCLUSIONS: results confirm N HSC-mobilisation effect and

suggest definition of differently responding MS patient populations. Data support further investigations of thymic output quantification during N treatment and of tissue-regenerating potential of N-mobilised HSC.

P670 Influence of mitoxantrone treatment in multiple sclerosis patients on serum paraoxonase 1 activity A. Jamroz-Wisniewska, J. Beltowski, Z. Stelmasiak, H. Bartosik-Psujek Lublin Medical University (Lublin, PL) Objective: Mitoxantrone is a synthetic antineoplastic anthracenedione indicated for reducing neurologic disability and/or the frequency of clinical relapses in patients with secondary progressive (SP), progressive relapsing, or worsening relapsing-remitting (RR) multiple sclerosis (MS). Paraoxonase 1 (PON1) is an antioxidant enzyme bound with HDL that protects both LDL and HDL against oxidative modification. The aim of this study was to examine the influence of mitoxantrone treatment in MS patients on serum PON1 activity. Methods: A studied group included 26 SP-MS patients (mean age was 41,1 years, mean disease duration – 8.9 years),16 women and 10 men, with a diagnosis of definite MS. The patients were in a stable stage of a disease. The blood was collected before the beginning of the therapy and after 6 and 12 months. Patients were receiving mitoxantrone every 12 weeks, the first dose was 10 mg/m2 and following doses – 12 mg/m2. Serum PON1 activity was assayed using two synthetic substrates: paraoxon and phenyl acetate. Plasma lipid profile was also assessed. Results: PON1 activity toward paraoxon and phenyl acetate and lipid profile did not change significantly in patients receiving mitoxantrone. We observed increased levels of total and LDL cholesterol. Conclusion: Mitoxantrone therapy in MS patients does not influence serum PON1 activity. We received support from Lublin Medical University.

P671 Vitamin D and interferon b influence on the monocytederived dendritic cells and CCL2 and CCL5 levels in multiple sclerosis patients K. Pocin˜ska, A. Gruszczak, H. Bartosik-Psujek, Z. Stelmasiak Clinical Hospital (Lublin, PL) Objectives: Multiple sclerosis is a chronic disease probably of autoimmune origin. Dendritic cells are professional antigen-presenting cells and play a major role in the immune system. Presently there are no effective methods of multiple sclerosis treatment. Commonly used treatment influencing the natural course of the disease is the use of interferon b. Therefore, further therapeutic methods need to be searched. Vitamin D is drug with the potential immunomodulative properties and some evidence indicating their effectiveness in multiple sclerosis. Material and methods: Peripheral blood mononuclear cells were isolated from twenty seven patients with relapsing-remitting multiple sclerosis and control group. Monocyte-derived dendritic cells were generated in vitro and incubated with IFN b and vitamin D. The dendritic cells differentiation and maturation were evaluated based on surface phenotypic changes and the expression of CD83, CD1a, CD80, CD86 was analyzed by FACS. The samples for analysis were centrifuged and supernatantas were removed and frozen at – 80C

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S222 until analysis. The levels of the CCL2 i CCL5 chemokines were determined in supernatants. All assays were determined in duplicate by enzyme – linked immunoassay (ELISA). Results: IFN-b, and vitamin D3 influence the immunophenotype of dendritic cells by modification of their functions in various ways. They all essentially decrease CD1 expression in comparison with non-treated patients. IFN-b causes increase while vitamin D3 result in the decrease of CD86 molecule expression in comparison with the control group. Vitamin D3 inhibits differentiation of dendritic cells from monocytes which is confirmed by statistically important increase in CD14 expression both in comparison with the control group. Moreover, vitamin D3 causes inhibition of dendritic cells maturation, decrease in CD80 and CD86 expressions in comparison with the control group. Moreover, IFN-b results in the essential increase of CCL2 chemokin secretion in comparison with patients not receiving such treatment. Conclusions: IFN-b, vitamin D3 in vitro treatment weakens the ability of glycolipid antigen presentation. Such action may limit autoaggressive reactions against own antigens. IFN-b in vitro treatment influences DC maturation and increases secretion of CCL2. Vitamin D3 in vitro treatment inhibits differentiation of monocytes in DC and inhibits their maturation which can activate DC tolerogenic properties.

P672 Serum levels of insulin-like growth factor- I and insulinlike growth factor binding protein-3 in relapsing and secondary progressive multiple sclerosis R. Lanzillo, C. Di Somma, M. Quarantelli, M. Gasperi, G. Ventrella, A. Prinster, G. Vacca, G. Orefice, A. Colao, V. Brescia Morra Hermitage Capodimonte (Naples, IT); Federico II University (Naples, IT); University of Molise (Campobasso, IT); NCR (Naples, IT) Background: there is a growing body of evidence of an alteration in peripheral Insulin Like Growth Factor-I (IGF-I) bioavailability in neurological diseases and a high interest on IGF-based therapy. IGF-I and IGF binding protein (BP)-3 serum levels are reported to be similar in controls and small cohorts of Relapsing remitting (RR) and Primary Progressive (PP) multiple sclerosis (MS) patients, but they were found to be higher in patients on Interferon (IFN) therapy. IGFBP-3 was found to correlate to progression index in PPMS. Objective: To evaluate IGF-I and IGFBP-3 serum levels in relapsing remitting (RR MS) and secondary progressive (SP-MS) courses of Multiple Sclerosis, with respect to normal controls and to evaluate correlations between these levels and clinical and radiological features of disease activity and progression. Methods: 63 (41 RRMS and 22 SPMS) ‘‘naive’’ patients and 60 age-matched healthy controls were enrolled. Patients were assessed through clinical [Expanded Disability Status Scale (EDSS)], Magnetic Resonance imaging (MRI) and laboratory investigations. IGF-I and IGFBP-3 were measured by Elisa on blood samples. A secondary progression index was calculated for SP patients. Results: Serum levels of IGF-I and IGFBP-3 were not different in the two MS patients groups. IGFBP-3 levels were higher in MS patients than in controls (p\0.001), with a corresponding reduction of IGF-I/ BP3 ratio (p\0.001). Patients showing IGFBP-3 levels higher than 2SD of the normal population had a higher EDSS (mean EDSS 3,7 vs 2,8, p=0.021). Secondary progression index did not correlate to IGFBP-3. Conclusions: IGFBP-3 serum levels were higher in MS patients than in controls and higher levels were associated to a higher EDSS. Therefore, a reduction in bioavailability of IGF-I seems to be correlated to a higher risk of developing MS and to a more aggressive course of disease. Secondary progression index is not related to

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IGFBP-3, substantiating a different pathogenetic mechanism of progression with respect to PP MS.

P673 Evidence for co-infections as environmental components in the pathogenesis of multiple sclerosis R.D. Serano, A. Fleg, A. Kenney Cape Fear Valley Health System (Fayetteville, US) Prior studies have attempted to associate MS with infectious agents without consensus for a single virus or bacterium. This is a retrospective analysis of antibodies to Herpes simplex (HSV 1), Herpes genitalis (HSV 2), Cytomegalovirus (HSV 4), Epstein Barr virus (HSV 5) and Chlamydia species in a cohort of 48 MS patients. Over a 3 year period six patients were not tested for HSV 5 and seven were not tested for HSV 1 or 2. 31 of 37 (86%) tested positive for HSV 1 or 2 and HSV 5. 11 of the 31 had the Early Antigen (EA) for HSV 5 as well as HSV 1 and /or HSV 2. 23 of 41 (56%)tested positive for antibodies for Chlamydia species and either HSV 1 or HSV 2. 21 of 42 (50%) tested positive for Chlamydia and HSV 5. 6 of 42 had HSV 5 EA and Chlamydia. We propose that the pathogenesis of MS may involve coinfections in susceptible individuals.Just because these agents are ubiquitous does not necessarily mean that they are innocuous.These three distinct patterns of coinfections in MS may be the basis for the variability in the presentation and clinical course which has been observed. Updated data regarding relapse rates and disability scores will be presented in this cohort treated with either antivirals, antibiotics or both over a 4 year period.

P674 Infectious and genetic factors in multiple sclerosis P. Karimi, Z. Pourpak, A. Shahin Jafari, M.H. Yazdi, S. Safaei, M. Mojdeh Ghabaee, A. Bayati Immunology, Asthma & Allergy Research Institute (Tehran, IR); Islamic Azad University (Karaj, IR); Tehran University of Medical Sciences (Tehran, IR); Iranian Center of Neurological Research (Tehran, IR) Objective: Multiple sclerosis (MS) is a complex pathology of the CNS in which genetic and environmental factors, such as viral infections, act together to cause disease. The aim of this study was to investigate the prevalence of EBV and HLA class II (DRB1*1501, DQA1*0102, DQB1*0602) in MS patients. Methods: A total of 200 MS patients (154 females; 46 males, Mean age=29 ± 8.5 y/o) were recruited. Patients with other neuralgic disease or infection were excluded. Demographic and clinical details (disease duration, initial symptom, disease course, EDSS and familial history) were recorded and peripheral blood was collected. PCR was performed using primers for detection of EBV genes. In addition, HLA typing for DR2&DQ6 alleles was obtained by polymerase chain reaction (PCR) amplification with sequence-specific primers (PCR-SSP) method. Results: EBV was found in 91(45.5%) samples. Frequency of HLA antigens in these patients were as follows: DRB1*1501: 85 (44.5%), DQA1*0102: 59(29.5%), DQB1*0602: 52(26%). There were no significant relationship between EBV prevalence and clinical manifestations. Moreover, no significant correlation was found among the presence of HLA DR2&DQ6 haplotypes and sex, type of disease; initial symptoms, expanded disability status scale (EDSS), as well as age at onset and familial MS. Discussion: This study indicates no significant relationship between EBV, HLA DR2&DQ6 haplotypes and MS clinical

S223 manifestations. These data are in line with some previous studies but in contrast to most of the studies conducted in Europe that demonstrate the significant role of environmental and ethnic factors in MS.

P675 Immunoproteasomes in brain: a new actor in ageing, Alzheimer’s disease and multiple sclerosis M. Mishto, E. Bellavista, C. Ligorio, K. Textoris-Taube, A. Santoro, M. Giordano, S. D’alfonso, F. Listi, B. Nacmias, E. Cellini, M. Leone, L. Grimaldi, C. Fenoglio, F. Esposito, F. Martinelli Boneschi, D. Galimberti, E. Scarpini, U. Seifert, M.P. Amato, C. Caruso, M.P. Foschini, P.M. Kloetzel, C. Franceschi Charite´ (Berlin, DE); University of Bologna (Bologna, IT); University of Eastern Piedmont (Turin, IT); University of Palermo (Palermo, IT); University of Florence (Florence, IT); Ospedale Maggiore della Carita` (Novara, IT); Istitute San Raffaele ‘‘G.Giglio’’ di Cefalu` (Milan, IT); University of Milan (Milan, IT); San Raffaele Scientific Institute (Milan, IT) Background/objectives: Proteasome is the major actor in cytosolic protein degradation. We have previously showed that immunoproteasome (IP), a proteasome iso-form, and PA28-a-b (a proteasome regulator) are expressed in several brain areas of primates and in different cell types of human brain upon ageing and AD development. It is well-known that IP plays an enhanced role in the production of MHC class I-restricted epitopes. Because of the raising evidences of CD8+ T cell and MHC class-I involvement in Multiple Sclerosis (MS) we investigated whether IP could play a role in MS and collected evidences that suggested its involvement in the production of a specific MBP epitope that is proposed to be involved in the MS: Methods: We combined genetic studies on Italian populations with immunohistochemistry assay on CNS MS and control samples and in vitro biochemical investigation of immunoproteasomes carrying different variants of LMP2 codon 60 polymorphism. Results: IP and PA28-a-b are present in MS affected brain area and accumulated in plaques. They are expressed in cell types supposed to be involved in MS development such as neurons, endothelial cells, oligodendrocytes, macrophages/macroglia and lymphocytes. Furthermore, in a genetic study on 1262 Italian MS cases and 845 controls we observed that HLA-A*02+ female subjects carrying the immunoproteasome LMP2 codon 60HH variant have a reduced risk to develop MS. Accordingly, immunoproteasomes carrying the LMP2 60H allele produce in vitro a lower amount of the HLA-A*0201 restricted immunodominant epitope MBP111-119. Conclusions: These observations suggest an involvement of the immunoproteasome and of its LMP2 60HH variant in the MS pathogenesis, by influencing the MHC class I antigen presentation, as suggested by our in vitro experiments, and therefore reducing the risk to develop the disease.

P676 Subpopulations of T-lymphocytes in patients with multiple sclerosis P. Praksova´, Z. Mikulkova´, P. Stourac, J. Micha´lek, J. Bednarik University Hospital (Brno, CZ) Background: Multiple sclerosis (MS) is a chronic disease characterized by demyelination and chronic inflamation of the central nervous

system (CNS). Many of the immune cells including T cells, B cells seem to be involved in disease pathogenesis by inducing or controlling the immune responses in the nervous system of MS patients. The aim of our research was to study subpopulations of T cells in newly diagnosed MS patients. Material and methods: Fifty eight patients with relapsing-remitting MS (RRMS; age 17 - 57 years, median 32 years) were included in the study. These patients were newly diagnosed of RRMS. Expanded disability status scale (EDSS) was recorded in all patients at the Department of Neurology, University Hospital Brno. Patients were excluded from the study if they had previously received IFN b 1a, IFN b 1b or glatiramer acetate. None of the patients received any immunomodulatory or immunosuppressive drugs at least 30 days before blood sample was taken for the purpose of the study. A control group consisted of 40 age-matched healthy volunteers (age 18 – 62, median age 28). Using four-color flow cytometry we identified naive T-cells CD4+CD45RA+, central memory T-cells CD4+CD45RO+CCR7+, effector memory T-cells CD4+CD45RO+CCR7-, T-regulatory cells (Treg) CD4+CD25highCD127low and T-suppressor cells CD8+CD28-. These data were analysed with non-parametric Mann–Whitney test, Kruskal–Wallis test, Spearman’s correlation analysis. Results: Increased numbers in populations of central memory T-cells (p = 0.014) and effector memory T-cells (p[0.001), decrease of naive T-cells (p = 0.017) and no difference in Treg cells (p = 0.882) and T-suppressor cells (p = 0.162) were observed between MS patients and healthy controls. In order to detect any correlation between severity of MS clinical symptoms and immunological changes we correlated studied T-cell populations with EDSS score. We found increasing numbers of central memory T-cells (p = 0.014) and effector memory T-cells (p = 0.007) with increased of EDSS. No correlation between naive T-cells, Treg cells and Ts cells and EDSS (p = 0.195, p = 0.318, p = 0.683, respectively) was noticed. Conclusions: Our results showed imbalance of immune system of MS patients compared to healthy controls.

P677 Possible predictive parameters to converse multiple sclerosis in patients with clinically isolated syndrome S. Ozakbas, B. Piri Cinar, E. Idiman Dokuz Eylul University (Izmir, TR) Objectives: Multiple sclerosis (MS) is a demyelinating disease which represents a spectrum that depends on disease duration and clinical categorization. Clinical isolated syndrome (CIS) is the earliest clinical presentation. The aim of our study was to evaluate the predictive value of immunological parameters on reaching MS in patients with CIS. Method: 44 patients (22 female, 22 male) with CIS was included in the study. Mean age at disease onset was 28.65. Presenting symptoms were motor involvement (13.3%), sensory involvement (28.9%), motor plus sensory involvement (6.7%), brainstem involvement (8.9%), brainstem plus cerebellar involvement (17.8%), optic neuritis (22.7%). All patients were undergone lumbar puncture. Cerebrospinal IgG, IgG index and oligoclonal bands (OBs) were evaluated. CIS patients and patients who reached MS were compared on the basis of these immunological parameters. Results: 21patients (46.7%) reached MS based on Poser’s criteria. Patients reached MS had significantly more OB positivity than CIS patients (p=0.032). IgG index was significantly higher in MS patients (1.27 versus 0.78, p=0.046). CSF IgG was also significantly higher in patients reached MS (41.27 versus 65.3, p=0.024). Percentage of reaching MS was significantly higher in female patients (64.6% versus 36.8%, p=0.046). All patients presenting motor symptoms

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S224 reached MS. Reaching to MS was significantly higher in patients presented with motor symptoms than the other symptoms (p=0.005). Conclusions: Our results demonstrated that immunological parameters could help the clinicians to predict reaching MS in patients with CIS. Presenting with motor involvement seemed to be unique in terms of prediction to reach MS. Higher IgG index and CSF OBs were found to be the other predictive parameters

P678 Is the increase of T-helper 17 lymphocyte percentage in peripheral blood a possible marker of disease activity in relapsing-remitting multiple sclerosis? L. Durelli, M. Clerico, G. Contessa, S. De Mercanti, A. Uccelli, C. Comi, P. Cavalla, L. Rinaldi, R. Cavallo, L. Sosso, S. Rolla, F. Novelli University of Turin (Orbassano, IT); University of Genoa (Genoa, IT); University of Eastern Piedmont (Novara, IT); Hospital San Giovanni Battista (Turin, IT); University of Padua (Padua, IT); Hospital San Giovanni Bosco (Turin, IT); Hospital Mauriziano (Turin, IT); University of Turin (Turin, IT) Objectives: Since we demonstrated that Th17 lymphocytes are increased during the active phases of relapsing remitting multiple sclerosis (RRMS) we decided to perform a longitudinal multicenter, analysis of peripheral blood (PB) T-helper 17 (Th17) cell percentage to individuate if it could be a possible indicator of disease activity. Methods: The intracellular cytokines IFN c, IL-17 and IL-22 were dosed using FACS analyses performed on polyclonally-stimulated PB lymphocytes. Peripheral blood was collected from 16 MS patients free from therapy and followed up from 6 to 12 months by 8 different Italian MS centers. The patients were age- and gender-matched with healthy subjects (n=12). Patients underwent monthly immunological tests and quarterly brain magnetic resonance imaging (MRI). Controls underwent monthly immunological tests. Disease activity has been identified with clinical relapse or new T2 or enhancing lesions at MRI; disease inactivity with no relapses and no new MRI activity. Results: In total 12 episodes of disease activity have been observed. We observed 8patients presenting a clinical relapse and 4 patients presenting an active MRI (new T2 or enhancing lesions). Th17 lymphocyte percentage, stable in controls, increased 5-7-fold compared to baseline in MS patients 3 to 7 days before any sign (either clinical or MRI) of disease activity. Moreover, IL-22 secreting cells increased even earlier, i.e., one month before an active phase. Consequently, also the IL-22/IL-17 ratio increased 7 to 10 fold compared to baseline or inactivity phases. By contrast Th1 lymphocyte percentage did not correlate with disease activity. Conclusion: In a small patient sample we observed as the disease activity (either clinical or MRI) was anticipated by a significant increase of PB Th17 percentage and of IL-22/IL-17 ratio. This might provide a suggestion toward the right way to find a reliable marker of disease activity in order to prevent and to treat it as earlier as possible. The study was partially supported by Bayer Schering Pharma Italy

P679 Relevance of microglial phagocytosis in cuprizone induced de- and remyelination E. Voss, J. Skuljec, M. Stangel Medical School Hannover (Hannover, DE); Center for Systems Neuroscience (Hannover, DE) Objectives: Microglia plays a key role in the initiation and perpetuation of de- and remyelination because of their ability to present

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antigens to other cells and clear cell debris by phagocytosis. Different factors and molecules expressed or secreted by microglia seem to play an important role in regenerative processes like remyelination. It remains unclear which factors lead to a protective microglial phenotype and recent data indicate that there are region-specific differences within the central nervous system (CNS) for both de-/ remyelination and microglial response. Therefore we examined changes in microglial phenotypes in the cuprizone model during deand remyelination in order to identify important factors that promote neuroprotective functions of microglia in the CNS. Methods: 8 week old C57BL/6 mice were fed for 5 weeks with 0.2% cuprizone, following one week of normal chow to allow remyelination. Animals were sacrificed at weeks 3, 3.5, 4, 4.5, 5 (demyelination), 5.5, and 6 (remyelination). Microglia were separately isolated from dissected corpus callosum and cerebral cortex, stained for various surface and intracellular marker (phagocytosis: CD32/16, CD36, Tim-3, TREM-2b, CD11b; antigen expression and costimulation: CD40, CD80, CD86, MHC-II; apoptosis: FAS-L; inhibition of microglia activation: CD200R, SIRP-a; cytokines: IL-12, IL-10, IFN-c, TNF-a), and analyzed by flow cytometry. Results: The expression of all studied phagocytic receptors was increased during demyelination with decreasing tendency during remyelination. The most prominent effect was seen on TREM-2b. TNF-a was up-regulated during demyelination while the other cytokines remained unchanged. Expression of both CD200R and SIRP-a was increased during demyelination and remained elevated during remyelination. Up-regulation of CD200R was more pronounced in the corpus callosum as compared to the cortex during both de- and remyelination. The expression of costimulatory molecules and MHC-II was not significantly changed. Conclusions: Our findings characterize changes of microglial markers during de- and remyelination indicating that phagocytosis plays a central role in the regulation of these processes. During demyelination the proinflammatory cytokine TNF-a seems to be an important factor. Detailed examination of microglial phenotypes is crucial in order to promote their beneficial role in neurodegenerative diseases.

P680 Glatiramer acetate modulates TNF-a and IL10-secretion in microglia and promotes its phagocytic activity R. Pul, D. Moharregh-Khiabani, J. Skuljec, T. Skripuletz, N. Garde, E. Voss, M. Stangel Medical School Hannover (Hannover, DE) Background: Glatiramer acetate (GA) is an approved immunomodulating agent for the treatment of multiple sclerosis acting on T cells inducing a Th1 to Th2 cytokine shift. Th2 type GA reactive T cells migrate into the brain and act suppressive at the sites of inflammation called bystander suppression. Recently, it has been shown that GA exerts direct effects on dendritic cells, peritoneal macrophages, and monocytes indicating that the effect of GA is not only confined to T cells. Objectives: In view of the immunomodulatory activity of GA and its neuroprotective effects, it was of interest to investigate whether GA has direct effects on microglia in vitro which may explain its mode of action within the CNS. Methods: Primary rat microglia were purified and cultured under standard conditions. Griess reaction was used to measure one of the stable end products of nitric oxide (NO), nitrite. Rat tumor necrosis factor (TNF)-a and interleukin-10 (IL-10) were measured in the cell culture supernatants using ELISA. Microglia were incubated with fluorescent latex beads and the phagocytic activity was determined by FACS.

S225 Results: Treatment of microglia with GA leads to a significant increase of interleukin-10 and decrease of TNF-a while there was no effect on NO production. GA treated microglia showed a significantly higher phagocytic activity. Conclusions: GA directly modulates microglia cells. It induces a Th2 type of microglia that may act anti-inflammatory and support removal of debris by enhancing phagocytosis.

