INTRODUCTION:Treatment with Botulinum Toxin (BT) is safe and effective. Nonetheless, dysphagia is perhaps the most common side effect of BT injections for Cervical Dystonia (CD). We aimed to characterize the population at risk of suffering from dysphagia following BT injections of cervical muscles. METHODS:This is a retrospective observational study. We retrieved demographic and clinical data from the files of all patients diagnosed with CD who attended the Movement Disorders Unit at Shaare Zedek Medical Center during the years 2019 to 2025, and who were regularly treated with BT. The Sternocleidomastoids (SCMs) were injected either under Ultrasound Guidance (USg) or unguided, according to Anatomic Landmarks (AL). Thirty patients (18 females, 243 treatments) were included. RESULTS:Dysphagia was reported in 12.6% of treatments, with a higher incidence in females compared to males (16.9% vs. 5.3%, p = 0.02). All reports of dysphagia (n = 25) were mild. Unguided SCM injections caused significantly less dysphagia than USg SCM injections (7.6% and 18.1%, respectively, p = 0.02). Among elderly patients (≥ 60 years), the incidence of dysphagia was also lower with unguided injections compared to US-guided injections (6.5% vs. 31.3%, p = 0.03). DISCUSSION:Unguided BT injections into the Sternocleidomastoid (SCM) muscle resulted in a lower incidence of dysphagia compared to Ultrasound-guided (USg) injections. Additionally, elderly patients and women are at a heightened risk of experiencing dysphagia. CONCLUSION:Dysphagia appears to be a common side effect of US-guided BT injections, and it is possibly related to SCM injections. Caution should be particularly made in older females. We recommend treating the SCM muscles without guidance, particularly in older female patients.

Abstract Background and aims Successful mechanical thrombectomy (EVT) does not always translate into functional independence, often due to residual hypoperfusion -“No Flow” phenomena. This proof-of-concept study investigated whether Cerebrolysin, in previous studies showing to promote neuroprotection and neuroplasticity, could improve outcomes in patients with less favorable post-EVT perfusion imaging profiles. Methods We prospectively evaluated 18 patients (N=18) who underwent EVT for large vessel occlusion and received IV Cerebrolysin post-procedure. Baseline demographics, vascular risk factors, and clinical severity (NIHSS) were recorded. Post-EVT CT Perfusion was performed to assess residual Ischemic Core (rCBF < 30%) and Hypoperfusion (Tmax > 6s). The primary outcome was functional recovery at follow-up (mRS) and neurological improvement (final NIHSS). Results Patients had a mean age of 69.8 (56% female) with a typical risk factor profile. Patients presented with a median admission NIHSS of 15 and Post-EVT imaging revealed a median residual hypoperfusion (Tmax > 6s) of 4.63 ml and a median ischemic core of 0.5 ml. Despite this "less favorable" perfusion profile a low final median NIHSS of 3.5 and functional independence (mRS <3) was achieved in 33.3% of patients. A strong correlation was observed between the post-EVT ischemic core and the final mRS (ρ= 0.80), and core volumes > 1 ml were found to be a robust predictor of poor functional outcomes (mRS >2). Conclusions This proof-of-concept study showed that Cerebrolysin may facilitate neurological recovery in patients with "high-risk" imaging category. These results suggest that Cerebrolysin may protect "at-risk" tissue within residual hypoperfused zones, potentially decoupling neurological recovery from unfavorable post-procedural perfusion parameters. Conflict of interest I have recieved a reaseach Grant from Everpharm

