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Mental health of the deaf population – a review to an inclusive approach - read full article

By: Beatriz Martins

Introduction: The Deaf population is approximately 70 million worldwide; a large part integrates a community with a unique culture and language, which mental health professionals are not always aware of.

Objectives: The objective of this review is to list the characteristics and difficulties in the approach to mental disorders in deaf individuals.

Methods: The results of this review come from a search of the literature on psychiatric disorders in deaf people and it was conducted on the PubMed platform. Demographic data was consulted in Portuguese Association of the Deaf, World Association of the Deaf and European Union of the Deaf’s websites.

Results: Regarding the psychopathological evaluation of deaf patients, by their particular characteristics, the screening for psychotic symptoms must be open to a wide range of sensory phenomena and it includes the possibility of language deficits resulting from early language deprivation. These language deficits may emerge as a factor for confusion on the assessment of thought organization. For mood evaluation, doctors may observe the speed of the patient’s signing, but also admit other typical mood changes (on sleep, appetite, attention) for a correct diagnosis. Further, the deaf population has the same cluster of depressive symptoms experienced by hearing people. Mood disorders and suicide attempts are estimated as more prevalent in the deaf population; substance use disorders are similar to the general population. However, many methodological problems hamper conclusions on the prevalence of these and other psychiatric diagnoses in deaf patients. This was also verified: a frequent restriction and late access to a spoken or gestual language and its impact on one’s life; a linguistic and cultural barrier between clinicians and deaf patients; the role of certified interpreters that are not always trained to deal with mental health issues; the interpreter’s interference on doctor-patient relationship and on diagnostic interpretation.

Conclusions: No real conclusions can be derived about the expression of psychiatric disorders on the Deaf population, as there are no large scale population-based studies on the subject. Isolation and inequality of the deaf population are perpetuated by the persistence of social and educational deficiencies, including some deficiencies in the psychiatric training of young doctors.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P1

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From a mental health dispensary to ULS do Nordeste - read full article

By: Carina B. Rodrigues, Mariana N. Andrade, and Virgílio Palma

Introduction: Portuguese Legislation concerning Mental Health was first published in 1889. However, little changes have been made until 1945’s Law 2006. Only since then, many structures aimed to psychiatric care have been created and, lately, reorganized. Our present Department of Psychiatry and Mental Health is an example of how Psychiatric Care has evolved in a countryside district.

Objectives: Our aim was to understand which local and national changes were relevant to build and maintain a Mental Health Department operating since its creation to the present.

Methods: To display the major changes on the national scene, objective data was collected from Legislation and historical documents. Though, it was an essential part of this work to interview former and actual workers of this institution who shared their memories of the last decades.

Results: Our Department of Psychiatry and Mental Health started operating as a Mental Health Dispensary in 1964. It ensured, since then, ambulatory psychiatric care to the population of Bragança’s district. For many years, all patients hospitalized in a psychiatric hospital were transferred to a Psychiatric Hospital or Asylum, further than a five hours trip to their homes. Later, influenced by sectorial psychiatry, a local Mental Health Centre was created, including a Psychiatric Clinic permitting for the first time the hospitalization of patients in their home district. Recently, in 1992, all local Centres have been included in General Hospitals. Consequently, Psychiatric Departments have been influenced by the recent changes in Hospital Management. Today, our Department is part of the Unidade Local de Saúde do Nordeste, a public institution administered by a private entity, composed by three hospitals and fourteen healthcare centres.

Discussion and Conclusions: Parallel to the evolution of Psychiatry worldwide, also here the social, political, cultural and scientific changes had a relevant role. And so, we witnessed the same difficulties, and developments. Nowadays, however, the lack of financial and, particularly, human resources remains a major issue.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P2

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“Cabbage lice infestation” – how psychiatrists solved this, in the past 1500 days - read full article

By: Cátia Martins, Fábio da Silva, M. Pinto da Costa, and Serafim Carvalho

Introduction: Delusional parasitosis, also known as Ekbom’s syndrome, is a form of psychosis that people acquire a strong delusional belief of being infested with parasites, whereas in reality no such parasites are present. Patients affected by this psychiatric condition usually go to several doctors, as dermatologists, in the expectation to have their conviction of real infection confirmed and treated. They have indeed skin lesions, either self-inflicted by itching or by attempts to eliminate the presumed infection with abrasive products.

Methods: We present a case-study of a 68 years old female patient followed at the Psychiatry department in the past four years, after being referred by a dermatologist and how this case has been diagnosed and treated, and the improvements achieved.

Results: The patient had a delusional belief of being infested with cabbage lice, presenting skin lesions in both lower limbs, self-inflicted with pliers in an attempt to remove the supposed lice. This condition caused her serious dysfunction, interfering with her personal and social functioning at home, work, with her relationships, and hobbies. She was treated with haloperidol combined with a topical antihistamine. This treatment resulted in total remission of her symptoms.

Discussion: She kept being followed in the Psychiatry department in outpatient care regimen for the last four years, during which she remained without symptoms, believing we cured her infection. She gradually got back to her usual daily activities and her responsibilities at work, recovering her functionality.

Conclusions: This case illustrates the importance of the observation, diagnosis and treatment by Psychiatrists, and in this case the administration of antipsychotics as the proper treatment to disorders that have been first observed by other medical specialties, combined with a solid therapeutic alliance with patients and proper referrals between colleagues. This brings attention to the consequences of working closely with other medical specialties, as psychiatry and dermatology or any other medical specialty according to how the body is involved in the delusion, raising awareness to the importance of Liaison Psychiatry at the General Hospitals and in Primary Care.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P3

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Perfectionism, regret and psychological distress – preliminary study in college students - read full article

By: Daniela Borges, Ana T. Pereira, Joana Borges, A. Primo Cabral, and António Macedo

Introduction: Counterfactual thinking (CT) is defined as a set of mental representations of alternatives to the past actions and, when it focuses on personal decisions, the emotion that results is regret. Regret is defined as an aversive negative emotion, associated to specific cognitive contents and that can be functional or dysfunctional, particularly when associated with perseverative negative thinking (PNT) and certain personality traits, such as perfectionism.

Objectives: To study for the first time the relationship between regret, perfectionism, PNT and psychological distress in the form of negative affect (NA).

Methods: 87 college students (73.6% girls, mean age 22.74±4.828) completed Portuguese validated versions of the Hewitt & Flett Multidimensional Perfectionism Scale, the Multidimensional Perfectionism Cognitions Inventory (MPCI), the Perseverative Thinking Questionnaire (PTQ), the Profile of Mood States, the Perceived Stress Scale and the Regret Scale (RS).

Results: Regret trait was positively correlated with perfectionism, PNT, NA and stress perception; and inversely with positive affect (PA) and support perception. The comparison of the regret trait scores showed overlapping results to correlations. It was found that even perfectionism and PNT are predictors of regret trait and interference and unproductiveness (IU-PTQ) is a partial mediator of the relationship between personal standards (PS-MPCI) and RS. Regret trait proved to be a predictor of stress perception. The PNT (IU) provided a significant increment in explained variance for depression and NA, and together with PS to the variance of anxiety-hostility.

Discussion and Conclusions: In this study, using the Portuguese validated version of RS, a correlation between regret trait and perfectionism was shown. Additionally, and for the first time we demonstrated an association between regret and PNT, NA, PA, perception of stress and support. It was found that higher correlations between regret trait, perfectionism and PNT were experienced with their more maladaptive dimensions (Socially-Prescribed Perfectionism and IU). The PNT, especially its more maladaptive dimension (IU), is a mediator of the relationship between perfectionism and regret. Regret also proved to be a predictor of perception of stress. This preliminary study warrants further research of the relationship between regret, perfectionism, PNT and psychological distress.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P4

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Is forced therapy the solution for addiction? – addressing a global key health issue in times of the highest numbers of new psychoactive drugs - read full article

By: Franziska Baessler

Introduction: Addiction is one of the key global health problems. Worldwide there are approximately 149 to 271 million people who use amphetamine, cannabis, cocaine or opioids. Precise numbers on prevalence of addiction are difficult to obtain as measurements methods are indirect and surveys depend on information provided by consumers. To face that problem a variety of approaches have been implemented in Europe.

Objectives: The presentation takes into account the diversity and classification of addiction related disorders in Europe focusing on the most consumed legal drug alcohol and the most consumed illicit drug, cannabis.

Methods: Definitions, prevalence, evidence for the effectiveness of interventions and legal issues will be on focus and the audience will be updated on characteristics of the newest psychoactive substances.

Results: Around two new psychoactive substances are discovered per week in Europe as published by the EU drugs agency EMCDDA in March 2015. The figures are the highest measured showing an upward trend. Results show that semi-compulsory therapy in addiction for convicts are as effective as voluntary treatment. Especially regarding cannabis the European area has controversial approaches from a different legal point of view. Some countries differentiate “soft” drugs (such as cannabis) from “hard” drugs (such as heroin and cocaine). Softening or aggravation of penalties does not show a direct association with prevalence.

Discussion and Conclusions: The diversity in psychoactive substances increases to a frightening extent. On top of that new psychoactive substances are difficult to detect by traditionally drug tests. Despite of recent revisions there is an ongoing need for updating addiction related classification systems such as in DSM and ICD. Quasi-compulsory therapy shows effects. Harsher penalties do not show a unidirectional relationship with prevalence.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P5

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Prevalence and correlates of suicidal ideation in Portuguese and immigrant pregnant women - read full article

By: M. J. Soares, S. C. Bos, A. T. Pereira, M. Marques, B. Maia, A. P. Amaral, D. Mota, S. Morais, N. Madeira, V. Nogueira, M. Bajouco, J. Valente, C. Roque, L. Oliveira, and A. Macedo

Introduction: Due to the acculturation, immigrants may be exposed to additional sources of stress that may predispose them to psychological distress or psychiatric disease, including depression and suicidal ideation. Several studies, but not all, found higher rates of suicidal behaviors in immigrants than in the host populations. However, the literature on perinatal suicidality in immigrant women is scarce.

Objectives: To analyze the prevalence and correlates of suicidal ideation in Portuguese and immigrant pregnant women in Portugal.

Methods: 491 Portuguese (mean age=29.62 years; sd=4.51) and 77 immigrant pregnant women (mean age=31.08 years; sd=4.61) completed the Portuguese versions of the Postpartum Depression Screening Scale (PDSS), the Beck Depression Inventory II (BDI-II), the Profile of Mood States (PoMS) and a questionnaire to assess demographic and obstetric data, self-reported health, sleep difficulties, social support, quality of life, and stress. The suicidal ideation level was assessed with the PDSS suicidal ideation subscale and the prevalence was calculated based on the positive/indecision answers to this subscale items.

Results: Portuguese and immigrant pregnant women did not significantly differ in suicidal ideation scores (M=5.36±1.44 and M=5.48±1.45, respectively; p=.584) and prevalence (1.8% versus 3.9%, respectively). In both groups, immigrant and Portuguese women, suicidal ideation was significantly associated with lower education level, increased parity and number of child, lower professional levels, poor quality of life, sleep difficulties, and high levels of depression (PDSS). Only in Portuguese women, the suicidal ideation was associated with the status “not married”, lower social support, lifetime poor physical health, previous history of insomnia, hopelessness, helplessness, low positive affect, high negative affect, high levels of depression (BDI-II Total) and high levels of psychosomatic symptoms (PDSS - Appetite/Sleep). Only in immigrant women, the suicidal ideation was associated with abortion and stress.

Discussion: Suicidal ideation levels and prevalence did not differ significantly between Portuguese and immigrant pregnant women, but there were similarities and differences in the correlates of suicidal ideation.

Conclusions: The immigrant condition confers some specificity to the factors associated with suicidal ideation. The findings from this study might have clinical implications in perinatal mental health, including in clinical interventions with immigrant women.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P6

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Clues to an expectable attack to public figures by mentally disordered people - read full article

By: Maria J. Peixoto, Mota Oliveira, Catarina Novais, Filipe Pinto, and Sertório Timóteo

Introduction: Public figures are constantly besieged with unwanted attention from mentally disordered people. The studies of attacks on public figures emphasize the role of mental illness and the relationship between delusional fixations and subsequent attacks.

Objectives: To review literature on predictive factors for the threat-approach-attack escalation.

Methods: Papers about the association between mental illness and public figures attacks were searched through PubMed database, using the following terms: mentally disordered; approach behavior; public figures; pre-requisite to attack.

Results: In a review of mental disorder role in attacks on European politicians the authors found that a high proportion of the attackers were psychotic at the time of the event. In other review, 70% of those who approached were men with a mean age of 39 years, and the presence of mental illness ranged from 59.6% to near 84%, with grandiosity and delusional ideas being more frequent than persecutory beliefs. Those who approached celebrities were more likely to evidence an excessive sense of self-importance or uniqueness and had written a letter more than once (or used other forms of communication). Those who engaged in abnormal communications, employed multiple means of communications and were considered to be driven by motivations that concern a personal entitlement to the public figure, were more likely to approach physically the person of interest. On the other hand, angry and hostile themes on letters to public figures occurred more frequently in those who did not pursue an encounter.

Discussion and Conclusions: Approaches are a pre-requisite to attack, therefore, the prediction of approaches can assist in the prediction of attacks. Approach behavior appears to be associated with more intrusive forms of attempted communication with multiple means of interaction and a desire for face-to-face contact. The recognition of pre-attack signals like inappropriate communications and visits, statements to third parties of their intention to harm a public figure and physical approaches might predict who among the mentally disordered could commit an attack to a public figure. The high prevalence of mental illness indicates the relevance of psychiatric intervention.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P7

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Global mental health – going from HIC to LIC - read full article

By: M. Pinto da Costa and José M. C. Almeida

Introduction: A growing movement to High Income Countries (HIC) is increasing, being a signal of the current globalization. While facing these movement flows, it can be demanding to adapt the gained knowledge to the resource settings. Services in Low and Middle Income Countries (LMIC) are often poorly resourced, being frequent the struggle to provide care. Nevertheless, the original ways to overcome the challenges and constraints faced in these settings, can be examples of different means to treat or prevent mental illness from which we can learn.

Objectives: To promote the discussion on the challenges and opportunities of cooperation and professional medical mobility from HIC to LMIC.

Methods: To present the experience of a European junior doctor in an African setting in the capital city of Angola, Luanda.

Results: This inter-continental medical professional experience in an environment with different background and less resources to provide care, has been very challenging and enriching, also to establish comparisons with different health systems. When settings face constraints with increased levels of poverty and social deprivation, it is a challenge to deliver mental health care, being essential to advocate towards the engagement of policy-makers and planners. Developing and promoting professional medical cooperation between HIC and LMIC can be a strategy in this global world, while HIC society face crisis and certain LMIC rise financially. The effects of this medical professional mobility, promoting junior doctors to go across borders worldwide, are beyond the increased knowledge or the encouragement to joint projects, and can reach establishing durable cooperations.

Conclusions: The challenges faced on the ground in this experience encouraged me to advocate to further comparisons, and endorse critical thinking in regards to public health priorities and innovative responses to the burden of care.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P8

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“It's psychiatric!” – about stigma in general hospital - read full article

By: M. Silva, S. Nunes, P. Macedo, A. Figueiredo, A. Fornelos, and D. Maia

Introduction: Stigma can be defined as ‘the co-occurrence of labeling, stereotyping, separation, status loss, and discrimination in a situation where power is exercised” and during the last years the interest in the stigma of mental illness has increased considerably. In fact, evidence exists about the stigmatization of patients with mental illness and stigmatization of psychiatry and psychiatrists. Sometimes not only the general population stigmatise and discriminate mental illness but also the non-psychiatric healthcare professionals.