P681 Excitotoxic damage to axons is not mediated by oligodendrocytes E.A. Akyol, D. Pitt The Ohio State University (Columbus, US) Background: Glutamate receptor overactivation (excitotoxicity) plays an important role in white matter injury in a wide range of neurological diseases, especially in multiple sclerosis. White matter elements, in particular oligodendrocytes are highly vulnerable to excitotoxicity, mediated through activation of oligodendroglial AMPA/Kainate receptors. Axons are also vulnerable to glutamate toxicity, but the mechanisms leading to excitotoxic damage in axons are poorly understood. Recent studies suggest that glutamate receptors are functionally expressed on axons and that their activation may play a role in axonal injury. Interestingly, isolated axons in culture are resistant to glutamate toxicity and become vulnerable only when co-cultured with oligodendrocytes, suggesting that excitotoxic injury to unmyelinated axons may require interaction with oligodendrocytes. Objectives: We examined the hypothesis, that excitotoxic axonal damage in vivo is transmitted through oligodendrocytes. Methods: We used double-transgenic mice that express diphtheria toxin (DT) receptors under the control of the MOG promoter (MOGiCre/iDTR) and yellow fluorescent protein (YFP) in axons under control of the thy1 promoter. Intraspinal injection of DT (0.4 lg/ml 1.1 ll) into the lumbar dorsal columns resulted in ablation of 90% of mature oligodendrocytes. The glutamate receptor agonist, AMPA (30 mM, 0.07 ll) was subsequently injected into oligodendrocyte-depleted or non-depleted lumbar dorsal columns and axonal morphology and behavioural changes were examined in both groups. Results: Injection of AMPA into the lumbar lumbar dorsal columns of oligodendrocyte-depleted mice induced a similar degree of axonal degeneration as in control mice and resulted in hind limb paralysis in both groups. Conclusions: Axons are damaged in our excitotoxicity model independent of presence or absence of oligodendrocytes. This suggests that different mechanisms may apply to excitotoxic axonal damage in vitro and in vivo. Thus, excitotoxic damage to axons may be mediated directly or through white or gray matter elements other than oligodendrocytes, i.e. astrocytes or neurons. Our results also suggest that axons in demyelinated multiple sclerosis lesions remain vulnerable to excitotoxic insults and thus may benefit from chronic anti-glutamatergic protection.

P682 Intravenous immunoglobulin inhibits antibody/ complement-mediated demyelination M. Harrer, K. Fischer, N. Goebels University of Zurich (Zurich, CH); University of Du¨sseldorf (Du¨sseldorf, DE) Objective: Intravenous immunoglobulins (IVIg) have become widely used as treatment for autoimmune and systemic inflammatory

diseases. By which mechanisms IVIg exerts these beneficial effects has not fully understood. Methods: We previously demonstrated that the addition of a demyelinating monoclonal antibody and complement induces complete myelin destruction and oligodendrocyte loss in murine cerebellar slice cultures. Here we investigated, whether IVIg inhibits this demyelination. Results: We demonstrate that pre-incubation with IVIg completely inhibits antibody/complement-mediated myelin damage and oligodendrocyte cell death. Results from competition assays suggest that IVIg inhibits demyelination rather by capturing complement proteins or blocking Fc receptors than through competing with anti-myelin specific antibodies. This work was funded by: SNF, SMSG, 3R Foundation, Biogen, Serono

P683 Neural precursor cells improve clinical outcome of experimental autoimmune encephalomyelitis via reduced chemotaxis of peripheral lymphocytes S. Ravanidis, E. Polyzoidou, A. Lourbopoulos, R. Lagoudaki, K. Poulatsidou, N. Tascos, G. Mosialos, M. Arsenakis, N. Grigoriadis Aristotle University of Thessaloniki (Thessaloniki, GR) Objectives: Neural precursor cell (NPC) transplantation has been proposed as a therapy for multiple sclerosis (MS) and other degenerative disorders of the central nervous system (CNS). It has been suggested that NSCs act via immunomodulation rather than as a replacement therapy. Chemokines and their receptors are important components of MS pathogenesis. CCL5 is responsible for the recruitment of autoimmune CD4+ T cells and CCL20 for the recruitment of Th17 cells as well as dendritic cells, into the CNS. In addition, signalling via CXCR4 is responsible for the recruitment of B cells whereas blockade of CXCR2 ameliorates experimental autoimmune encephalomyelitis (EAE). Herein we explore the effect of NPCs, following transplantation into EAE, on mRNA expression of chemokines and their receptors whith CNS. Materials and methods: NPCs were isolated from neonatal C57/ Bl6 mice brain and BrdU-labeled according to a standardized protocol. Myelin Oligodendrocyte Glycoprotein (MOG) – induced EAE was performed in 15 adult female animals. On day 7 post EAE induction, either NPCs (NL group, n=8) or vehicle (CP group, n=7) were subcutaneously administered. Animals were daily evaluated for clinical signs of disease. During the acute phase of EAE, total RNA was extracted from brain and spinal cord (s.c.). RNA was transcribed to cDNA, for semiquantitative Real-time PCR. Unpaired t-test was used to evaluate the statistical significance between the groups’ expression of chemokines, whereas Mann Whitney non parametric test was used for comparisons of clinical scores. Results: Control animals exhibited significantly increased clinical score compared to NL group (area under curve: CP=33,60±14,67, NL=16,31±18,49, p\0.05). NPCs were detected in the lymph nodes. Chemokine gene expression was reduced both in brain and spinal cord in NL group compared to the CP one: CCL5 (brain:2,72 fold; p=0.0164, s.c.:1,71 fold;p=0.003), CCL20 (brain:2,18 fold; p=0.0404, s.c.:3 fold;p=0.0288), CXCR2 (brain:1,92 fold; p=0.0428, s.c.:3,15 fold;p=0.0157) and CXCR4 (brain:2,34 fold; p=0.0035, s.c.:3,96 fold;p=0.0295). Conclusions: NPCs transplantation can ameliorate EAE, despite their absence in the inflamed CNS. Our findings show that one

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S226 perspective of immunomodulation of NPCs, may be the down regulation of the expression of CNS chemokines which are related to the recruitment of inflammatory cells and the concomitant demyelination. Supported by the grant PYTHAGORAS II (EPEAEK) of the Greek Ministry of National Education and Religious Affairs and the European Union

P684 Altered cerebral biochemical pathways in experimental autoimmune encephalomyelitis due to mycobacteria adjuvant: a metabolomic pilot study N.W. Lutz, P.J. Cozzone, E. Beraud Aix-Marseille University (Marseille, FR) Objectives: Metabolomic studies are still sparse in muliple sclerosis (MS), and are extremely rare in its animal model, the experimental autoimmune encephalomyelitis (EAE). Complete Freund’s adjuvant (CFA) is a well established mycobacteria-containing immunopotentiator that is employed with spinal cord or brain homogenate to facilitate active induction of EAE in laboratory animals. Here we demonstrate (i) the feasibility and potential of metabolomic EAE research by NMR spectroscopy of brain extracts, and (ii) the effects of CFA on brain metabolite profiles in CFA-inoculated rats and in CFA/ spinal cord homogenate (SC-H)-inoculated rats with chronic–relapsing EAE, compared to healthy rats. Methods: Brain tissue from CFA-treated (CFA), CFA/SC-Htreated (CFA/SC-H), and healthy (Contr) Lewis rats was extracted with methanol/chloroform/water (1:1:1). The resulting two phases were separated, and organic solvents were removed from both phases under a nitrogen stream. The residue of the lipid-containing phase was redissolved in a mixture of deuterochloroform, methanol, and an aqueous CDTA (trans-1,2-cyclohexyldiaminetetraacetic acid) solution (5:4:1). The aqueous phase was lyophilized and redissolved in deuterated water. 31-P and 1-H NMR spectra were acquired on an AVANCE 400 NMR spectrometer (Bruker, Wissembourg). Results: The brain concentrations of all major phospholipids (PL) and PL metabolites were decreased by about 1/3 in CFA and CFA/ SC-H vs. Contr. These differences were significant (p \= 0.05) for phosphatidylcholine, alkyl-acyl-phosphatidylcholine, phosphatidylinositol, sphingomyelin, phosphatidylethanolamine, ethanolamine plasmalogen, and the sum of all PL. Levels of the amino acids, c-aminobutyrate, leucine, glutamate, as well as glutamine, were lower in CFA than in Contr (0.05\p\0.10) or CFA/SC-H. Conclusion: The global reduction of the PL pool for CFA and CFA/SC-H vs. Contr may hint at a diminished capacity to incorporate polyunsaturated fatty acids such as arachidonic acid into PL. This would be in accordance with features of cerebral inflammation upon inoculation with CFA. Coordinated reduction in multiple free amino acids for CFA may be indicative of diminished degradation or enhanced synthesis of proteins. The findings of our metabolomic pilot study may provide a basis for highlighting a novel pathogenic mechanism most likely due to components of mycobacteria, which induce innate immunity and thus inflammation in the CNS. Support from the following institutions is greatfully acknowledged: ARSEP; CNRS; Programme National Imagerie du Petit Animal, grant #: 2003-3, 2004-1; ACI PEFT, grant # ACI 2003 PEFT-12

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P685 Oral genistein, extracted from soy bean, exerts protective properties in animal model of multiple sclerosis (autoimmune encephalomyelitis) S. Razeghi Jahromi, M. Togha, A. Ghaemi, A. Alizadeh Shefa Neuroscience Research Centre (Tehran, IR); University of Medical Sciences (Tehran, IR); Golestan University of Medical Sciences (Gorgan, IR) Objectives: Multiple Sclerosis (MS) is a chronic and often debilitating demyelinating disease of the Central Nervous System (CNS). Many of the current treatments are costly, limited in efficacy, and possess unpleasant side effects. These drawbacks bring the protective strategies into the center of attention. Genistein is one of the components of soy bean which happen to have anti-inflammatory, antioxidative and neuroprotective properties. We conducted this study to assess the potential protective role of genistein in animal model of MS. Methods: We used Experimental Autoimmune Encephalomyelitis (EAE) -an inducible CD4+ T cell-mediated autoimmune disease with pathological features similar to MS. Ten to twelve week C57BL/6 mice with mean weight of about 21.4 were assigned to three groups (6/group): 1) Immunized with Myelin Oligodendrocyte Gelicopeptide (MOG) and administered with genistein (20 mg/kg). 2) Immunized with MOG and gavaged with 100 micro liter Dimetyl Sulgoxide (DMSO). 3) Not immunized. Oral administration of genistein and DMSO was started 21 days before the induction of disease and continued for 42 days. The effects of interventions on the severity of EAE were assessed by clinical, histological (inflammation and demyelination) and immunological (brain TNF-a, IFN-c, IL-10, IL12, and proliferation of lymphocytes) evaluations. Results: Genistein significantly prevented mice from prolonged neurological sequel by postponing the disease onset (p= 0.006), attenuating EAE course (p= 0.004) and alleviating the severity of clinical (p= 0.002) and histological signs of EAE (p\0.001). Genistein impose its beneficial role by modulating T-helper1/T-helper2 balance by decreasing CD4+ T-helper 1 cells (p=0.02). Furthermore it inhibited encephalitogenic and systemic release of IFN-c (p\0.005 in both assessments) and IL-12 (p\0.005 in both assessments) and encephalogenic secretion of TNF-a (p\0.005). On the contrarily it increase the production of IL-10 in central nervous system (p\0.005)and spleen (p\0.005). Conclusion: Results suggest that genistein may represent a new protective approach for MS by anti-inflammatory and immunemodulating properties. 1 mg/kg genistein in mice is equal to 0.011 mg/cm2 of body surface in mice or human. Therefore, for example in a man with 70 kg weight and 170 cm height, daily consumption of 209 mg of genistein might prevent from prolong neurological sequel of MS.

P686 Acetylation and deacetylation gene expression in neural precursor cells in the presence of trichostatin-A and cytokines, in vitro K. Poulatsidou, R. Lagoudaki, E. Polyzoidou, S. Ravanidis, N. Tascos, M. Grigoriou, A. Chlichlia, N. Grigoriadis Aristotle University of Thessaloniki (Thessaloniki, GR); Democritus University of Thrace (Alexandroupoli, GR) Objectives: Neural precursor cells (NPCs) have been proposed as a means for cell replacement therapy in neurodegenerative diseases,

S227 such as Multiple sclerosis (MS). Histone acetylation, a basic epigenetic mechanism, has been implicated in the regulation of expression of neuronal, immune and other tissue specific cells. Histone acetyltransferases (HATs) and Histone deacetylases (HDACs), the enzymes that catalyze acetylation and deacetylation respectively, have been shown to play important roles in cell growth, development and differentiation. In this study we investigated the mRNA expression of three HDACs (HDAC1, HDAC2, HDAC3) and two acetyltransferases (CBP, P300) in NPCs treated either with Trichostatin A (TSA), an HDAC inhibitor, or cytokines, the later in order to simulate the inflammatory environment of MS, in vitro. Materials and methods: NPCs isolated from newborn C57bl/6 mice were cultured as expanding floating spheres for seven days. Groups of 5*105 NPCs were treated with TSA in high (100ng/ml) or low (10ng/ml) concentration for 24 or 48 hours (TSA-h and TSA-l groups, respectively), or pro- and anti-inflammatory cytokines for 48 hours (IFNg and TGFb groups respectively), in vitro. Vehicle-treated NPCs served as controls. RNA extracted from each group was reversely transcribed to cDNA and used for semi-quantitative Real time PCR analysis. Results: HDAC1 was significantly elevated in both TSA-h 24h and TSA-h 48h groups (3.37 fold; P\0.0001, 2.12 fold; P=0.018). HDAC2 gene expression was up-regulated in group TSA-h 24h (1.75 fold; P\0.0001). CBP (1.54 fold; P=0.0058) and P300 (3.36 fold; P\0.0001) showed increased expression in groups TSA-l 24h. In groups treated with cytokines no variance was observed in genes expression. Conclusion: According to protein-based studies, TSA inhibits HDAC activity and causes histone hyperacetylation in a variety of tissue types, though its mechanism of action is not well defined. HDAC1, HDAC2, CBP and P300 genes seem to be up-regulated by TSA and therefore be a useful tool for the study of histone hyperacetylation at gene level. In addition, either pro- or anti-inflammatory cytokines found in abundance in MS, were not adequate to drive changes in acetylation gene expression, in vitro. Supported by the grant PYTHAGORAS II (EPEAEK) of the Greek Ministry of National Education and Religious Affairs and the European Union

General neurology P687 Progressive encephalomyelitis with rigidity and myoclonus associated with glycine receptor antibodies N. Mas, A. Aceituno Gonza´lez, D. Castan˜o, A. Saiz, M.I. Leite, A. Vincent, F. Graus Hospital Clinic of Barcelona (Barcelona, ES); University of Oxford (Oxford, UK) Background/objectives: Glycine receptors are mainly concentrated in the brainstem and spinal cord, and glycine receptor antibodies (GlyR-ab) have been reported in a patient with progressive encephalomyelitis with rigidity and mycolonus (PERM) (Neurology 2008;71:1291). We describe the clinical features of two additional cases. Case 1: a 33-year-old woman presented with brainstem symptoms, diplopia, dysphagia, and gait ataxia of subacute onset that spontaneously improved in 5 weeks. Then, she progressively developed rigidity of lower limbs with painful spasms, involuntary jerks, contracture of both ankles, and urinary disturbances requiring urethral catheter. CSF was normal and oligoclonal bands negative. Brain and spinal MRI was normal. EMG demonstrated involuntary continuous motor unit activity and abnormal exteroceptive reflexes. Glutamic

Acid Decarboxylase (GAD) and onconeuronal antibodies were negative. GlyR-ab were positive in the serum and could not be evaluated in the CSF. A complete recovery was obtained after corticosteroids therapy. Seventeen months later, the stiff-person symptoms relapsed, and she received IV immunoglobulins with full recovery. She has been asymptomatic for 8 years. Case 2: a 60-year-old man presented with brainstem symptoms, diplopia, left facial palsy and dysphagia that developed over a few days, followed by rigidity of lower limbs, painful spasms, spontaneous and stimulus induced myoclonic jerks, severe autonomic dysfunction and seizures that required intensive care support. CSF was normal and oligoclonal bands negative. EMG demonstrated involuntary continuous motor unit activity. Brain MRI was normal. GAD and onconeuronal antibodies were negative, but GlyR-Abs were positive. The patient suffered a cardiac arrest and he is in a persistent vegetative state since then. Conclusions: GlyR-ab expand the members of antibodies to receptors involved in neuronal autoimmune disorders. They should be looked in PERM and in cases of stiff-person syndrome with atypical presentation. These patients may be at risk of sudden death.

P688 NMDA-receptors antibodies and neuropsychiatric lupus: application of a novel immunofluorescence assay L. Zuliani, M. Zoccarato, C. Briani, A. Doria, K.P. Wandinger, B. Giometto Hospital of Treviso (Treviso, IT); University of Padua (Padua, IT); Institute for Experimental Immunology - Euroimmun (Lu¨beck, DE) Objective: Central nervous system involvement (CNS) occurs in up to 80% of patients affected by systemic lupus erythematosus (SLE), determining the complex set of syndromes classified as neuropsychiatric SLE (NPSLE). Antibodies against NR2 (A and B) subunits of N-methyl-D-aspartate glutamate receptors (NMDAR) have been claimed to be involved in the pathogenesis of NPSLE although this association is still controversial. More recently antibodies against NR1 subunit of NMDARs have been specifically associated with an autoimmune encephalitis commonly associated with ovarian teratoma. In the latter case autoantibodies were identified by immunofluorescence on mammalian cells expressing NMDAR. The aim of this study was to evaluate the presence of antibodies against NMDARs in its native conformation and other possible novel autoantibodies in a group of patients affected by NPSLE. Methods: A novel immunofluorescence (IF) assay provided by Euroimmun was used, based on 5 biochips per field: rat hippocampus and cerebellum sections, NR1 subunit transfected cells, NR1 and NR2B transfected cells and non-transfected cells (null cells). Eight serum samples from patients affected by NPSLE were tested and 3 SLE without neurologic involvement. The following samples were used as controls: 1 healthy control; 1 Hu-Ab / ANNA1; 1 VGKC-Ab; 1 NMDAR-Ab positive encephalitis. Results: None of the 8 NPSLE samples proved positive for NMDAR-Ab (nor the SLE samples) while immunofluorescence (IF) on tissues confirmed the presence of anti-nuclear antibodies (ANA). The NMDAR-ab positive control sample reacted with NR1 transfected cells and showed a neuropil staining patterns on hippocampus. Conclusion: This preliminary study suggests that serum samples from patients affected by NPSLE do not harbour antibodies able to recognize NMDAR expressed on mammalian cell lines. This novel assay permits to detect specifically NMDAR-ab involved in paraneoplastic and idiopathic encephalitis. In addition other immunohistochemical reactivities related to onconeural, ANA and neuronal-surface antigens antibodies can be detected thus prompting further analysis.

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P689 Paraneoplastic cerebellar degeneration associated with anti-Yo antineuronal antibodies complicating ovarian carcinoma: case report and review of the literature J. Rallis, N. Andronas, D. Pectasidis, L. Stefanis Attikon University Hospital of Athens (Athens, GR) Paraneoplastic cerebellar degeneration (PCD) is a disabling neurological disorder that has been associated with several types of systemic cancer, including small cell lung carcinoma, Hodgkin lymphoma and carcinomas of the breast, ovary and female genital tract. The prevailing theory regarding the pathogenesis of PCD involves an autoimmune response against cerebellar antigens that resemble ‘‘onconeural’’ antigens expressed by tumor cells. This theory is supported by the presence of antineuronal antibodies against Purkinje cells in the serum and CSF of PCD patients. We report the case of a 43 year-old female that presented with a two week history of diplopia, slurred speech, hand incoordination and progressively deteriorating gait. She had a history of ovarian serous cystadenocarcinoma that had been diagnosed several months prior to the appearance of symptoms and was treated with surgical resection and Taxotere/Carboplatin chemotherapy. Follow-up CT scans showed complete remission. Neurologic examination revealed the presence of down-beat nystagmus and severe bilateral appendicular ataxia. Serologic testing for antineuronal antibodies showed a high titre of anti-Yo antibodies. She was initially treated with high-dose intravenous methylprednisolone and afterwards she received intravenous immunoglobulin (2g/Kg) that was repeated in monthly cycles. Her symptoms showed moderate improvement with therapy and she was clinically stable at 6 months follow-up. Anti-Yo antibodies are positive in approximately 38% of cases with PCD. In terms of therapy, successful treatment of the underlying cancer remains the most potent prognostic factor. Various immunosuppressive/immunomodulatory agents have been used in the literature. In some cases intravenous immunoglobulin treatment has been associated with significant clinical improvement, especially if it is administered early in the course of the disease. We review the literature regarding anti-Yo PCD and the current concepts in therapy.

P690 Laboratory diagnosis and follow-up in patients with anti-NMDA-receptor encephalitis K.P. Wandinger, J. Dalmau, K. Borowski, C. Probst, A. Rosemann, K. Fechner, W. Sto¨cker EUROIMMUN AG (Lu¨beck, DE); University of Pennsylvania (Philadelphia, US) Objectives: Anti-NMDA-receptor encephalitis is a severe, treatable and potentially reversible disorder of the central nervous system. Early diagnosis is crucial since patients often improve with immunotherapy and, in many cases, after removal of an associated teratoma. Final diagnosis is based on the determination of anti-glutamate receptor (type NMDA) antibodies in serum or cerebrospinal fluid (CSF). We report on a recombinant assay for standardized detection of anti-glutamate receptor (type NMDA) antibodies applicable in each laboratory familiar with indirect immunofluorescence. Methods: cDNA for the glutamate receptor (type NMDA; subunbits NR1/NR1 and NR1/NR2, respectively) was inserted into eukaryotic expression vectors and transfected into HEK293 cells. Substrates were fixed with acetone and used side by side with frozen sections of rat hippocampus and cerebellum in indirect immunofluorescence. Samples from 66 patients with anti-NMDA-receptor encephalitis, 31 with other autoimmune encephalopathies, 100 with

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multiple sclerosis, 50 with SLE as well as 200 healthy blood donors were investigated. Results: Anti-glutamate receptor (type NMDA) antibodies were detected in all patients with anti-NMDA-receptor encephalitis at disease onset. In patients studied longitudinally, immunosuppressive treatment strategies (e.g. plasmapheresis, rituximab etc.) resulted in a marked decrease in antibody titers. During remission, anti-NMDAreceptor antibodies were absent in patient sera. Anti-glutamate receptor (type NMDA) antibodies were not detected in any of the control groups. Conclusions: Indirect immunofluorescence using glutamate receptors (type NMDA) recombinantly expressed in human cells as antigenic substrate represents a highly sensitive and specific method, suitable for both the serological diagnosis of patients with antiNMDA-receptor encephalitis and monitoring of the disease activity.