Background and Purpose: Despite high rates of macrovascular recanalization, approximately half of patients with large vessel occlusion stroke fail to achieve functional independence after endovascular thrombectomy (EVT). Residual tissue-level perfusion abnormalities on post-procedural CT perfusion (CTP) may indicate futile recanalization and inform selection for adjuvant therapy. We synthesized post-EVT CTP thresholds, summarized acquisition timing, and discussed implications for patient selection in trials of intra-arterial thrombolysis, antithrombotics, and neuroprotection, limited to studies performing perfusion imaging after EVT. Methods: We searched MEDLINE, EMBASE, and the Cochrane Library (January 2018-April 2026) for studies performing perfusion imaging after EVT, reporting ≥1 quantitative CTP parameter with functional or neurological outcome, and enrolling ≥10 patients; pre-EVT CTP studies were excluded. Functional independence with versus without post-EVT hypoperfusion was pooled using DerSimonian-Laird random-effects. Individual patient data from our prospective Cerebrolysin proof-of-concept cohort (N=18) were integrated. Results: Nine post-EVT perfusion imaging studies (497 patients) met inclusion criteria. Residual hypoperfusion occurred in 21-53% of angiographically successful reperfusions and was associated with lower odds of functional independence (pooled OR 0.23, 95% CI 0.17-0.33; I2=29%). A Tmax >6 s volume <3.5 mL at 30-90 minutes post-EVT was the most consistently validated threshold (OR 3.5, 95% CI 1.6-7.8). In our cohort, an ischemic core (rCBF <30%) of 0 mL versus any detectable residual core was associated with markedly higher odds of independence (OR 27.5, 95% CI 1.0-746 with continuity correction; ρ=0.77, p=0.003). The optimal CTP acquisition window is 30-120 minutes post-EVT. Conclusions: Post-EVT CTP outperforms modified TICI grading for predicting functional outcome and identifies biologically distinct subgroups for adjuvant therapy selection. Standardized post-EVT CTP at 30-120 minutes, applied with the proposed threshold framework, should be used for eligibility and stratification in future trials of intra-arterial thrombolysis, antithrombotics, and neuroprotection. ### Competing Interest Statement The authors have declared no competing interest. ### Clinical Trial NCT06070753 ### Funding Statement EverPharm supported this study through unrestricted Grant ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: Shaare Zedek Medical Center Local IRB I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes I'll be happy to chare our data on 18 patients with POST EVT cerbrolysin treatment and CTP

BACKGROUND AND PURPOSE:Despite high rates of macrovascular recanalization, approximately half of patients with large vessel occlusion stroke fail to achieve functional independence after endovascular thrombectomy (EVT). Residual tissue-level perfusion abnormalities - detectable on post-procedural CT perfusion (CTP) - have been proposed as a biomarker of futile recanalization. We aimed to establish post-EVT perfusion imaging (by CT or MR perfusion) as a surrogate marker predictive of functional independence on the modified Rankin Scale - by synthesizing evidence-based perfusion thresholds and defining the optimal acquisition timing. Analysis was restricted to studies performing perfusion imaging exclusively after EVT, so that thresholds reflect post-procedural reperfusion status rather than pre-treatment ischemic burden. METHODS:We systematically searched MEDLINE, EMBASE, and the Cochrane Library from January 2018 through April 2026 for cohort studies performing perfusion imaging after EVT, reporting at least one quantitative CT- or MR-perfusion parameter alongside functional outcome (modified Rankin Scale [mRS] at any post-procedural time point) or neurological outcome (National Institutes of Health Stroke Scale [NIHSS]), and enrolling ≥10 patients. Both anterior and posterior circulation occlusions were eligible. The review was conducted in accordance with PRISMA 2020 (checklist provided as supplementary material). Risk of bias was assessed using the ROBINS-I tool. Pooled odds ratios (ORs) were estimated using the DerSimonian-Laird random-effects estimator. A pre-specified sensitivity analysis excluded our proof-of-concept cohort (which received adjunctive cerebrolysin) to isolate the pooled estimate from any treatment-related influence. RESULTS:Eight independent post-EVT perfusion imaging studies (670 patients; five CT-perfusion, two MR-perfusion, and one mixed CT/MR cohort) met inclusion criteria. Residual hypoperfusion was present in 21-53% of angiographically successful reperfusions and was consistently associated with reduced odds of functional independence (pooled OR 0.28, 95% CI 0.15-0.51; I²=6%). The pre-specified sensitivity analysis excluding the cerebrolysin-treated cohort yielded a pooled OR of 0.30 (95% CI 0.16-0.54; I²=0%), confirming that the pooled effect is not driven by the adjuvant-treated subgroup. A Tmax >6 s volume <3.5 mL at 30-90 min post-EVT was the most consistently validated CT-perfusion threshold (adjusted OR 3.5, 95% CI 1.6-7.8); for MR perfusion, an rCBV-defined impaired-microvascular-reperfusion volume >5 mL was the corresponding threshold. The optimal perfusion acquisition window is 30-120 min post-EVT. CONCLUSIONS:Post-EVT perfusion imaging (CT or MR) provides tissue-level reperfusion information that complements modified Thrombolysis in Cerebral Infarction (mTICI) grading and identifies biologically distinct patient subgroups. Standardized post-EVT perfusion imaging at 30-120 min, applied with the proposed threshold framework, should be considered as an eligibility criterion and stratification variable in future trials of post-EVT adjuvant therapy across the pharmacological spectrum.