Objectives and Methods: Review of the literature using medline database to research some topics: (1) Stigma of mental health (patients, psychiatry and psychiatrists), (2) Stigmatization by non-psychiatrists healthcare professionals, (3) Repercussions in physical health of the patients, and (4) How to combat this stigma in general hospital.

Results: Many articles address the stigma of mental illness but most of them report the perspectives of patients, patient’s family and describes the discrimination behavior by general population. There are few studies that discuss this problematic in health professionals but enough to conclude that stigma of mental illness has been identified as a significant barrier to help-seeking and care. In recent decades it has become widely acknowledged that there are physical health disparities between patients with and without mental illness. For this situation contributes: poorer access to physical healthcare, diagnostic overshadowing and the notion that health professionals are not immune to the effects of stigma attached to mental illness, despite formal education in psychiatry. Although “often unintentional” such discrimination remains a major barrier to quality care, treatment and recovery.

Discussion and Conclusions: Stigma is a cruel reality in mental health care and this can negatively impact on physical health outcomes. As professionals, we must always be aware of how our own attitudes may affect our ability to provide appropriate, individualised care. Stigma reduction in healthcare students and professionals needs to be sustained over time if it is to result in positive changes for people living with mental illness. To achieve this, it is necessary education, inclusion of contact with people with mental illness and burnout reduction.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P9

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Job quality and mental health – the role of the economic crisis - read full article

By: Marta Queirós and Marlene Alves

Objectives: Review available literature concerning the impact of the Economic Crisis in Workplace Mental Health focusing mainly on European data.

Methods: Non systematic review using PubMed database with the Mesh words "Job Satisfaction" and "Mental Health". Review of the European Union (EU) Official Publications regarding this subject. Publications dating from 2007 to present were considered.

Results: PubMed database found 126 results from which 13 were considered relevant. Four EU Official Publications available online were also considered relevant.

Discussion: In recent years there has been a substantial change in European workplaces and an increasing concern about job-related mental health. Work-related stress occurs when workers are presented with work demands that are not matched with their knowledge, skills or abilities, and that challenge their ability to cope. The Financial crisis has accentuated some negative aspects of work that influence mental health, such as: workforce ageing, emergence of new forms of employment contracts, increased job insecurity, work intensification, and use of irregular and flexible working time. In 2012, about 20% of workers reported poor mental well-being. As a result, stress, depression and anxiety, were the second most frequently reported work-related health problems in Europe.

Conclusions: Psychosocial risks that negatively impact workers' mental health have been increasing due to the financial crisis. Work-related mental ill-health is a growing public health problem in Europe. Measures must be taken to improve job quality so that these health burdens decrease.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P10

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Implementation of Open Dialogue Approach in Polish mental health structures - read full article

By: Michal Klapcinski, Aleksandra Matuszek, and Renata Wojtynska

Introduction: In Poland since 2013 first one-year Open Dialogue Approach (ODA) courses has been carried out for mental health professionals (MDs, nurses, psychologists, psychotherapists, educators, social workers) ran by Polish Institute of Open Dialogue. Until now more than 50 people working in different professional backgrounds (stationary wards, ambulatory wards, daily clinics, mobile-crisis team, supportive housing facilities) have been trained and started to apply dialogical practices in their daily routine. First ODA practitioners report a significant change in communication patterns that occurs among professionals when dialogical practices are applied.

Objectives: The aim of this poster is to depict current state of ODA application in Polish psychiatric services and to discuss hardships as well as benefits that experience ODA practitioners.

Methods: 87 college students (73.6% girls, mean age 22.74±4.828) completed Portuguese validated versions of the Hewitt & Flett Multidimensional Perfectionism Scale, the Multidimensional Perfectionism Cognitions Inventory (MPCI), the Perseverative Thinking Questionnaire (PTQ), the Profile of Mood States, the Perceived Stress Scale and the Regret Scale (RS).

Discussion: ODA has been developed in Western Lapland [Finland] since early ‘90s. At the outset it was conceived as psychotherapeutically oriented, need-adapted treatment of schizophreniform psychosis. Willing to achieve “wide-range impact” it further evolved into comprehensive model of psychiatric service organization with challenging treatment outcomes (especially regarding sharp decrease in schizophrenia incidence in the catchment area). Meanwhile psychiatry in Poland, for years financially underestimated, leads a transformation, following the guidelines issued in Polish Mental Health Program, where considerable importance is attached to de-institutionalization of mental health structures and to foundation of community based facilities. Bottom-up patients’ family movement put effort into arranging first ODA workshops that where held in Wroclaw in 2012 with its architect Jaakko Seikkula and method’s practitioners. Meeting emphasized the need of further trainings led by experienced tutors. ODA due to its network- and need-adapted orientation may become an eligible standard for community psychiatry training, where shared decision making lie at the core of professionals’ everyday work, stressing the need for other than pharmacological interventions. Furthermore, being an attractive organizational solution it might satisfy demands drawn up by the mental health policy-makers. Well–design surveys that could undoubtedly support method’s replicable outcomes in different settings are required.

Conclusions: To summarize ODA provides a new perspective on mental health care, however multicenter, comparative (at best randomized clinical trials) studies are necessary to assess ODA impact on the long-term outcomes.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P11

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Psychopathology: is it still important for clinical practice? - read full article

By: Ana F. Freitas, A. Gameiro, and H. Esteves

Introduction: In the last years, psychiatry has given primarily importance to the construction of categorical classification systems (DSM and ICD), neglecting the importance of recognizing and describing the signs and symptoms of mental illnesses. On the other hand, the increasing use of scales and questionnaires has further undermine the semiotic investigation, acting as if psychopathology is a transparent instrument in which symptoms are seen as stable entities over time. This idea is wrong, as Jaspers has already postulated, considering psychopathology as a dynamic and continuously evolving entity.

Objectives: To provide a review to understand the importance of psychopathology in today’s psychiatric practice.

Methods: A literature review was taken using PubMed and Medscape databases with the following search terms: psychopathology, practice, importance.

Results: Psychopathology means the study of the diseases of the soul, spirit or mind. It appeared as an organized discipline, in the early XX century, with the publication of Karl Jaspers “Allgemaine Psychopathologie” (General Psychopathology). Psychopathology can be seen essentially from two perspectives: the phenomenological (Comprehensive or Descriptive Psychopathology) and the psychodynamic (Explanatory Psychopathology). In 1952, a categorical system (DSM) appeared with the purpose of facilitating diagnosis and treatment of soldiers. Since then, it has been an important tool, having been revised several times. Other tools appeared and are used currently – such as questionnaires and scales – trying to bring objectivity to clinical practice. In the last 20 years, neurosciences and genomics have also contributed to revolutionary changes in psychiatry. Yet, phenomenological psychopathology maintains a core role in clinical practice and could have an important place in the future growth of scientific psychiatry.

Discussion and Conclusions: Neuroscience and genetics contributions, the use of questionnaires and scales in the clinical evaluation and classification systems, are in fact relevant tools in clinical practice, which importance should not be neglected. However, they should be used with caution, never in a reductionist way, warning about the misunderstanding of pathology as simply check-lists. Instead, they must be understood in a dynamic/longitudinal perspective. In conclusion, it seems that psychopathology continues to be the main discipline in which psychiatric practice relies.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P12

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The EFPT psychoactive substances use disorders (PSUD) study - read full article

By: Duccio Papanti, Matis Martens, Andrew Putskys, Diego Quattrone, Irena R. Palavra, Franziska Baessler, Tomasz M. Gondek, Athanasios Kanellopoulos, M. Casanova Dias, M. Pinto da Costa, and Laura Orsolini

Introduction: Disorders due to psychoactive substance are considered by the World Health Organization as mental disorders, and therefore codified in ICD Classification of Mental and Behavioural Disorders. However, both the role of psychiatrists and trainees in the treatment of addiction and the practices used vary greatly among European Countries.

Objectives: We aim at understanding the attitude of psychiatric trainees towards people who use substances, the use of medications for treating patients with substance use disorders, if they feel confident and skilled to work in addiction psychiatry.

Methods: We drafted a 60 items questionnaire about: the attitude of trainees towards PSUD, PSUD pharmacologic treatment, best practices used, structuration and satisfaction about PSUD training; with the aim of having questionnaires filled out by 40 psychiatric trainees (both from General Adult and Child and Adolescent) per country, in about 20 EFPT partner countries (sample expected population of 800). One national coordinator per country will help in delivering the questionnaires and collect data on an online database.

Discussion and Conclusions: So far we enrolled national coordinators from: Italy, Croatia, Estonia, Lithuania, Portugal, United Kingdom, Germany, Greece and Poland. We still need to reach coordinators from other 11 EFPT partner countries to fulfil the above criteria and start the study. This survey will be the first to explore European psychiatric trainees attitudes and practices about PSUD. Findings from this independent and low-cost survey may serve in understanding the needs of trainees in the field of addiction psychiatry, and about the organization of such training across Europe.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P13

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EFPT health-seeking attitudes and existing support services for psychiatric trainees - read full article

By: Ema Conde, Alice Lomax, Telma Santos, Sonila Tomori, Thomas Pattyn, Celina Skjødt, Teelia Rolko, Laura Shtane, Sigita Rozanskiene, Sigita Rozanskiene, Egle Biliute, Liana Kobylinska, Branimir Radmanovic, Sonja Virag, Sara Meier, Bojana Rueegg, Romy Jost, and Deniz Ceylan

Introduction: Concern for medical doctors’ health has been widely recognized over the past ten years. EFPT is aware of the heterogeneity of support set up for doctors in distress and recognizes the need for further cross-Europe research. This project aims to gather information and carry out research in order to improve services for physician health Europe-wide.

Objectives: The “HELP Project” was designed to investigate psychiatry trainees’ perceptions of and attitudes towards health seeking at a Europe-wide scale. Furthermore, it aims to determine what services are available in Europe specifically to support physicians’ health.

Methods: This is a multinational, cross-sectional survey conducted in 14 European countries. Data collection was accomplished by an anonymous online or hard-copy questionnaire. Completion implied consent to participate.

Results: Of the respondent trainees, 98% said they would have surgery in the public sector, versus 42.3% who agree to get treatment there for an eating disorder, for depression (28.8%) or for addiction (17.3%). Trainees from developing economies were significantly less confident in using public sector help for mental health difficulties. Specific services for doctors only exist in the UK, Spain, The Netherlands and Switzerland.

Discussion and Conclusions: It was striking that for surgical and general medical problems, the majority of trainees would use public sector help, however, for psychiatric illness and substance use disorders, trainees tended to prefer the private sector or said they would not seek help or tell anyone at all. When asked for advice regarding the same problems in their fellow trainees, they said they would recommend public sector help, suggesting doctors may be reluctant to seek help in situations in which they would advise others to seek help. The EFPT believes specialised physician health services are needed to ensure doctors seek help when necessary, while avoiding feeling stigmatised or punished in doing so, particularly in mental health disorders.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P14

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The experience of psychiatry trainees who have participated in the Faculty of Medical Leadership’s National Medical Director’s Scheme in England - read full article

By: H. Ryland, L. Potter, M. Husain, and M. Casanova Dias

Introduction: Leadership is increasingly recognised as an important skill for junior psychiatrists to acquire in order to address the many challenges facing mental healthcare globally.

Objectives: This presentation will provide an insight from the perspective of psychiatry trainees who have participated in a high profile leadership-training scheme established by the UK Faculty of Medical Leadership and Management (FMLM). They will describe their experiences and tips to apply the learnt skills to improve global mental health.

Methods: In 2011 FMLM set up the National Medical Director’s Clinical Fellowship Scheme to provide experiential training for junior doctors from all specialties in a variety of national organisations. These have included NHS England, Health Education England, the National Institute for Health and Care Excellence, the General Medical Council, British Medical Journal and the Royal College of Psychiatrists. Fellowships last for a year and are full time. Each fellow works directly with one of the most senior leaders within the organisation on a range of activities including drafting policy, chairing meetings, developing strategy and liaising with external stakeholders.

Results: The scheme has proved to be hugely popular, with applications far exceeding places available each year. The scheme has expanded from 11 placements in the first year to 29 this year. Participants have reported a wide range of benefits, including exposure to high-level leaders, the opportunity to gain practical experience of national policy making and the benefits of being part of a multi-specialty cohort of their peers.

Discussion: There is an increasing emphasis on the need for psychiatrists across the world to develop leadership skills, but there has been much debate on how to most effectively deliver such training. The National Medical Director’s Clinical Fellowship Scheme provides an intensive and immersive model, which several junior psychiatrists have benefitted from in England. It has a particular focus on experiential learning and on the development of policy at a national or international level.

Conclusions: The FMLM National Medical Director’s Clinical Fellowship Scheme provides a highly successful model of leadership training, which may be of interest to other countries looking to develop similar opportunities.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P15

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Specialty programs in psychiatry in Poland - read full article

By: Irena Wojciechowska, Maja Krefft, Tomasz M. Gondek, and Michal Klapcinski

Introduction: Specialty training in psychiatry in Poland lasts for 5 years (60 months). During this time a trainee is obligated to attend certain internships and courses. In an attempt to prepare physicians to direct clinical work, recently the specialty training program has been updated.

Objectives: The main goals of the specialty training is to achieve theoretical and practical background to diagnose and cure patients according to the latest knowledge.

Methods: Specialty training ensures a robust and strong foundation to build specialist skills.

Results/Discussion: We have our doubts if the new curriculum is actually better. New specialty program consists of six courses and five internships. The most important and the longest among them is the internship on general ward for adults in a clinical ward and in a in-patient ward (40 months). Other internships include: neurology, child and adolescent psychiatry, neuroses treatment and addiction treatment. Compared with the new training program, the previous one consisted of seven obligatory courses and nine internships in: general psychiatry on hospital wards (22 months), the internship on daily ward, in mental health unit, internship in consultant psychiatry, neurology, child and adolescent psychiatry, neuroses treatment and addiction treatment. The last internship is devoted to deepen trainee's own interests in psychiatry. Specialist training in Poland does not contain psychotherapy course. Following successful completion of five years of training, a trainee will take the final exam. Once a trainee has passed the written and oral exam, he becomes a specialist in adult psychiatry.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P16

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Medfest 2015 – Global medicine & civilizations - read full article

By: Khurram Sadiq and Howard Ryland

Introduction: Medfest is an International medical film festival, in its fifth year of inception, this was pioneered by a Higher trainee based in London. Every year there is a specific theme selected for the festival and this year’s theme is Global Medicine & Civilization. Each year a Lead is selected through a strenuous interview process that then selects a team to the lead the events of the year. The committee then selects 6-9 movie clips, from documentaries, movies, news and other sources, relevant to the theme, once permissions are sought from the production houses, a DVD is created. Copies of the DVDs are then sent to the leads. The leads then select a 3-member panel, venue and start advertising the event.

Objectives: (1) To improve the outlook of psychiatry and (2) to help in recruitment of trainees to Psychiatry.

Methods: In 2015, A Medfest Committee was selected that included Local UK liaison, International liaison, European liaison and Medfest Arts & Music Leads. The UK Liaison links with the Psychiatric Society (Psychsocs) lead from the medical school to organize local events. This year, the theme was unanimously agreed by the leads and selected 9 clips in total for the DVD. The clips mainly consisted of documentaries from different regions of the world. Another initiative that is Medfest Music and Arts was finalized with a focus on patient participation for the event. There were two events finalized in Manchester & London and one final Gala event at the Royal College of Psychiatrists HQ London in June 2015.