P691 Antigliadin antibody in sporadic adult ataxia M. Togha, Y. Hamidian, S. Nafisi, S. Dowlatshahi, S. Razeghi Jahromi University of Medical Sciences (Tehran, IR); University of Medical Sciences (Mashhad, IR); Shefa Neuroscience Research Center (Tehran, IR) Objectives: The most common neurologic manifestation of gluten sensitivity is ataxia, the so-called gluten ataxia which accounts for up to 40% of idiopathic sporadic ataxia. Timing of diagnosis of gluten ataxia is vital as it is one of the very few treatable causes of sporadic ataxia and causes irreversible loss of Purkinje cells. Antigliadin antibody (AGA) of the IgG type is the best marker for neurological manifestations of gluten sensitivity. This study was conducted to measure the prevalence of gluten ataxia in a group of Iranian patients with idiopathic ataxia. Methods: For 30 patients with idiopathic cerebellar ataxia, a questionnaire about clinical and demographic data was completed. Blood sample were taken for AGA (IgA and IgG) and anti-endomesial antibody (AEA) assessment. Gluten ataxic patients underwent duodenal biopsy. To see if cerebellar atrophy is present magnetic resonance imaging was done for all patients. Results: Only 2 patients had a positive IgG AGA (6.7%) who both had a positive AEA while none of them showed changes of celiac disease in their duodenal biopsies. Only presence of gastrointestinal symptoms and pursuit eye movement disorders were higher in patients with gluten ataxia. Conclusion: Prevalence of gluten ataxia in Iranian patients with idiopathic ataxia (6.7%), seems to be lower than most of other regions. This could be explained by small sample size, differences in genetics and nutritional habits and also effect of serologic tests setting. So it is needed to perform further researches with larger samples to measure Prevalence of gluten ataxia in Iranian patients.

P692 From myeloradiculopathy to lung cancer: the diagnostic work-up of a paraneoplastic neurologic syndrome M.T. Ferna´ndez, A.B. Pinel, M.J. Gil, I. Camacho, C. Isart University Hospital of Getafe (Getafe, ES) Objectives: Debut of a lung adenocarcinoma as a paraneoplastic neurologic syndrome with negative antineuronal antibodies. Methods: Case report. Results: Medical history: a 72 year-old man with past history of hypertension and idiopathic thrombocytopenic purpura, ex-smoker,

S229 complaints of a 3-week history of back pain and progressive painful weakness in the lower limbs with gait claudication, and no sphincter dysfunction. Examination reveals a predominantly distal bilateral asymmetric paraparesis with vibratory sensory loss up to the knees, generalized areflexia and indifferent plantar reflex. Initial investigations: Blood tests: thrombocytopenia; normal autoimmunity tests, antiphospholipid antibodies, immunoelectrophoresis, serum protein electrophoresis, erythrocyte sedimentation rate (ESR) and prostate-specific antigen (PSA); negative tumoral markers and antineuronal antibodies. Cerebrospinal fluid (CSF): lymphocytic pleocytosis, increased protein, immunoglobulin G (Ig G) index 0’8 with oligoclonal bands, negative cytology for malignant cells; negative Mantoux test; Electromyogram (EMG): acute severe bilateral denervatory lumbosacral poliradiculopathy; Magnetic resonance imaging (MRI): hyperintensity in conus medullaris and cauda equine with mild linear leptomenigeal enhancement. Evolution: Both intravenously administered methylprednisolone (1 gram a day) and immunoglobulines are tried with no improvement. In the search for an underlying tumor, a lung nodule with a hilar adenopathy is found in the chest computerised tomography (CT) scan and removed through a lobectomy, showing a poorly differentiated adenocarcinoma in the histopathology. 4 months following admission the patient develops dysphagia, dysphonia, and left hypoglossal nerve and sphincter dysfunctions with normal head MRI and CSF tests; 2 months later he dies of an aspiration pneumonia, showing findings consistent with a paraneoplastic encephalomyelitis in the pathologic examination. Conclusion: Paraneoplastic neurologic syndromes, mostly related to small cell lung cancer (SCLC), pose a challenge to the clinician due to the varied range of presentation, lack of pathognomonic data, development in up to a 60% in patients with no previously known cancer and antineuronal specific antibodies sensibility of only 50%. We describe a patient with negative antineuronal antibodies and tumoral markers, related to a non SCLC.

P693 Idiopathic hypertrophic pachymeningitis: a 15-year follow-up M. Apoil, T. Danaila, N. Derache, F. Viader University Hospital of Caen (Caen, FR) Goals and method: Idiopathic hypertrophic pachymeningitis (IHP) is a rare chronic inflammatory disorder that causes localized or diffuse thickening of dura mater. Alternative etiologies (infectious, systemic auto-immune and malignant diseases) must be ruled out before this diagnosis can be accepted. Its clinical presentation includes headache and multiple cranial neuropathies. We report the case of two patients who were successfully treated with an association of steroids and cyclophosphamide and had no relapse after a follow up of 15 years. Results: Both patients presented with headache and diplopia caused by sixth nerve palsy. The first patient also had right trigeminal neuralgia, and the second one left auditory impairment. The cerebrospinal fluid contained 8 cells/mm3 in the first patient and was normal in the second. MRI showed an enlargement of the cavernous sinus wall on the side of symptoms and marked contrast enhancement of the skull base dura mater in both patients. An extensive work up was negative. In the first patient a meningeal biopsy showed nonspecific inflammation. Both patients initially improved on steroid treatment but steroid tapering was followed by clinical relapse in both cases and the first patient developed steroid-related glaucoma. Prednisolone was switched to monthly then every other month intravenous infusions of 600 mg/m2 cyclophosphamide. Total cumulated doses were 20.4g during 24 months and 18.9g during 35 months in the first and second patient, respectively. The first patient recovered

completely and the second one was left with persisting mild diplopia. No further symptoms occurred during the following 15 years. Conclusion: Although a steroid-responsive disorder, IHP frequently relapses on steroid tapering. Early intravenous cyclophosphamide is an effective, well-tolerated therapy that may hasten recovery, help avoid steroid-related side-effects and allow definitive control of the disease.

P694 Pachymeningitis as rare manifestation of primary angiitis of the CNS W. Heide, D. Sinn, J. Stewen, A. Brandis, S. Gottschalk General Hospital Celle (Celle, DE); Hannover Medical School (Hannover, DE); University Lu¨beck (Lu¨beck, DE) Background and objective: The rare syndroms of cranial pachymeningitis is characterized by inflammatory infiltration of the dura and the leptomeninx. This may cause various neurological symptoms, most frequently headache. It may be caused by tuberculous meningitis, Wegener’s granulomatosis, rheumatoid arthritis, temporal arteriits, or by idiopathic hypertrophic pachymeningitis. We present a case with cranial pachymeningitis as rare manifestation of primary angiitis of the central nervous system (PACNS). Case report: A white female aged 69 presented with progressive right occipital headache and transient paresthesia of the left arm and leg. There was no history of migraine or other neurological disorders. Initially, neurological examination, CT scan and EEG were regular. Within the next days the patient developed massive headache, blurred vision, and deficits of orientation and memory. There was general and bilateral temporal slowing of EEG activity. The CSF was xanthochrome, with 66 lymphocytes per microliter and markedly elevated protein content of 583 mg/dl, but normal glucose. MRI scans revealed gyral swelling and hyperemia of both posterior cerebral hemispheres, a small subcortical intracerebral hemorrhage in the right precentral region and meningeal enhancement and thickening, particularly of the dura mater. Intense microbiological testing and cerebral panangiography were without pathological findings. Only the antinuclaear antibodies (ANA) were mildly elevated (1:320). Histologically, a leptomeningeal biopsy revealed extensive granulomatous, partly necrotising vasculitis of the pachy- and leptomeninx, predominantly involving the small vessels. With intravenous methylprednisolone (1000 mg per day for 5 days) and repeated pulses of intravenous cyclphosphamid (750 mg per m2), the patient recovered almost completely. Conclusions: Cranial pachymeningitis presents with headache, possibly associated with focal neurological or neuropsychological symptoms, and typical MRI findings. As it may be caused by primary angiitis of the CNS in rare cases, cerebral angiography and leptomeningeal biopsy are recommended to clarify the etiology.

P695 Silverstein’s syndrome: amyotrophy of parietal origin M.C. Thakre, J.S Inshasi Rashid Hospital (Dubai, AE) Objective: To present a rare case of Silvertein’s Sydrome presenting as isolated upper limb atrophy due to arachnoid cyst in the temperoparietal region. Methods: Case report- 40 years Indian gentleman working as a construction site worker, presented with 2 months history of right arm weakness and thinning. There was no neck pain, trauma or fever associated. There was no numbness in the right upper extremity. No weakness of right leg or any bladder or bowel symptoms. On

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S230 examination, he had wasting of right arm as a whole with predominant wasting of the flexar compartment of right forearm. Power was 4/ 5 in pyramidal distribution in right arm while power in right leg and left side was 5/5. Deep tendon reflexes were exaggerated on the right side and right planter was extensor. Sensory examination including cortical functions were normal. Investigations showed normal MRi cervical spine, Normal nerve condution study and EMG. CT brain and MRI brain showed a right tempero-Parietal arachnoid cyst with compression of the underlying tempero-parietal lobe. Results: The Physiopathology of Silvertein’s syndrome remains hypothetical. The decreased transsynaptic trophic influence of central on peripheral cells could result in a reduced trophic effect of nerves on muscles causing muscle atrophy. Conclusion: We present a rare case of intra cranial arachoid cyst causing upper extremity amyotrophy with upper motor signs which is explained by Silvertein’s syndrome of Parietal amyotrophy

P696 Botulinum toxin injections for the facial region Z. Matur, A. Coban, G. Babacan, E. Shugaiv, H. Hanagasi, Y. Parman Istanbul University (Istanbul, TR); Balikesir University (Balikesir, TR) Objective: Therapeutic use of botulinum neurotoxins (BoNT) are widely used in neurology. Local injection of BoNT is a highly effective treatment and there is now considerably well documented experience and knowledge of its indications, effects and safety in clinical practice. In this study, we report our experience in BoNT use for facial region. Methods: Patients who have been followed at the Botulinum Toxin Outpatient Clinic of the Neurology Department of the Istanbul Medical School from 1996 to December 2009 are evaluated. Two preparations of BoNT type A (Botox, Dysport) are used. The efficacy of BoNT injections are judged as very good if the symptoms are relieved 75-100%, as good if 50-74%, as average if 25-49% and as insufficient if less than 25%. Results: Two hundred ten patients (87 male) were included. The mean age was 57,6 (range 18–88 years). The mean follow-up period was 3,9 years (range 1–12). Hundred and fourteen patients had hemifacial spasm. Of the remaining 96, thirty had facial synkinesis, 25 blepharospasm, 9 oromandibular dystonia (OMD), 8 Meige Syndrome and 6 had drooling. Eighteen were considered as miscellaneous (hemimasticatory spasm, musician’s cramp, tics, hyperhidrosis etc.). A total of 1134 injections were made. The efficacy rates were high (very good and good) in blepharospasm, Meige syndrome and HFS whereas 73,8% in facial synkinesis, 58.8% in oromandibular dystonia and 41,7% in drooling. Temporary weakness was the most common side effect. Conclusion: BoNT injections are very effective for the treatment of blepharospasm, Meige Syndrome and HFS whereas the effect is moderate in facial synkinesis and OMD.

P697 Bilateral mental neuropathy as presentation of lymphoproliferative disease J. Domı´nguez Be´rtalo, A. Herna´ndez Gonza´lez, M.J. A´lvarez, S. Carrasco-Garcı´a de Le´on B. Martı´n, M.J. Gallardo Alcan˜iz, P. Caldero´n General Hospital Ciudad Real (Ciudad Real, ES) Objectives: Mental neuropathy or numb chin syndrome has a low incidence. The sensory fibers of the chin and lower lip converge to

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form the mental nerve, which enters the mandible through the mental foramen, to continue along the narrow mandibular canal. Multiple etiologies of this syndrome have been described in the literature, highlighting the lesions that cause local damage, mainly secondary to dental disease. Other less common associations are herpes simplex virus infection or systemic processes such as sickle cell disease or sarcoidosis. Mental neuropathy is of great clinical significance because its appearance without objectifying local condition usually indicates the existence of an underlying malignancy or metastasis. We report a case of mental neuropathy as the initial manifestation of lymphoproliferative disease. Methods: A 47 year old male with history of hypertension, diabetes and ischemic cardiopathy, referred right neck pain radiating to the mandible four days ago, with subsequent and persistent numbness of right lower lip. He was admitted because another episode of bilateral pain and numbness of the lower lips and mental region. On examination there was bilateral hypoesthesia of chin and lower lips, with no other neurological deficits. Results: Mandibular radiographs were normal. Laboratory tests showed leukocytosis, mild anaemia, and severe thrombocytopenia. A peripheral blood smear confirmed thrombocytopenia, dyserythropoiesis and leukoerythroblastic syndrome, all suggestive of acute leukemia. The bone marrow biopsy confirmed high-grade lymphoma with transformation to acute lymphoid leukemia. Conclusion: Mental neuropathy can be the initial sign of an unknown neoplasia. Different pathogenic mechanisms have been suggested such as local invasion of the periosteum with compression and ischemia of the mental nerve, nerve sheath involvement or leptomeningeal infiltration. In some cases a paraneoplastic mechanism is proposed. It has been more frequently associated with breast malignancy and lymphoproliferative diseases. Among these, lymphomas and less commonly leukemias have been reported. Association has also been described with lung and prostate carcinoma, and melanoma. Mental neuropathy is usually unilateral and painless, in contrast with the case reported here. We remark the need of a high level of suspicion when a patient with a similar clinical picture is observed, in order to make an early diagnosis leading to a life-saving treatment.

P698 Guillain-Barre´ syndrome: some clinical data of patients treated at the Department of Neurology, Tuzla, Bosnia and Herzegovina L. Zonic University Clincal Centre (Tuzla, BA) Aim: The aim of this study was to analyze frequency and some clinical demographic data of patients with Guillain-Barre syndrome (GBS), that have been treated at Department of Neurology Tuzla, University Clinical Center Tuzla, during period of fortheen years (1995–2009). Patients and methods:We have analyzed data from hystory of patients that have been treated during period of 1995-2009 at Department of Neurology (50 beds), University Clinical Center Tuzla. The diagnosis in all patients was confirmed by history of disease, neurologic examination, electromioneurography finding as well as biochemical analysis of liquor. All of them fulfilled clinical criteria for GBS. Results: Out of 20.177 hospitalized patients during tested period, 65 (0,32%) had GBS, and the majority of patients with GBS was in 2007. Patient’s age ranged from 16 to 79. Men have fallen ill more frequently than women (37:28). The frequency of disease appearance when season is taken as parameter is the following: the majority of patients fell ill during winter (22), then spring (18), summer (14) and

S231 fall (11). Acute inflammatory demyelinating type was the most frequented type of GBS in patients. The lesion of cranial nerves was registered in 12 (18,5%) patients. The most frequently affected was facial nerve (10 patienst), whereas a lesion of oculomotory and glossopharingeal nerve was registered in two individual cases. Conclusion: GBS was found in less than 0,5% out of 20.177 hospitalized patients during fortheen years (1995-2009) at the Department of Neurology in Tuzla. Majority of patients had acute inflammatory demyelinating type of GBS. According to the seasonal appearing the biggest number of patients were during the winter and spring. The lesion of cranial nerves was found in 18,5% of cases with GBS, with facial nerve as the most frequently affected.

P699 Landry-Guillain-Barre´ syndrome and celiac disease A. Efthymiou, E. Meidani, G. Bamias, K. Karydakis Laiko General Hospital (Athens, GR) Introduction: Celiac disease (CD) or gluten–sensitive enteropathy is a genetically determined autoimmune disorder of the small intestine caused by intolerance to gluten. The prevalence of the disease is estimated to be 1 in 300 persons. CD is typically presented with

gastrointestinal symptoms but in some cases extra-intestinal manifestations can be the presenting sign. Neurological manifestations including cerebellar ataxia, epileptic seizures, dementia, myelopathy, multifocal leucoencephalopathy and peripheral neuropathy have been reported in 7%-10% of the CD patients. We present a case of Guillain Barre Syndrome (GBS) and CD without previous gastrointestinal involvement. Case report: A 56 year-old woman was admitted with non-symmetric pure motor flaccid paraparesis, gradually established over 4 days. Ten days before admission, the patient suffered from painful abdominal bloating, diarrhea and fever. Blood examination revealed only a microcytic anemia. The brain and spine MRI were normal. The EMG/ENG displayed sings of sensory-motor polyradiculopathy. The CSF examination revealed cytoalbuminologic dissociation (2 cells/ mm3, protein 73mg/dl). At that time, she was found to have circulating antigliadin antibodies and classic histological lesions compatible with CD. She was given intravenous immunoglobulin 0,4 mg/kg for 5 days and was put on a gluten–free diet. Six months later her neurological symptoms had disappeared almost completely. Conclusion: GBS as the presenting extra-intestinal manifestations of CD is exceptionally rare. Probably a common autoimmune – pathogenic mechanism affects both the nervous system and the gastrointestinal tract.

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Author Index Nachname, Initialen . . . . . . . . . . . ProgNr. Aasly, J. . . . . . . . . . . . . . . . . . . . . .O125 Abad, J.M. . . . . . . . . . . . . . . . . . . . . P612 Abare, A.. . . . . . . . . . . . . . . . . . . . . O61 Abdalla, M. . . . . . . . . . . . . . . . . . . .O119 AbdelKader, A. . . . . . . . . . . . . O85, P546 Abdelkarim, A.. . . . . . . . O85, O85a, O119 Abderrahim, H.. . . . . . . . . . . . . . . . . O60 Abdullahi, I.. . . . . . . . . . . . . . . . . . . P389 Abicht, A. . . . . . . . . . . . . . . . . . . . . P521 Abolfazli, R. . . . . . . . . . . . . . P187, P408 Abramova, A.. . . . . . . . . . . . . . . . . . P189 Absinta, M. . . . . . . . . . . . . . . . O45, P351 Aburakawa, Y. . . . . . . . . . . . . . . . . . P225 Accolla, E.A. . . . . . . . . . . . . . . . . . . P280 Aceituno Gonza´lez, A. . . . . . . O144, P687 Achilli, A. . . . . . . . . . . . . . . . . . . . .O139 Achtnichts, L.. . . . . . . . . . . . . . . . . .O123 Afazel, S.. . . . . . . . . . . . . . . . P664, P667 Afrantou, T. . . . . . P538, P539, P548, P640 Aghaghazvini, M. . . . . . . . . . . . . . . . P543 Agoropoulou, C. . . . . . . . . . . . . O76, P445 Agosta, F. . . .O52, O68, O87, O116, O146, O147, P351 Aguas, M. . . . . . . . . . . . . . . . . . . . . P642 Aguennouz, M.. . . . . . . . . . . . P514, P529 Ahi, N. . . . . . . . . . . . . . . . . . . . . . . P567 Ahmed, R. . . . . . . . . . . . . . . . . . . . .O162 Ahn, S.W. . . . . . . . . . . . . . . . P349, P353 Ahn, T. . . . . . . . . . . . . . . . . . . . . . . P643 Akagawa, H. . . . . . . . . . . . . . . . . . . P368 Akbari, M. . . . . . . . . . . . . . . . . . . . . P244 Akdag, B. . . . . . . . . . . . . . . . . . . . . P648 Akdal, G.. . . . . . . . . . . . . . . . . . . . . P438 Akgu¨n, H. . . P310, P338, P342, P345, P346 Akhalghi, H. . . . . . . . . . . . . . . . . . . P626 Akman-Demir, G. . . . . . . . . . . . O92, P233 Akyol, E.A. . . . . . . . . . . . . . . . . . . . P681 Al Jumah, M. . . . . . . . . . . . . . P275, P305 Al Khathaami, A. . . . . . . . . . . P275, P305 Al Oayed, A. . . . . . . . . . . . . . . . . . . P305 Al Thubaiti, I. . . . . . . . . . . . . . . . . . P275 Al Zahrani, M. . . . . . . . . . . . . . . . . . P275 Al-Dahhak, R. . . . . . . . . . . . . . . . . . P314 Al-lozi, M. . . . . . . . . . . . . . . . . . . . . P631 Alakhyat, A.. . . . . . . . . . . . . . . . . . . P320 Albertini, G.. . . . . . . . . . . . . . . . . . . P533 Albertini, V.. . . . . . . . . . . . . . . . . . .O149 Aldeia, E. . . . . . . . . . . . . . . . . . . . . P564 Alderuccio, J. . . . . . . . . . . . . . . . . . . P468 Alegria, P. . . . . . . . . . . . . . . . P594, P629 Alfutaisi, A. . . . . . . . . . . . . . . . . . . . P320 AlHammad, R. . . . . . . . . . . . . . . . . . P313 Alizadeh, A.. . . . . . . . . . . . . . . . . . . P685 Allard, E.. . . . . . . . . . . . . . . . . . . . . P607 Allera, F. . . . . . . . . . . . . . . . . . . . . . P257 AlMajed, K. . . . . . . . . . . . . . . . . . . . P313 Almeida, A.G. . . . . . . . . . . . . . . . . . P183 Almeida, R. . . . . . . . . . . . . . . . . . . . P654 Almeida, V. . . . . . . . . . . . . . . . . . . . O88 Almuzara, M. . . . . . . . . . . . . . . . . . . P365

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Alonso-Bejar, P. . . . . . . . . . . . . . . . . P211 Alstadhaug, K.B. . . . . . . . . . . . . . . . O49 AlTahan, A. . . . . . . . . . . . . . . . . . . . P313 Alteri, E. . . . . . . . . . . . . O44, P443, P444 Altunkaynak, Y. . . . . . . . . . . . . . . . . P219 ´ lvarez, M.J. . . . . . . . . . . . . . . . . . . P697 A Alvarez Linera, J. . . . . . . . . . . . . . . . P499 Alva´rez Soria, M.J. . . . . . . . . . . . . . . P469 Alvarez-Soria, M.J. . . . . . . . . . . . . . . P372 Alves, D. . . . . . . . P284, P334, P344, P634 Alves, P. . . . . . . . . . . . . . . . . . . . . . P564 Alvi, M. . . . . . . . . . . . . . . . . . . . . . P230 Amadio, S.. . . . . . . . . . . . . . . . O99, P204 Amani, A. . . . . . . . . . . . . . . . . . . . . P508 Amann, M. . . . . . . . . . . . . . . O123, P406 Amaral, C.H. . . . . . . . . . . . . . . . . . . P596 Amato, M.P. . . . . . . . . . . . . . P572, P675 Ambrosi, C. . . . . . . . . . . . . . . . . . . . O69 Amosa, M. . . . . . . . . . . . . . . . . . . . . P168 Amouyel, P. . . . . . . . . . . . . . . . . . . . P621 Anand, P.. . . . . . . . . . . . . . . . . . . . . P553 Anastasiou, I. . . . . . . . . . . . . . . . . . . P657 Anastasopoulos, D. . . . . . . . . . . . . . . P650 Andreadou, E. . . . . . . . . . . . . P239, P249 Andresen, I. . . . . . . . . . . . . . . . . . . . P330 Andrikopolou, A. . . . . . . . . . . . . . . . P471 Andronas, N. . . . . . . . . . P471, P644, P689 Angelini, M.. . . . . . . . . . . . . . . . . . . P646 Anker, S.D. . . . . . . . . . . . . . . . . . . . P381 Annesi, F. . . . . . . . . . . . . . . . . . . . . P627 Annesi, G. . . . . . . . . . . . . . . . . . . . . P627 Annovazzi, P. . . . . . . . . . . . . . P449, P450 Antochi, F.. . . . . . . . . . . . . . . P273, P278 Antunes, A. . . . . . . . . . . . . . . . . . . . P493 Apoil, M.. . . . . . . . . . . . . . . . . . . . . P693 Ara, J.R. . . . . . . . . . . . . . . . . . . . . . P612 Araki, A. . . . . . . . . . . . . . . . . . . . . . P390 Arbizu, T. . . . . . . . . . . . . . . . . . . . . P248 Archontaki, A. . . . . . . . . . . . . . . . . . P178 Ardalan, M. . . . . . . . . . . . . . . . . . . . P421 Ardic¸, F. . . . . . . . . . . . . . . . . . . . . . P648 Areovimata, A. . . . . . . . . . . . . . . . . . P249 Ariatti, A. . . . . . . . . . . . P337, P518, P533 Arnason, B. . . . . . . . . . . . . . . . O77, P665 Arndt, R.C. . . . . . . . . . . . . . . . . . . . P527 Arnold, D. . . . . . . . . . . . . . . . . O77, P457 Arnold, M. . . . . . . . . . . . . . . . O105, P383 Arroyo, E. . . . . . . . . . . . . . . . P576, P579 Arroyo, J. . . . . . . . . . . . . . . . . . . . . P369 Arsenakis, M. . . . . . . . . . . . . . . . . . . P683 Arslan, H. . . . . . . . . . . . . . . . . . . . . P186 Artenie, V. . . . . . . . . . . . . . . . P194, P195 Artmann, I. . . . . . . . . . . . . . . . . . . .O130 Arvaniti, C. . . . . . . . . . . . . . . . . . . . P471 Ashina, M. . . . . . . . . . . . . . . . . . . . . O48 Assefi, M. . . . . . . . . . . . . . . . . . . . . P508 Asztely, F. . . . . . . . . . . . . . . . . . . . . O81 Ato, M. . . . . . . . . . . . . . . . . . . . . . . P505 Audebert, H. . . . . . . . . . . . . . P592, P593 Auribault, C. . . . . . . . . . . . . . . . . . .O120 Avantaggiato, P. . . . . . . . . . . . P257, P315

Avetisyan, Z. Ayad, M. . . . Aysal, F. . . . Azakir, B. . . Azimova, J. . Azmanov, D. Azouvi, P. . . Azqueta, C. . Azulay, J.P. .