Abstract Background and aims Pre-hospital stroke code activation by emergency medical services (EMS) is essential for timely treatment in the emergency department (ED) but is frequently triggered by non-stroke conditions (“stroke mimics”). A protocol-driven pilot program was implemented allowing ED nurses to cancel pre-hospital activated stroke codes when predefined criteria were met for non-stroke presentations or acute treatment ineligibility. We evaluated the impact of this pilot on the distribution of final diagnoses and stroke mimics. Methods We retrospectively compared consecutive ED stroke code activations during two periods: pre-pilot (n = 258) and post-pilot (n = 493). Final diagnoses were classified as confirmed stroke or stroke mimic, and mimics were further categorized (e.g., infection, dizziness, seizure, functional). Proportions of stroke and mimic subtypes were compared between periods. Results The proportion of confirmed strokes remained stable (33.3% pre-pilot vs. 34.9% post-pilot). The overall rate of stroke mimics was unchanged (66.7% vs. 66.5%). However, the distribution of mimics shifted: infection (11.2% to 8.5%), metabolic (5.4% to 3.2%), and Bell’s palsy (3.1% to 1.0%) decreased, while dizziness (12.0% to 14.4%) and functional presentations (1.6% to 4.1%) increased. Other mimic categories showed minimal change. No reduction in the proportion of true strokes was observed. Conclusions Empowering nurses to cancel EMS-activated stroke codes did not alter the overall yield of stroke activations but was associated with a reduction in easily recognized non-stroke presentations. Remaining mimics were predominantly conditions that are clinically difficult to distinguish from stroke. The findings support the safety and potential efficiency benefits of nurse-led stroke code triage. Conflict of interest Michael Teitcher: nothing to disclose

Variants in the glucocerebrosidase gene (GBA1) are the predominant genetic risk factor for Parkinson’s disease (PD), often accelerating disease progression. While biological sex modulates PD progression, the longitudinal association between rasagiline (a monoamine oxidase-B [MAO-B] inhibitor) and motor outcomes in GBA1-associated Parkinson’s disease (GBA1-PD) remains unclear. This retrospective cohort study (2019–2026) analyzed 259 patients with PD (106 females, 153 males) with a median follow-up of 1.56 years to evaluate the association between rasagiline use and motor decline, emphasizing sex-stratified outcomes. Motor progression was evaluated using the Movement Disorder Society—Unified Parkinson’s Disease Rating Scale part III (MDS-UPDRS-III). Rates of change were calculated using sex-stratified Generalized Estimating Equations models, with adjustment for age at diagnosis to evaluate treatment effects and sex-specific associations. Among 259 patients, rasagiline use was associated with a significantly slower annual rate of motor decline (Slope Difference: −0.95; p = 0.03). In the GBA1-PD subgroup, females using rasagiline exhibited a clinically relevant slower rate of progression (approximately 1 point/year on the MDS-UPDRS-III) compared with non-users, although not statistically significant (p = 0.08); no association was observed in males. These findings suggest a potential sex-specific association of rasagiline with motor progression in GBA1-PD. Results highlight the importance of sex-stratified analyses to support personalized therapeutic approaches for PD genetic variants.

