Fifty years have passed since Parkinson's disease was first treated with levodopa. And in the last twenty years, various therapeutic tools including dopamine receptor agonists have been approved. Moreover, it has been revealed that Parkinson's disease includes so-called non-motor symptoms such as autonomic symptoms, cognitive impairment and sleep disturbance and so on, based on degeneration of the amine neuron system, which also results in the Parkinsonian tetrad : rigidity, tremor, akinesia and postural instability. This paper includes a history of the therapies used to treat Parkinson's disease from the start to the present as well as an overview of drug therapy commencement, the initial medication selection, non-motor symptoms and a look at possible future therapies for Parkinson's disease.
There are many cases of dementia in Japan, the number is now over 3,000,000, and this situation is expected to only worsen given Japan's rapidly aging population. Because of this, most neurosurgeons are required to see dementia patients as part of their daily practice. There are four drugs used to treat Alzheimer's disease (AD) in Japan. Clinical registry of an AD drug trial was finished in 2011 in Japan. This trial showed that it is very important to choose the proper drug for each stage of dementia and BPSD. A compact version of the AD guideline was published in 2012. It contains a typical flow chart for the diagnosis and treatment policy in AD. Donepedil, garantamine, rivastigmine, and memantine were all shown to slow the decline in memory and ADL in AD patients, reduce the amount of care time, and also reduce patient care and drug expense. Donepedil which has good effect and few side-effects is a good drug for AD. Galantamine is good for patients with cerebrovascular disease and AD, especially. Rivastigmine is good for improving IADL in early AD. Memantine's strength is its ability to maintain memory function for a long time. Furthermore, good circumstances, proper care and adequate rehabilitation are also important to maintain patients' memory function and QOL.
Headache diagnoses are based on the international classification of headache disorders ; 2nd edition (ICHD-II). In Japan, migraine management is practiced using the Japanese guideline for primary headache. There are many acute and preventive migraine treatments. The triptans, selective serotonin 5-HT1B/1D agonists, are specific acute migraine drugs ; five brands including sumatriptan, zolmitriptan, eletriptan, rizatriptan and naratriptan are presently available in Japan. We can also choose from tablet, oral, nasal or hypodermal injection administraction. To obtain satisfactory results with triptans, proper diagnosis and early intervention before cutaneous allodynia emerges are required. Because frequent use of triptans for more than ten days a month over a three month period may evoke medication overuse headache, increased headache frequency is an indication for preventive treatment.
Oral aspirin is highly recommended for acute antithrombotic therapy and secondary prevention in ischemic stroke patients. Clopidogrel and cilostazol presented as good or better effectiveness in reducing the risk of recurrent stroke than aspirin. Dual antiplatelet agents may be used with the exception of aspirin plus dipyridamole, which is not generally recommended for secondary stroke prevention because of the associated high bleeding risk. The addition of dabigatran to warfarin therapy was approved for ischemic stroke prevention in patients with non valvular atrial fibrillation (NVAF). In addition, novel oral anticoagulants (e. g., factor Xa inhibitors : rivaroxaban, apixaban) have been tested in several ongoing large randomized trials. When administering anticoagulant agents for patients with NVAF, the estimation of the embolic and bleeding risks using CHADS2 score, CHA2DS2-VASc score and HASBLED score is recommended. In the Bleeding with Antithrombotic Therapy (BAT) Study group, the characteristics of bleeding complications in Japanese antithrombotic users were reported.
Spontaneous intracranial hypotension (SIH) can present with a variety of clinical symptoms ; a few cases presented with disturbances of consciousness. A fatal case of SIH with bilateral chronic subdural hematoma (CSDH), who presented with severe headache and unconsciousness, is described. A 50-year-old man who had been suffering from headache for about one month was admitted unconscious to our hospital. The patient's level of consciousness improved after bilateral burr-hole irrigation therapy. However, three days after irrigation therapy, the patient's consciousness level deteriorated. One week following admission, an epidural blood patch (EBP) was performed, but his consciousness level deteriorated further. After serial EBPs, his consciousness level failed to improve, and he died 17 days after admission. SIH is generally considered to have a benign prognosis, but when patients have an associated disturbance of consciousness, they should be rapidly and appropriately treated.
Spontaneous intratumoral hemorrhage secondary to meningioma in a child is rarely encountered. Here, we report a very rare case of anaplastic meningioma with intratumoral hemorrhage presenting with rapid neurological deterioration in a child. A 3-year-old boy with a large anaplastic meningioma presented with mild left hemiparesis. Magnetic resonance imaging (MRI) showed a giant tumor in the right frontal lobe with heterogeneous intensity associated with intratumoral hemorrhage. Contrast-enhanced fast imaging employing steady-state acquisition (FIESTA) showed that the tumor was attached to the falx and extended to the contralateral side. On the day after admission, the patient's consciousness level rapidly deteriorated, and he underwent emergency surgery. The tumor attached to the falx was completely removed with dural attachment. The tumor was histologically diagnosed as anaplastic meningioma. Two months after the surgery, MRI showed tumor recurrence. The tumor was extensively removed again, and the patient underwent radiotherapy. Eight months after the initial operation, the patient showed no neurological deficits. No tumor recurrence was detected on follow-up MRI. The epidemiological, prognostic, and therapeutic features of pediatric meningiomas are poorly defined because of its rarity. We present this rare case to emphasize the necessity of close observation of MRI after an aggressive surgery of anaplastic meningioma in children and highlight the importance of surgery and irradiation once recurrence has been detected.
A thirteen-year-old girl with lumbosacral lipoma was originally operated on at three months of age. After partial resection of the lipoma and untethering, her condition followed a good course with minimal bladder dysfunction despite suspicion of retethering as shown on magnetic resonance imaging (MRI). At the age of thirteen years old, she was admitted to our hospital complaining of transient consciousness loss after she slipped down on the ground while playing tennis. Muscle weakness and hypesthesia were present in her left leg and MRI revealed a tethered cord which was consistent with the previous findings. Untethering was performed three months later and the symptoms involving her lower extremity improved after the surgery. Her sphincter function became disturbed transiently, but came into remission within two months. Retethering after spinal lipoma surgery is not rare, which leads to exacerbation of tethered cord syndrome (TCS) and it is well known that head trauma or exercise is relevant to the onset of TCS in adolescents with occult spina bifida. Careful consideration should be given to the management of recurrent TCS although the timing and operative method of untethering are still controversial.