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. . . . . P200 . . . . . P560 . . . . . P219 P531, P532 . . . . . P189 . . . . . P545 . . . . .O150 . . . . . P248 . . . . . P621

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. . . . . . . . . . . . . . P347 . . . . . . . . . P439, P625 . . . . . . . . . . . . . . O58 . . . . . . . . . . . . . . O94 . . . . . . . . . O128, O129 . . . . . . . . . . . . . . P570 . . . . . . . . . . . . . . O84 . . . . . . . . . . . . . . P621 . . . . . . . . . . . . . . P535 . . . . . . . . . O130, P535 . . . . . . . . . . . . . . P442 . . . . . . . . . . . . . . P201 . . . . . . . . . . . . . . O53 . . . . . . . . . P362, P597 . . . . . . . . . . O77, P665 . . . . . . . . . . . . . . P328 . . . . . . . . . . . . . . P374 . . . . . . . . . . . . . . P216 . . . . . . . . . P328, P575 . . . . . . . . . . . . . . P545 . . . . . . . . . . . . . . P485 . . . . . . . . . . . . . . P234 . . . . . P259, P260, P261 . . . . . . . . . O118, P511 . . . . . . . . . . . . . . P646 . . . . . . . . . . . . . . P439 . . . . . . . . . . . . . . O51 . . . . . . . . . . . . . .O146 . . . . . . . . . O140, P392 . . . . . . . . . . . . . . P494 . . . . . . . . . P513, P624 . . . . . . . . . . . . . . P356 . . . . . . . . . . . . . . P690 . . . . . . . . . . . . . . P525 . . . . . . . . . . . . . . O86 . . . . . . . . . O148, P253 . . . . . . . . . . . . . . P599 . . . . . P259, P260, P261 . . . . . . . . . . . . . . P457 . . . . . . . . . . . . . . P447 . . . . . . . . . . . . . . P619 . . . . . . . . . . . . . . P400 . . . . . . . . . . . . . .O129 . . . . . . . . . . . . . . P626 . . . . . . . . . . . . . . P535 P245, P373, P577, P627 . . . . . . . . . . . . . . O60 . . . . . . . . . . . . . . P694 . . . . . . . . . . . . . . P435 . . . . . . . . . . . . . . P609 . . . . . . . . . . . . . . P498 . . . . . . . . . . . . . . P201 . . . . . . . . . . . . . . P535 . . . . . . . . . . . . . . P374 . . . . . . . . . . . . . . P383 . . . . . . . . . . . . . .O143 . . . . . . . . . . . . . . P375 . . . . . . . . . . . . . . P672 O40, O149, P391, P402, P507, P512, P624 . . . . . . .O50, O57, O90 . . . . . . . . . . . . . . P688 . . . . . . . . . . . . . . P256 . . . . . . . . . . . . . .O125 . . . . . . . . . . . . . . P650 . . . . . . . . . . . . . . P181

Brueckner, A. . Brugger, F. . . Brunetti, M. . . Bruno, M.-A. .

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Cho, K.H. . . . . . . . . . . . . . . . . . . . . P547 Choi, J.C. . . . . . . . . . . . . . . . . . . . . P517 Choi, K.D. . . . . . . . . . . . . . . . . . . . . P164 Choi, Y. . . . . . . . . . . . . . . . . . . . . . P165 Chojdak-Lukasiewicz, J. . . . . . . . . . . P581 Chopra, K. . . . . . . . . . . . . . . . . . . . . P205 Chora˜o, M. . . . . . . . . . . . . . . . . . . . P637 Christ-Crain, M. . . . . . . . . . . . . . . . . P383 Christine, C.W.. . . . . . . . . . . . . . . . .O125 Chu, A.C. . . . . . . . . . . . . . . . . . . . .O156 Chumillas, M.J. . . . . . . . . . . . . . . . .O127 Chung, P.W. . . . . . . . . . . . . . . . . . . P336 Churchyard, A.J.. . . . . . . . . . . . . . . . P626 Ciano, C. . . . . . . . . . . . . . . . . . . . . . P628 Ciavardelli, D. . . . . . . . . . . . . . . . . . P198 Ciccolella, M.. . . . . . . . . . . . . . . . . . P625 Ciceri, F. . . . . . . . . . . . . . . . . . . . . . P462 Cicuendez, M. . . . . . . . . . . . . . . . . . P168 Cihelkova´, S. . . . . . . . . . . . . . . . . . . P575 Cinque, P. . . . . . . . . . . . . . . . . . . . . P448 Ciobica, A. . . . . . P194, P195, P431, P497 Ciocalteu, A. . . . . . . . . . . . . . . . . . . P437 Cistaro, A. . . . . . . . . . . . . . . . . . . . . P356 Ciubotariu, R.I.. . . . . . . . . . . . . . . . . P497 Classen, J. . . . . . . . . . . . . . . . . . . . . P658 Claussen, M.C. . . . . . . . . . . . . . . . . . O64 Clerici, F. . P391, P393, P402, P501, P504, P506 Clerico, M. . . . . . . . . . . O63, P229, P678 Coban, A. . . . . . . . . . . . . . . . . . . . . P696 Cock, H. . . . . . . . . . . . . . . . . . . . . . O83 Codeluppi, L. . . . . . . . . . . . . . . . . . . P518 Coelho, P. . . . . . . . . . . . . . . . . . . . . P488 Cojocaru, I. . . . . . . . . . . . . . . . . . . . P235 Colao, A. . . . . . . . . . . . . . . . . P217, P672 Coletti Moja, M.. . . . . . . . . . . . . . . . O63 Colombo, B.. . . . . . O42, O45, O60, O141, P397, P449 Colombo, I. . . . . . . . . . . . . . . . . . . . P512 Comanescu, M.. . . . . . . . P370, P479, P639 Combarros, O. . . . . . . . . . . . . P396, P557 Comi, C. . . . . . . . . . . . .O149, P632, P678 Comi, G. . . . . . . .31, O41, O42, O45, O60, O75, O77, O97, O99, O100, O121, O122, O124, O141, O159, P204, P282, P285, P330, P351, P397, P414, P441, P442, P448, P449, P450, P459, P460, P462, P472, P572, P665 Comi, G.P.. . . . . . . . . . . P512, P513, P624 Comola, M. . . . . . . . . . . . . . . . . . . .O100 Connelly, J. . . . . . . . . . . . . . . . . . . . P476 Connolly, S.J.. . . . . . . . . . . . . . . . . .O103 Consoli, A. . . . . . . . . . . . . . . . . . . . P610 Constantinescu, C. . . . . . . . . . . . . . . P456 Constantinescu, R. . . . . . . . . . . . . . . P258 Contessa, G.. . . . . . . . . . O63, P229, P678 Cook, S. . . . . O75, O77, P441, P442, P665 Coplin, W. . . . . . . . . . . . . . . . . . . . . P604 Coppi, E. . . . . . . . .O97, O100, P285, P472 Corben, L.A. . . . . . . . . . . . . . . . . . . P626 Corbu, A.-F.. . . . . . . . . . . . . . . . . . . P276 Cordonnier, C. . . . . . . . . . . . . . . . . .O107 Coriasco, M. . . . . . . . . . . . . . . . . . . P400 Corlier, F. . . . . . . . . . . . . . . . . . . . . O68 Cornelisse, P. . . . . . . . . . . . . . . . . . . P456 Corno, F. . . . . . . . . . . . . . . . . . . . . . P354

Corona, C. . . . . . . . Correas Callero, E. . Correia, F. . . . . . . . Correnti, A. . . . . . . Cortes-Santiago, N. . Corti, M. . . . . . . . . Corti, P.. . . . . . . . . Corti, S.. . . . . . . . . Cortijo, E. . . . . . . . Cortini, F. . . . . . . . Cosgrove, J. . . . . . . Costa, C. . . . . . . . . Costa, D.I. . . . . . . . Costa, G.L.C. . . . . . Costa, S. . . . . . . . . Costigan, D. . . . . . . Counihan, T. . . . . . Coutinho, P. . . . . . . Cova, I. . . . . . . . . . Cozzone, P.J. . . . . . Crepaldi, G. . . . . . . Cristiano, L. . . . . . . Croce, M. . . . . . . . Cruts, M. . . . . . . . . Cruz De Souza, L. . Cuadrado, E. . . . . . Cucumo, V. . . . . . . Cunningham, H. . . . Curthoys, I. . . . . . . Cutter, G.. . . . . . . . Czlonkowska, A. . . Czlonkowski, A. . . .

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. . . . . . . . . . P197 . . . . . . . . . . P371 . . . . . P334, P344 . . . . . . . . . . P598 . . . . . . . . . . P465 . . . . . . . . . . P365 . . . . . . . . . . P507 . . . . . P512, P624 . P298, P299, P300 . O40, P391, P402 . . . . . . . . . . P649 . . . . . . . . . . P316 . . . . . . . . . . P544 . . . . . . . . . . P596 . . . . . P395, P490 . . . . . . . . . . O67 . . . . . . . . . . P463 . . . . . . . . . . P534 . . . . . P504, P506 . . . . . . . . . . P684 . . . . . . . . . .O139 . . . . . . . . . . P447 . . . . . . . . . . P400 . . . . . . . . . . P620 . . . . . . . . . . O68 . . . . . . . . . . P647 . . . . . . . . . . P504 . . . . . . . . . . P476 . . . . . . . . . .O161 . O77, P237, P238 . . . . . . . . . . O55 . . . . . . . . . . O55

D’Agata, F. . . . . . . . . . . . . . . . . . . . P400 D’alfonso, S. . . . . . . . . . . . . . . . . . . P675 D’angelo, M.G. . . . . . . . . . . . . . . . . P513 D’Onofrio, H.. . . . . . . . . . . . . . . . . . P215 D’Urso, O. . . . . . . . . . . . . . . . . . . . . P467 da Costa, J.C. . . . . P183, P424, P425, P544 Dahab, M. . . . . . . . . . . . . . . . . . . . .O113 Dalis, M. . . . . . . . . . . . . . . . . . . . . . P181 Dalla Libera, D. . . O141, P282, P397, P449 Dalmau, J. . . . . . . . . . . . . . . . . . . . . P690 Danaila, T.. . . . . . . . . . . . . . . . . . . . P693 Danburam, A.. . . . . . . . . . . . . . . . . . O61 Dardiotis, E.. . . . . . . . . . . . . . P622, P623 Dashti, M. . . . . . . . . . . . . . . . . . . . . P543 Daum, I. . . . . . . . . . . . . . . . . . . . . . P495 Daumer, M. . . . . . . . . . . . . . . . . . . . P232 Davar, G.. . . . . . . . . . . . . . . . . . . . . P457 Daveluy, W.. . . . . . . . . . . . . . . . . . . P607 Davis, M.B. . . . . . . . . . . . . . . O128, O129 Dazzi, F. . . . . . . . . . . . . . . . . . . . . . P669 De Biasi, F. . . . . . . . . . . . . . . P484, P661 De Carvalho, A. . . . . . . . . . . . . . . . . P638 de Carvalho, M. . . . . . . . . . . . . . . . . O88 de Curtis, M. . . . . . . . . . . . . . . . . . . P375 De Feo, D. . . . . . . . . . . .O141, P397, P449 de la Fuente, M. . . . . . . . . . . . P468, P473 De Marchis, G.M. . . . . . . . . . . . . . . . P383 De Mercanti, S. . . . . . . . O63, P229, P678 De Meyer, S.F. . . . . . . . . . . . . . . . . .O136 De Michele, G.. . . . . . . . . . . . . . . . . P217 De Michele, M. . . . . . . . . . . . . . . . . P598 de Pablo Ferna´ndez, E. . . . . . . . . . . . P371 De Reuck, J. . . . . . . . . . . . . . . . . . .O107

S235 de Riz, M. . . . . . . . . . . . . . . . . O40, P507 De Santi, L. . . . . . . . . . . . . . . P245, P577 De Toni Franceschini, L. . . . . . . . . . . P204 DeArmond, S.J. . . . . . . . . . . . . . . . .O125 Debouverie, M.. . . . . . . . . . . . . . . . . P256 Debska-Vielhaber, G. . . . . . . . . . . . . O91 Dec, M. . . . . . . . . . . . . . . . . . . . . . . P210 Deckmyn, H. . . . . . . . . . . . . . . . . . .O136 Defazio, G. . . . . . . . . . . . . . . . . . . . P308 Defebvre, L.. . . . . . . . . . . . . . . . . . . P621 Del Bo, R. . . . . . . . . . . . P512, P513, P624 Del Carro, U. . . . . . . . . . . . . . . O99, P204 Del Real-Francia, M.A. . . . . . . . . . . . P372 Delatycki, M.B. . . . . . . . . . . . . . . . . P626 Deleva, N. . . . . . . . . . . . . . . . . . . . . P565 Delfico, L. . . . . . . . . . . . . . . . . . . . . O63 Delikan, O. . . . . . . . . . . . . . . . . . . . P250 Della Corte, M. . . . . . . . . . . . . . . . . P439 Demertzi, A. . . . . . . . . . O98, O143, P259, P260, P261 Demir, C.. . . . . . . . . . . . . . . . . . . . . P540 Demir, O. . . . . . . . . . . . . . . . . . . . . P224 Demirci, N.O P567 Demirkaya, S. . . . . . . . . . . . . . . . . . P251 Denis, C.V. . . . . . . . . . . . . . . . . . . .O136 Denke, E.. . . . . . . . . . . . . . . . . . . . . P392 Deplancke, A. . . . . . . . . . . . . . . . . . P172 Dera, T. . . . . . . . . . . . . . . . . . . . . . . P435 Derache, N. . . . . . . . . . . . . . . . . . . . P693 Deramecourt, V. . . . . . . . . . . . . . . . .O107 Deretzi, G. . . . . . . . . . . . . . . . P422, P599 Desgrandchamps, D. . . . . . . . . . .O78, O79 Deutschla¨nder, A. . . . . . . . . . . . . . . . P435 Devile, C. . . . . . . . . . . . . . . . . . . . .O128 Di Maio, L. . . . . . . . . . . . . . . . . . . . P217 Di Mascio, M.T. . . . . . . . . . . . . . . . . P610 Di Pasquale, G. . . . . . . . . . . . . . . . .O103 Di Serio, C. . . . . . . . . . . . . . . . . . . . P572 Di Somma, C. . . . . . . . . . . . . . . . . . P217 Di Somma, C. . . . . . . . . . . . . . . . . . P672 Di Stasi, V. . . . . . . . . . . . . . . P554, P555 Diaz, F. . . . . . . . . . . . . . . . . . . . . . . P266 Dickson, D.W. . . . . . . . . . . . . . . . . .O125 Diederich, N. . . . . . . . . . . . . . . . . . . P180 Die´guez Perdiguero, E. . . . . . . . . . . . P176 Diener, H.C.. . . . . . . . . . . . . . O103, P304 Dieterich, M. . . . . . . . . . . . . . . . . . . P435 Diez, B. . . . . . . . . . . . . . . . . . P468, P473 Dı´ez-Tejedor, E. . . P350, P382, P573, P601, P668 DiFulvio, S. . . . . . . . . . . . . . . . . . . . P531 Dimitriou, A. . . . . . . . . . . . . . . . . . . P239 Dimova, P.. . . . . . . . . . . . . . . . . . . . P545 Dinis-Ribeiro, M. . . . . . . . . . . . . . . . P284 Diogo, C.. . . . . . . . . . . . . . . . . . . . . P316 DiRosario, J. . . . . . . . . . . . . . . . . . . P314 Djuric, S. . . . . . . . . . . . . . . . . . . . . . P613 Dodel, R. . . . . . . . . . . . . . . . . . . . . . O53 Doehner, W.. . . . . . . . . . . . . . . . . . . P381 Dolezal, O. . . . . . . . . . . . . . . . . . . . P227 Dolgan, A. . . . . . . . . . . . . . . . . . . . . P581 Domı´nguez Be´rtalo, J. . . . P372, P469, P697 Donadio, M.. . . . . . . . . . . . . . . . . . .O153 Donadio, V. . . . . . . . . . . . . . . P554, P555 Dong, H.J. . . . . . . . . . . . . . . . . . . . .O138 Doria, A. . . . . . . . . . . . . . . . . . . . . . P688

Dorobat, B. . . . . . Dorta, A.J. . . . . . . Dowlatshahi, S. . . Dragomir, A. . . . . Drazhina, L. . . . . . Drislane, F. . . . . . Drory, V.E. . . . . . Drouet, A. . . . . . . Drulovic, J. . . . . . Duarte, J.M. . . . . . Dubois, B. . . . . . . Duerr, E.-M. . . . . Dufour Gaume, F.. Dumitrescu, L. . . . Dunne, V. . . . . . . Durelli, L. . . . . . . Du¨rr, A.. . . . . . . . Duru, C. . . . . . . . Dusek, P. . . . . . . .

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. . . . . . . . . . P303 . . . . . . . . . . P232 . . . . . . . . . .O142 . . . . . . . . . . P369 . . . . . . . . . . P511 . . . . . . . . . . O51 . . . . . P582, P699 . . . . . . . . . . P626 . . . . . . . . . .O110 . . . . . . . . . . P301 . P377, P378, P587 . . . . . . . . . .O102 . . . . . . . . . .O102 . . . . . . . . . .O102 . . . . . . . . . . P560 . . . . . . . . . .O105 . . . . . . . . . . . . 21 . . . . . . . . . . P453 . . . . . . . . . . P196 . . . . . O133, O134 . . . . . . . . . . P401 . . . . . O106, O117 . . . . . . O96, P233 . . . . . P362, P597 . . . . . P531, P532 . . . . . . . . . . P238 . . . . . . . . . . P346 . . . . . . . . . . P219 . . . . . P208, P209 . . . . . . . . . . P190 . . . . . . . . . .O127 . . . . . . O60, P675 . . . . . . . . . . P485 . . . . . . . . . . P244 . . . . . . . . . . P582 . . . . . P239, P249 . . . . . P226, P474 . . . . . . . . . .O103 . . . . . . . . . . P184

Faber, H. . . . . Fabrini, M.G. . Fabris, F. . . . . Fabrizi, G. . . . Facer, P. . . . . Fahoum, S. . .