Abstract Background and aims Pre-hospital stroke code activations frequently include patients ultimately diagnosed with stroke mimics, leading to unnecessary mobilization of acute resources. A protocol-driven pilot program was implemented empowering trained nurses to cancel pre-hospital stroke codes upon emergency department arrival when clinical assessment suggested a non-stroke diagnosis or a presentation that would not warrant acute intervention. The objective was to evaluate the accuracy and safety of this nurse-led triage approach. Methods During the pilot period, protocol-trained nurses assessed patients for whom a pre-hospital stroke code had been activated. When criteria code cancellation were met, the code could be cancelled, and the patient was triaged through the standard emergency department pathway. All cancelled cases were reviewed for final diagnosis and treatment eligibility. Results Among 107 cancelled stroke codes, 99 cases (92.5%) were ultimately diagnosed as stroke mimics, most commonly infection (26.2%), generalized weakness (15.0%), and other non-stroke etiologies (22.4%). Eight patients (7.5%) were later confirmed to have stroke. Of these, seven would not have been candidates for acute reperfusion therapy due to exclusion criteria (out of window = 1; poor baseline function = 3; minor/non-disabling = 2; spontaneous resolution = 1). One patient experienced delayed but ultimately successful treatment. Thus, only 0.9% of all cancellations had treatment implications. Conclusions Nurse-led stroke code cancellation accurately identified stroke mimics while maintaining a very low rate of missed treatment opportunities. This approach appears safe and efficient when applied by trained nursing staff with ongoing oversight, supporting its potential role in optimizing emergency stroke triage. Conflict of interest Michael Teithcer: nothing to disclose

ImportanceThe net clinical effect of early vs later direct oral anticoagulant (DOAC) initiation after atrial fibrillation–associated ischemic stroke is unclear.ObjectiveTo investigate whether early DOAC treatment is associated with a net clinical benefit (NCB).Design, Setting, and ParticipantsThis was a post hoc analysis of the Early Versus Late Initiation of Direct Oral Anticoagulants in Post–Ischaemic Stroke Patients With Atrial Fibrillation (ELAN) open-label randomized clinical trial conducted across 103 sites in 15 countries in Europe, the Middle East, and Asia between November 6, 2017, and September 12, 2022, with a 90-day follow-up. Participants included patients with atrial fibrillation–associated acute ischemic stroke, excluding those with therapeutic anticoagulation at stroke onset or with severe hemorrhagic transformation of the ischemic infarct.InterventionEarly DOAC initiation (<48 hours after minor and moderate stroke, 6-7 days after major stroke) vs later initiation (3-4 days after minor stroke, 6-7 days after moderate stroke, and 12-14 days after major stroke).Main Outcomes and MeasuresThe main measure was the NCB of early treatment over later treatment, calculated by subtracting the weighted rate of excess bleeding events (major extracranial or intracranial hemorrhage) attributable to early treatment from the rate of excess ischemic events (recurrent stroke or systemic embolism) possibly prevented by early treatment within 30 days (main analysis) or 90 days (ancillary analysis). An established weighting scheme was used to account for the different clinical impact of bleeding relative to ischemic outcomes. Event rates were derived from adjusted logistic models. The analysis included all evaluable randomized ELAN participants.ResultsOf the original 2013 ELAN participants, 1966 were eligible for analysis (977 [49.7%] assigned to early DOAC initiation, 989 [50.3%] assigned to later DOAC initiation; median [IQR] age 77 [70-84] years; 1075 [54.7%] male). The 30-day NCB of early treatment over later treatment ranged from 1.73 (95% CI, 0.06-3.40) to 1.72 (95% CI, −0.63 to 3.98) weighted events possibly prevented per 100 participants for intracranial hemorrhage weights 1.5 to 3.3. The 90-day NCB ranged from 2.16 (95% CI, 0.30-3.87) to 2.14 (95% CI, −0.26 to 4.41) weighted events per 100 participants.Conclusions and RelevanceThis post hoc analysis of a randomized clinical trial estimated a sizeable NCB of early anticoagulation for patients after atrial fibrillation–associated ischemic stroke. Although estimates cannot exclude the possibility of no benefit or small net harm, the findings suggest that early treatment may be more favorable.Trial RegistrationClinicalTrials.gov Identifier: NCT03148457