Results and Conclusions: Medfest 2015 has been a big success with all the local UK events concluded and few International events to follow. We are anticipating an audience of 3000 combined for UK & International events. Most of the International events are in April & May 2015. India’s event has been a huge success with an attendance of around 200.



From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P17

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International experiences that shape professional identities in Hungary - read full article

By: Petra Ulbert, Luca Egervári, Hajnalka Nórándt-Pásztor, Nóra Horváth, Balázs Jeges, Anett Balázs, Attila Nagy, and Tibor Jáger

Introduction: Studying abroad during university or even short term foreign work experiences can have life altering effects by broadening one’s horizon on both personal and professional levels.

Objectives: Our aim was to assess the international experiences and their influences on the professional lives of the members of the Hungarian Association of Psychiatric Trainees (HAPT).

Methods: A survey was sent out to all HAPT members regarding previous international educational experiences and international scientific or clinical work experiences, and their influence on the participants’ professional identities.

Results: Erasmus experiences have been the most popular during university years, few of our members have tried the EFPT Exchange during the past year, some had the chance to attend international congresses and make a poster presentation or publish an article in an international scientific journal during their residency. All of the responders claimed that these experiences had a great effect on their choice of career, work style and their professional identities. However, the majority of the HAPT members have not yet had international experiences to affect their professional lives.

Discussion and Conclusions: Since HAPT was formed 1.5 years ago, we are still in the phase of recruitment, with a larger handful of members. Therefore, our sample was not representative, and our conclusions may not reflect the real conditions in Hungary. Consequently, further surveys will be necessary on this matter. However, we find it important that all responders highlighted the benefits and positive outcomes on their professional lives in relation with their international experiences. It seems that international educational, work or scientific experiences have a beneficial role in shaping professional identities. In the future, we would like to encourage and facilitate these experiences among HAPT members, thus contributing to the national psychiatric training system and our members’ professional identities.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P18

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Migration and brain drain: findings in Portugal - read full article

By: M. Pinto da Costa, Cátia Moreira, Mariana Andrade, Sara Carneiro, Sérgio Saraiva, and the EFPT research group

Introduction: The increasing migration of health professionals to affluent countries, a phenomenon known as “brain drain”, is not a recent phenomenon and has continued to fuel the huge inequities in global health. International professional mobility is inevitable when persons have skills they can put in the global marketplace.

Objectives: This work assessed junior doctors training in psychiatry in Portugal on their opinions and experiences of international migration, the migratory tendency of colleagues to migrate, the push and pull factors that pressure trainees to migrate in Portugal, the patterns of migration, as well as the features of an attractive job, and what should be improved in psychiatry in Portugal.

Methods: A cross-sectional survey was carried out in 33 countries. Hard-copy questionnaires or an online invitation link (surveymonkey) were circulated to junior doctors training in psychiatry in Portugal. The findings gathered through this pilot investigation were discussed based on a bibliographic search using PubMed/MedLine databse with the keywords “Migration” and “Brain Drain”.

Results: A total of 104 questionnaires were collected. From these findings, few respondents were immigrants, and impressively most of the trainees had a Portuguese citizenship. Almost two-thirds did not have a short-mobility experience, and the majority never migrated to another country. From those that did migrate, the majority has moved to neighbouring countries as Spain. Less than half consider staying in Portugal as a working perspective for the next years, and nearly four fifths have ever considered leaving the country. The majority of trainees earn between 1000-1499€, stating to be mostly dissatisfied with this income. Top reason to leave was financial, followed by work and academical. Working conditions ranked first as the priority condition to be improved in psychiatry in Portugal, followed by financial conditions. In fact, an attractive job for psychiatry trainees in Portugal must have as the most important feature a pleasant work environment.

Conclusions: An alarming percentage of psychiatry trainees in Portugal intend to migrate. Financial conditions, future perspectives of their career seem to have a lead role in the migratory tendency in Portugal, with trainees looking for better paid job opportunities and working conditions abroad.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P19

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Polish path to a National Psychiatric Trainees Association - read full article

By: Tomasz M. Gondek, Maja Krefft, Irena Wojciechowska, and Michal Klapcinski

Introduction: A few years ago there was an attempt to establish a national trainee association (NTA) in Poland. In the end, though, there was something lacking and the project was never brought to the close. When there appeared to be little hope to change this fact in the forseeable future, unexpectedly a group of new trainees from Poland attended the EFPT Forum for the first time in 2014. Armed with an uncanny motivation, they wanted to make their mark.

Objectives: Our objective is to establish the Polish Psychiatric Association in 2015, in order to soon become full members of the European Federation of Psychiatric Trainees (EFPT).

Methods: We joined various EFPT working groups, i.a. the ENTA Working Group and determined creating NTA in Poland one of our main goals. In December 2014 we participted in the International Congress of Psychiatry Medforum in Wisla, Poland, to promote EFPT and the idea of establishing the Polish NTA. We agreed to make it a section of the Polish Psychiatric Association (PTP) and received support from the organisation. Later on we promoted EFPT at local PTP meeting in Wroclaw as well as during specialization courses. In April 2015 we issued an official application to create a trainee section at PTP.

Results: Building network across Poland and getting support from decision makers: contact with over 200 trainees from various parts of Poland via e-mail, social networks groups or during psychiatry training courses. Support received from: Department of Psychiatry, Wroclaw Medical University; Lower-Silesian regional consultant in psychiatry; President of Wroclaw section of PTP; Secretary of the Polish Psychiatric Association and other influential members of PTP.

Discussion: We discuss future initiatives of our NTA that lie ahead: promoting EFPT during the conference in Katowice, representing EFPT at Congress in Wisla in 2015 (international societies session, young doctors session), creating a website of the Polish NTA which will include information relevant to trainees, building up further our network.

Conclusions: We discuss future initiatives of our NTA that lie ahead: promoting EFPT during the conference in Katowice, representing EFPT at Congress in Wisla in 2015 (international societies session, young doctors session), creating a website of the Polish NTA which will include information relevant to trainees, building up further our network.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P20

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European Federation of Psychiatry Trainees (EFPT) exchange programme – growing experience in Portugal - read full article

By: Vítor Pimenta, M. Pinto da Costa, Catarina Klut, Cátia Guerra, João C. Santos, Inês Fernandes, Fernando O. Leite, Cátia Moreira, Clara Feteanu, and Marina Fistonic

Introduction: The EFPT exchange programme was created in 2011 as the first exchange programme for Psychiatry Trainees in Europe. Its main goal has been to provide the possibility to undertake 2-6 weeks observational rotations in different countries.

Objectives: The authors intend to update, analyze and characterize the participation of Portugal in the EFPT exchange programme from its beginning up till now.

Methods: All the applications of trainees in Portugal who participated in the EFPT exchange were analyzed, as well as those of the other European colleagues that elected Portugal as their host country for the exchange and completed successfully the exchange in Portugal. The following variables were collected: sex, year of training, specific training programme and chosen city.

Results: Portugal has started the EFPT exchange programme since its inception, having progressively expanded the number of placements available in different cities across the country. Since the beginning, 19 applications for the exchange have been submitted in Portugal, having 18 trainees from Portugal proceeded effectively and participated in the EFPT exchange programme. The majority was female, with a median age of 28 years, and chose the United Kingdom as the preferred destination. Of the 17 applications received 11 foreign trainees came to Portugal to have their exchange. The majority was female, with a median age of 28 years, were at their 1st year of training, and most frequently came from Turkey. Moreover, Porto was the Portuguese city that received the higher number of candidates.

Discussion and Conclusions: The EFPT exchange programme provides to trainees the opportunity to contact with other mental health systems, getting contact with different intercultural aspects of psychiatry, both through clinical and research activities. The EFPT exchange programme in Portugal is having an important role in the improvement of training and psychiatric practice, supporting trainees and contributing to the expansion of the international network of professionals in this area. The increasing participation and increased programme options confirm the relevance and the prestige of this project within the Psychiatry training in Portugal, for which we want to acknowledge the associated Hospitals and Universities in Portugal that enable this.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P21

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Delusional disorder-jealous type: sleeping with the enemy - read full article

By: Adriana Carapucinha and Safira Hanemann

Introduction: Jealousy, the emotional state linked with the desire to preserve one's possession, is a common human response. It may present as the content of a psychopathological phenomenon such as delusions - delusional or morbid jealousy. These terms are sometimes used interchangeably with “Othello’s syndrome”, referring to a delusion characterized by the false absolute certainty of the infidelity of a partner. Delusional jealousy may be associated with several psychiatric and neurological disorders including Delusional Disorders (DD). DD are characterized by the presence of one or more nonbizarre delusions (jealousy, persecutory, somatic, erotomaniac or grandiose) and the relative absence of associated psychopathology. It is classically described that individuals suffering from delusional jealousy frequently harbor varying forms of hostility, posing medicolegal consequence.

Objectives: Concerning a clinical vignette of a patient with DD – jealous type, the purpose of this work is to make a critical review of literature on this disorder.

Methods: A search through electronic databases has been made for original research and review articles using the search terms 'Othello syndrome, morbid jealousy, pathological jealousy, delusional disorders, paranoia'. All literature in English or Spanish dated from twenty years ago onward was examined and 15 articles were selected.

Results: Among 398 patients with a jealousy disorder, only 4% met diagnostic criteria for DD-jealous type. Age at onset is usually middle or late adulthood and the jealous type corresponds to approximately 10% of DD. Depression is more frequent among the jealous and persecutory types. Speech comprehension, executive functioning, attention and verbal memory are functions which appear to be altered in DD. Erotomanic, jealous, and persecutory types might be associated with higher risk for violence.

Discussion: DD is not rare, but DSM criteria might not be inclusive enough to diagnose the jealous type of DD. Despite having some disabilities, “pure” DD seem to have preserved basic social cognitive abilities. Regarding therapeutics aspects, literature is confusing, but the last decade’s results suggest optimism about the potential for treatment effectiveness..

Conclusions: It is concluded that further exploration is required and greater epidemiologic, diagnostic and therapeutic attention needs to be given to Delusional Disorders

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P22

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Olfactory dysfunction in schizophrenia - read full article

By: M. Amélia Aleixo, Cátia Moreira, Gonçalo Sobreira, João Oliveira, and L. Carvalhão Gil

Introduction: The sense of smell and its relation to neurological and psychiatric diseases is a field of growing interest in clinical research. Like other neuropsychological measures, it provides the opportunity to assess brain function in a non-invasive way. Previous research has provided compelling support for olfactory dysfunction in schizophrenia patients, their first-degree relatives, and youth at-risk for psychosis.

Objectives: The authors’ aim is to describe and highlight the clinical and scientific relevance of olfactory dysfunction in schizophrenia patients, their first-degree relatives, and youth at-risk for psychosis.

Methods: A literature search was performed on PubMed database using the keywords olfactory, olfaction, dysfunction and schizophrenia and retrieved papers were selected according to their relevance.

Results: There are robust olfactory deficits in schizophrenia patients that include reduced odor identification, odor detection threshold sensitivity, odor discrimination, odor memory, and odor hedonic judgments. They have also been documented in ultra high-risk cohorts, nonpsychotic first-degree relatives of schizophrenia patients, and in individuals scoring high on psychometrically defined measures of schizotypal personality features. Structural and physiological abnormalities in the underlying neurocircuitry of the olfactory system have been documented, ranging from reduced volume in the olfactory bulbs, posterior nasal cavity, and olfactory eloquent brain regions to abnormal olfactory event related potentials and electro-olfactograms.

Discussion and Conclusions: These findings raise the possibility that these deficits represent a biobehavioral marker of vulnerability for the illness and olfactory measures may be a useful marker of schizophrenia risk status.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P23

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Late schizophrenia in a patient with previous opiate dependence? A clinical report - read full article

By: M. Amélia Aleixo, Cátia Moreira, Gonçalo Sobreira, João Oliveira, and L. Carvalhão Gil

Introduction: Schizophrenia is a severe psychiatric disorder that can cause long-standing impairments in several life domains. Substance abuse disorder (SUD) is very common in psychiatric patients and is associated with worse outcome. In fact, patients with schizophrenia and SUD, when compared to patients with a single diagnosis, have more severe (positive) symptoms, less treatment compliance, more re-hospitalizations, a higher degree of homelessness, and more legal, medical and social problems.

Objectives: The authors’ goal is to understand the complex role of substance abuse disorder in the patients with schizophrenia, more specifically opiate dependence. Additionally we present an illustrative clinical case.

Methods: A literature research was performed on PubMed database using the keywords schizophrenia, substance abuse, opiate dependence and retrieved papers were selected according to their relevance. The patient clinical record was reviewed.

Results: The authors report a case of a 51 year old woman with psychotic symptoms of persecutory and religious content for 4 years. She had tactile, somatic, auditory and command hallucinations. She has a history of cocaine and heroin abuse and she never felt symptoms while she was abusing of heroin or when she was in a methadone program.

Discussion and Conclusions: Despite the clinical presentation may lead us to the diagnosis of late schizophrenia, the opiate dependence may mask the symptoms. Because of that, in this clinical case the duration of the illness may have been longer than expected. It is important to access the history of substance abuse because it may lead to a different course of the disease, outcome and therapeutic approaches.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P24

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Schizophrenia and Fahr disease: a case report - read full article

By: Ana Barcelos and Magda Pereira

Introduction: Schizophrenia enfolds a variety of cognitive and emotional dysfunctions. Its diagnosis involves recognition of a constellation of signs and symptoms associated with functional impairment. Fahr disease, also knowns as idiopathic calcification of the basal ganglia, presents itself as a complex pathology that may arise in neurological and psychiatric context. In this line of concepts, we report a case of a patient presenting with Schizophrenia and Fahr disease.

Objectives: Our purpose is to analyze the process from diagnosis to treatment, of patients that present with psychotic symptoms.

Methods: Review of the literature, clinical interviews, as well as the consult of clinical records.

Results: This case highlights literature findings respecting the expression of symptoms, forcing us to admite that the distinction was not linear and the treatment presented to us as demanding.

Discussion and Conclusions: Both pathologies recognise perceptual distortions and delusions as symptoms. The challenges behind the neuro and psychopharmacological interventions emphasize the need of further research on this matter. This is required to improve the understanding of psychopathology, define incidence and prevalence rates, in order to improve the quality of patient's treatment.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P25

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Suicide among lesbian, gay, bisexual, and transgender individuals - read full article

By: Ana R. Figueiredo and Tânia Abreu

Introduction: Mental disorders constitute the most important risk factor for suicidal behaviour. Studies have found that LGBT (lesbian, gay, bisexual, and transgender) individuals are at increased risk for mental health problems, as a consequence of an hostile and stressful environment. There has been an historical pathologization of sexual orientation and gender identity; however, lately there have been significant changes in medical understanding about this theme.

Objectives: The authors aim to determine the possibility of increased suicidal ideation/suicidal behaviour among LGBT individuals.

Methods: Review of the literature using the terms LGBT, lesbian, gay, bisexual, transgender, sexual orientation, gender identity, suicide, suicidal ideation and suicidal behaviour.

Results: Studies provide evidence that individuals in a sexual or gender minority are at greater risk for suicidal thoughts and behaviours. There is evidence of elevated rates of reported suicide attempts in LGBT compared to heterosexual adolescents and adults, worldwide. Individuals reporting a bisexual orientation had an increased risk of suicide attempts and ideation compared with their homosexual and heterosexual peers.