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. . . . . . . . . P278 . . . . . . . . . P617 . . . . . . . . . P691 . . . . . . . . . P639 . . . . . . . . . P461 . . . . . . . . . O84 . . . . O130, P535 . . . . . . . . . P638 . . . . . . . . . P241 . . . . P215, P365 . . . . . . . . . O68 . . . . . . . . . P664 . . . . . . . . . P638 . . . . . . . . . P235 . . . . . . . . .O162 O63, P229, P678 . . . . . . . . . P621 . . . . . . . . . P621 . . . . . O54, P662

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. . . . . P663 . . . . .O151 P308, P661 P325, P628 . . . . . P553 . . . . . P387

Falautano, M. . . . . . . . . . . . . . O122, P572 Falcou, A. . . . . . . . . . . . . . . . . . . . . P598 Falini, A. . . . . . . . O45, O122, O124, O159 Fang, L.. . . . . . . . . . . . . . . . . . . . . . O90 Farah, B. . . . . . . . . . . . . . . . . . . . . . P364 Farina, L.. . . . . . . . . . . . . . . . . . . . . O58 Farrag, A. . . . . . . . . . . . . . . . . . . . . P560 Fatahi, J. . . . . . . . . . . . . . . . . . . . . . P187 Fazekas, F.. . . . . . . .16, O106, O117, P404 Fazio, L. . . . . . . . . . . . . . . . . . . . . . P570 Fazio, R. . . . . . . . . . . . . . . . . P330, P351 Fechner, K. . . . . . . . . . . . . . . . . . . . P690 Fedorenko, D.A. . . . . . . . . . . . . .O43, O80 Fedulov, A. . . . . . . . . . . . . . . . . . . . P461 Felbecker, A. . . . . P213, P357, P492, P641 Fele, M.. . . . . . . . . . . . . . . . . . . . . . P234 Felgueiras, R. . . . . . . . . . . . . . . . . . . P212 Fe´lix, L. . . . . . . . . . . . . . . . . . . . . . P270 Fenoglio, C. . O40, O149, P391, P402, P507, P675 Ferens, A. . . . . . . . . . . . . . . . . . . . .O108 Fernandes, H. . . . . . . . . . . . . . . . . . . P659 Fernandes, K.C. . . . . . . . . . . . . . . . . P494 Ferna´ndez, M.T. . . . . . . . . . . . P319, P692 Fernandez, R. . . . . . . . . . . . . . . . . . . P266 Ferna´ndez, R. . . . . . . . . . P298, P299, P300 Ferna´ndez Ale´n, J. . . . . . . . . . . . . . . P171 Fernandez-Torre, J. . . . . . . . . . . . . . . P396 Fernandez-Travieso, J.. . . . . . . . . . . . P601 Ferracci, F. . . . . . . . . . . P484, P660, P661 Ferrarese, C.. . . . . . . . . . . . . . . . . . . P375 Ferraris, A. . . . . . . . . . . . . . . . . . . . O51 Ferraro, D. . . . . . . . . . . . . . . . . . . . . P562 Ferreira, A. . . . . . . . . . . . . . . . . . . . P534 Ferreira, F. . . . . . . . . . . . . . . . . . . . . P218 Ferreira, F. . . . . . . . . . . . . . . . . . . . . P270 Ferreira, J. . . . . . . . . . . . . . . . P424, P425 Ferrero, B. . . . . . . . . . . . . . . . . . . . . O63 Ferrio, F. . . . . . . . . . . . . . . . . . . . . . P400 Ferro, J.M. . . . . . . . . . . . . . . . . . 17, O115 Fevr, T. . . . . . . . . . . . . . . . . . . . . . . P442 Fickl, A. . . . . . . . . . . . . . . . . . . . . .O120 Fiebach, J. . . . . . . . . . . . . . . . P592, P593 Fighera, M.R. . . . . . . . . . P183, P424, P425 Figols, J. . . . . . . . . . . . . . . . . . . . . . P396 Filippi, M. . . . . . . . . O41, O42, O45, O52, O68, O77, O87, O116, O121, O122, O124, O146, O147, O159, P351, P404, P414, P665 Filla, A. . . . . . . . . . . . . . . . . . . . . . . P217 Fincke, F. . . . . . . . . . . . . . . . . . . . . P401 Fineza, I. . . . . . . . . . . . . . . . . . . . . . P316 Fiorelli, L. . . . . . . . . . . . O46, O145, P384 Firtina, B. . . . . . . . . . . . . . . . . . . . . P338 Fischer, D. . . . . . . . . . . . . . . . . . . . . P521 Fischer, K. . . . . . . . . . . . . . . . . . . . . P682 Fisher, E. . . . . . . . . . . . . . . . . . . . . . P403 Flanagin, V.L. . . . . . . . . . . . . . . . . . P435 Fleg, A. . . . . . . . . . . . . . . . . . . . . . . P673 Fleury, A. . . . . . . . . . . . . . . . . . . . . P636 Flores, J. . . . . . . . . . . . . . . . . . . . . . P404 Florez, L.. . . . . . . . . . . . . . . . . . . . . P545 Foerch, C. . . . . . . . . . . . . . . . . . . . . P383 Fonseca, A.C.. . . . . . . . . . . . . . . . . . P542 Fonseca, B.A.. . . . . . . . . . . . . . . . . . P332 Fonseca, J. . . . . . . . . . . . . . . . . . . . . O72

123

S236 Fontanella, M. . . . . . Fook-Chong, S. . . . . Formica, F. . . . . . . . Forn, C. . . . . . . . . . . Fornasier, A. . . . . . . Fo¨rstl, H. . . . . . . . . . Fortunato, F. . . . . . . Foschini, M.P. . . . . . Fothiadaki, A. . . . . . Fouad, B.E. . . . . . . . Foulds, P. . . . . . . . . Fountas, K. . . . . . . . Fox, R. . . . . . . . . . . Frades Payo, B. . . . . Franceschi, C. . . . . . Franceschi, M. . . . . . Franchino, F. . . . . . . Frank Garcia, A. . . . . Franssen, H. . . . . . . . Fratiglioni, L. . . . . . . Fredrickson, J. . . . . . Fredrikson, S. . . . . . . Freitas, L.S. . . . . . . . Frey, J. . . . . . . . . . . Freyre, E.. . . . . . . . . Friend, S.. . . . . . . . . Frisoni, G.B. . . . . . . Frutos-Gonza´lez, V. . Fu, H. . . . . . . . . . . . Fuentes, B.. . . . . . . . Fuertes, J.J. . . . . . . . Fueyo, J. . . . . . . . . . Fujioka, M. . . . . . . . Fujita, M.. . . . . . . . . Fujiwara, M. . . . . . . Funakoshi, K. . . . . . . Fusari Imperatori, S. .

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. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

. . . . . . . . . . P400 . . . . . . . . . . P302 . . . . . P257, P315 . . . . . . O42, O122 . . . . . . . . . . P661 . . . . . . . . . . P392 . . . . . . . . . . P513 . . . . . . . . . . P675 . . . . . . . . . . P178 . . . . . . . . . .O119 . . . . . P455, P458 . . . . . P622, P623 . . . . . . . . . . P403 . . . . . . . . . . P499 . . . . . O139, P675 . . . . . P391, P402 . . . . . . . . . . O63 . . . . . . . . . . P499 . . . . . . . . . . P287 . . . . . P504, P506 . . . . . . . . . . P404 . . . . . P569, P571 . . . . . . . . . . P494 . . . . . P206, P207 . . . . . . . . . .O127 . . . . . . . . . . P458 . . . . O116, O146 . . . . . P584, P585 . . . . . . . . . . P314 . . . . . P382, P601 . . . . . . . . . . P369 . . . . . . . . . . P465 . . . . . . . . . .O135 . . . . . . . . . . O62 . . . . . . . . . .O135 . . . . . . . . . . P337 . P393, P504, P506

Gabaldo´n Torres, L. . . . . . . . . P573, P668 Gabelli, C. . . . . . . . . . . . . . . . . . . . .O139 Gabern, J.Y. . . . . . . . . . . . . . . . . . . .O125 Gabilondo, I. . . . . . . . . . . . . . . . . . .O155 Gaidolfi, E. . . . . . . . . . . . . . . . . . . .O151 Gaig, C.. . . . . . . . . . . . . . . . . . . . . .O111 Gainotti, S. . . . . . . . . . . . . . . . . . . . P393 Gala´n, M. . . . . . . . . . . . . . . . . . . . . P396 Galantucci, S.. . . . . . . . . . . . . . . . . . O52 Galassi, G. . . . . . . P337, P518, P533, P562 Galbiati, S.. . . . . . . . . . . . . . . P257, P315 Galbusera, R. . . . . . . . . . . . . . . . . . . P375 Galgani, S. . . . . . . . . . . . . . . . . . . . . P234 Galimberti, D. . . . . . . . . O40, O149, P391, P402, P504, P506, P507, P675 Galland, A. . . . . . . . . . . . . . . . . . . . O73 Gallardo, E. . . . . . . . . . . . . . . . . . . . P557 Gallardo, M.J. . . . . . . . . . . . . . . . . . P697 Gallardo Alcan˜iz, M.J.. . . . . . . P372, P469 Gallo, A. . . . . . . . . . . . . . . . . P439, P625 Gallo, S. . . . . . . . . . . . . O86, P354, P356 Gallone, S. . . . . . . . . . . . . . . . P391, P402 Galovic, M. . . . . . . . . . . . . . . . . . . . P641 Gama, H. . . . . . . . . . . . . . . . . . . . . . P404 Gambardella, A. . . . . . . . . . . . . . . . . P627 Ganetsos, T. . . . . . . . . . . . . . . . . . . . P657 Gao, B. . . . . . . . . . . . . . . . . . . . . . .O114 Garcia, A. . . . . . . . . . . . . . . . . . . . . P266

123

Garcı´a, A. . . . . . . . . . . Garcia, P.Y. . . . . . . . . . Garcia Cobos, R. . . . . . Garcia-Carrizo, F. . . . . . Garcı´a-Este´vez, D.A.. . . Garde, N.. . . . . . . . . . . Garicochea, B. . . . . . . . Garrabou, G. . . . . . . . . Garufi, A. . . . . . . . . . . Gasche, Y. . . . . . . . . . . Gasparotti, R. . . . . . . . . Gasperi, M. . . . . . . . . . Gasperini, C. . . . . . . . . Gass, A.. . . . . . . . . . . . Gassama, S. . . . . . . . . . Gassmann, M. . . . . . . . Gatta, V. . . . . . . . . . . . Gattringer, T. . . . . . . . . Gaul, C.. . . . . . . . . . . . Gavan, C. . . . . . . . . . . Gawel, M. . . . . . . . . . . Gazzellini, S. . . . . . . . . Gedney, L. . . . . . . . . . . Geerlings, M.I. . . . . . . . Gellera, C. . . . . . . . . . . Ge´ly-Nargeot, M.C.. . . . Gemignani, F. . . . . . . . Genari, B. . . . . . . . . . . Genc, G. . . . . . . . . . . . Gentile, M. . . . . . . . . . Geny, C. . . . . . . . . . . . Georgakoudas, G. . . . . . George, J.M. . . . . . . . . Georgiou-Karistianis, N. Geraldes, R. . . . . . . . . . Gerchman, F. . . . . . . . . Gerevini, S. . . . . . . . . . Gerischer, L.M. . . . . . . Geroldi, C. . . . . . . . . . . Gerostergios, G. . . . . . . Gervasi, G. . . . . . . . . . Gezawa, I.D. . . . . . . . . Ghaemi, A. . . . . . . . . . Ghayeghran, A.R. . . . . . Ghazi-Visser, L. . . . . . . Ghezzi, A. . . . . . . . . . . Ghezzi, S. . . . . . . . . . . Ghidoni, R. . . . . . . . . . Ghidoni, R. . . . . . . . . . Ghika, A.. . . . . . . . . . . Ghisleni, G. . . . . . . . . . Ghoraba, M.A. . . . . . . . Giacalone, G. . . . . . . . . Giacone, S . . . . . . . . . . Giagnacovo, M. . . . . . . Gianfreda, C. . . . . . . . . Giannoccaro, M. . . . . . . Gianouli, J. . . . . . . . . . Gibbons, V.S.. . . . . . . . Gil, A.. . . . . . . . . . . . . Gil, S. . . . . . . . . . . . . . Gil, M.J. . . . . . . . . . . . Gille, M. . . . . . . . . . . . Gilmore, C. . . . . . . . . . Gime´nez-Mun˜oz, A. . . . Giometto, B. . . . . . . . .

. . . . . . . . . . P557 . . . . . P264, P600 . . . . . . . . . . P499 . . . . . . . . . . P211 . . . . . . . . . . P480 . . . . . . . . . . P680 . . . . . . . . . . P544 . . . . . . . . . . P329 . . . . . . . . . . P514 . . . . . . . . . . P263 . . . . . . . . . . O69 . . . . . . . . . . P672 . . . . . . . . . . P234 .O123, P404, P406 . . . . . . . . . . P172 . . . . . . . . . .O137 . . . . . . . . . . P199 . . . . . . . . . .O106 . . . . . . . . . . P304 . . . . . . . . . . P394 . . . . . . . . . . P528 . . . . . . . . . . O70 . . . . . . . . . . P444 . . . . . . . . . . P611 . . . . . . . . . . P628 . . . . . . . . . . P574 . . . . . . . . . . P325 . . . . . . . . . . P309 . . . . . . . . . . P251 . P484, P660, P661 . . . . . . . . . . P574 . . . . . . . . . . P500 . . . . . . . . . . P302 . . . . . . . . . . P626 . . . . . P489, P493 . . . . . . . . . . P294 . . . . . . . . . . P448 . . . . . . . . . . P593 . . . . . . . . . .O116 . . . . . . . . . . P178 . . . . . . . . . . P373 . . . . . . . . . . P389 . . . . . . . . . . P685 . . . . . . . . . . P190 . . . . . . . . . . P580 . . . . . . O60, P450 . . . . . . . . . . P513 O139, O149, P402 . . . . . . . . . . P391 . . . . . . . . . .O118 . . . . . . . . . . P294 . O85, O85a, O119 . . . . . . . . . . O60 . . . . . P354, P356 . . . . . . . . . . P525 . . . . . . . . . . P467 . . . . . P554, P555 . . . . . . . . . . P478 . . . . . . . . . .O128 . . . . . . . . . . P266 . . . . . . . . . . P266 . . . . . P319, P692 . . . . . . . . . . P223 . . . . . . . . . . P649 . . . . . . . . . . P612 . . . . . . . . . . P688

Giordana, M.T. . . . . . . . . . . . . P391, P402 Giordano, M. . . . . . . . . . . . . . . . . . . P675 Gioulis, M. . . . . . P308, P484, P660, P661 Giovannoni, G. . . . . . . . . O75, P441, P442 Giralt, E. . . . . . . . . . . . . . . . . . . . . . P647 Gitto, L. . . . . . . . . . . . . . . . . . . . . . P577 Glasauer, S. . . . . . . . . . .O157, P296, P435 Glick, G. . . . . . . . . . . . . . . . . . . . . . P455 Go, T. . . . . . . . . . . . . . . . . . . . . . . . P323 Godefroy, O. . . . . . . . .O120, O148, O150, P177, P253, P264, P600, P621 Godinho, A. . . . . . . . . . . . . . . . . . . . P331 Goebels, N. . . . . . . . . . . . . . . . . . . . P682 Goizet, C. . . . . . . . . . . . . . . . . . . . . P621 Golaszewski, S. . . . . . . . . . . . . . . . . O39 Golenia, A. . . . . . . . . . . . . . . . . . . . P348 Golub, H.. . . . . . . . . . . . . . . . P237, P238 Gomez-Amor, J . . . . . . . . . . . P503, P505 Gomez-Gallego, M.. . . . . . . . . P503, P505 Gomez-Garcia, J. . . . . . . . . . . . . . . . P503 Gomez-Lopez, M.J.. . . . . . . . . . . . . . P509 Gomez-Manzano, C. . . . . . . . . . . . . . P465 Gonc¸alves, J.G. . . . . . . . . . . . P331, P488 Gonc¸alves, M.V.. . . . . . . . . . . . . . . . P596 Gonc¸alves, O.. . . . . . . . . . . . . . . . . . P316 Gonen, O. . . . . . . . . . . . . . . . . . . . .O123 Gon˜i Imizcoz, M. . . . . . . . . . . . . . . . P176 Gonza´lez, B. . . . . . . . . . . . . . . . . . . P298 Gonzalez, V. . . . . . . . . . . . . . . . . . .O155 Gonzalez Fernandez, J. . . . . . . . . . . . P176 Gonza´lez-Aramburu, I. . . . . . . . . . . . P396 Gonzalez-Rosa, J. . . O99, P282, P285, P414 Gonzalo Martı´nez, J.F. . . . . . . . . . . . P371 Goodin, D.S. . . . . . . . . . . . . . . O77, P665 Goodman, B. . . . . . . . . . . . . . . . . . .O125 Gordon, C.R. . . . . . . . . . . . . . P420, P436 Gormley, G. . . . . . . . . . . . . . . . . . . . P463 Gorno-Tempini, M.L. . . . . . . . . . . . .O147 Gorodokin, G. . . . . . . . . . . . . . .O43, O80 Go¨rz, E.. . . . . . . . . . . . . . . . . . . . . . P201 Gosseries, O. . . . . . . . . . . . . . O98, O143, P259, P260, P261 Goto, K. . . . . . . . . . . . . . . . . . . . . . P515 Gotoh, T. . . . . . . . . . . . . . . . . . . . . . P524 Gottschalk, S. . . . . . . . . . . . . . P440, P694 Govoni, A. . . . . . . . . . . . . . . . P512, P513 Grabova, S. . . . . . . . . . . . . . . . . . . . P247 Graf, R. . . . . . . . . . . . . . . . . . O133, O134 Graff-Radford, N. . . . . . . . . . . . . . . .O125 Gralla, J. . . . . . . . . . . . . . . . . . . . . .O105 Grau, C. . . . . . . . . . . . . . . . . P576, P579 Graus, F. . . . . . . . . . . . . . . . . O155, P687 Grebe, H.P. . . . . . . . . . . . . . . . . . . . P534 Grebe, P. . . . . . . . . . . . . . . . . . . . . . P284 Greco, R. . . . . . . . . . . . . . . . . . . . . . P462 Greco Crasto, S. . . . . . . . . . . . . . . . .O151 Greenberg, S. . . . . . . . . . O75, P441, P442, P443, P444 Grgic, S. . . . . . . . . . . . . . . . . . . . . . P241 Grigaitis, M.. . . . . . . . . . . . . . . . . . . P174 Grigoriadis, N. . . . . . . . . P426, P683, P686 Grigoriou, M. . . . . . . . . . . . . . . . . . . P686 Grimaldi, G.. . . . . . . . . . . . . . . . . . . O56 Grimaldi, L. . . . . . . . . . . . . . . P450, P675 Grool, A.M. . . . . . . . . . . . . . . . . . . . P611 Gross, D. . . . . . . . . . . . . . . . . . . . . .O130

S237 Grossman, R.I. . . . Gro¨tzinger, D. . . . Grubneac, A.H.A. . Gruszczak, A.. . . . Guan, J.X. . . . . . . Guarneri, D. . . . . . Guarnieri, B. . . . . Gubieras, L. . . . . . Guekht, A. . . . . . . Guerra, G.P. . . . . . Guerrero, A.L. . . . Guilloton, L. . . . . Gu¨ler, S. . . . . . . . Gunduz, T.. . . . . . Guo, X.Q. . . . . . . Gupta, P. . . . . . . . Gurevich, M. . . . . Gurgu, R.. . . . . . . Gurses, C. . . . . . . Guseo, G. . . . . . . Gutowski, N.J. . . . Guven Yorgun, Y.

. . . . . . . . . . . . . .O123 . . . . . . . . . . . . . . O50 . . . . . . . . . . . . . . P635 . . . . . . . . . P242, P671 . . . . . . . . . . . . . .O138 . . . . . . . . . . . . . .O151 . . . . . . . . . . . . . . P619 . . . . . . . . . . . . . . P248 . . . . . . . . . . . . . . O53 . . . . . . . . . . . . . . P424 . . . . P184, P298, P299, P300, P369, P584, P585 . . . . . . . . . . . . . . P638 . . . . . . . . . . . . . . P648 . . . . . . . . . . . . . . P233 . . . . . . . . . P415, P588 . . . . . . . . . . . . . . P605 . . . . . . . . . . . . . . P535 . . . . . P370, P437, P639 . . . . . . . . . . . . . . O96 . . . . . . . . . . . . . . P660 . . . . . . . . . . . . . . P430 . . . . . . . . . P243, P568

Haas, J. . . . . . . . . . Ha˚berg, A. . . . . . . . Haberlova, J. . . . . . Hadjigeorgiou, G. . . Hadjiloizou, S. . . . . Ha¨gele-Link, S. . . . Haggiag, S. . . . . . . Haghighi, S. . . . . . . Haji Abolhasan, F. . Halmagyi, M. . . . . . Hamann, J.. . . . . . . Hamidian, Y. . . . . . Hamlett, A. . . . . . . Hamzavi, Y.. . . . . . Han, I.T. . . . . . . . . Han, S. . . . . . . . . . Hanagasi, H. . . . . . Hannan, M. . . . . . . Hannequin, D. . . . . Hansen, J.M. . . . . . Hansen, N. . . . . . . . Hardy, J. . . . . . . . . Harigaya, Y.. . . . . . Ha¨ring, D. . . . . . . . Harrer, A. . . . . . . . Harrer, M. . . . . . . . Hartig, M. . . . . . . . Ha¨rtig, W. . . . . . . . Hartmann, N. . . . . . Hartung, H.P. . . . . . Hasan, M. . . . . . . . Haschke-Becher, E.. Hasegawa, Y. . . . . . Hashimoto, S.. . . . . Hassan, B. . . . . . . . Hassan, G.Z. . . . . . Hauge, A.W. . . . . . Haulica, I. . . . . . . . Havla, J. . . . . . . . . Havlova, M. . . . . . . Havrdova´, E. . . . . . Hawlik, A. . . . . . . .

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. . . . . . . . . . P452 . . . . . . . . . . P429 . . . . . . . . . . P328 . . . . . P622, P623 . . . . . . . . . . P293 . . . . . . . . . . P213 . . . . . . . . . . P234 . . . . . . . . . . P244 . . . . . . . . . . P187 O131, O161, O162 . . . . . . . . . . P392 . . . . . . . . . . P691 . O75, P441, P442 . . . . . . . . . .O152 . . . . . . . . . . P165 . . . . . . . . . . P423 . . . . . . . . . . P696 . . . . . . . . . . O67 . . . . . . . . . . P177 . . . . . . . . . . O48 . . . . . . . . . . P559 . . . . . . . . . . . . 37 . . . . . . . . . . P516 . . . . . . O76, P445 . O39, P664, P667 . . . . . . . . . . P682 . . . . . . . . . . O64 . . . . . . . . . . P376 . . . . . . . . . . O50 . . . 33, O77, P665 . . . . . . . . . . P432 . O39, P664, P667 . . . . . . . . . . P390 . . . . . . . . . . O62 . . . . . . . . . . O61 . . . . . . . . . . P635 . . . . . . . . . . O48 . . . . . . . . . . P431 . . . . . . . . . . P464 . . . . . . . . . . P328 . . . . . . . 34, P227 . . . . . . . . . . P201

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Iaffaldano, P. . . . . . . . . . . . . . . . . . . P570 Ickenstein, G.W. . . . . . . . . . . . . . . . . P609 Idiman, E. . . . . . . . . . . P228, P243, P410, P568, P677 Iida, M. . . . . . . . . . . . . . . . . . . . . . . P433 Ilardi, A. . . . . . . . . . . . . . . . . P354, P356 Ilg, R. . . . . . . . . . . . . . . . . . . . . . . . O64 Infante, J.. . . . . . . . . . . . . . . . . . . . . P557 Inokuchi, K. . . . . . . . . . . . . . . . . . . . P502 Inoue, N. . . . . . . . . . . . . . . . . . . . . . P502 Inshasi, J.S. . . . . . . . . . . . . . . . . . . . P695 Inuggi, A. . . . . . . . . . . .O100, P285, P414 Ioacara, S. . . . . . . . . . . . . . . . . . . . . P394 Ionescu, P. . . . . . . . . . . . . . . . P367, P407 Ionova, T.I. . . . . . . . . . . . . . . . .O43, O80 Iranzo, A. . . . . . . . . . . . . . . . . . . . .O111 Irie, K. . . . . . . . . . . . . . . . . . . . . . .O135 Isak, B. . . . . . . . . . . . . . . . . . . . . . . P288 Isart, C. . . . . . . . . . . . . . . . . . P319, P692 Ishikawa, H.. . . . . . . . . . . . . . . . . . . P352 Iskedjian, M. . . . . . . . . . . . . . . . . . . P364 Italiano, D.. . . . . . . . . . . . . . . . . . . . P627 Iudicello, M. . . . . . . . . . . . . . . . . . . O63 Iversen, V.C. . . . . . . . . . . . . . . . . . . O82 Iwahashi, Y.. . . . . . . . . . . . . . . . . . . P651 Iyadurai, S. . . . . . . . . . . P591, P630, P631 Jablensky, A. Jacobs, B.C. . Jadraque, R. . Jagiella, J. . .