This article provides perspectives on the use of Cerebrolysin as an adjunct treatment to reperfusion therapy in acute ischemic stroke (AIS). In the evolving landscape of AIS reperfusion therapy, we hypothesize that adjunctive cerebroprotective therapy, such as Cerebrolysin, is likely to further improve patient outcomes. Beyond its established neurorecovery benefits, recent data indicate that Cerebrolysin also offers protection to the neurovascular unit and the blood-brain barrier. This paper introduces the CErebrolysin in RECanalization And Perfusion (CERECAP) program, a collaborative initiative of independent academic investigations exploring the favorable trends of Cerebrolysin in reperfusion. The CERECAP program has generated compelling data demonstrating Cerebrolysin's alignment with current AIS reperfusion therapy concepts, particularly its role in early intervention targeting multiple pathways. We review these studies and discuss the critical need to clearly define the patient population that benefit most from adjunctive Cerebrolysin therapy in AIS.

BACKGROUND:Botulinum Toxin type A (BonTA) is the preferred treatment for Cervical Dystonia (CD). However, the success rate is often suboptimal. One of the reasons for treatment failure is the inaccuracy of injections. Some physicians rely on Anatomical Landmarks (AL) for injections, while others use either Ultrasound (US) or Electromyography guidance (EMGg) to improve accuracy. METHODS:This retrospective two-center study compared the therapeutic outcomes of AL-based and EMGg injections with USg injections. Demographic and clinical assessments of previous visits and current visits were recorded between 2019 and 2023. RESULTS:Fifty-one patients were included. Six patients were injected using AL, 14 patients under EMGg, and 31 patients received USg injections. Pain relief was significantly lower for the AL group (40.0% ± 22.4%) compared to both USg and EMGg (81.2% ± 34.0% and 82.2% ± 10.3%, respectively; p = 0.001). Dysphagia was reported in 7.1% of EMGg and 16% of the USg group and none of those treated with AL (p > 0.05). CONCLUSION:The results of this study demonstrated that the clinical outcomes of USg and EMGg BonTA injections are comparable and both techniques are superior to AL. The main side effect observed was dysphagia, which was more common in the USg group, although without reaching statistical significance.

BACKGROUND:Botulinum toxin (BT) can alleviate limb dystonia, but limited insurance coverage hinders its utilization. OBJECTIVES:To compare the therapeutic efficacy of BT injections for spasticity and dystonia of the limbs. METHODS:BT injections of hypertonic limbs were administered under ultrasound guidance between 2019 and 2024 for either limb dystonia or limb spasticity. RESULTS:Of 74 patients included, 57 were diagnosed with spasticity and 17 with dystonia. In total, 276 therapeutic cycles were administered. The dropout rates were 45.6% in the spasticity group and 41.2% in the dystonia group (P = 0.48). There was no significant difference in subjective motor improvement between dystonia and spasticity (P = 0.16). Dystonia patients reported significantly better pain relief (98.5 ± 4.9% vs. 72.4 ± 35.6% respectively, P < 0.001). Notably, 74.3% of dystonia treatments reported moderate or marked improvement, whereas only 54.0% of spasticity treatments did (P > 0.05), based on patient the global impression of change (PGI-C) scale. Side effects were infrequent. CONCLUSIONS:BT injections for limb spasticity and dystonia are partially effective. Nonetheless, the dropout rate is high. While BT injections are more effective in relieving pain for dystonia compared to spasticity, disease severity gradually improves over time in treated patients with spasticity but not with dystonia.