Discussion and Conclusions: Mental disorders do not appear to entirely explain elevated rates of suicide attempts in these individuals. Social stigma, prejudice and discrimination associated with this individual are important factors. Health professionals should be aware to the higher risk of suicidal behaviour in lesbian, gay, bisexual and transgender people. Further research is needed in order to prevent suicide in these populations.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P26

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When wives are diagnosed with breast cancer – psychopathology in partners, a review - read full article

By: Ana R. Figueiredo, Susana Nunes, Mariana Silva, Pedro Macedo, and Antónia Fornelos

Introduction: Breast cancer is the most common malignant tumor in women. This diagnosis affects not only the patients, but also their partners. The development of physical and psychological symptoms of stress in breast cancer survivors is affected by the partners support and vice versa.

Objectives: Assessment of the eventual existence of psychopathology in the partners of patients with breast cancer.

Methods: Literature review using the terms breast cancer, partners, spouses, psychopathology, psychological/psychiatric symptoms, depression, anxiety.

Results: Partners of patients with breast cancer are the most involved family members in their support. In one article, these individuals reported feeling "in limbo". They may have difficulties in social, sexual and emotional adjustment and in marital relationship. While some studies show that a small proportion of partners present high levels of long term anxiety, others show that they are subjected to a higher stress level, psychiatric morbidity and increased risk of developing depression. They visit the physician more often for somatic and psychological symptoms, and are at greater risk of being hospitalized with affective disorder. The social support has influence in Depression, through various coping mechanisms.

Discussion and Conclusions: Facing a threatening event (diagnosis, consultation surveillance and results) can be seen as an interpersonal experience shared by the couple. Higher quality of relationship predicted better mental health in patients with breast cancer. Greater quality of their physical health predicted higher quality of mental and physical health in the partners. Further research is necessary, to identify and create assessment and assistance strategies to these partners with psychopathology.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P27

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“Psychogenic psychosis and the ongoing debate of the “third psychosis” - read full article

By: André Sousa, Corona Solana, Joana Gomes, Guida da Ponte, and António Paiva

Introduction: The existence of acute psychoses of short duration, often associated with an intense symptomatology, but also full remission, has always been described over the last two centuries. The concept of psychogenic psychosis was first published in 1916 by August Wimmer, and is widely used in scandinavian countries. According to Wimmer, psychogenic psychoses are etiologically defined as psychoses apparently caused by a mental trauma in predisposed individuals. The traumatic stress determines the content and the course of the psychotic reaction, which tend to remit in days to weeks.

Objectives: To make an historical review of the concept of psychogenic psychosis and discuss the debate over the classification and description of acute and transient psychosis.

Methods: A bibliographic review is made of the psychogenic psychosis, based on the data published in PubMed.

Results: The studies demonstrate a considerable prevalence of this clinical entity among all psychiatric admissions in scandinavian countries.

Discussion: After Emil Kraepelin’s division of the so-called endogenous or functional psychoses into a group of dementia praecox and manic-depressive insanity, some of the acute, brief, transient and good prognosis psychoses were classified as schizophrenia and some others as belonging to the affective category. However, the possibility of a "third psychosis”, apart from the Kraeppelin dychotomia system has always been debated since then. Such different concepts as the "bouffée delirante", "cycloid disorders", "atypical psychosis" and "reactive or psychogenic psychoses" have influenced this debate, lasting until our days. The concept of psychogenic psychosis through most of the 20th century has been widely used in the scandinavian countries for a major group of the so-called functional psychoses, separate from manic-depressive psychosis and schizophrenia. However, since Wimmer's works had not been translated from danish into any other language until recently, his contribution must surely be one of the least frequented in other countries.

Conclusions: The phenomenology and classification of acute and transient psychotic episodes with good prognosis has always been a matter of discussion in psychiatry. Thus, it is important to review and acknowledge this entity in order to strength the debate of the classification of the episodes mentioned above.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P28

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Delusion of pregnancy and pseudocyesis - read full article

By: Antónia Fornelos, Pedro Macedo, and Filipa Veríssimo

Introduction: Reports in delusion of pregnancy literature are rare and there are no specific epidemiological data on its prevalence. Although not being nosologically specific, these delusions can occur in several mental disorders. This mental illness has been reported in association with the use of antipsychotics, emotional conflicts, adverse life experiences and severe depressive symptoms. In what concerns to the differential diagnosis pseudocyesis should not be forgotten. This is understood as a form of hysterical neurosis, resembling in every aspect to a real pregnancy except, obviously, in the presence of the fetus.

Objectives: This research aims to clarify the notions of pseudocyesis and delusion of pregnancy and discuss their clinical implications and therapeutic approaches.

Methods: A literature review of scientific articles was conducted about this issue through the PubMed database.

Results: Despite the lack of specific epidemiological data, it is known that the delusion of pregnancy usually arises in developing countries. It can occur in schizoaffective and schizophrenic psychoses, epilepsy, depression and dementia. The reported cases in male appears as a percentage equal to or higher than females. The delusion of pregnancy has been reported in association with iatrogenic hyperprolactinemia. The emotional conflicts as the intense desire to become pregnant or fear that to happen, adverse life events and severe depressive/anxiety symptoms may be on it´s origin. Certain cultural beliefs, a sudden weight increase or social isolation can similarly take the patient to dysfunctional interpretations of body sensations. Delusion of pregnancy and pseudocyesis are related. The first one usually appears as a symptom of a psychotic disorder. However, this can precede the physical symptoms present in pseudocyesis. In the latter condition the woman believed to be pregnant, developing some of signs and symptoms of pregnancy such as abdominal enlargement, amenorrhea, feeling fetal movements, gastrointestinal discomfort and breast and/or genital changes.

Discussion/Conclusion: This study presents a brief survey of the literature on delusion of pregnancy and pseudocyesis. This aims to encourage a holistic and comprehensive approach to these disorders, taking into account the complex nature of pregnancy.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P29

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Kretschmer's syndrome of sensitive delusions - read full article

By: Catarina P. Ferreira, Maria J. Avelino, Susana Alves, José M. Jara, Ciro Oliveira, and José Salgado

Introduction: Kretschmer's syndrome of sensitive delusions is a self delusion that occurs in patients with sensitive Kretschmer character and develops after a triggering traumatic event in patient’s life, like a discussion or a humiliation. The delusion may be of several types, from persecutory, to guilt and/or ruin. Hallucinations may also be present. It is fundamental to establish an early diagnosis in order to improve the prognosis of this disease.

Methods: This work presents a systematic review about Kretschmer's syndrome of sensitive delusion and reports a real clinical case as an example, describing and explaining the so called sensitive personality that predisposes to that kind of delusion.

Results: Female, 50 years old patient, with obsessive and dependent traits of personality, history of sad mood and possibly depressive disorder since her father’s disease diagnosis in 2011. After a humiliating triggering event in patient’s life, psychotic symptoms developed, with auditory hallucinations as commentator voices and self-reference delusions. Besides that, the patient presents with major depressive symptoms, probably with suicide ideation (which the patient probably hides).

Discussion and Conclusions: Kretschmer sensitive delusions generally appear in subjects with a predisposing character named Kretschmer sensitive personality. These individuals are usually hypersensitive, demanding, with high moral principles and hardly deal with errors or frustrations. When a given triggering event happens they may have a psychotic development with escalation of their previous personality traits. A depressive disorder may precede or follow the delusion. Psychotic depression usually occurs in association with a pre-morbid sensitive Kretschmer character. In that case the patient develops the so called Kretschmer's syndrome of sensitive delusions. It is therefore fundamental to perform a complete clinical history, investigating the premorbid personality of the patient. An early and correct diagnosis allows an earlier institution of treatment and therefore a better outcome for the patient.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P30

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Circadian rhythm and affective disorders - read full article

By: Cátia A. Moreira, Gonçalo Sobreira, João M. Oliveira, M. Amélia Aleixo, and Ana Ramos

Introduction: The study of molecular clock mechanisms in psychiatric disorders is gaining significant interest due to data suggesting that a misalignment between the endogenous circadian system and the sleep-wake cycle might contribute to the clinical status of patients suffering from a variety of psychiatric disorders, including affective disorders.

Objectives: The aim of this study is to review scientific literature regarding the circadian rhythm and his effect on affective disorders.

Methods: A non-systematic review of English scientific literature was conducted, through research in the PubMed search engine, using the keywords "Circadian Rhythm" and "Affective Disorders".

Results: Mood disorders such as major depressive disorder and bipolar may be more prevalent in individuals that are born with an abnormally shifted or arrhythmic clock. Indeed, abnormal circadian rhythms in a variety of bodily functions (body temperature, plasma cortisol, norepinephrine, thyroid stimulating hormone, blood pressure, pulse, and melatonin) have been found in depressed and bipolar patients. Interestingly, these rhythms seem to return to normal with antidepressant or mood stabilizer treatment and patient recovery. Furthermore, genetic sleep disorders such as familial advanced phase sleep syndrome or delayed sleep phase syndrome are both highly co-morbid with depression and anxiety.

Discussion and Conclusions: The connection between mood disorders and circadian rhythms is becoming increasingly clear. Studies examining the biology behind this association and the clock’s influence on mood are now being conducted. These studies should provide valuable information in terms of our overall understanding of the development of mood disorders and the most appropriate ways to treat them.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P31

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First episode psychosis service – one year of experience - read full article

By: Cátia A. Moreira, Gustavo Jesus, Catarina Ferreira, Bernado C. Neves, Filipe Gomes, Marco Duarte, José Jara, Rita Mateiro, Maria J. Avelino, Ana Ramos, and José Salgado

Introduction: In the last few decades, substantial research has focused on the possibility of early detection and prevention of the first psychotic episode in young individuals at risk. Subtle motor, emotional, cognitive, and behavioral changes are often observed in young individuals who later develop schizophrenia, leading several authors to hypothesize that early detection and prevention strategies may provide an opportunity to reduce the incidence of an unfavorable outcome of the disease. The First Episode Psychosis Service of Centro Hospitalar Psiquiátrico de Lisboa (CHPL) was developed in 2014 and is an integrated and comprehensive inpatient service aimed at addressing the needs of people with emerging psychotic disorders.

Objectives: This study pretends to present the preliminary results from a descriptive analysis of patients admitted to the First Episode Psychosis Service of CHPL.

Methods: For obtaining clinical data, the authors reviewed a database containing all patients who had been admitted to first episode psychosis unit during the year of 2014. Statistical analysis was performed using SPSS®.

Results: A total of 91 patients were included in the study. Among these, 60.44% were male, 71,91% were single and 44,94% were unemployed. The average age of onset was higher in women. The mean of Duration of Untreated Psychosis (DUP/ weeks) was 26. The great majority of patients were treated with atypical antipsychotics and Olanzapine was the most used drug.

Discussion and Conclusions: The results of this study are in line with the literature. The type patient admitted to First Episode Psychoses Service is a single, unemployed and male patient without a psychiatric history and no drug use. This study represents the first step of a wider study being conducted in CHPL on the subject about first Psychosis episode in CHPL.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P32

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Suicide and Schizophrenia - read full article

By: Cátia A. Moreira, Inês Capeto, Margarida Bairrão, Leonor Queiroz, and Maria J. Carnot

Introduction: It is generally acknowledged that over 90% of those who commit suicide have a psychiatric diagnosis at the time of death. The presence of psychiatric illness is an important risk factor for suicide, and different risk profiles may emerge for different diagnoses. Among the various psychiatric illnesses, schizophrenia (19–46%) and mood disorders (28–62.4%) account for a high portion of suicide attempters/victims, and are known to be the most frequent risk factors for suicide. Patients with schizophrenia experience personal distress, socio-occupational dysfunction and reduced expectancy.

Objective: The aim of this study is to review scientific literature regarding suicide ideation among schizophrenic patients.

Methods: A non-systematic review of English scientific literature was conducted through research in the PubMed search engine, using the keywords “Suicide” and “schizophrenia”.

Results: The risk factors with a strong association with later suicide include: being young, male, and with a high level of education. Illness-related risk factors are important predictors, along with number of prior suicide attempts, depressive symptoms, active hallucinations and delusions, and the presence of insight all having a strong evidential basis. A family history of suicide and comorbid substance misuse is also positively associated with later suicide. The only consistent protective factor for suicide was delivery of and adherence to effective treatment.

Discussion and Conclusion: Prevention of suicide in schizophrenia relies on identifying those individuals at risk, and treating comorbid depression and substance misuse, as well as providing the best available treatment for psychotic symptoms.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P33

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She loves me, she loves me not: an atypical case of De Clèrambault syndrome - read full article

By: Célia Soares, Ricardo Ribeiro, and Natália Fernandes

Introduction: The De Clèrambault syndrome (DCS) or erotomania is a rare disorder characterized by a delusional conviction of being loved. Because of its rarity it is difficult to study and its classification as a nosological entity has been a matter of disagreement. According to the available knowledge the course of DCS is chronic and the prognosis is poor with severe impairments to the patients and families.

Objectives: The purpose of this work is to review the available literature about DCS published in the last decades and to present a case followed in our hospital.

Methods: A systematic review of DCS was carried out by searching the database Medline/PubMed comprising the articles published since the first description of this form of pathological love. An atypical case report is described and analyzed based on the reviewed literature.

Results: A 23-years-old man, with no previous history of psychiatric or medical history and no history of alcohol or substance abuse. He was admitted in our urgency for a psychiatric assessment because of a stalker behavior to a girl of the same social status that he believed to be loved by, despite the fact that she had done nothing to sustain that belief. No other psychiatric comorbidities were presented at admission or during the time of follow-up. The delusional system was intense and remained untouchable after 3 hospitalizations with psychotherapy and pharmacotherapy interventions. At the time of the last observation he was still symptomatic.

Discussion/Conclusions: This case shows an atypical presentation of the disorder and states the need for further studies in order to promote a better understanding of the disorder and to offer a satisfactory treatment for affected patients.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P34

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Bereavement and depression: a review concerning the DSM-5 - read full article

By: Filipa Novais and Luís C. Pestana

Introduction: One of the most significant decisions of the recent 5th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM 5) of the American Psychiatric Association was the elimination of bereavement exclusion criteria in Major Depressive Disorder. Some authors have seen this change as a positive development in psychiatry allowing early diagnosis and appropriate treatment of depressive syndromes that are associated with bereavement as significant life event. Others relate this change with another attempt to classify as pathological the normal human reactions.

Objectives: This work aims to review the validity of elimination of bereavement exclusion criterion in major depression in the new classification of the DSM-5.

Methods: In this study, we performed a search on the Anglo-Saxon literature. The EMBASE, MEDLINE and PubMed were consulted retrospectively by the year 1960, using the following key words: "bereavement", "depression", "DSM 5","ICD""criteria","mood disorders". A total of 20 articles were considered relevant to this review, including original research papers and review articles.

Results: Studies attempting to establish whether there are differences between depression associated with grief or not related to this event found some differences between patients. In depression associated with bereavement there was a higher probability of late onset, African-American ethnicity, less problems in social functioning, fewer symptoms of fatigue, feelings of worthlessness and suicidal ideation than in individuals with depression not related with bereavement. However, the similarities, in most studies, outweigh the differences and there are no randomized controlled studies that distinguish depression associated with bereavement from depression associated with any other significant event.

Discussion and Conclusions: Most studies seem to support the decision of the elimination of bereavement as exclusion criterion. However, major depressive disorder as defined by DSM 5 has yet to be definitively validated.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P35

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Can we predict de novo psychopathology after refractory temporal epilepsy surgery? The role of predisposing and related factors - read full article

By: Filipa Novais, Ricardo Prata, and Luís C. Pestana

Introduction: The gold-standard treatment in refractory epilepsy is the surgical ablation of the epileptic focus. However, while most patients can be “cured” with dramatically improvement in their quality of life, others show de novo psychopathology and changes in behaviour and personality.