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Jahn, K. . . . . . . . . . . . . Jahn, O. . . . . . . . . . . . . Jakob, P. . . . . . . . . . . . Jalaie, S. . . . . . . . . . . . Jamroz-Wisniewska, A. . Jamrozik, Z. . . . . . . . . . Jancic, J. . . . . . . . . . . . Janelidze, M. . . . . . . . . Jansen, O. . . . . . . . . . . Janua´rio, C. . . . . . . . . . Javanmard, SH. . . . . . . Jech, R. . . . . . . . . . . . . Jeffery, D. . . . . . . . . . . Jensen, U. . . . . . . . . . . Jesse, S.. . . . . . . . . . . . Jiang, H. . . . . . . . . . . . Jime´nez, J. . . . . . . . . . . Jime´nez Rolda´n, L. . . . . Jin, D.K. . . . . . . . . . . . Jingjing, L. . . . . . . . . . Jo, H.J. . . . . . . . . . . . . Jo, H.Y.. . . . . . . . . . . . Jordanova, A. . . . . . . . . Jovanovic, D.R. . . . . . . Jox, R.J. . . . . . . . . . . . Jung, D.S. . . . . . . . . . . Jung, H.Y. . . . . . . . . . . Jung, M. . . . . . . . . . . . Jung, S. . . . . . . . . . . . . Jungehu¨lsing, G.J. . . . . . Juste, R. . . . . . . . . . . .

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Ka¨gi, G. . . . . . . . . . . . . . . . . . . . . . P213 Kahn, A.K. . . . . . . . . . . . . . . . . . . . P559

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S238 Kaklamanis, D.. . Kalaydjieva, L. . . Kalenova, I. . . . . Kalfakis, N. . . . . Kaliszewska, M. . Kallweit, U. . . . . Kalnina, J. . . . . . Kalyadina, S.A. . Kang, D.H. . . . . Kang, J.H. . . . . . Kang, S.Y. . . . . . Kang, S.Y. . . . . . Kaplan, P.W. . . . Kappeler, L. . . . . Kappos, L. . . . . .

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Krupa, M. . . . . . . . Krupinska-Dulemba, Krupinski, R. . . . . . Krystkowiak, P. . . . Krzovska, M. . . . . . Ktonas, P. . . . . . . . Ku¨bler, A. . . . . . . . Kuca, K. . . . . . . . . Kudakova, A. . . . . . Kudin, A.P. . . . . . . Kuehlmeyer, K. . . . Kuhad, A. . . . . . . . Kullmann, D.M. . . . Kumagai, T. . . . . . . Kumaram, S. . . . . . Ku¨mpfel, T. . . . . . . Kung, T. . . . . . . . . Kunizawa, A. . . . . . Kunz, A. . . . . . . . . Kunz, W. . . . . . . . . Ku¨ppers-Tiedt, L. . . Kupsky, W. . . . . . . Kuqo, A. . . . . . . . . Kurbatova, K.A. . . . Kuroda, K. . . . . . . . Kuroiwa, Y. . . . . . . Ku¨rtu¨ncu¨, M. . . . . . Kutukcu, Y. . . . . . . Kuznetsov, A.N. . . . Kwak, Y.T. . . . . . . Kwan, J.S. . . . . . . . Kwiecinski, H. . . . . Kwon, J.H.. . . . . . . Kwon, K.H. . . . . . . Kwon, S.B. . . . . . . Kyriazopoulou, E. . . Kyrozis, A. . . . . . . Kyrtsonis, M.C. . . .

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. . . . . P481, P482 . . . . . . . . . . P581 . . . . . . . . . . P272 . . . . . O148, P621 . . . . . . . . . . P201 . . . . . . . . . . P511 . . . . . . . . . . O98 . . . . . . . . . . P432 . . . . . . . . . . P265 . . . . . . . . . . O91 . . . . . . . . . .O140 . . . . . . . . . . P205 . . . . . P470, P589 . . . . . . . . . .O134 . . . . . . . . . . P608 . . . . . . . . . . P464 . . . . . . . . . . P381 . . . . . . . . . .O135 . . . . . . . . . . O39 . . . . . . . . . . O91 . . . . . . . . . . P376 . . . . . . . . . .O125 . . . . . . . . . . P247 . . . . . . .O43, O80 . . . . . . . . . . P225 . . . . . . . . . . P651 . . . . . . O92, P233 . P224, P590, P652 . . . . . . . . . . O80 . . . . . P179, P289 . . . . . . . . . .O156 . . . . . . . . . . P528 . . . . . . O66, P487 . . . . . . . . . . P530 . P361, P530, P563 . . . . . P422, P599 . . . . . O118, P511 . . . . . . . . . . P478

L’esperance, V. . . . . . . . . . . . . . . . . O94 La Fauci Belponer, F. . . . . . . . . . . . . P577 La Gioia, S. . . . . . . . . . . . . . . . . . . . P347 Labiano Foncuberta, A. . . . . . . . . . . . P371 Ladewig, G. . . . . . . . . . . . . . . . . . . .O132 Ladurner, G.. . . . . . . . . . O39, P664, P667 Lagana`, A. . . . . . . . . . . . . . . . . . . . . P627 Lagares, A. . . . . . . . . . . . . . . P168, P171 Lagoudaki, R.. . . . . . . . P426, P538, P539, P548, P640, P683, P686 Lambolay, J.L. . . . . . . . . . . . . . . . . . P638 Lampreia, T. . . . . . . . . . P594, P618, P629 Lamy, C. . . . . . . . . . . . .O120, P264, P600 Landragin, N. . . . . . . . . . . . . . . . . . . P574 Lang, B. . . . . . . . . . . . . . . . . . . . . .O154 Langdon, D. . . . . . . . . . . . . . . P569, P571 Langen, K.J.. . . . . . . . . . . . . . . . . . .O152 Langkammer, C. . . . . . . . . . . . . . . . .O106 Lanzillo, R. . . . . . . . . . . . . . . . . . . . P672 Lash, J. . . . . . . . . . . . . . . . . . . . . . .O125 Latanza, L.. . . . . . . . . . . . . . . . . . . . P439 Lauer, K. . . . . . . . . . . . . . . . . . . . . . P615 Laura, M.. . . . . . . . . . . O128, O129, P325 Laureys, S.. . . . . . . . . . . O98, O143, P259, P260, P261, P262 Lauricella, P. . . . . . . . . . . . . . . . . . . P660 Lauterbach, M. . . . . . . . . O72, P398, P398

S239 Lavrnic, D. . . . . . Le Gall, D. . . . . . Leal, G. . . . . . . . . Lebedeva, E.R. . . . Ledoux, D.. . . . . . Lee, G. . . . . . . . . Lee, H.J. . . . . . . . Lee, J. . . . . . . . . . Lee, J.-C. . . . . . . . Lee, J.J. . . . . . . . . Lee, J.J. . . . . . . . . Lee, J.S. . . . . . . . Lee, J.X. . . . . . . . Lee, K.J. . . . . . . . Lee, K.S. . . . . . . . Lee, K.W. . . . . . . Lee, K.Y.. . . . . . . Lee, M.J. . . . . . . . Lee, S.J. . . . . . . . Lee, S.Y. . . . . . . . Lee, S.Y. . . . . . . . Lee, Y. . . . . . . . . Lehembre, R. . . . . Lehericy, S. . . . . . Lehmensiek, V. . . Lehnen, N. . . . . . . Lehnert, S. . . . . . . Lehr, S. . . . . . . . . Leita˜o, A. . . . . . . Leite, M.I. . . . . . . Leiva-Santana, C. . Lemesiou, A. . . . . Leocani, L. . . . . .

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Leone, M. . . . . . . Leopizzi, E. . . . . . Leroy, M. . . . . . . Leschnik, B.. . . . . Leupold, D. . . . . . Leyendecker, S. . . Leys, D. . . . . . . . Li, C.Y. . . . . . . . . Li, D. . . . . . . . . . Liberatore, G.. . . . Ligorio, C. . . . . . . Liguori, R. . . . . . . Lim, J.. . . . . . . . . Lima, J. . . . . . . . . Lin, P.F. . . . . . . . Linaker, O.M.. . . . Lindquist, C. . . . . Lindstrom, E. . . . . Linhares, P. . . . . . Linjun, J. . . . . . . . Linortner, P.. . . . . Lipton, R. . . . . . . Lispi, L. . . . . . . . Listi, F. . . . . . . . . Litterio, P. . . . . . . Liu, D. . . . . . . . . Liu, H.H. . . . . . . . Liu, W.W. . . . . . . Liudong, W.. . . . . Llanero Luque, M. Lo, Y.L. . . . . . . . Lo Cascio, C. . . . .

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. . . . . P360, P522 . . . . . . . . . .O150 . . O72, O72, P398 . . . . . . . . . . P188 . P259, P260, P261 . . . . . . . . . . P185 . . . . . . . . . . P252 . . . . . . . . . . P355 . . . . . . . . . . P403 . . . . . . . . . . P252 . . . . . . . . . . P366 . . . . . . . . . . P517 . . . . . . . . . . P517 . . . . . . . . . . P549 . . . . . P169, P551 . . . . . P349, P353 . . . . . P380, P388 . . . . . . . . . . P361 . . . . . . . . . . P169 . . . . . . . . . . P614 . . . . . . . . . . P603 . . . . . P380, P388 . . . . . . . . . . O98 . . . . . . . . . . O68 . . . . . . . . . . O50 . . . . . . . . . .O157 . . . . . . . . . . P201 . . . . . . . . . . P665 . . . . . . . . . . P488 . . . . . . . . . . P687 . . . . . . . . . . P509 . . . . . . . . . . P293 . O97, O99, O100, P282, P285, P414 . . . . . . . . . . P675 . . . . . . . . . . P572 . . . . . . . . . . P256 . . . . . . . . . . P268 . . . . . . . . . . P357 . . . . . . . . . . O47 . . . . . . . . . .O107 . . . . . . . . . .O138 . . . . . . . . . . P456 . . . . . . . . . . P460 . . . . . . . . . . P675 . . . . . P554, P555 . . . . . . . . . . P355 . . . . . . . . . . P476 . . . . . . . . . . P279 . . . . . . . . . . O82 . . . . . . . . . . O81 . . . . . . . . . . O60 . . . . . . . . . . P659 . . . . . . . . . . P208 . . . . . . . . . .O117 . . . . . . . . . . P305 . . . . . . . . . . P290 . . . . . . . . . . P675 . O46, O145, P384 . . . . . . . . . . P465 . . . . . . . . . . P520 . . . . . . . . . . P416 . . . . . P208, P209 . . . . . . . . . . P499 . . . . . . O59, P302 . . . . . . . . . . P661

Locatelli, F. . . . . . Locatelli Smith, A. Lohse, P. . . . . . . . Lolli, I. . . . . . . . . Lombardi, G. . . . . Longo, A.L. . . . . . Lopate, G. . . . . . . Lopes, L.C. . . . . . Lo´pez, M. . . . . . . Lopez, R.. . . . . . . Lopez Soriano, A.. Lopez-Arrieta, J.. . Lo´pez-Gasto´n, J.I. . Lorenzano, S. . . . . Lorenzoni, P.J. . . . Lorke, D. . . . . . . . Lourbopoulos, A. . Lourenc¸o, S.. . . . . Lovati, C. . . . . . . Lu, Z.N. . . . . . . . Lubrini, G. . . . . . . Luca, D. . . . . . . . Lucchetti, P.. . . . . Lucchini, V. . . . . . Luchowski, P. . . . Ludolph, A.C. . . . Lule´, D. . . . . . . . . Lundequam, P. . . . Lunn, M.P.. . . . . . Lutz, N.W.. . . . . . Luyt, C.E. . . . . . .

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. . . O70, P257, P315 . . . . . . . . . . . . P294 . . . . . . . . . . . . P464 . . . . . . . . . . . .O151 . . . . . . . . . . . . P217 . . . . . . . . . . . . P596 . . . . . . . . . . . . P591 . . . . . . . . . . . . P332 . . . . . . . . . . . . P647 . . . . . . . . . . . . O84 . . . . . . . . . . . . P227 . . . . . . . . . . . . P499 . . . . . . . . . . . . P612 . . . . . . . . . . . . P598 . . . . . . . . . . . . P527 . . . . . . . . . . . . P432 . . . . . . . P426, P683 . . . . . . . . . . . . P270 . . . . . . . . . . . . P297 . . . . . . . . . . . .O138 . . . . . . . P573, P668 . . . . . . . . . . . . P235 . . . . . . . . . . . . P610 . . . . . . . . . . . . P513 . . . . . . . . . . . . P272 O50, O57, O90, P201 . . . . . . . . . . . . O98 . . . . . . . . . . . . O95 . . . . . . . . . . . .O129 . . . . . . . . . . . . P684 . . . . . . . . . . . . P496

Ma, S.M. . . . . . . . Macdonald, J. . . . . MacDougall, H. . . Machado, D.C. . . . Machner, B. . . . . . Machtoub, L.H. . . Mackowiak, M.A. . Maddison, P. . . . . Madhavan, R. . . . . Madureira, S. . . . . Maegli, J.. . . . . . . Magalha˜es, C. . . . Magalha˜es, M. . . . Magalha˜es, P.S. . . Maggiore, L. . . . . Maghzi, A.. . . . . . Magliozzi, M.. . . . Magnani, G. . . . . . Magni, D.V. . . . . . Magoni, M. . . . . . Magri, F. . . . . . . . Maillard, L. . . . . . Majerus, S. . . . . . Majjhoo, A. . . . . . Mak, W.W. . . . . . Makris, N. . . . . . . Mali, W.P. . . . . . . Malik, O. . . . . . . . Malkin, M.. . . . . . Mancarella, G. . . . Mandrioli, J.. . . . . Manganelli, F. . . . Mano, T. . . . . . . . Manoli, D. . . . . . .

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. . . . . . . . . . P614 . . . . . . . . . .O162 . . . . . . . . . .O161 . . . . . . . . . . P544 . . . . . . . . . .O158 . . . . . . . . . . P202 . . . . . . . . . . P175 . . . . . . . . . .O154 . . . . . . . . . . P604 . . . . . . . . . .O115 . . . . . . . . . . P215 . . . . . . . . . . P255 . . . . . . . . . . O65 . . . . . . . . . . P494 . . . . . P393, P506 . . . . . . . . . . P244 . . . . . . . . . . O51 . . . . . . . . . . P397 . . . . . P424, P425 . . . . . . . . . . O69 . . . . . P512, P513 . . . . . . . . . . P537 . P259, P260, P261 . . . . . . . . . . P604 . . . . . . . . . . P520 . . . . . . . . . . P500 . . . . . . . . . . P611 . . . . . . . . . . P669 . . . . . . . . . . P476 . . . . . . . . . . P624 . . . . . . . . . . P562 . . . . . . . . . . P326 . . . . . . . . . . P390 . . . . . P226, P474

Manso, R. . . . . Manta, L.. . . . . Manto, M. . . . . Manzano, B.. . . Mao-Ying, Q.L. Marchegiani, F. Marchesi, C.. . . Marchesi, E.. . . Marchini, C.. . . Marco, E.. . . . . Marcone, A. . . . Mariani, C. . . .

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. . . . . . . . . P214, P363 . . . . . . . . . . . . . . P479 . . . . . . . . . . . . . . O56 . . . . . . . . . . . . . . P573 . . . . . . . . . . . . . . P427 . . . . . . . . . . . . . .O139 . . . . . O58, P326, P628 . . . . . . . . . . . . . . P646 P308, P484, P660, P661 . . . . . . . . . . . . . . P396 . . . . . . . . . P391, P402 . . . . P297, P391, P393, P402, P501, P504, P506 Marinovic, D. . . . . . . . . . . . . . . . . . . P544 Marjanovic, I.. . . . . . . . . . . . . P241, P522 Markoulatos, P. . . . . . . . . . . . . . . . . P426 Marotta, E.. . . . . . . . . . . . . . . . . . . . P632 Marouf, H. . . . . . . . . . . . . . . . . . . . . P560 Marques, J. . . . . . . . . . . . . . . . . . . . P490 Marques, V.D. . . . . . . . . . . . . . . . . . P332 Marques Jr., W. . . . . . . . . . . . . . . . . P332 Marquez, S.V. . . . . . . . . . . . . . . . . . P424 Marra, A.. . . . . . . . . . . . . . . . . . . . . P373 Marrone, L.C.. . . . . . . . . . . . . . . . . . P183 Marrosu, M.G. . . . . . . . . . . . . . . . . . P356 Marta, J. . . . . . . . . . . . . . . . . . . . . . P612 Martı´, F. . . . . . . . . . . . . . . . . . . . . .O111 Martı´n, B. . . . . . . . . . . . . . . . . . . . . P697 Martin, V. . . . . . . . . . . . . . . . . . . . . P465 Martı´n-Barriga, M.L.. . . . P184, P573, P668 Martinaud, O. . . . . . . . . . . . . . . . . . . P177 Martinelli, V. . . . . . O41, O60, O99, O121, O141, P282, P397, P448, P449, P450, P459, P460, P462, P472, P572 Martinelli Boneschi, F. . . O60, P459, P675 Martinetto, H.. . . . . . . . . . . . . . . . . . P468 Martinez, B. . . . . . . . . . . . . . . . . . . . P319 Martinez Corral, M. . . . . . . . . . . . . . P523 Martinez Martinez, M.. . . . . . . P382, P601 Martinez Rubio, M.. . . . . . . . . . . . . .O127 Martinez-Corral, M. . . . . . . . . . . . . . P485 Martı´nez-Sa´nchez, P.. . . . . . . . . . . . . P382 Martı´nez-Ye´lamos, S. . . . . . . . . . . . . P248 Martini-Robles, L.. . . . . . . . . . . . . . . P617 Martins, A. . . . . . . . . . . . . . . . . . . . P510 Martins, I. . . . . . . . . . . . . . . . . O72, P398 Marusic, P. . . . . . . . . . . . . . . . . . . . P550 Marziani, E. . . . . . . . . . . . . . . . . . . . P501 Mas, F. . . . . . . . . . . . . . . . . . . . . . .O127 Mas, N. . . . . . . . . . . . . . . . . . . . . . . P687 Mas Sala, N. . . . . . . . . . . . . . . . . . .O144 Mascarenhas de Moraes, J.B.M.M. . . . P191 Maselbas, W. . . . . . . . . . . . . . . . . . . O55 Matas, E. . . . . . . . . . . . . . . . . . . . . . P248 Mateus, S. . . . . . . . . . . . . . . . . . . . . P270 Matias, G. . . . . . . . . . . . . . . . P594, P637 Matsi, S. . . . . . . . . . . . . . . . . . . . . .O118 Mattioli, F.. . . . . . . . . . . O69, P231, P572 Mattle, H. . . . . . . . . . . . . . . . O105, P383 Mattoscio, M. . . . . . . . . . . . . . . . . . . P669 Matur, Z. . . . . . . . . . . . . . . . . . . . . . P696 Maues De Paula, A. . . . . . . . . . . . . .O125 Maurage, C. . . . . . . . . . . . . . . . . . . .O107 Maurya, S. . . . . . . . . . . . . . . . . . . . . O93 Mavromatis, I. . . . P538, P539, P548, P640

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S240 Mayordomo, F.. . . . . . Mazanec, R. . . . . . . . . Mazzini, L. . . . . . . . . Mc Guigan, C. . . . . . . McCarty, D. . . . . . . . . McGarvie, L. . . . . . . . McLean, C. . . . . . . . . Meacci, M. . . . . . . . . Medaglini, S. . . . . . . . Medeiros, L.. . . . . . . . Meert, T. . . . . . . . . . . Mehrabian, S. . . . . . . . Meidani, E. . . . . . . . . Meier, S. . . . . . . . . . . Meister, S. . . . . . . . . . Meixensberger, J. . . . . Melero, M.. . . . . . . . . Meletti, S. . . . . . . . . . Meliksetyan, I. . . . . . . Mellesi, L. . . . . . . . . . Melnichenko, V.Y. . . . Melø, T. . . . . . . . . . . Melzi, L. . . . . . . . . . . Mendel, R. . . . . . . . . . Mendes, I. . . . . . . . . . Mendes-Ribeiro, J.A.. . Menegatti, R.S.. . . . . . Menezes Xavier, A.C. . Meola, G. . . . . . . . . . Mertgens, H. . . . . . . . Mesaros, S. . . . . . . . . Metra, M. . . . . . . . . . Meulemans, T. . . . . . . Meys, V. . . . . . . . . . . Meysami, S. . . . . . . . . Mi, W. . . . . . . . . . . . Micha´lek, J. . . . . . . . . Michalski, D. . . . . . . . Michalski, M. . . . . . . . Michel, B.F. . . . . . . . . Mies, G. . . . . . . . . . . Migliaccio, R. . . . . . . Mijo, S. . . . . . . . . . . . Mikami, H. . . . . . . . . Mikol, D.. . . . . . . . . . Mikulis, D. . . . . . . . . Mikulkova´, Z. . . . . . . Milani, M. . . . . . . . . . Milanovich, N. . . . . . . Milesi, J. . . . . . . . . . . Milheiro, M.. . . . . . . . Milic Rasic, V. . . . . . . Milla´n, J. . . . . . . . . . . Miller, B.. . . . . . . . . . Miller, B.L. . . . . . . . . Miller, D.. . . . . . . . . . Milosevic, V. . . . . . . . Minicuci, N.. . . . . . . . Minin, I. . . . . . . . . . . Minzer, M.. . . . . . . . . Miranda, A.P.. . . . . . . Miranda, B. . . . . . . . . Miret, M. . . . . . . . . . . Mirzadjanova, Z. . . . . Misbah, S. . . . . . . . . . Mishima, K. . . . . . . . .