Parkinson’s disease (PD) associated with GBA1 mutations—recently termed Sidransky syndrome—differs from idiopathic PD (iPD) by earlier onset, more rapid progression, and higher rates of non-motor symptoms. Our objective was to assess whether GBA1 mutations contribute to olfactory dysfunction in PD and in asymptomatic carriers of the mutation. We compared olfactory and motor functions in 119 participants: Sidransky syndrome (n = 18), iPD (n = 30), GBA1 variant carriers without PD (n = 21), Gaucher disease patients (n = 20), and healthy controls (n = 30). All were evaluated with the Brief Smell Identification Test (BSIT®) and the motor part of the Movement Disorders Society Unified PD Rating Scale (MDS-mUPDRS). Mean age was 59.2 ± 11.7 years. Mean disease duration was 2.5 ± 2.2 years in Sidransky syndrome and 5.4 ± 4.9 years in iPD. We found that both PD groups had significantly lower BSIT® scores than non-PD groups (p < 0.001), particularly for leather, smoke, natural gas, pineapple, clove, rose, and lemon. Sidransky syndrome patients scored lower than iPD patients (p = 0.04). No significant olfactory deficits were observed in GBA1 carriers or Gaucher patients without PD. We conclude that hyposmia is more pronounced in Sidransky syndrome than in iPD. However, normal olfaction in non-parkinsonian GBA1 carriers suggests that GBA1 variants alone do not account for olfactory loss in PD. Hyposmia likely reflects broader PD pathology rather than a direct effect of the GBA1 mutation.

Early neurological deterioration (END) affects 20–30

Objectives: Past reports have suggested that attention-deficit/hyperactivity disorder (ADHD) may be a risk factor for Lewy body disease (LBD). To confirm this relationship, we conducted the present study. Design: A prospective observational cohort study with a follow-up to 15 years. Setting: The subjects were recuitted from cognitive neurology clinics, where they attended for a cognitive complaint or health check-up. Participants: Two groups of subjects: ADHD adults and healthy subjects. Measurements: The risk of dementia and LBD was estimated with Kaplan-Meier analysis comparing for the presence or absence of ADHD with the log-rank test. Predictors of conversion were assessed through separate univariate and multivariate Cox regression analyses, adjusting for several variables. Results: The baseline sample consisted of 161 subjects with ADHD and 109 without ADHD. At the end of the follow-up, 31 subjects developed dementia, 27 cases in the ADHD group and 4 in comparison group. Dementia with Lewy bodies (DLB) was the most frequent type (N:20) of which 19 corresponded to the ADHD group. The incidence of non amnestic-MCI in the ADHD group was higher representing 67.1 % of these subjects (N: 108), and 17.4% (N:19) of healthy cases. The hazard ratios for dementia and LBD in the multivariate adjusted model were 3.33 (95% CI 1.0915 to 10.1699) and 54.54 (95% CI 7.4849 to 397.5028), respectively in the ADHD group. Conclusions: This study showed that adult ADHD is independently associated with an increased risk of LBD, dementia, and na-MCI. Future studies should clarify this relationship to develop preventive measures for these patients.

Background: Subjects carrying mutations in the GBA gene, whether in one or two alleles pose a risk to develop Parkinson's disease (PD). This type of GBA-related PD has usually a severe course, and patients tend to develop cognitive deficits faster. Herein we describe 8 cases of GBA-PD patients with a markedly benign course (bGBA-PD), and compared them to the other regular GBA-PD group (rGBA-PD) and to mutation negative patients (MNP). Methods: All patients who performed next generation testing were enrolled. We defined bGBA-PD as patients with disease duration of at least 5 years, with Hoehn and Yahr (HY) <= 3 and MoCA score of >= 24. Following a selection of patients with a disease duration of 3 years or longer up to 15 years or shorter, we compared the bGBA-PD group to the rGBA-PD and MNP in terms of demographic and clinical features. Results: 166 patients (58 males) diagnosed with PD were genotyped. Twenty-five patients were GBA-PD, of whom 7 were defined as bGBA-PD. Seventeen patients were LRRK2-PD and 123 patients were MNP. The rate of Rapide Eye Movement Behavioral Disorder (RBD) was highest in the rGBA-PD group and lowest in the bGBA-PD group (100 % vs. 28.6 %) (p < 0.001). The bGBA-PD group scored significantly higher in the Montreal Cognitive Assessment (MoCA) than rGBA-PD and MNP (27.6 +/- 2.0 vs. 19.8 +/- 3.9 vs. 23.5 +/- 3.7, respectively; p = 0.006). There were no significant differences in MDS-UPDRS part-3 among the groups. There was no specific GBA mutation which was more commonly associated with bGBA-PD. Conclusion: While GBA-PD has a severe course of disease, a subgroup of which shows a benign course with a relatively preserved cognitive function even years after onset. We might suggest that these cases have other pathomechanism leading to PD, including an incidental GBA carriership.