Objectives: We aimed to study de novo psychopathology after epilepsy surgery as well as predisposing and related factors.

Methods: We performed a search on the Anglo-Saxon literature, the EMBASE, MEDLINE and PubMed were consulted using the following key words: "epilepsy”, "psychopathology”, personality", “behaviour", “outcome” and "surgery".

Results: After temporal epilepsy surgery, 9,6 to 31% of patients may refer the onset of new psychiatric problems. On the other hand 15% to 54% report the resolution of previous psychiatric diagnoses. The most common reported de novo diagnoses were depression, anxiety, organic mood and personality disorders there are also reports of the emergence of psychosis possibly related to “forced normalization”. Psychiatric diagnoses appear to be more common in patients with right temporal lobe seizure focus, preoperative postictal psychosis, younger age at surgery, temporal lobe epilepsy, poor family adjustment to life after surgery, preoperative psychiatric history and ongoing seizures postoperatively. However these finding are not consistent across different studies and conflicting results have been reported. Beside psychological factors such as the burden of normality and disturbed family dynamics, biologically, the disruption of mesial temporal structures via mesial temporal lobe resection may contribute to the emergence of these side effects considering its role on mood and psychosis. On the other hand personality scales show improvement in some aspects such as a decrease in interpersonal sensitivity, irritability, and social introversion suggesting greater social desirability and self-control abilities.

Discussion and Conclusions: There is still little research on other kinds of surgery as well as what concerns the study of predictors of psychiatric side effects. This study emphasises the importance of pre and post psychiatric evaluation of patients submitted to epilepsy surgery.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P36

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When Sound is not of Music: psychotic depression in a nun with Parkinson’s Disease - read full article

By: Filipe F. Almeida, Joana A. Ribeiro, and Carlos Ramalheira

Introduction: Psychotic symptoms occur in 4% of patients with Parkinson’s Disease (PD) and its management remains a challenge. In this work, we report a case of psychotic depression in PD.

Objectives: To discuss an integrated approach toward treating psychiatric and motor symptoms in PD.

Methods: After admission for inpatient treatment, we interviewed and performed regular neurological examinations on R., a 59 year old nun, diagnosed with PD 10 years ago and treated with several dopaminergic agents (ropinirole, carbidopa+levodopa and entacapone). R. started developing delusions of guilt and auditory hallucinations two months before presenting to our hospital. At our first interview, she described hearing accusatory voices and had become convinced she had committed sins that would cause her to be expelled from her congregation. Furthermore, some traits of an obsessive personality became apparent and fellow nuns reported severe hoarding behaviour.

Results: After suspending ropinirole and entacapone, reducing the dose of carbidopa+levodopa and introducing clozapine, quetiapine and clomipramine, we observed a marked improvement in the patient’s condition. The hallucinations and delusions gradually stopped, mood and social behaviour improved greatly. Tremor increased slightly, but to a degree the patient was comfortable with.

Discussion: A predisposition toward obsessive ruminations seems to have, on the one hand, caused a negative view of PD in our patient, leading to an aggressive treatment with high doses of dopaminergic agents and, on the other hand, paved the way to a severe depression. We believe an interplay of both these factors was the key to the appearance and specific presentation of these psychotic symptoms. Conclusions: Considering the frequency of psychiatric symptoms in PD, there must be great care in taking a global approach. A careful interview and neurological examination, together with a strong knowledge of psychoactive and antiparkinsonic medication, are crucial.


From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P37

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Anxiety and depression: towards a CBT competencies model in children and adolescents - read full article

By: I. Peixoto, R. Velasco Rodrigues, and C. Marques

Introduction: There is a myriad of evidence-based and empirically supported cognitive behavioral treatments for child and adolescent anxiety and depressive disorders. However, there is now substantial research indicating that such interventions might be less effective when applied to clinical populations or with more complex psychopathology. A model of cognitive behavioral therapy (CBT) specific competencies in this population is thus crucial for the integration of the best available research with clinical expertise.

Objectives: Summarize and review pros and cons of the current interventions and the mounting efforts in the development of a CBT competencies model, providing data for innovative clinical training and the integration and implementation of psychotherapy skills in daily practice.

Methods: Selective review of the evidence was conducted with a computerized search on PubMed (MEDLINE). Review of empirically supported manuals in the treatment of child and adolescent internalizing disorders.

Results: Although there is consistent positive data regarding the outcomes of CBT interventions in children and adolescents with anxiety and depressive disorders, there is still little evidence concerning their translation into clinical practice particularly in adapting treatment sessions flexibly for child development and family factors. New approaches taking such aspects into account are growing, namely modular interventions and a set of generic, CBT, and of specific CBT therapeutic competencies model.

Discussion: The development of manualized CBT interventions allowed significant advances in the field of child and adolescent anxiety and depression study and treatment. However their weak dissemination potential, the substantial overlap between protocols and the encouragement of a categorical thinking of psychopathology dampen their consensual acceptance in clinical practice. A modular approach to treatment preserves the benefits of standardization inherentin manualized protocols while allowing flexibility through the use of a guiding algorithm for the application of individualized treatment techniques and might prove beneficial. The current development of a set of therapeutic competencies will probably overcome challenges while providing a solid training curriculum.

Conclusions: These integrative approaches will continue to provide a conceptual framework for operationalizing clinical competencies needed by therapists treating children and adolescents with internalizing disorders.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P38

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Boufée délirante in the contemporary psychiatric nosology - read full article

By: João Perestrelo, Ana Coutinho, and Georgina Lapa

Introduction: The French nosological concept of bouffée délirante (literally “delusional flush or rush”) may define a subgroup of non-affective, acute remitting psychoses with an especially favorable prognosis. To date, relatively little published literature is available about this entity.

Objectives: To discuss the concept, nosological status, diagnostic features and associated clinical characteristics of bouffée délirante.

Methods: A literature review of the theme is surveyed. Several articles were search on MEDLINE with the key-words: bouffée délirante, acute psychosis and acute paranoid reaction.

Results and Conclusions: Bouffée délirante is a historic French diagnostic term used in the past to describe a short-lived psychosis. It was termed differently in ICD-10 (described as acute and transient psychotic disorders) and DSM 5 (brief psychotic disorder). The key diagnostic features are acute, floridly psychotic symptoms with complete remission.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P39

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Hyponatremia and Psychosis: a case report with review - read full article

By: João Perestrelo, Ana Coutinho, and Georgina Lapa

Introduction: Hyponatraemia is known to occur as a rare but clinically important adverse reaction to treatment with different psychotropic drugs, including selective serotonin reuptake inhibitors and antiepileptic drugs. In past decades, reports have been published that describe the development of hyponatraemia in association with antipsychotic drug treatment. Our objective was to review the available evidence on antipsychotic-induced hyponatraemia.

Methods: The authors present a case report of a 56 years old woman with the diagnosis of Schizoaffective Disorder taking antipsychotics (clozapine and haloperidol). At the admission she had a serum sodium of 120 mEq/L without any symptomatology. The sodium was corrected with hypertonic solution with an improvement in psychotic symptoms. A literature review of the theme is surveyed.

Results and Conclusions: The incidence of hyponatraemia induced by antipsychotics may be much higher than is currently thought. Both the newer atypical antipsychotics and the older drugs have been associated with the development of hyponatraemia. Physicians, psychiatrists and other healthcare workers should be aware of the possibility of hyponatraemia associated with the use of antipsychotics. Further studies are required to establish the risks of and risk factors associated with antipsychotic-induced hyponatraemia.



From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P40

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Late-onset schizophrenia: a review - read full article

By: João Perestrelo, Ana Coutinho, and Georgina Lapa

Introduction: Although schizophrenia is generally regarded as an illness with onset in late adolescence or early adult life, a sizeable minority of patients first become ill in middle or old age. Inconsistencies in diagnostic systems and nomenclature have led to such cases occupying an ambiguous position in relation to schizophrenia.

Objectives: The concept, nosological status, diagnostic and associated clinical features involved in late-onset schizophrenia are reviewed.

Methods: A literature review of the theme is surveyed. Several articles were search on MEDLINE with the key-words: late-onset schizophrenia, very late-onset schizophrenia AND late-onset psychosis.

Results and Conclusions: In terms of epidemiology, symptom profile, and identified pathophysiology, the diagnosis of late-onset schizophrenia (illness onset after 40 years of age) has face validity and clinical utility. General adoption of this category will foster systematic investigation of such patients.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P41

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Relevance of allostatic load concept – the new notion describing course and outcome of schizophrenia - read full article

By: Maja Krefft, Dorota Frydecka, and Blazej Misiak

Introduction: Allostasis is the process that allows the achievement and maintenance of stability through physiological changes. The main mediators of allostasis are hypothalamic-pituitary-adrenal axis hormones, catecholamines, neurotrophins, cytokines and oxidative stress mediators. Allostatic load (AL) refers to variety of mechanisms that are activated in response to stress exposure. Permanent overactivation by chronic stress may lead to maladaptive disease outcomes and this process is called allostatic overload. Several physical health impairments such as obesity, hypertension, type 2 diabetes or cardiovascular diseases might be caused by overload of mechanisms that are responsible for maintaining homeostasis and by overproduction of stress mediators.

Objectives: The aim was to provide an evidence that schizophrenia can be perceived in terms of the AL concept with summarizing the current state of understanding on this topic, introducing the AL paradigm as a novel model to explain the course and outcome of this severe mental illness.

Methods: Authors, relying on previously published literature, provided a constructive analysis of the publications in a field of schizophrenia research and the AL paradigm, through description, specification, comparison and summary.

Results: The AL concept provides possible explanation for the causes, course and outcome of several mental disorders including affective disorders, post-traumatic stress disorder, substance use disorders and Alzheimer’s disease. Our group has provided evidence that schizophrenia might be another psychiatric disorder perceived in terms of the AL concept.

Discussion: Schizophrenia is a chronic mental disorder with multiple psychopathological domains including positive, negative and affective symptoms, as well as cognitive impairment. Importantly, schizophrenia has been linked to poor physical health status that contributes to excessive mortality. Above mentioned mediators of allostasis are increasingly recognized as core factors in the pathophysiology of schizophrenia.

Conclusions: Overwhelming evidence indicates that chronic exposure to stress represents an important etiological and prognostic factor in schizophrenia. This sheds a new light on the biological and clinical sequelae that occur throughout the course of schizophrenia. Therefore, this severe mental illness can be described in frame of the AL concept providing the consensus between neurodevelopmental and neuroprogressive models of schizophrenia conceptualization.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P42

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“Raro” – Conrad’s trema stage in a Spanish patient - read full article

By: Marco Duarte, Corona Solana, Filipe Gonçalves, Inês Capeto, and Rita Mateiro

Objectives: Increase the awareness about cycloid psychosis.

Methods: Case report of a patient with a cycloid psychosis that exhibits Conrad’s prodromal symptoms in a second psychotic episode. Review of literature about the subject.

Results: We present a case of 31 year old woman, Spanish resident admitted to the acute inpatient unit, after observation in the emergency service with a psychosis NOS diagnose (10th International Classification of Diseases (ICD 10) – F 29). Two weeks before, she started to feel “raro” (strange, different) and could not explain why. In the week before, she watched a talk show about a rare disease with a Portuguese doctor; she found similar cutaneous spots in her arm and the doctor nose, so she started thinking that everything made sense. She also thought that people in street started to call her “cerda” (hooker). Then she drove from Catalonia to a village near Lisbon. The next day she was taken to the emergency with an unspecific thoracic pain. Previously she had been admitted to psychiatric hospital in Spain around 2010 for another psychotic episode. After discharge, she gradually stopped the medication and consultations, returned to work, apparently with the same premorbid functioning. Treatment with a second generation antipsychotic was effective. In 6 days the delusions and hallucinations were no longer objectified. Two weeks, she was discharged and returned to Spain.

Discussion and Conclusions: The first publication of a psychopathological disorder characterized by sudden onset, polymorphous psychotic symptoms and recurrent course was made by Magnan in the 1880. Since then several studies addressed the nosological classification of this disorder, either as an independent diagnose, atypical variant of affective disorders or atypical form of schizophrenia, but no consensus was found. In the ICD 10 is found in the group F 23 - Acute and Transient Psychotic Disorders. In this patient, despite a previous psychotic episode, we can observe the different stages describe by Conrad in 1958 in the formation and maintenance of a primary delusion. The authors found no consensual guidelines regarding the treatment or the prevention of new psychotic episodes. Randomized studies are need to help to clarify this diagnose and treatment.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P43

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Pregnancy in bipolar disorder - read full article

By: Corona Solana, André Sousa, and Marco Duarte

Introduction: Bipolar disorder is a chronic psychiatric illnesses characterized by alternating episodes of mania/hypomania and major depression, or with mixed features. They represent a spectrum of illnesses characterized by frequent relapses, symptom recurrences, and persisting residual symptomatology. Both acute exacerbations and maintenance treatment with appropriate pharmacotherapy (e.g. mood stabilizers and antipsychotic) are mandatory. Long-term treatment with mood-stabilizing medications is typically required. Bipolar disorder has an estimated lifetime prevalence of 3%–7%. The incidence of bipolar disorders in women during the primary reproductive years is very high, raising the possibility of considerable bipolar illness burden during pregnancy and the postpartum period. Episodes of mania or depression are thought to occur in an estimated 25%–30% of women with bipolar disorder during pregnancy.

Objectives: Provide a clinically focused review of the available information on the effectiveness and safety of the different pharmacotherapies in the treatment of bipolar disorder during pregnancy.

Methods: A bibliographic review is made of the pregnancy in bipolar disorder, based on the data published in PubMed.

Results: The treatment of bipolar disorders during pregnancy presents numerous clinical challenges. Clinical decision making about the use of mood stabilizers and atypical antipsychotics by pregnant women can be conceptualized as balancing the competing risks imposed by withholding or stopping pharmacotherapeutic treatment (thus increasing the risk of maternal and fetal/neonatal harm from untreated illness or acute relapses) against that of continuing or initiating pharmacotherapy during pregnancy (thus introducing the possibility of fetal/neonatal harm associated with in utero medication exposure). Some of the most effective pharmacotherapies (such as valproate) have been associated with the occurrence of congenital malformations or other adverse neonatal effects in offspring. There is few information about the safety profile and clinical effectiveness of atypical antipsychotic drugs when used to treat bipolar disorder during pregnancy.

Discussion and Conclusions: Treating women with bipolar disorders during pregnancy is a challenge. There are no uniformly effective or risk-free treatment options. Fully informed decision making requires the review of the risks of both untreated maternal bipolar disorder and risks associated with each potential intervention, and the discussion of all reasonable treatment options.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P44

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Natural causes of death in persons with schizophrenia: review of European literature - read full article

By: Tomasz M. Gondek, Anna Królicka, Patryk Piotrowski, and Andrzej Kiejna

Introduction: Schizophrenia is a chronic mental disorder which, apart from being associated with a significantly higher suicide risk when compared with the general population, is characterised by an increased risk of developing a comorbid somatic disease. Elevated mortality rate from natural causes of death in persons with schizophrenia is currently one of the most important challenges for mental health policy in Europe.

Objectives: We reviewed the current literature on this subject to establish what are the most prevalent causes of death in persons with schizophrenia in Europe and what are the mortality ratios for the respective natural causes of death.

Methods: We searched PubMed database for articles in English, using MeSH (heading: schizophrenia with subheading: mortality; combined with heading: Europe). Publication years were limited to 2009-2014. The articles were then analyzed in order to find relevant data regarding the natural causes of death in patients with schizophrenia.