123

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. . . . . . . . . .O127 . . . . . . . . . . P328 . . . . . . . . . . O86 . . . . . . . . . . P669 . . . . . . . . . . P314 . . . . . . . . . .O161 . . . . . . . . . .O131 . . . . . . . . . . P337 . . . . . . . . . . O99 . . . . . . . . . . P564 . . . . . . . . . . P553 . . . . . . . . . . P620 . P582, P657, P699 . . . . . . . . . . P201 . . . . . . . . . . O89 . . . . . . . . . . P658 . . . . . . . . . . P365 . . . . . P337, P518 . . . . . . . . . . P200 . . . . . . . . . . O40 . . . . . . . . . . O80 . . . . . . . . . . P429 . . . . . . . . . .O124 . . . . . . . . . . P392 . . . . . . . . . . P270 . . . . . . . . . . P284 . . . . . . . . . . P494 . . . . . . . . . . P294 . . . . . . . . . . P525 . . . . . . . . . .O133 . . . . . . O41, O121 . . . . . . . . . . P453 . . . . . . . . . .O150 . . . . . . . . . . P558 . . . . . . . . . . P421 . . . . . . . . . . P427 . . . . . . . . . . P676 . . . . . . . . . . P376 . . . . . . . . . . P210 . . . . . . . . . .O125 . . . . . O133, O134 . . . . . . O68, O147 . . . . . . . . . . P247 . . . . . . . . . . P352 . . . . . . . . . . P443 . . . . . P416, P417 . . . . . . . . . . P676 . . . . . O128, P628 . . . . . . . . . . P461 . . . . . O124, O159 . . . . . . . . . . P534 . . . . . P322, P335 .O127, P168, P171 . . . . . . . . . .O125 . . . . . . . . . .O147 . . . . . . . . . . P404 . . . . . . . . . . P613 . . . . . . . . . .O139 . . . . . . . . . . O91 . . . . . . . . . . P461 . . . . . P494, P596 . . . . . . . . . .O115 . . . . . . O44, P444 . . . . . . . . . . P536 . . . . . . . . . . P330 . . . . . . . . . .O135

Mishto, M. . . . . . . . . . . . . . . . O139, P675 Mitrova´, E.J. . . . . . . . . . . . . . . . . . . P616 Mitsikostas, D.D. . . . . . . . . . . . . . . . P454 Mitsuma, N. . . . . . . . . . . . . . . . . . . . P390 Mittas, S. . . . . . . . . . . . . . . . . . . . . . P492 Miyata, T. . . . . . . . . . . . . . . . . . . . .O135 Mizushima, K. . . . . . . . . . . . . . . . . . P516 Mladenovic, J. . . . . . . . . . . . . . . . . . P335 Mnatsakanyan, H. . . . . . . . . . . . . . . . P200 Mnatsakanyan, V. . . . . . . . . . . . . . . . P200 Moallemi, M. . . . . . . . . . . . . . . . . . . P187 Mocanu, B. . . . . . . . . . . . . . . . . . . . P437 Mochkin, N.E. . . . . . . . . . . . . . . . . . O43 Mogel, H. . . . . . . . . . . . . . . . . . . . . O50 Moggio, M. . . . . . . . . . . . . . . . . . . . P513 Moglia, C. . . . . . . . . . . . O86, P354, P356 Mohammadi, A. . . . . . . . . . . . . . . . . P508 Mohanty, S. . . . . . . . . . . . . . . . . . . . P608 Moharregh-Khiabani, D. . . . . . . . . . . P680 Mohr, C. . . . . . . . . . . . . . . . . . . . . . O47 Mohsenzadeh, M. . . . . . . . . . . . . . . . P379 Moiola, L. . . . . . . . . . . . .O60, O99, P282, P448, P450, P462, P472 Moita, S. . . . . . . . . . . . . . . . . . . . . . P255 Mojdeh Ghabaee, M.. . . . . . . . . . . . . P674 Moldovan, M. . . . . . . . . . . . . . . . . . P434 Moliola, L.. . . . . . . . . . . . . . . . . . . .O141 Moll, N. . . . . . . . . . . . . . . . . . . . . . P403 Mollenhauer, B. . . . . . . . . . . . . . . . .O109 Molyneux, M. . . . . . . . . . . . . . . . . . P281 Monaco, F. . . . . . . . . . . . . . . O149, P632 Monge-Argiles, J.A. . . . . . . . . . . . . . P509 Mongini, T. . . . . . . . . . . . . . . . . . . . P529 Montinaro, A.. . . . . . . . . . . . . . . . . . P467 Montoya-Gutierrez, J. . . . . . . . . . . . . P509 Montuschi, A. . . . . . . . . . . . . P354, P356 Moon, H.S. . . . . . . . . . . . . . . . . . . . P336 Moon, Y. . . . . . . . . . . . . . . . . . . . . . P423 Moonen, G. . . . . . P259, P260, P261, P262 Mora, G. . . . . . . . . . . . . . . . . . . . . . O86 Moraga, M. . . . . . . . . . . . . . . . . . . . O44 Morais, H. . . . . . . . . . . . . . . . P334, P344 Morales, M. . . . . . . . . . . . . . . . . . . . P329 Moreira, B. . . . . . . . . . . . . . . . . . . . O65 Moreira, F.. . . . . . . . . . . . . . . . . . . . P654 Moreira, J.M. . . . . . . . . . . . . . . . . . . P617 More´n, C. . . . . . . . . . . . . . . . . . . . . P329 Morgadinho, A.S. . . . . . . . . . . P331, P488 Morgante, A. . . . . . . . . . . . . . . . . . . P525 Morken, G. . . . . . . . . . . . . . . . . . . . O82 Moro, C.H. . . . . . . . . . . . . . . P494, P596 Moro, F. . . . . . . . . . . . . . . . . . . . . . P660 Moro, M. . . . . . . . . . . . . . . . . P660, P661 Morozov, I. . . . . . . . . . . . . . . . . . . . P254 Morrone, R. . . . . . . . . . . . . . . . . . . . P439 Mortara, P.. . . . . . . . . . . . . . . . . . . . P400 Mosialos, G.. . . . . . . . . . . . . . . . . . . P683 Moskala, M.. . . . . . . . . . . . . . P481, P482 Mossman, S. . . . . . . . . . . . . . . . . . .O131 Motamed, M. . . . . . . . . . . . . . . . . . . P421 Motuzova, Y. . . . . . . . . . . . . . . . . . . P461 Moustris, A. . . . . . . . . . . . . . . . . . . . P249 Muggeri, A. . . . . . . . . . . . . . . P468, P473 Mula, M. . . . . . . . . . . . . . . . . . . . . . P632 Mulero, P. . . . . . . . . . . . P298, P299, P300 Mu¨ller, K.I. . . . . . . . . . . . . . . . . . . . P312

Mu¨ller, R. . . . . . . . . . . . . . . . . . . . . P609 Mu¨ller-Sarnowski, F.. . . . . . . . . . . . . P663 Mulley, J. . . . . . . . . . . . . . . . . . . . . P545 Mungen, B. . . . . . . . . . . . . . . . . . . . P540 Munjev, N. . . . . . . . . . . . . . . P407, P434 Mun˜oz-Ruiz, C. . . . . . . . . . . . . . . . . P509 Muntean, W. . . . . . . . . . . . . . . . . . . P268 Muraro, P.A. . . . . . . . . . . . . . P232, P669 Muroi, C.. . . . . . . . . . . . . . . . . . . . .O135 Murzina, M. . . . . . . . . . . . . . . . . . . . P453 Musch, B. . . . . . . . O75, P441, P442, P443 Musumeci, O.. . . . . . . . . . . . . P514, P529 Mutani, R. . . . . . . . . . . . . . . . . . . . . O86 Mutti, E. . . . . . . . . . . . . . . . . . . . . . P428 Mwandira, E. . . . . . . . . . . . . . . . . . . P281 Myrianthopoulou, P. . . . . . . . . . . . . . P293 Nacmias, B. . . . . . . . Nadais, G. . . . . . . . . Naegelin, Y.. . . . . . . Nafisi, S. . . . . . . . . . Nagel, M. . . . . . . . . Nagy, N. . . . . . . . . . Najafi, F. . . . . . . . . . Najafi, M. . . . . . . . . Nakai, N. . . . . . . . . . Nakamura, H. . . . . . . Nakamura, Y. . . . . . . Nakano, T. . . . . . . . . Nakano, T. . . . . . . . . Nam, H.W. . . . . . . . Nanetti, L. . . . . . . . . Narayanan, S. . . . . . . Nasilowska-Barud, A. Naska, J. . . . . . . . . . Nasuelli, N. . . . . . . . Naumiuk-Sojczuk, K. Navarro, C. . . . . . . . Nechifor, R. . . . . . . . Necula, G. . . . . . . . . Nedeltchev, K. . . . . . Negrotti, A. . . . . . . . Neppert, B. . . . . . . . Neri, M.J. . . . . . . . . Neuhaus, A. . . . . . . . Neuper, C. . . . . . . . . Neutel, D. . . . . . . . . Newton, H. . . . . . . . Nica, A.S. . . . . . . . . Nichelli, P.F. . . . . . . Nicholas, R. . . . . . . . Nickel, J. . . . . . . . . . Nicolae, H. . . . . . . . Nicola`s, M. . . . . . . . Nieswandt, B.. . . . . . Nieweglowska, D.. . . Nikaki, M. . . . . . . . . Nikiforidis, D. . . . . . Nikodinovic, J. . . . . . Nikolic, O. . . . . . . . . Ning, L.. . . . . . . . . . Ninkovic, M. . . . . . . Nischwitz, S. . . . . . . Nishino, I. . . . . . . . . Nishio, K. . . . . . . . . Nisipeanu, P. . . . . . .

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.O139, P619, P675 . . . . . . . . . . P475 . . . . . O123, P406 . . . . . . . . . . P691 . . . . . . . . . .O160 . . . . . . O85, P546 . . . . . . . . . . P244 . . . . . P244, P543 . . . . . . . . . . P390 . . . . . . . . . .O134 . . . . . . . . . . P286 . . . . . . . . . .O135 . . . . . . . . . . P651 . . . . . . . . . . P353 . . . . . . O58, P628 . . . . . . . . . . P604 . . . . . . . . . . P246 . . . . . . . . . . P247 . . . . . . . . . . P632 . . . . . . . . . . P246 . . . . . . . . . . P396 . . . . . . . . . . P278 . . . . . . . . . . P561 . . . . . . . . . .O105 . . . . . . . . . . P646 . . . . . . . . . . P440 . . . . . . . . . . P298 . . . . . . . . . . P232 . . . . . . . . . .O117 . . . . . . . . . . P489 . . . . . . . . . . P476 . . . . . . . . . . P258 . . . . . . . . . . P562 . . . . . . . . . . P669 . . . . . . . . . .O152 . . . . . P370, P639 . . . . . . . . . . P329 . . . . . . . . . .O136 . . . . . . . . . . P216 . . . . . . . . . .O118 . . . . . P539, P640 . . . . . . . . . . P335 . . . . . . . . . . P385 . P415, P418, P588 . . . . . . . . . . P385 . . . . . . . . . . P663 . . . . . . . . . . P515 . . . . . . . . . .O135 . . . . . . . . . . P535

S241 Noachtar, S. . . . . . . . . . Noguchi, S. . . . . . . . . . Nogue´s, M. . . . . . . . . . Noirhomme, Q.. . . . . . . Nolte, C.H. . . . . . . . . . Nomura, M. . . . . . . . . . Nonaka, I. . . . . . . . . . . Norris, G. . . . . . . . . . . Notermans, N.C. . . . . . . Novakova, L. . . . . . . . . Novelli, F. . . . . . . . . . . Novelli, G. . . . . . . . . . . Novik, A.A. . . . . . . . . . Nowakowska-Kotas, M.. Nurulain, S. . . . . . . . . . Nyandaiti, Y.W. . . . . . . Nzwalo, H. . . . . . . . . .

. . . . . . . . . . P536 . . . . . . . . . . P515 . P411, P468, P473 . . . . . . . . . . O98 . . . . . P592, P593 . . . . . . . . . . P352 . . . . . . . . . . P515 . . . . . . . . . . P604 . . . . . P327, P556 . . . . . . . . . . P328 . . . . . . . . . . P678 . . . . . . . . . . P525 . . . . . . .O43, O80 . . . . . P343, P486 . . . . . . . . . . P432 . . . . . . . . . . P389 . . . . . P218, P642

O’Connor, P. . . . . . . . . . . O76, O77, O79, P405, P445, P665 Obermann, M. . . . . . . . . . . . . . . . . . P304 Odabasi, Z. . . . . . . . . . P224, P251, P310, P311, P338, P339, P342, P345, P346, P590, P652 Odaka, M. . . . . . . . . . . . . . . . . . . . . P337 Odeh, F. . . . . . . . . . . . . . . . . . . . . . O49 Oertel, W. . . . . . . . . . . . . . . . . . . . . O53 Ogino, T. . . . . . . . . . . . . . . . . . . . . . P318 Ogur, R. . . . . . . . . . . . . . . . . . . . . . P203 Oh, Y.S. . . . . . . . . . . . . . . . . . . . . . P549 Ohana, B. . . . . . . . . . . . . . . . . . . . . O88 Ohle, S. . . . . . . . . . . . . . . . . . . . . . . P541 Ohno, S. . . . . . . . . . . . . . . . . . . . . . P318 Ohta, K. . . . . . . . . . . . . . . . . . . . . .O126 Ohtsuka, Y. . . . . . . . . . . . . . . . . . . . P318 Oikonomopoulos, N. . . . . . . . . P471, P644 Oikonomou, E. . . . . . . . . . . . . . . . . . P239 Oka, M. . . . . . . . . . . . . . . . . . . . . . . P318 Okuchi, K. . . . . . . . . . . . . . . . . . . . .O135 Olazaran Rodriguez, J. . . . . . . . . . . . P499 Olesen, J.. . . . . . . . . . . . . . . . . . . . . O48 Oliva-Navarro, J. . . . . . . . . . . . . . . . P601 Oliveira, A. . . . . . . . . . . . . . . P425, P475 Olivieri, F. . . . . . . . . . . . . . . . . . . . .O139 Olokoba, A. . . . . . . . . . . . . . . . . . . . O61 Onigman, T.. . . . . . . . . . . . . . . . . . . P455 Ono, S. . . . . . . . . . . . . . . . . . . . . . . P352 Opalka, M.. . . . . . . . . . . . . . . P481, P482 Oppermann, K. . . . . . . . . O39, P664, P667 Oprisan, A. . . . . . . . . . . . . . . . . . . . P235 Orefice, G. . . . . . . . . . . . . . . . . . . . . P672 Oreja Guevara, C. . . . . . . P350, P573, P668 Orlandi, C. . . . . . . . . . . . . . . . . . . . . P533 Osman, G. . . . . . . . . . . . . . . . . . . . .O102 Ossola, I. . . . . . . . . . . . . . . . . . . . . . P356 Ostrowska, M. . . . . . . . . . . . . . . . . . P348 Oter, S. . . . . . . . . . . . . . . . . . . . . . . P203 Otto, M. . . . . . . . . . . . . . . . . . . . . . P201 Owygarden, S. . . . . . . . . . . . . . . . . .O125 Oyama, K. . . . . . . . . . . . . . . . . . . . . P390 Oyama, Y. . . . . . . . . . . . . . . . . . . . . P524 ¨ z, O. . . . . . . . . . P224, P310, P338, P342, O P345, P346 Ozakbas, S. . . . . . . . . . P228, P243, P410, P568, P677 ¨ zer, F. . . . . . . . . . . . . . . . . . . . . . . P250 O

Ozler, M. . . . . . . . . . . . . . . . . . . . . . P203 ¨ ztu¨rk, B. . . . . . . . . . . P224, P310, P338, O P342, P345, P346 Pacca, P. . . . . . . Pace, A.. . . . . . . Padilla-Docal, B. Padua, L. . . . . . . Padurariu, M. . . . Paegle, A. . . . . . Pagani, E. . . . . .

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Pavan, G.. . . . . . . . . . . . . . . . P397, P449 Pearl, D. . . . . . . . . . . . . . . . . . . . . . P476 Pectasidis, D. . . . . . . . . . . . . . . . . . . P689 Pekmezovic, T.. . . . . . . . . . . . P241, P613 Pelissier, J.. . . . . . . . . . . . . . . . . . . .O125 Pellegrini, F. . . . . . . . . . . . . . . . . . . O78 Pelletier, J.. . . . . . . . . . . . . . . . . . . . P457 Pen˜as, M.L. . . . . . . . . . . P298, P299, P300 Pendl, B. . . . . . . . . . . . . . . . . . . . . .O117 Pera, J. . . . . . . . . . . . . . . . . . P481, P482 Peral, E. . . . . . . . . . . . . . . . . P485, P523 Peralta, R. . . . . . . . . . . . . . . . . . . . . P542 Pereira, J.. . . . . . . . . . . . . . . . . . . . . P659 Pereira, J.. . . . . . . . . . . . . . . . . . . . . P212 Pereira, L. . . . . . . . . . . . . . . . . . . . . P424 Pereira-Mendes, V. . . . . . . . . . . . . . . P263 Peric, S.. . . . . . . . . . . . . P360, P385, P522 Perini, M. . . . . . . . . . . . . . . . . O87, P351 Perren, F.. . . . . . . . . . . . . . . . . . . . . P263 Peskine, A. . . . . . . . . . . . . . . . O73, P496 Pestronk, A. . . . . . . . . . . . . . . . . . . . P630 Peters, A.. . . . . . . . . . . . . . . . . . . . . P536 Petersen, D. . . . . . . . . . . . . . . . . . . . O47 Petitnicolas, G. . . . . . . . . . . . . . . . . .O120 Petrescu, S. . P367, P407, P434, P437, P479 Petrini, C. . . . . . . . . . . . . . . . . . . . . P393 Petroianu, G. . . . . . . . . . . . . . . . . . . P432 Petrolini, M.. . . . . . . . . . O87, O124, O159 Petrova, M. . . . . . . . . . . . . . . . . . . . P653 Petrovic, I. . . . . . . . . . . . . . . . . . . . . O52 Petrovic, K. . . . . . . . . . . . . . . . . . . .O117 Petrucci, A. . . . . . . . . . . . . . . . . . . . P290 Peyer, A.-K. . . . . . . . . . . . . . . . . . . . P521 Pfister, H. . . . . . . . . . . . . . . . . . . . . O57 Piaceri, I. . . . . . . . . . . . . . . . . . . . . . P619 Picard, C.. . . . . . . . . . . . . . . . . . . . . P177 Picco, E. . . . . . . . . . . . . . . . . O151, O153 Piccoli Garcia, S. . . . . . . . . . . . . . . . P294 Picconi, O. . . . . . . . . . . . . . . . . . . . . P234 Pieri, V.. . . . . . . . . . . . . . . . . . . . . . P180 Pietroboni, A. . . . . . . . . . . . . . . . . . . O40 Pievani, M. . . . . . . . . . . . . . . O116, O146 Pilz, G. . . . . . . . . . O39, P268, P664, P667 Pimentel, J. . . . . . . . . . . . . . . P395, P489 Pinel, A.B. . . . . . . . . . . . . . . . . . . . . P692 Pinho e Melo, T. . . . . . . . . . . . . . . . P489 Pinto, A. . . . . . . . . . . . . . . . . . . . . . O88 Pinto, S. . . . . . . . . . . . . . . . . . O88, P358 Piola, M. . . . . . . . . . . . . . . . . . . . . . O40 Pirazzini, C. . . . . . . . . . . . . . . . . . . .O139 Pires, M. . . . . . . . . . . . . . . . . . . . . . P212 Pires-Barata, S.. . . . . . . . . . . . P255, P270 Piri Cinar, B. . . . . . . . . . . . . . . . . . . P677 Piroozi, A. . . . . . . . . . . . . . . . . . . . . P379 Pisciotta, C. . . . . . . . . . . . . . . . . . . . P326 Pita Lobo, P. . . . . . . . . . . . . . . . . . . P358 Pitt, D. . . . . . . . . . . . . . . . . . . . . . . P681 Plaghki, L. . . . . . . . . . . . . . . . . . . . . P553 Planellas, L. . . . . . . . . . . . . . . . . . . . P647 Pluchino, S. . . . . . . . . . . . . . . . . . . .O137 Plueger, M. . . . . . . . . . . . . . . . . . . . P174 Pocinska, K.. . . . . . . . . . . . . . P242, P671 Pocoski, J. . . . . . . . . . . . . . . . . . . . . P238 Podemski, R. . . . . . . . . . P359, P486, P581 Poewe, W. . . . . . . . . . . . . . . . . . . . . O53 Poggi, A. . . . . . . . . . . . . . . . . . . . . .O100

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S242 Poggi, G. . . . . . . . . . . . . . . . . P257, P315 Pogue, J. . . . . . . . . . . . . . . . . . . . . .O103 Pohl, C. . . . . . . . . . . . . . . . . . . O77, P665 Pokharel, D.K. . . . . . . . . . . . . . . . . . P656 Pokryszko-Dragan, A. . . . . . . . . . . . . P486 Polimeni, G.. . . . . . . . . . . . . . . . . . . P577 Polke, J. . . . . . . . . . . . . . . . . O128, O129 Polman, C.H. . . . . . . . . . . O76, O79, P445 Polo, J. . . . . . . . . . . . . . . . . . . . . . . P396 Poloni, M. . . . . . . . . . . . . . . . . . . . . P347 Polyzoidou, E. . . . . . . . . P426, P683, P686 Pomati, S. . . . . . . . . . . . . . . . P501, P504 Pontikis, K. . . . . . . . . . . . . . . . . . . . P644 Popescu, D. . . . . . . . . . . . . . . P273, P278 Popescu, R. . . . . . . . . . . . . . . . . . . . P431 Popescu, R.E. . . . . . . . . . . . . . . . . . . P258 Portuguez, M.W.. . . . . . . . . . . . . . . . P544 Po´s-de-Mina, V. . . . . . . . . . . . . . . . . P270 Posenato, N.. . . . . . . . . . . . . . . . . . . P183 Pothalil, D. . . . . . . . . . . . . . . . . . . . P223 Potic, A. . . . . . . . . . . . . . . . . . . . . . P322 Potman, M. . . . . . . . . . . . . . . . . . . .O154 Poublanc, J. . . . . . . . . . . . . . . . . . . . P417 Poulatsidou, K. . . . . . . . . . . . . P683, P686 Pourpak, Z. . . . . . . . . . . . . . . . . . . . P674 Poveda, J.-D. . . . . . . . . . . . . . . . . . . P666 Pozzilli, C.. . . . . . . . . . . . . . . . . . . . P572 Pradat-Diehl, P. . . . . . . . . . . . . O73, P496 Praksova´, P. . . . . . . . . . . . . . . . . . . . P676 Pramstaller, P. . . . . . . . . . . . . . . . . .O158 Prasad, K. . . . . . . . . . . . . . . . . . . . . P605 Prasad, K. . . . . . . . . . . . . . . . . . . . . P291 Prayoonwiwat, N. . . . . . . . . . . P569, P571 Preblick, R. . . . . . . . . . . . . . . . . . . . P237 Preiningerova Lı´zrova´, J. . . . . . . . . . . P230 Prelle, A. . . . . . . . . . . . . . . . . . O87, P351 Prinster, A. . . . . . . . . . . . . . . . . . . . P672 Probst, C.. . . . . . . . . . . . . . . . . . . . . P690 Prokisch, H. . . . . . . . . . . . . . . . . . . . O64 Pro¨pper, C. . . . . . . . . . . . . . . . . . . . P201 Prosiegel, M. . . . . . . . . . . . . . . . . . . P609 Provenzano, G. . . . . . . . . . . . . . . . . . P627 Prufer de Queiroz Campos Araujo, A. . P317 Puca, E. . . . . . . . . . . . . . . . . . . . . . . P598 Puente, V. . . . . . . . . . . . . . . . . . . . . P647 Pujal, J. . . . . . . . . . . . . . . . . . . . . . . P248 Pul, R.. . . . . . . . . . . . . . . . . . . . . . . P680 Pulido Valedolivas, I. . . . . . . . . . . . . P296 Pulur, N. . . . . . . . . . . . . . . . . . . . . . O96 Putzki, N. . . . . . . . . . . . . . . . P409, P451 Pyzik, M.. . . . . . . . . . . . . . . . . . . . . P386 Qiu, Q.C. . . . . . Quanqing, W. . . Quarantelli, M. . Quartuccio, E. . Quattrone, A. . . Quesnel, L. . . . Quinzii, C.M. . .