OBJECTIVES:This is a case series and a review of the literature of therapeutic outcomes of botulinum toxin (BT) injections for anterocollis.METHODS:Data collected included gender, age, age at onset, muscles targeted, and doses injected. Routine forms were filled out during each visit: Patient Global Impression of Change, Clinician Global Impression of Severity, Tsui scale. The effect duration and side effects (SEs) of the previous treatment were noted.RESULTS:We described 4 patients (3 men, 13 visits) with anterocollis, as primary postural abnormality of the neck, emphasizing the therapeutic response to BT injection. Mean age at onset was 75.3 ± 7.0 years, age at first injection was 80.7 ± 3.5 years. The mean total dose per treatment was 290.0 ± 95.6 units. Patient Global Impression of Change with any grade of favorable effect was reported in 27.3% of the treatments. In objective assessment, Global Impression of Severity and Tsui scores did not show a consistent tendency of improvement. Neck weakness was prevalent in 18.2% of the visits of the anterocollis group while no other SEs were noted. We found 15 articles describing experience with BT for anterocollis in 67 patients (19 in deep and 48 in superficial neck muscles).CONCLUSIONS:This case series describes the poor outcome of BT treatment for anterocollis, with low efficacy and bothersome SE. Levator scapulae injection for anterocollis is not effective and is highly associated with head drop and should perhaps be abandoned. Injection to the longus colli might give some benefit in non-responders.

BACKGROUND:Little is known about phenotypical variations among ethnic groups in patients with Parkinson's disease (PD) in Israel. Clinical characteristics of non-Ashkenazi Jews (NAJ) are scantly described.OBJECTIVES:To describe clinical aspects of PD in ethnic groups in Israel, focusing on NAJ and Ashkenazi Jews (AJ).METHODS:In this cross-sectional retrospective study, we collected demographic, genetic, and clinical characteristics of patients from different ethnic Jewish backgrounds. Ethnic groups included AJ; North African Jews (NAFJ); oriental Jews (OJ) originating from Iran, Iraq, and Buchara; Balkan Jews; Yemenite Jews (YJ); and Jews of mixed origin. Clinical characteristics included hyposmia, urinary complaints, constipation, and rapid eye movement sleep behavioral disorder. Cognitive complaints, motor features, levodopa-induced dyskinesia, and motor fluctuations were collected. Motor part of the MDS-UPDRS and Hoehn and Yahr scores were collected.RESULTS:The study comprised 174 PD Jewish patients (63.2% AJ, 56.4% males). The age at onset was 65.3 ± 10.2 years; 106 patients (60.9%) were genotyped (17 glucocerebrosidase [16.0%], 13 leucine-rich repeat kinase 2 [LRRK2] [12.3%]). Rates of hyposmia were significantly higher in AJ than NAJ (56.6% vs. 39.5%, respectively, P = 0.003). No significant differences were found in motor features in all variables. Of 13 AJ patients carrying the LRRK2 mutation, only one had hyposmia. Three patients with LRRK2 were NAJ.CONCLUSIONS:Hyposmia is less prevalent in PD patients of NAJ origin than in AJ. The rate of hyposmia in NAFJ patients is particularly low. The rate of other non-motor features is similar between NAJ and AJ patients.