Results: Fifty articles met the search criteria. Eleven of them concerned somatic comorbidity and mortality from natural causes in schizophrenia. According to the current data, the majority of schizophrenia patients die due to natural causes, with cardiovascular diseases being prevalent among them. The patients are characterized by increased standardized mortality ratios for natural causes of death compared to general population, which contributes to the existence of mortality gap and reduced life expectancy.

Discussion: Compared to the data from the past decades, there were significant changes to the most frequent causes of death in persons with schizophrenia. Recent reviews of literature on this matter confirm our results: the leading causes of mortality in schizophrenia are currently natural causes, similar to those in general population.

Conclusions: Despite the elevated risk of suicide and other unnatural causes of death during the course of schizophrenia, the majority of persons with this diagnosis die due to natural causes, most frequently cardiovascular diseases. Despite the recent advances in treatment of psychotic disorders, there is still a siginificant mortality gap between the patients and general population, which is mainly a consequence of the excess mortality from natural causes. This issue warrants further attention from the researchers and health policy-makers.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P45

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Are people with schizophrenia more violent than the general population? – A look towards the stigma on mental illness - read full article

By: Zita Gameiro, Filipa Freitas, and H. Esteves

Introduction: Mental illness and mentally ill patients are surrounded by stigma and discrimination. Stigmatizing views about mental illness include the belief that psychotic patients, particularly those with schizophrenia, are violent persons. However, violent behaviour is quite uncommon among patients with schizophrenia. On the other hand, being object of society stigma and discrimination may increase the unemployment and the feeling of not being part of anything and decrease the social network, self-esteem and the financial income of patients. These findings have been related with violence in the general population.

Objectives: The author’s goal is to review the literature concerning the prevalence rates of violent behavior among schizophrenic patients in comparison with the same prevalence rates in general population. The authors also aim to understand whether there are grounds for the generic attribution of violence to these patients. Additionally we try to find which factors increase the risk of violence in schizophrenia patients.

Methods: A literature search was performed using the following key words schizophrenia, violent behaviour, violence prevalence and stigma and retrieved papers were selected according to their relevance.

Results: Patients diagnosed with schizophrenia are four to six times more likely to commit a violent crime than the general population. However, a significant amount of the excess risk appears to be mediated by substance abuse comorbidity. In fact, the risk of violence in schizophrenia patients with substance abuse is similar to that of substance abusers without psychosis. Due to the fact that schizophrenia is a disease with a prevalence of only 1%, even an increased risk of violent behaviour still remains a low absolute risk. In Western countries the homicide acts committed by schizophrenia patients are around 6%. Younger age, male sex, being single, lower socioeconomic status, refusing treatment, substance abuse and duration of illness were associated with the risk of violence in these patients.

Discussion and Conclusions: The vast majority of schizophrenia patients are not violent people so they don’t deserve the stigma of being considered potential murderers. However, the community and the mental health professionals in particular should reflect on the risk factors of violence and how to prevent them.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P46

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Attention deficit hyperactivity disorder (ADHD) and comorbid eating disorder - read full article

By: Cátia A. Moreira, Gonçalo Sobreira, João M. Oliveira, M. Amélia Aleixo, Gustavo Jesus, and Catarina Cotta

Introduction: The attention deficit hyperactivity disorder (ADHD) onsets during childhood and is characterized by symptoms of impulsivity, hyperactivity and lack of attention. According to studies of prevalence, up to 70% of the patients with ADHD have at least one psychiatric comorbidity, which leads to diagnostic and therapeutic difficulties as well as more severe functional impairment. Nonetheless, several studies have found positive associations between abnormal eating patterns and ADHD.

Objectives: The aim of this study is to review scientific literature regarding the attention deficit hyperactivity disorder and eating disorders comorbidityThe aim of this study is to review scientific literature regarding the attention deficit hyperactivity disorder and eating disorders comorbidity.

Methods: A non-systematic review of English scientific literature was conducted, through research in the PubMed search engine, using the keywords "ADHD" and "eating disorder".

Results: The three key features of ADHD – lack of attention, hyperactivity, and impulsivity – are often present in individuals with eating disorders. Core features of bulimia nervosa (BN) include binge eating and purging behaviours that can be described as impulsive. In fact, impulsiveness has been shown to be increased in subjects with eating disorders, particularly in those with binge eating behaviour, when compared to healthy controls. Subjects with anorexia nervosa (AN) or BN also showed significant attention impairment in neuropsychological testing when compared to healthy controls. Last but not least, excessive exercise, which is typical in AN patients, may be considered a restless or hyperactive behaviour.

Discussion and Conclusions: Binging or purging eating disorders subtypes have a high correlation with ADHD, which is also related with more severe eating patterns, general and personality psychopathology. The role of ADHD features for the development, maintenance and treatment of eating disorders seems to be intricate and requires further study.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P47

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“The Spirit Vine” - read full article

By: F. Leite, P. Carvalho, H. Salgado, C. Cochat, M. Queirós, and O. Campos

Introduction: Ayahuasca is a natural psychedelic brew prepared from Amazonian plants and rich in dimethyltryptamine and harmine. Throughout time, humans have used psychoactive plants and plant-derived products for spiritual, therapeutic and recreational purposes.

Objectives: To review the evidence regarding the use of ayahuasca for medical purposes.

Methods: Online search/review of the literature has been carried out, using Medline/Pubmed, concerning “ayahuasca”.

Results: Ayahuasca has been used as a pharmacological tool by therapists to treat mental conditions such as substance addiction.

Conclusions: There is little understanding of the neuroscience behind ayahuasca, however recent evidence suggests that its use can be beneficial under some circunstances.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P48

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How are you now? Follow-up study of the children who have attended an Early Childhood Unit consultation in 2008, 2009 and 2010 - read full article

By: P. Caldeira da Silva, S. Carmenates, T. Cartaxo, R. Cifuentes, M. L. Costa, T. Duque, J. Mesquita Reis; I. Moreira; J. Morgado; N. Pangaio, B. Pinto Ferreira; M. Pinto; L. Queiroga; C. Santos; and R. Teixeira

Introduction and Objective: “Unidade da Primeira Infância” (UPI) is a specialized unit in infant and early childhood mental health. Founded in March, 1983, it emerged as a place focused on the clinical study of babies’ behaviour, infant psychopathology and interaction between parents and babies. Nowadays, UPI provides intervention (preventive and therapeutic) for young children aged from zero to three and their parents or caregivers. The systematic research in this early age is still very limited and there is little information about the future impact of psychopathology diagnosed at this age. Thus, the aim of this study is to know, through five years follow-up, what is the evolution of the children whose first observation took place in this unit in 2008, 2009 and 2010.

Methods: The sample used in this study consists of children aged from zero to three years old whose first observation took place in UPI in 2008, 2009 and 2010. The data used to characterize our sample were obtained by consulting the clinical record. The following parameters were considered: Age at the time of the first psychiatric observation; gender; diagnosis according to DC 0-3R (Axis I and II); therapeutic intervention and duration of the intervention. An interview with the main caregivers was made, by telephone, which involved applying an appropriate follow-up questionnaire, which included completing the SDQ scale - version for parents.

Results: The results were submitted to a statistical analysis using SPSS. The rate of responders was approximately 64% from a total N of 301. Everyone that we were able to reach (n=192) agreed to participate in the study. From those, 91,6% are statisfied with the quality of the service provided and 85% refer to clinical improvement of the child. According to DC 0-3R, Relating and Communicating Disorders was the most common diagnosis on Axis I (19,3%), and Underinvolved relationship was the most frequent one in Axis II (18,8%). 31,8% had abnormal results on SDQ, and there was a significant association between Regulation Disorders of Sensory Processing and abnormal results on SDQ hyperactivity and behavior problems subscales. Learning disabilities are more common among those with more severe cases of Relating and Communicating Disorders.

Conclusion: Early and adequate intervention seems to have an important and positive impact in prognosis of the children referred to an early childhood psychiatry consultation. The children diagnosed with Regulation Disorders of Sensory Processing before the age of three seem to have more behaviour and hiperactivity relsted problems during school years, suggesting an associations between these disorders. Further investigation in early childhood psycopathology and its impact in the future of the child and family must be done.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P49

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Child and adolescent psychiatry in Poland – to improve is to change - read full article

By: Krefft Maja, Gondek Tomasz, Klapcinski Michal, and Wojciechowska Irena

Introduction: Last decades were very significant for the recognition of the wide range of mental disorders in children and adolescents as well as the availability and quality of undertaken interventions . Serious attention is given to the development of appropriate human resources for mental health care. These changes affect the guidelines contained in the specialty training in child and adolescent psychiatry (CAP). Integration of biological, psychological and social approach determine the core of the training curriculum.

Objectives: The aim was to assess the quality of the child and adolescent mental health care in Poland with a particular reference to the specialty training curriculum in Poland.

Methods: The authors analysed the legislation regarding the mental health care in Poland as well as the training programme for CAP and compared it with CAP training programmes in other European countries.

Results: In Poland certain steps were taken to ensure the best use of the available knowledge and train an increased number of CAP specialists in past few years. These include facilitated availability of the specialization, amenities provided to the CAP trainees related to the salaries and changes in training program adjusting it to the current research trends and requirements in the world. A new approach was proposed according to the current trends in the community care with the extension of the internship in the day-care ward and in the community treatment team. Also a holistic approach to young patient resulted in prolonged internships in pediatric neurology and general pediatric wards. Emphasis has been laid on the stronger separation of child and adolescent psychiatry from adult psychiatry resulting in shortening the internships in psychiatric wards for adults.

Discussion: Despite all the measures applied to improve the situation of Polish Child and Adolescent Psychiatry we are still struggling a fail to provide easier and faster access to health services specially in the provinces and smaller towns. Poland is a country with an average scale of the prevalence of mental disorders comparing to both Europe and the whole world with a slight upward trend.

Conclusion: Changes for the better are still made, but we will have to wait a few more years for their rewarding effects. Further work on improving the access to mental health care and on refining the training in CAP in Poland is necessary. To improve is to change; to be perfect is to change often.*
*Winston Churchill

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P50

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Psychopathology in pediatrics settings – case of Albania - read full article

By: Sonila Tomori, Agim Gjikopulli, Alma Babo, Aferdita Tako, Aida Bushati, Florida Dobi, and Eriona Shehu

Introduction: Mental disorders in children are quite common, occurring in about one-quarter of this age group in any given year. Mental illness are blamed for 10% of kids' hospitalizations. Mental health professionals consider the need for psychological help necessary and useful not only when diagnose is established or a co-morbidity is present, but in every phase of a diagnostic process in pediatric population at risk. Relatively little is known about children who present to emergency departments to stabilize acute emergencies related to behavioral disorders. In chronically ill children who are hospitalized for instance with cancer or renal or cardiac failure prolonged hospitalization and chemotherapy can lead to many mood changes and they result at higher risk for mood disorders in comparison with the ones of acute disorders.

Objectives: The aim of the study is to evaluate the effectiveness of mental health screening to identify psychiatric co morbidities in different units of general pediatric hospital (population at risk).

Methods: Analyzing data of 416 inpatient general pediatric hospital where SDQ, a brief screening questionnaire that investigates the presence of emotional and behavioral problems in children and adolescents, has been completed over a three years period, referred and hospitalized for neurological, endocrinological or gastroenterological diagnoses.

Results: High level of psychopathology in the entire study population, indicating high needs for therapeutic intervention. The more frequent psychiatric diagnoses result: ADHD 2,9%, Anxiety Disorders 13,2%, Somatisation Disorder 12%, Obsessive-compulsive disorder 5,7% and Conduct Disorder 2,9%.

Conclusions: The SDQ could be used by clinicians in a pediatric general hospital to detect psychopathology. These findings draw attention to the important role of screening for mental health problems in emergency situations especially in front of self-harm, depression and violent behaviors.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P51

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The impact of cannabis use on the outcome of psychosis - read full article

By: André Ponte, Henrique P. Ribeiro, L. Carvalhão Gil, Filipa Freitas, Bernardo Neves, Margarida Mota, Mariana Lázaro, and Catarina Ferreira

Introduction: The relationship between cannabis use and psychosis is complex and remains unclear. Although the common assumption is that cannabis use leads to worse outcomes in people with psychosis, it is uncertain whether research findings support this clinical opinion.

Objectives: To review the literature pertaining to whether cannabis use affects the outcome of psychotic disorders.

Methods: The authors have conducted an online search on PubMed, using keywords “cannabis use”, “outcome” and “psychosis”.

Results: Use of cannabis was associated with increased rehospitalisation and decreased adherence to treatment. Associations between cannabis and psychotic symptoms or other outcome measures were more inconsistent.

Discussion and Conclusions: There is still insufficient empirical evidence to satisfactorily establish whether cannabis use has detrimental effects on the outcome of psychotic disorders. More research is needed to understand which outcomes are particularly susceptible and to determine the pathways by which cannabis use influences the course of psychotic disorder.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P52

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A historical perspective of alcoholism – from sin and crime to disease - read full article

By: Beatriz Lourenço, Mónica Marinho, João C. Fernandes, and Teresa Mota

Introduction: Alcoholism concept, research and treatment underwent major changes in the previous century.

Objectives: The aim of this work is to review the historical evolution of this condition, its understanding and different concepts that are associated with it.

Methods: Review of selected literature on the subject.

Results: During the 19th century, the temperance and degeneration movements influenced the understanding of alcohol addiction, providing a theoretical platform for the implementation of alcohol prohibition the United States of America and also the compulsory sterilization of severe alcoholics during the Nazi Era. The conceptualization of alcoholics as patients with the right to medical treatment came out of the work of several researches such as E. Jellinek and self-organized groups as the Alcoholics Anonymous. It provided medical care and social support for these patients, but also raised the question about the influence of social constructs in the medicalization of deviants behaviors. Since the late 20th century, there has been a progressive understanding of the neurobiology of alcohol ingestion, dependence and withdrawal, as well as multiple attempts to describe subgroups of patients.

Discussion and Conclusions: The way that alcoholism is conceptualized through time reflects the influence of social and political movements and also the knowledge of the aetiopathology and the treatment options available at that time. Although there is still an open debate about ethic and stigma, the current valued research tries to integrate both neurobiological and psychosocial models, in order to provide tailored therapeutic projects to each individual.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P53

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Multiple substance use among alcohol dependents - read full article

By: Filipa Novais, Samuel Pombo, and Fátima Ismail

Introduction and Objectives: Relatively few studies have investigated the role of personality in the different patterns of multiple substance use among alcohol dependents. The authors assessed the association of several clinical, socio-demographic and personality predictors of nicotine and multiple substance use (MSU) in 178 patients receiving treatment for alcohol dependence.

Methods: The sample was divided into three groups: 60 only alcohol dependents, 78 tobacco and alcohol dependents and 40 alcohol dependants with multiple substance use..

Results: Regression and comparative analysis showed that age, educational background, occupational status, years of alcoholism and the personality trait of openness to experience were predictors of MSU in alcohol dependent outpatients. The results also showed significant differences on the NEO-PPI dimension openness to experience.