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Rabinovici, G.D.. . . . . . . . . . . . . . . .O147 Radaelli, M. . . . . . . . . . . O99, P282, P448, P450, P459, P462, P472, P572 Rademakers, R. . . . . . . . . . . . . . . . .O125 Radice, D. . . . . . . . . . . . . . . . . . . . . P325 Radionova, M. . . . . . . . . . . . . . . . . . P545

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Radue, E.W.. . . . . . . . . . . . . . . . . . . P406 Rage´, M. . . . . . . . . . . . . . . . . . . . . . P553 Rahimian, E. . . . . . . . . . . . . . . . . . . P408 Rai, A. . . . . . . . . . . . . . . . . . . . . . . O93 Rainero, I. . . . . . . . . . . . . . . . P391, P402 Rajamani, K. . . . . . . . . . . . . . . . . . . P604 Rakocevic-Stojanovic, V.. . . . . . . . . . P522 Rallis, J. . . . . . . . . . . . . P471, P644, P689 Ramachandran, B.. . . . . . . . . . . . . . . P207 Rammohan, K. . . . . . . . . O75, P441, P442 Ramolfo, P. . . . . . . . . . . . . . . . . . . . P501 Ramo´n, C. . . . . . . . . . . . . . . . . . . . . P557 Ramos, A. . . . . . . . . . . . . . . . P168, P171 Ramos, J.O. . . . . . . . . . . . . . . . . . . . P332 Ramos Cejudo, J. . . . . . . . . . . . . . . . P668 Rangel-Guerra, R. . . . . . . . . . . . . . . . P491 Ranieri, M. . . . . . . . . . . . . . . . . . . . P624 Rankin, C. . . . . . . . . . . . . . . . . . . . . P314 Ransohoff, A.J.. . . . . . . . . . . . . . . . . P403 Ransohoff, R.M. . . . . . . . . . . . . . . . . P403 Raptis, G. . . . . . . . . . . . . . . . . . . . . P471 Raschetti, R.. . . . . . . . . . . . . . . . . . . P393 Raupp, E.F. . . . . . . . . . . . . . . . . . . . P544 Ravanidis, S. . . . . . . . . . P426, P683, P686 Raviolo, M. . . . . . . . . . . . . . . . . . . . P376 Ray Chaudhuri, K. . . . . . . . . . . . . . . P412 Raycheva, M. . . . . . . . . . . . . . P620, P653 Razeghi Jahromi, S. . . . . P306, P685, P691 Real, R. . . . . . . . . . . . . . . . . . P475, P659 Rebocho, L. . . . . . . . . . . . . . . P255, P270 Reddy, U. . . . . . . . . . . . . . . . . . . . . P589 Reese, J.P. . . . . . . . . . . . . . . . . . . . . O53 Rego, R. . . . . . . . . . . . . . . . . . . . . . P284 Reichmann, H. . . . . . . . . . . 35, P222, P609 Reilly, M. . . . . . . O128, O129, P325, P326 Reilly, P. . . . . . . . . . . . . . . . . . . . . .O103 Reima˜o, S. . . . . . . . . . . . . . . . . . . . . P358 Reis, J. . . . . . . . . . . . . . . . . . . . . . . P594 Reischl, J. . . . . . . . . . . . . . . . . . . . . P665 Reitmeir, R. . . . . . . . . . . . . . . . . . . .O137 Rejdak, K. . . . . . . . . . . . . . . . . . . . . P483 Renier, J. . . . . . . . . . . . . . . . . . . . . . P175 Rentzos, M. . . . . . . . . . . . . . . P226, P474 Reshef, S. . . . . . . . . . . . . . . . . . . . . P237 Restagno, G. . . . . . . . . . . . . . . . . . . P356 Rey, J.. . . . . . . . . . . . . . . . . . . . . . . P369 Rha, H.K. . . . . . . . . . . . . . . . . . . . . P269 Rha, J.H. . . . . . . . . . . . . . . . . . . . . . P165 Ribeiro, A.C. . . . . . . . . . . . . . P331, P488 Ribeiro, J. . . . . . . . . . . . . . . . . . . . . P284 Ricci, G. . . . . . . . . . . . . . . . . . . . . . P234 Riccitelli, G. . . . . . . . . . O42, O122, P414 Richard, F. . . . . . . . . . . . . . . . . . . . . P621 Richman, S. . . . . . . . . . . . . . . P455, P458 Riecker, A. . . . . . . . . . . . . . . . . . . . P609 Rieckmann, P. . . . . . . . . O75, P441, P442 Rietsch, A.M. . . . . . . . . . . . . . . . . . . P403 Rigotti, D. . . . . . . . . . . . . . . . . . . . .O123 Rimoldi, M. . . . . . . . . . . . . . . . . . . . O58 Rinaldi, C. . . . . . . . . . . . . . . . . . . . . P217 Rinaldi, F. . . . . . . . . . . . . . . . . . . . . P525 Rinaldi, L. . . . . . . . . . . . . . . . . . . . . P678 Rin˜o´n, A.. . . . . . . . . . . . . . . . . . . . . P236 Ripellino, P. . . . . . . . . . . . . . . . . . . . P632 Risa, Ø. . . . . . . . . . . . . . . . . . . . . . . P429 Riva, N.. . . . . . . . . . . . . . . . . . . . . . P351

Rivasseau Jonveaux, T. . . . . . . . . . . . P498 Rivera, V. . . . . . . . . . . . . . . . . . . . . P456 Rizoulis, A. . . . . . . . . . . . . . . . . . . . P178 Rizzi, L. . . . . . . . . . . . . . . . . . . . . . P400 Rizzuto, N. . . . . . . . . . . . . . . . . . . . P325 Robaczewska, A. . . . . . . P343, P359, P486 Robalo, C. . . . . . . . . . . . . . . . . . . . . P316 Robert, P. . . . . . . . . . . . . . . . . . . . .O150 Rocca, M.A.. . . . . . . O41, O42, O45, O77, O121, O122, O124, O159, P414 Roceanu, A. . . . . . . . . . . . . . . P278, P394 Rocha, L.. . . . . . . . . . . . . . . . . . . . . P358 Rodegher, M. . . . . . . . . . O60, O99, O122, P282, P459, P460 Rodolico, C.. . . . . . . . . . . . . . . . . . . P514 Rodriguez, A.B. . . . . . . . . . . . . . . . . P396 Rodriguez de Antonio, L. . . . . P382, P601 Rodrı´guez de Rivera, F.. . . . . . . . . . . P350 Rodriguez Rodriguez, E. . . . . . . . . . . P396 Rodriguez-Borja, E. . . . . . . . . . . . . . P509 Roessy, W. . . . . . . . . . . . . . . . . . . . P655 Rojo, E. . . . . . . . . . . . . . P298, P299, P300 Rolla, S. . . . . . . . . . . . . . . . . . . . . . P678 Romanitan, M.O. . . . . . . . . . . P273, P278 Romano, R. . . . . . . . . . . . . . . . . . . . P570 Romeo, M.. . . . . . . . . . . . . . . P459, P460 Romero, C. . . . . . . . . . . . . . . . . . . . P411 Romero-Pinel, L. . . . . . . . . . . . . . . . P248 Romon, M. . . . . . . . . . . . . . . P607, P621 Ropele, S. . . . . . . . . . . . . . . . O106, O117 Roquer, J. . . . . . . . . . . . . . . . . . . . . P647 Roriz, J.M.. . . . . . . . . . . . . . . O112, P634 Rosa´rio, P. . . . . . . . . . . . . . . . . . . . . P642 Rosas, M.J. . . . . . . . . . . . . . . . . . . . P659 Rose, G. . . . . . . . . . . . . . . . . . . . . .O139 Rosemann, A.. . . . . . . . . . . . . . . . . . P690 Roser, F. . . . . . . . . . . . . . . . . O142, P583 Rosini, F.. . . . . . . . . . . . . . . . . . . . .O139 Rossetti, A.O.. . . . . . . . . . . . . . . . . . P280 Rossi, P. . . . . . . . . . . . . . . . . . . . . .O122 Rosso, C. . . . . . . . . . . . . . . . . . . . . . O73 Roth, R.H. . . . . . . . . . . . . . . . . . . . . P196 Rothbard, M. . . . . . . . . . . . . . . . . . . P230 Rotondo, E. . . . . . . . . . . . . . . . . . . . P507 Rottoli, M. . . . . . . . . . . . . . . . . . . . . P347 Rousseaux, M. . . . P172, P173, P175, P607 Roussel, B. . . . . . . . . . . . . . . . . . . . P600 Roussel, M. . . . . . . . . .O120, O148, O150, P253, P264 Routier, A. . . . . . . . . . . . . . . . . . . . .O148 Routsis, C. . . . . . . . . . . . . . . . . . . . .O118 Rovira, A. . . . . . . . . . . . . . . . . . . . . P404 Roy Bellina, S. . . . . . . . . . . . . . . . . . P574 Royes, L.F. . . . . . . . . . . . . . . P424, P425 Rozeman, C. . . . . . . . . . . . . . . . . . . P558 Rubio, J. . . . . . . . . . . . . . . . . . . . . . O60 Ruda`, R. . . . . . . . . . . . . . . . . O151, O153 Rudick, R. . . . . . . . . . . . . . . . . . . . . O79 Rudolf, J.. . . . . . . . . . . . . . . . P422, P599 Rudzinska, M. . . . . . . . . . . . . P210, P216 Rueda, E.. . . . . . . . . . . . . . . . . . . . . P396 Ruhe, R. . . . . . . . . . . . . . . . . . . . . . P374 Ruiz-Vegara, M. . . . . . . . . . . . . . . . . P509 Rupprecht, T. . . . . . . . . . . . . . . . . . . O57 Russo, M. . . . . . . . . . . . . . . . . . . . .O129 Rutgers, M.P. . . . . . . . . . . . . . . . . . . P223

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Sannomiya, A. . Sansone, V. . . . Santamaria, J.. . Santorelli, F. . . Santoro, A. . . . Santoro, L. . . . . Santos, A. . . . . Santos, A.C. . . . Santos, C. . . . . Sanz Gallego, I. Sapuwa, M. . . . Sarazin, M. . . . Sauvee, M.. . . . Savastano, S. . . Savic, J.. . . . . . Savic, O. . . . . . Savio, K. . . . . . Savoiardo, M.. . Savvidou, E.. . . Scaioli, V. . . . . Scalabrini, D. . . Scalabrino, G. .

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. . . . . . . . . . P535 . . . . . . . . . . P633 . P415, P418, P588 . . . . . . . . . . P368 . . . . . . . . . . P188 . . . . . . . . . . P336 . . . . . . . . . . P526 . O66, P366, P487 . . . . . . . . . .O126 . . . . . P549, P551 . . . . . . . . . . O67 . . . . . . . . . . P552 . . . . . . . . . .O105 . . . . . . . . . . P696 . . . . . . . . . .O125 . . . . . P478, P582 . . . . . . . . . . P223 . . . . . . . . . . P635 . . . . . . . . . . P640 . . . . . . . . . . O53 . . . . . . . . . .O160 . . . . . . O54, P662 . . . . . . . . . . P371 . . . . . . . . . .O135 . . . . . . . . . . P178 . . . . . . . . . . P321 . . . . . . . . . .O154 . . . . . . . . . . P510 . . . . . . . . . . P596 . . . . . . . . . . P510 . . . . . . . . . . P536 . . . . . . . . . . P527 . . . . . . . . . . P405 . . . . . . . . . . P562 . . . . . . . . . . P572 . . . . . . . . . . P621 . . . . . . . . . . P200 . . . . . . . . . . P203 . . . . . . . . . . P605 . . . . . . . . . . P694 . P521, P531, P532 . O92, P250, P567 . . . . . . . . . .O127 . . . . . . . . . .O139 . . . . . . . . . .O109 . . . . . . . . . . P583 . . . . . . . . . . P680 . . . . . P679, P680 . . . . . . . . . . P666 O108, P481, P482, P622, P623 Sluzewska-Niedzwiedz, M. . . . P343, P359 Smith, S. . . . . . . . . . . . . . . . . . . . . . P545 Smolnikova, V.. . . . . . . . . . . . . . . . . P461 Soares, P.. . . . . . . . . . . . . . . . . . . . . P594 Soddu, A. . . . . . . . . . . . . . . . . . . . . O98 Soelberg Sørensen, P. . . . O75, P441, P442 Soffietti, R. . . . . . . . . . . . . . . O151, O153 Sojczuk, S.. . . . . . . . . . . . . . . . . . . . P246 Sola`, N. . . . . . . . . . . . . . . . . . . . . . .O101 Sola, P. . . . . . . . . . . . . . . . . . . . . . . P562 Solari, A. . . . . . . . . . . . . P325, P326, P572 Solovieva, N. . . . . . . . . . . . . . . . . . . P461 Sommer, C. . . . . . . . . . . P303, P559, P561 Sonbolestan, A. . . . . . . . . . . . . . . . . P271 Song, C.S. . . . . . . . . . . . . . . . . . . . . P165

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S244 Song, D. . . . . . . . Sonnewald, U. . . . Sont, J.K.. . . . . . . Sorbi, S. . . . . . . . Soriano, A. . . . . . Sormani, M.P. . . . Sosso, L. . . . . . . . Soto-Hernandez, J. Sousa, A.P. . . . . . Souza, M.A. . . . . . Spagnolo, F.. . . . . Spagnolo, S.. . . . . Spila Alegiani, S. . Spillane, J.E. . . . . Spisak, K. . . . . . . Sprecher, E. . . . . . Sprenger, A.. . . . . Srivastava, P. . . . . Stamatopoulou, G. Stamboulis, E. . . . Stamouli, S. . . . . . Stampatori, C. . . . Stanarcevic, P. . . . Stangel, M. . . . . . Stark, L. . . . . . . . Staurenghi, G. . . . Stazka, J. . . . . . . . Stecco, A. . . . . . . Steck, A. . . . . . . . Stefanescu, C. . . . Stefanis, L. . . . . . Stein, P.. . . . . . . . Steinacker, P. . . . . Steiner, T. . . . . . . Stelmasiak, Z. . . .

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Stemper, B. . . Stepanyan, H. . Stephan, T. . . Stephen, M. . . Stettner, M. . . Stevic, Z. . . . . Stewen, J. . . . Stipsanelli, A.. Sto¨cker, W. . . Stoessl, A.J. . . Stoffels, G. . . Stojkovic, T. . Stoll, G.. . . . . Stoquart, G. . . Storch, A. . . . Storey, E.. . . . Stork, A.C.. . . Stortini, M. . . Stourac, P. . . . Straffi, L. . . . .

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Strandberg, J. . . . Strauss, A. . . . . . Straver, D.C. . . . Strazzer, S. . . . . Strupp, M. . . . . . Stuppia, L. . . . . . Sturzenegger, M. Sue´, M. . . . . . . . Suh, B.C. . . . . . .

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. . . . . . . . . . P355 . . . . . . . . . . P429 . . . . . . . . . .O154 . . . . . O139, P619 . . . . . . . . . . P329 . . O41, O87, O121 . . . . . . . . . . P678 . . . . . . . . . . P636 . . . . . . . . . . P564 . . . . . P424, P425 . O97, O100, P285 . . . . . . . . . . P253 . . . . . . . . . . P393 . . . . . P470, P589 .O108, P481, P482 . . . . . P387, P413 . . . . . O158, O160 . . . . . P605, P608 . . . . . P538, P539 . . . . . . . . . . P471 . . . . . . . . . . P500 . . . . . . . . . . P231 . . . . . P597, P645 . . . . . P679, P680 . . . . . . . . . . P668 . . . . . . . . . . P501 . . . . . . . . . . P272 . . . . . . . . . . P632 . . . . . . . . . . . . .2 . . . . . . . . . . P497 . . . . . P644, P689 . . . . . . . . . .O105 . . . . . . . . . . P201 . . . . . . . . . . P305 . . . . . P246, P272, P483, P670, P671 . . . . . . . . . . P665 . . . . . . . . . . P200 . . . . . . . . . . P435 . . . . . . . . . . O61 . . . . . . . . . . P541 . . . . . P360, P522 . . . . . . . . . . P694 . . . . . . . . . . P178 . . . . . . . . . . P690 . . . . . . . . . .O125 . . . . . . . . . .O152 . . . . . . . . . . O52 . . . . . O132, O136 . . . . . . . . . . P364 . . . . . . . . . . P222 . . . . . O131, P626 . . . . . . . . . . P556 . . . . . . . . . . O70 . . . . . . . . . . P676 . O97, O100, P282, P285, P459, P460 . . . . . . . . . . O81 . . . . . . . . . . P541 . . . . . . . . . . P287 . O70, P257, P315 . . . . . . . . . . P435 . . . . . . . . . . P199 . . . . . . . . . . P330 . . . . . . . . . .O134 . . . . . . . . . . P336

Suh, C.K.. . . . . . . . . . Suk, S.H. . . . . . . . . . . Sulzer, C.. . . . . . . . . . Sun, A. . . . . . . . . . . . Sung, H.Y.. . . . . . . . . Sung, J.J. . . . . . . . . . . Sunter, G. . . . . . . . . . Sunwoo, I.N. . . . . . . . Suzuki, M. . . . . . . . . . Suzuki, M. . . . . . . . . . Suzuki, Y. . . . . . . . . . Suzuki, Y. . . . . . . . . . Sweeney, M.G. . . . . . . Swerdlow, R.H. . . . . . Sykova´, E. . . . . . . . . . Szabo, T. . . . . . . . . . . Szabo-Taylor, K. . . . . Szczepanska, A. . . . . . Szczepanska-Szerej, A. Szczudlik, A. . . . . . . . Szczygiel, E. . . . . . . . Szewczyk, P. . . . . . . . Szmulewicz, D. . . . . . Szymczyk, M. . . . . . . Tabassum, H. . Tabeeva, G. . . Tahir, A. . . . . Tahsini, M. . . Takada, H. . . . Talarico, M. . . Taleb, M.. . . . Tamim, H. . . . Tanabe, K. . . . Tanasescu, R. . Tanridag, T. . . Tarantino, P. . Taratuto, A. . . Tarenzi, L. . . . Tarnow, E. . . . Taroni, F.. . . . Tascos, N. . . .

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. . . . . . . . . . P595 . . . . . . . . . . P179 . . . . . P664, P667 . . . . . . . . . . P288 . . . . . . . . . . P606 . . . . . P349, P353 . . . . . . . . . . P288 . . . . . . . . . . P336 . . . . . . . . . . P352 . . . . . . . . . . P368 . . . . . . . . . . P225 . . . . . . . . . . P651 . . . . . . . . . .O128 . . . . . . . . . .O125 . . . . . . . . . . P550 . . . . . . . . . . P381 . . . . . . . . . . P430 . . . . . . . . . . P581 . . . . . . . . . . P272 . P210, P216, P348 .O108, P481, P482 . . . . . . . . . . P359 . . . . . . . . . .O131 . . . . . P359, P486

. . . . . . . . . . . . . . P206 . . . . . . . . . . . . . . P189 . . . . . . . . . . . . . . P389 . . . . . . . . . . . . . . P408 . . . . . . . . . . . . . . P524 . . . . . . . . . . . . . . P215 . . . . . . . . . . . . . . P508 . . . . . . . . . . . . . . P305 . . . . . . . . . . . . . . P368 . . . . . . . . . . . . . . P235 . . . . . . . . . . . . . . P288 . . . . . . . . . . . . . . P627 . . . . . . . . . . . . . . P411 . . . . . . . . . . . . . .O153 . . . . . . . . . . . . . . P586 . . . . . . . . . O128, P628 . . . . P426, P538, P539, P548, P640, P683, P686 Tatagiba, M.. . . . . . . . . . . . . . O142, P583 Taurisano, P. . . . . . . . . . . . . . . . . . . P570 Tavano, F. . . . . . . . . . . . . . . . . . . . .O139 Tay, L. . . . . . . . . . . . . . . . . . . . . . . P291 Taylor, B. . . . . . . . . . . . . . . . . . . . . O60 Taylor, C. . . . . . . . . . . . . . . . P470, P589 Taylor, T. . . . . . . . . . . . . . . . . . . . . P281 Tedde, A.. . . . . . . . . . . . . . . . . . . . . P619 Tedeschi, G.. . . . . . . . . . . . . . P439, P625 Tedeschi, S. . . . . . . . . . . . . . . . . . . . P513 Teixeira da Silva, M.H. . . . . . . P255, P270 Telman, G.. . . . . . . . . . . . . . . P387, P413 terBrugge, K. . . . . . . . . . . . . . P416, P417 Terecoasa, E. . . . . . . . . . . . . . . . . . . P394 Terreni, M. . . . . . . . . . . . . . . . . . . . P472 Tettenborn, B. . . . P213, P357, P492, P641 Teuchert, M. . . . . . . . . . . . . . . . . . . O90 Tevzadze, N. . . . . . . . . . . . . . . . . . . P283 Textoris-Taube, K. . . . . . . . . . . . . . . P675 Thakre, M.C. . . . . . . . . . . . . . . . . . . P695 Thelen, P. . . . . . . . . . . . . . . . . . . . . P541 Theodoropoulos, P. . . . . . . . . . . . . . . P511 Theotokis, P. . . . . . . . . . . . . . . . . . . P426

Therrien, C. . . . . Thissen, S. . . . . . Thomas, S.. . . . . Thonnard, M. . . . Thouvenot, E.. . . Thurtell, M. . . . . Ticca, A. . . . . . . Ticmeanu, M.. . . Timmers, M. . . . Timoteo, A. . . . . Tinazzi, M. . . . . Tio, A.P. . . . . . . Tiraboschi, I. . . . Titulaer, M.J. . . . Tiu, C.. . . . . . . . Tiwari, V. . . . . . Toba, M. . . . . . . Todica, O. . . . . . Todorova, A. . . . Togha, M. . . . . . Tok, F. . . . . . . . Tomaszewski, T.. Tomic, A. . . . . . Tomik, B. . . . . . Toni, D.. . . . . . . Tonska, K. . . . . . Topal, T. . . . . . . Topc¸ular, B. . . . . Torne´, L. . . . . . . Torrabadella, M. . Torrente, I.. . . . . Torres, C.M. . . . Torri Clerici, V. . Torroni, A.. . . . . Tortorella, C. . . . Toscano, A. . . . . Toskas, A. . . . . . Tournev, I. . . . . . Toyka, K.V. . . . . Traboulsee, A. . . Tranchant, C. . . . Trautmann, E. . . Traykov, L. . . . . Traynor, B.J. . . . Tredici, G. . . . . . Trenkwalder, C. . Trevisan, E. . . . . Tripathi, M. . . . . Trognon, A. . . . . Trojano, M. . . . . Trulec, S.. . . . . . Tsakris, A. . . . . . Tsang, J.W. . . . . Tsaroucha, A. . . . Tse, C. . . . . . . . Tselis, A. . . . . . . Tsigos, G. . . . . . Tsiligiris, A.. . . . Tsiptsios, I. . . . . Tsirigotis, P.. . . . Tsushima, Y. . . . Tucci, T. . . . . . . Tufan, S. . . . . . . Tumani, H. . . . . Tuna, A. . . . . . . Turaj, W. . . . . . .

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S245 Turan, H. . . . Turhan, G. . . Tu¨tu¨ncu¨, M. . Tzoukeva, A.

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