Conclusions: There are increasingly alcoholic polymorphic subtypes derived from the interactive complexity between genetic/family and psychosocial factors of civilization. Findings have implications for understanding differences between different profiles of alcohol dependents and for novel treatment opportunities in therapeutic settings.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P54

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Realities of pharmacogenetic testing in psychiatry - read full article

By: Gonçalo Sobreira, Cátia Moreira, João Oliveira, and Ana Ramos

Introduction: Pharmacogenomics has become increasingly significant in clinical practice, in several fields of Medicine. Psychiatric patients, in particular, may benefit from pharmacogenetic testing as many of the psychotropic medications prescribed may lead to varied response rates and a wide range of side effects. Thus, the use of pharmacogenetics may help tailor psychotropic treatment improving the likelihood of success. Several studies, have recently, tried to demonstrate the benefits of using genetic testing in order to improve patient outcomes and decrease healthcare costs.

Objectives: This brief review, aims to analyse the evidence supporting the present clinical utility and benefits of genetic testing in psychiatric patients.

Methods: A PubMed database review, using “pharmacogenomics”, “pharmacogenetics”, “psychiatry” as keywords.

Results: Response to psychotropic medication is a complex trait; the identification of key phenotypic measures for its definition is still a major issue in psychiatry. This is further increased by disparities of pharmacodynamics and pharmacokinetics across different ethnic groups, caused by genetic variations. In a study conducted, 57% of the papers examined, showed significant association between genetic variations and improved patient outcome. Clinical response and remission were significantly associated with variants within SLC6A4 and cytochrome P450 2D6 (CYP2D6), as well as serotonin receptor 2A (5HTR2A) and cytochrome P450 1A2 (CYP1A2). Adverse events were most associated with variations in CYP2D6, serotonin receptor subtype 2C, SLC6A4, and 5HTR2. These examples advocate the usefulness of genetic testing in psychiatry. However most of said test are not required to show their analytical validity and clinical utility, before being approved for marketing, something that the forthcoming FDA guidelines on laboratory-developed tests will likely encourage. Even though some studies have proven that tailored medicine has improved adherence and reduced cost of outpatients, the overall benefit have not been well established.

Discussion and Conclusions: Pharmacogenetic is a newly evolving field and is rapidly gaining wide acceptance. However to further substantiate the utility of genetic testing in psychiatry large randomized controlled and independent assessment of any genetic test would be ideal.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P55

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Antipsychotic induced sexual dysfunction - causes and management - read full article

By: Gonçalo Sobreira, Cátia Moreira, João Oliveira, M. Amelia Aleixo, and Ana Ramos

Introduction: Sexual dysfunction (SD) is a potential side effect of antipsychotic drugs. Until a few years ago, these side effects were neglected and received mild attention by research teams. This was mainly due to the fact that most studies were directed towards the effects of the underling disease on patient’s sexuality and that most patients, especially those suffering from schizophrenia, do not spontaneously report these side effects.

Objectives: This brief review, aims to analyse the current information concerning SD caused by antipsychotic treatment and the present management options.

Methods: A PubMed database review, using “antipsychotic”, “psychotropic drugs”, “sexual dysfunctions”, “sexual side effects” as keywords.

Results: The mechanism of action leading to sexual dysfunction is complex and sometimes multifactorial. Several studies agree that all antipsychotic can compromise, up to certain extent, all phases of the sexual response cycle. Different hypotheses have been formulated to explain these side effects (dopaminergic antagonist action, increased prolactin secondary to dopaminergic antagonist action, blockage of alpha-adrenergic receptor, blockage of acetylcholine receptors, serotonin antagonist action, histamine antagonist action and the different receptor affinities among antipsychotics). In addition to direct pharmacological effects and endocrine dysfunction (e.g. increased prolactin levels), other pharmacological side effects including sedation, extrapyramidal effects and weight gain, can indirectly reduce sexual desire and lead consequently to SD. In order to obviate the deleterious effect of antipsychotics on sexual function, several treatment options have been proposed like decreasing or switching to prolactin sparing antipsychotics (ariprazole, clozapine, olanzapine), the use of dopamine agonists or drugs with specific effects on sexual function such as phosphodiesterase inhibitors.

Discussion and Conclusions: It has been proven that SD can be a major cause for treatment noncompliance, and most studies agree that antipsychotic therapy may be responsible for SD. However, further research is needed to better understand the causes and factors linking antipsychotic use and sexual dysfunction. It is also important, to state the necessity, to enquire for SD symptoms and also to exclude other physical or psychiatric causes of SD in patients undertaking antipsychotic treatment.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P56

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Naturalistic study of a Long-Acting injectable antipsychotic drugs clinic - read full article

By: Gustavo Jesus, Cátia A. Moreira, João M. Oliveira, M. Amélia Aleixo, L. Carvalhão Gil, Marco Duarte, Corona Solana, and Rui Durval

Introduction: High rates of non adherence to antipsychotics are commonly seen in the treatment of schizophrenia and other psychotic disorders. Long acting injectable antipsychotics (LAIs) are a pharmacological option increasingly used for its potential to effectively treat symptoms. Simultaneously, they guarantee good therapeutic compliance therefore preventing relapses and improving prognosis. Several recent studies advocate early use of LAIs challenging the old perspective they should be reserved for non-compliant patients.

Objectives: The authors of the current study intend to evaluate the patterns of prescription of LAIs in patients attending an LAI clinic at Centro Hospitalar Psiquiátrico de Lisboa, Lisbon, Portugal.

Methods: For obtaining clinical data, the authors reviewed a database containing all patients who had an LAI regularly administered between the years of 2009 and 2014. Statistical analysis was performed using SPSS®. Review of relevant literature obtained from online medical databases under the keywords “long acting antipsychotic” and “injectable antipsychotic”.

Results: A total of 1052 patients were included in the study. Among these, 64.3% (676) were male. All available LAIs (haloperidol, zuclopentixol, flupenthixol, fluphenazine, risperidone, and paliperidone) were used, more often in monotherapy, although there were patients where combination therapy was used. A great majority of patients were on typical LAIs. Two patients were found taking Olanzapine Palmoate although it is not available on the Portuguese market.

Discussion and Conclusion: This study uses a large sample which allows us to discuss several issues: patients under LAI were found to include not only patients with a diagnosis of schizophrenic disorder but also bipolar, schizoaffective, and delusional disorders, intellectual disability and Not Otherwise Specified Psychosis, which raises the question of off-label use of LAIs; frequency of relapse and the results of different drugs will be discussed with an emphasis on comparison between typical and atypical antipsychotics. This study represents the first step of a wider study being conducted about LAI use in mental disorders.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P57

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“Mathematically very complex problem” and corticosteroids - read full article

By: Joana Ferreira, Carla Araújo, Rita Gonçalves, Sara Pedroso, Sónia Silva, Manuel J. Brito, and Carla Pinho

Introduction: Over the years, exogenous corticosteroids have been used in the treatment of various medical illnesses and a number of adverse reactions have been established. About 6% of patients develop psychiatric disorders due to steroid therapy, although many more suffer from mild symptoms which do not fulfill a diagnosis. Evidence suggests that elevations in hypothalamic–pituitary–adrenal (HPA) axis activity have been implicated in the origins and exacerbation of mental disorders, as well as stress sensitivity and trauma, that can be related to chronic and disabling illnesses.

Objectives: To describe a case of substance-induced psychotic disorder in a patient diagnosed as having Hodgkin’s lymphoma, resulting from corticosteroids administration.

Methods: We describe a 16-year-old girl admitted to our liaison unit while she was as inpatient on paediatric oncology unit.

Results: After her second corticosteroid cycle she started being delusional with passivity experiences, showing psychomotor retardation and mannerisms, blunted affect, diminished spontaneous speech with higher latency, severe impairment of attention and concentration, time and space disorientation and flight of ideas. She was insightless and with poor judgment.

Discussion and Conclusions: Once starting Lorazepam 1mg + 1mg + 2mg; Olanzapine 5mg + 10mg; Haloperidol 5mg; Biperiden 4mg, she improved her condition, showing only psychomotor retardation. She improved whenever she was not in the interval period of the corticosteroids cycles, but her psychotic symptoms reappeared when approaching the end of the cycles. Currently she holds antipsychotic medication, with good response, and her main concern is returning to school, which is still postponed due to their organic condition. In management of physical illnesses with psychiatric features, we suggest that psychotic reaction should be taken into account as a possibility in all children and adolescents who develop behavioral changes during and after corticosteroid treatment. This study suggests that the biopsychosocial approach to health care and consultation-liaison psychiatry should be emphasized.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P58

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Baclofen-induced manic episode – a case report - read full article

By: Joana V. Silva, Joana Pinheiro, and Jorge Mota

Introduction: Baclofen is a gamma-aminobutyric acid type B receptor agonist usually prescribed for muscle spasticity, in a dosage that goes from 15 mg to 120 mg per day. The risk of psychiatric side effects associated with this medication is described as “frequent”, and psychiatric population are at an increased risk of relapse.

Objectives: Summarize the latest literature about manic episodes associated with baclofen prescription, with a case report.

Methods: Case report of a 43-year-old male who exhibited manic symptoms during treatment with baclofen for post stroke muscle spasticity. Literature review, using Pubmed and the keywords baclofen, mania.

Results: Mr. M. was admitted to Hospital de Magalhães Lemos, 1 week after discharge from an internal medicine ward where he was admitted for a stroke. During that week he was medicated with carvedilol 25 mg/day and losartan 20 mg/day for hypertension, oxazepam 80 mg/day, baclofen 30 mg/day, and haloperidol 4 mg/day. He had a previous history of drug and alcohol abuse. When admitted, he presented disinhibition, restlessness and pressured speech, with flight of ideas and delusions, decreased need for sleep, but no elated mood. The situation worsened in the first four days with haloperidol, so baclofen was suspended after a diagnosis review. The patient recovered adequate behavior and speech, with no delusions, and was discharged on the 10th day. 3 months later he is still stable, without antipsychotics, and on physiotherapy for the muscle spasticity.

Discussion and Conclusions: Despite its safety, baclofen has to be carefully considered in the psychiatric population, because of its side effects, even in a low dosage like 30 mg /day. Physichians need to be aware of this, but more studies are needed in order to clarify the underlying mechanisms of action of these side effects and how to prevent them.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P59

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Lithium neurotoxicity – a review - read full article

By: João M. Oliveira, M. Amélia Aleixo, Gonçalo Sobreira, and Cátia Moreira

Introduction: Lithium is commonly used in Psychiatry, either to treat Bipolar Disorder or as an add on treatment in Unipolar Depression; it has also been used as an off-label treatment in several other fields of Medicine. Side effects are usually gastrointestinal, weight gain and tremor; neurotoxicity is an uncommon but serious adverse reaction of lithium therapy.

Objectives: Brief review of literature concerning neurotoxicity of lithium with an emphasis on clinical syndrome and management.

Methods: A PubMed database review, using “lithium neurotoxicity” as a keyword.

Results: Lithium toxicity can be acute, chronic or acute-on-chronic. In acute toxicity neurological signs are delayed whereas in chronic toxicity they predominate. Lithium encephalopathy refers to a global neurological dysfunction attributed to lithium and which usually reverses upon cessation and treatment. Onset tends to be gradual and progress to coma and occasionally death. Symptoms do not correlate with lithium concentrations, and toxicity can occur with levels within the standard therapeutic window. In patients medicated with lithium attention must be paid to factors that may interfere with serum lithium levels, such as dehydration, drugs, or pre-exiting conditions. Aggressive treatment with fluid resuscitation and hemodialysis, sometimes requiring multiple sessions due to rebound, is the rule and should be undertaken based on clinical features and not serum lithium levels. Rarely, symptoms will persist beyond 2 months of lithium cessation, a condition known as syndrome of irreversible lithium-effectuated neurotoxicity.

Discussion and Conclusions: In any patient taking lithium who develops a clinical picture of neurotoxicity this possibility should be considered, regardless of serum lithium levels and prompt treatment should be initiated.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P60

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Alcohol misuse among older women – an under-recognized problem - read full article

By: Mariana Marinho, João Marques, and Miguel Bragança

Introduction: Population is aging quickly and there is an increasing number of older women misusing alcohol, which is of concern because the adverse health effects in this group are greater. Clinical research is beginning to explain the results of unrecognized alcohol abuse or dependence on elderly.

Objectives: To provide an overview of alcohol misuse among older women.

Methods: Literature review based on articles published on PubMed/MEDLINE, between January 2005 and January 2015, using the keywords “alcohol use”, “alcoholism”, “women”, “elderly”.

Results: The prevalence of alcohol misuse among older women ranges between less than 1% and 8%. Looking at the growing ageing population, effective prevention and intervention techniques and approaches targeted to older at–risk drinkers are essential. Elderly people suffer from many medical and psychiatric conditions influenced by alcohol consumption. However, alcohol problems in older women are less likely to recognize by health care providers, probably because this group generally drink less than older men or abstain from alcohol. Importantly, this population may be especially at risk for alcohol problems. They have social, psychological and physical risk factors that make them particularly susceptible. Comparing with men in same age group, elderly women are less likely to be financially independent and tend to live alone longer and to face other losses that can exacerbate depression and the use of alcohol. Furthermore, physiologically, women are at greater risk for negative effects of increased alcohol consumption as they age. Alcohol misuse is associated with adverse medical outcomes, including osteoporosis, cardiovascular disease and cancer. Also, it can lead to negative psychosocial effects (social isolation, legal problems, financial distress, and/or family or relationship problems). Crucially, physical and/or psychiatric comorbidity heightens the alcohol effects. Screening, brief intervention, and referral to treatment is the recommended approach for identifying persons engaged in at-risk alcohol use.

Discussion and Conclusions: Early detection by health care providers can reduce the prevalence of alcohol problems and improve overall health in older women. So, an increased effort on effective identification and subsequent treatment is warranted.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P61

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Khat and cathinones: from cultural use to drug of abuse - read full article

By: Pedro Macedo, Ana R. Figueiredo, Antónia Fornelos, Mariana Silva, and Filipa Veríssimo

Introduction: Among several communities around Saudi Arabia and East African countries, khat has played a major social role. The identification of cathinone as the main psychoactive compound led to the synthesis of several derivatives.

Objectives: The present work provides a review on khat and synthetic cathinones, concerning their historical background, prevalence, patterns of use, and their physiological and toxicological effects on humans.

Methods: The bibliographic research was concluded using the queries “cathinone” in the PubMed network.

Results/Discussion: In the mid-2000’s, synthetic cathinones emerged in the recreational drug markets as legal alternatives ("legal highs") to amphetamine, "ecstasy", or cocaine. Currently, they are sold as ‘bath salts’ or "plant food". Cathinone derivatives are available online or at "smartshops" and are much more affordable than the traditional illicit drugs. Available as powders, substituted cathinones are self-administered by snorting, oral injestion, or intravenous injection. They act as central nervous system stimulants through the release of catecholamines and by blocking their reuptake in the central and peripheral nervous system. Nevertheless, considerable differences have been found in the potencies of the different substituted cathinones in vitro. Desired effects reported by users include increased energy, empathy, and improved libido. Cardiovascular (tachycardia, hypertension) and psychiatric/neurological signs/symptoms (agitation, seizures, paranoia, and hallucinations) are the most common adverse effects reported. Severe toxicity signs compatible with excessive serotonin activity, such as hyperthermia, metabolic acidosis, and prolonged rhabdomyolysis, have also been observed. In case of overdose, no specific antidote exists and no curative treatment has been approved by health authorities. Therefore, management of acute toxic effects is mainly extrapolated from experience with cocaine/amphetamines.

Conclusion: Despite their now illegal status in many countries, substituted cathinones continue to be prevalent drugs of abuse. Routine toxicology screens may not detect the presence of these compounds and more specific methods are needed. Additionally, several new derivatives emerge in the recreational legal markets every year.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P62

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Suicide and forensic toxicology results: retrospective study of the cases from the south branch of national Institute of Legal Medicine and Forensic Sciences (2007 – 2012) - read full article

By: Susana Gonçalves, Joana Lucas, Tiago Costa, Luísa Eiras, and Jorge C. Santos

Introduction: Toxicological analyses are an important complementary exam for medico-legal autopsies, particularly in cases of suicide associated to substance use and dependency. Suicide sub-notification has been recognized worldwide as a serious public health issue, namely in fatal intoxication cases without enough circumstantial information for the differential diagnosis between accident and suicide.

Objectives: To characterize the forensic toxicology results in victims of suicide and violent deaths of undetermined intent, subjected to medico-legal autopsy in the South Branch of National Institute of Legal Medicine and Forensic Sciences, between 2007 and 2012.

Methods: A total of 996 medico-legal autopsy cases were identified, in which circumstantial information of suspected or probable suicide was registered at the corpse admission. We excluded 125 cases in which no toxicological exams were performed, ending up with a total sample of 871 cases.

Results: In 774 (90%) of these, the basic cause of death was certified as suicide, and in the remaining as undetermined intent. The direct cause of death resulted from intoxication in 108 (14%) of the suicide cases, and in 69 (71%) of the undetermined intent cases. Pharmaceutical drugs were surveyed in the forensic toxicology laboratory in 96% of the overall cases, and were found to be the cause of the majority of the intoxications: 60 (56%) of the suicide cases and 44 (64%) of the undetermined intent cases. In both groups, the most common pharmacological classes were benzodiazepines, antidepressants and antipsychotics.

Discussion: Our data shows a high prevalence of consumption of psychiatric medication, with obligatory medical prescription, among victims of suicide and intoxications of undetermined intent. Access to suicide methods is known to have a decisive influence on the direct causes of death of the victims, so it is relevant to discuss the patients’ access to toxic amounts of prescription drugs.

Conclusion: The analysis of this data might be an important contribution to a better definition of suicide prevention strategies, with a focus on medical drug prescription in psychiatric patients.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P63

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ADHD and drug abuse - read full article

By: Catarina Freitas, Tânia Abreu, Rita Figueiredo, and Sandra Queirós

Introduction: Several studies have shown a high prevalence of comorbidity between attention deficit hyperactivity disorder and drug abuse in adolescence and in adulthood. It is argued if ADHD is, in itself, a risk factor for drug abuse or if both are interconnected by conduct disorder, very common in individuals with ADHD.

Objectives and Methods: The authors proposed to conduct a literature review on the subject, trying to establish mechanisms, prevalence, onset and consumption patterns and associated factors.

Results: The prevalence of ADHD patients who abuse alcohol or illicit drug is estimated to be between 9 to 40%. Patients with ADHD appear to abuse earlier of alcohol and illicit drugs, with much more pronounced frequency and rate dependence. Approximately one third of patients with ADHD and substance use disorder abuse of the prescribed psychostimulant medication. However, there are disparate results regarding the influence of the pharmacological treatment of ADHD in risk of development drug addiction.

Discussion and Conclusions: Some theories relate the development of some symptoms with factors affecting cognitive processes that can also be associated with drug abuse. ADHD and substance abuse and dependence have similarities in terms of neurotransmission systems and anatomical structures, for example, the mesolimbic dopamine system.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P64

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Neuropsychiatric symptoms in frontotemporal dementia - read full article

By: Ana D. Amaral, Catarina Novais, Ana S. Costa, and Isabel Costa

Introduction: Frontotemporal dementia (FTD) comprises a heterogeneous group of clinical and pathological syndromes, with presenile onset and variable combinations of behavioural, executive, language or motor symptoms. FTD includes three main subtypes: behavioural variant, progressive non-fluent aphasia and semantic dementia.

Objectives: We aim to review and summarize the neuropsychiatric symptoms in behavioural variant.

Methods: Literature review up to 13th March 2015, using MeSH term frontotemporal dementias.

Results: Behavioural variant is the most common phenotype accounting for 50% of cases. Common symptoms can be either positive (disinhibition, hyperorality, stereotypies, compulsive and ritualistic behaviours) and negative (apathy, loss of empathy, social withdrawal and low self-care). These translate in to major personality changes from which we highlight social behaviour – patients lack tact and manners, use unacceptable physical contact, improper verbal or physical acts and are socially awkward. Compulsive and ritualistic behaviours may mimic obsessive-compulsive disorder. Disinhibition and mood elation can mimic a maniform state. Depression, as in other dementias, is common. However, its diagnosis is complicated by the negative symptoms overlap. Suicide attempts are not rare and are more likely in FTD patients as compared with controls. Prefrontal cortex malfunction and related impulsiveness may explain the increased risk of suicide. Curiously, risk is higher in patients with previous history of depression. Regarding the increased impulsiveness, there are at least five reported cases presenting as pathological gambling. One-third of the patients also exhibit excessive somatic complaints as headache and gastrointestinal, urogenital or musculoskeletal pain. The association between depression and somatic complaints is not well established in FTD. Sleep disturbances have also been reported with increased nocturnal activity and decreased morning activity, suggesting phase delay. Psychotic symptoms may occur in one third of FTD patients some time during the course of dementia: paranoid delusions and visual hallucinations are the most common, but auditory hallucinations may also occur. There seems to be a strong correlation between psychotic symptoms and predominantly right-sided degeneration.

Discussion and Conclusions: Neuropsychiatric symptoms in FTD may lead to misdiagnosis, most commonly with other neurodegenerative dementias, psychotic disorders or depression. We believe that if physicians are aware of their existence, diagnosis delay can be avoided.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P65

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Neuropsychiatric symptoms in Huntington’s disease - read full article

By: Ana S. Costa, Ana D. Amaral, Mota Oliveira, and Ricardo Moreira

Introduction: Huntington's disease (HD) is an autosomal dominant inherited disorder of the central nervous system with characteristic neurodegenerative alterations in the basal ganglia and cortex. HD is characterized by a triad of symptoms including motor disturbance, cognitive impairment and psychiatric features.

Objectives: Authors aim to review and summarize the neuropsychiatric symptoms associated with HD.

Methods: Literature review based on articles published on PubMed/MEDLINE using the keywords “Huntington’s Disease”, “neuropsychiatry” and “psychiatric aspects”.

Results: Psychiatric symptoms in HD may be associated with three different situations – they may be directly caused by the disease, may appear as a comorbid disorder or as a consequence of the pre-diagnosis of this disease. Approximately 40% of patients with HD present a mood disorder during the course of the disease – 30% major depression and 10% bipolar disorder, generally type II. In two thirds of cases, mood disorders may precede the movement disorders of HD in 2 to 20 years. Suicide rates among patients with HD are 4 to 6 times superior to the general population, and occur more frequently in patients between 50 and 69 years of age. Psychotic symptoms may appear in up to 30% of patients. A schizophrenia-like disorder, with paranoid delusions and auditory hallucinations, occurs in 4 to 12% of patients. Psychotic symptoms usually appear early in the disease course and become less common as cognitive decline progresses. Irritability and aggressive behaviour are also common, with the latter being a common cause for hospitalization. Other possible neuropsychiatric manifestations are apathy, obsessive-compulsive disorder, sexual disorders and sleep disorders. Authors provide a brief illustrative case report.

Discussion and Conclusions: Neuropsychiatric symptoms are prevalent in Huntington's disease and are relatively independent of cognitive and motor aspects of the disease. Psychiatric symptoms and behavioural changes together with a growing level of physical dependence make hospitalization frequent, requiring a multidisciplinary approach and specialized care.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P66

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Defensive pessimism: a hypothetical explanatory model - read full article

By: Ana Araújo, Maria J. Soares, Daniela Silva, Ana T. Pereira, and António Macedo

Introduction: Defensive Pessimism (DP) is a cognitive coping strategy that increases the feeling of control in anxious and perfectionist subjects, decreasing their anxiety previously to a task. It involves the setting of low expectations – Pessimism (Pess-DP) – and reflection about the possible negative/positive task outcomes – Reflectivity (Ref-DP). Perfectionism is associated with anxiety, and both traits are associated with poor mental health and vulnerability to psychopathology. DP effectively lowers anxiety leading to more successful performances, however it is associated with negative affect. Anxious subjects who use DP show significant increases in self-esteem over time, suggesting that, when used over time, DP constitutes a self-improvement strategy.

Objectives: To study a) if DP, anxiety and perfectionism are predictors of psychological health; b) if DP is a mediator between anxiety/perfectionism and psychological health; c) to present an hypothetical explanatory model of DP.

Methods: The Portuguese versions of the Revised Defensive Pessimism Questionnaire, State Trait Anxiety Inventory, two Multidimensional Perfectionism Scales (Hewitt & Flett, Frost et. al) and one item to measure perceived psychological health were administered to 192 university students (78.1% girls), aged 19,7±2,10 years. Correlation, regression and mediation analyses were performed.

Results: Anxiety (Beta=-.191), negative perfectionism (Beta=-.214), DP (Beta=-.171) and Pess-DP (Beta=-.245) (all p<.05) were independent negative predictors of psychological health. Ref-DP (Beta=.189/.201; p<.05) was a predictor of good psychological health only when both Pess-DP and anxiety/negative perfectionism were also included in regression model. Pess-DP was a full mediator between anxiety (95%CI=-.024;-.002) /negative perfectionism (-.006;-.001) and poor psychological health.

Discussion and Conclusions: Ref-PD/Pess-PD are associated with good/bad psychological health. Ref-PD may be the nuclear component and key for self-improvement (through self-awareness and emotional regulation), although Pess-PD remains a necessary condition, as it may be self-protective (“protective expectations”) despite its adverse outcomes.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P67

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Genetics of individual differences in chronotype and circadian rhythms - read full article

By: Ana Poças and Aníbal Fonte

Introduction: Chronotype refers to the behavioural manifestation of underlying circadian rhythms of various physical processes. We can describe it as a propensity to sleep at a particular time during a 24 hour period. 'Eveningness' (delayed sleep period) and 'morningness' (advanced sleep period) are the two extremes but most individuals have some flexibility in the timing of their sleep period. Interindividual differences in morningness–eveningness are believed to manifest into extreme cases classified as primary circadian rhythm sleep disorders, with altered phase relationships of the biological clock to the light–dark cycle, including alterations in sleep timing.

Objectives and Methods: By the review of the literature we tried to understand the knowledge about genetics of individual differences in chronotype and circadian rhythms and how it can be useful in our psychiatric patient’s future life. Sources of data: Pubmed; keywords: chronotype; circadian rhythms; clock genes.

Results: The causes and regulation of chronotypes aren’t clear but there are some candidate genes - clock genes - that exist in most cells of the body, referred to as the circadian system that regulate physiological phenomena. There are also important environmental cues (zeitgebers) include light, feeding, social behaviour and daily schedules that can influence it. Morningness–eveningness is estimated to be about 50% heritable. The genetic basis in the general population has been investigated by targetingseveral core circadian genes but the results are inconsistent. The 3111C allele of the clock gene 5'-UTR region has been associated with eveningness and delayed sleep timing in some studies, but not others. Also, the variable numbertandem repeat (VNTR) polymorphism in PERIOD3 (PER3), another core clock gene, has been linked to diurnal preference, but not consistently. Both the 111G polymorphism in the 5'-untranslated region of PERIOD2 (PER2) and the T2434C polymorphism of PERIOD1 have been associated with morning preference, though not consistently too.

Discussion and Conclusions: This area of research has promising implications to detect differential vulnerability to circadian disorders and lifestyles that adversely affect alertness, performance and sleep duration.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P68

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The endless dissatisfaction: association between body dysmorphic disorder and compulsive cosmetic surgery - read full article

By: Catarina Novais, Maria J. Peixoto, Ana D. Amaral, and Alexandra Côrte-Real

Introduction: Body dysmorphic disorder (BDD) is an under-recognized psychiatric condition which appears to be common in cosmetic settings. Its core symptom is an impairing worry about a nonexistent or slight defect in appearance.

Objectives: The aim of this study was to review the association between BDD and demand for cosmetic procedures among these patients.

Methods: Relevant literature from 2000 to March 2015 was identified by searching the PubMed, using the search terms body dysmorphic disorder, cosmetic surgery and compulsive cosmetic surgery.

Results and Discussion: BDD is a relatively common disorder with a prevalence of 0.7% to 2.4 % in community samples. Its course tends to be chronic and is one of the most common psychiatric conditions found in patients seeking cosmetic surgery, with a reported prevalence of 6% to 15% in these settings. Patients seek out psychiatric treatment after an average estimated delay of 10 to 15 years following onset of the disorder. Concerns about appearance may focus on any body area and are typically intrusive, unwanted, and usually difficult to resist or control. These worries trigger feelings of depression, anxiety or shame, which, in turn, trigger repetitive compulsive behaviors. Psychiatrists are often not aware of this diagnosis as patients turn to other specialists like cosmetic surgeons, even though patient should benefit from psychiatric approach alone. A surgical intervention, even if perfectly performed, may be unable to fix the psychological discomfort stemming from the supposed physical defect. Thus, the outcome of the procedure is very often disappointing, with the patient requesting further interventions for the same or other parts of the body. Most of the available data suggest that cosmetic treatment is almost never effective for BDD, can worsen symptoms, and can trigger legal action or even violent behavior.

Conclusions: BDD is usually chronic and associated with substantial morbidity and mortality if no appropriate treatment is provided. A significant number of patients seeking cosmetic treatment suffer from BDD, which may contraindicate it. Cosmetic surgeons should be aware of the clinical characteristics of BDD to identify and refer these patients to Psychiatry for a better treatment outcome.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P69

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Melatonin and Anxiety: from animal models to clinical practice - read full article

By: Filipa Novais and Sofia Paulino

Introduction: There has been a considerable amount of scientific literature focusing the role of circadian disturbances and sleep changes in depression, bipolar disorders and even in schizophrenia but few have explored the relationship between disruption of melatonin circadian release and anxiety symptoms. This association is frequent, for example, in shift work disorder with important implications on social and professional capacity and quality of life. Disruption in circadian rhythms has been related with low nighttime and 24h levels of melatonin, a neurohormone known to be involved in the regulation of anxiety. The underlying mechanism correlating disruption of circadian rhythms and melatonin levels to the emergence of anxiety is not well understood.

Objectives: This study aims to review the state of the art on the subject concerning pathophysiological mechanism, clinical findings and relevance as well as treatment options for anxiety.

Methods:A nonsystematic review of all English language PubMed articles published between 1991 and 2014 using the terms “anxiety”, “circadian”, “melatonin”, “treatment” and “sleep”.

Results: Chronic circadian disruption has been associated with higher levels of anxiety. Studies with animal models have been used to study the effects of internal and external melatonin on anxiety showing a correlation between melatonin levels and anxiety. In healthy subjects, anxiety levels were significantly and negatively correlated with melatonin production in summer and winter. This neurohormone is also known to have an anti-inflammatory activity in central nervous system, which is a general underlying mechanism in neuropsychiatric disorders. It has also been hypothesized that melatonin could be evolved in the immune-opioids network that mediate the return to baseline states after stressful events. The disruption in this system could be more specific in anxiety pathophysiology. Recently some melatonin receptor agonists like UCM765 and agomelatine have shown anti anxiety effects on animal models. Effects on clinical samples are yet to be determined.

Discussion and Conclusion: Chronic circadian disruption through could make neural systems less able to cope with stress and lead to the development of anxiety disorders. The interaction between opioid system and melatonin mechanism could provide a possible explanation for the pathophysiological mechanism underlying this symptomatology.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P70

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Personality and behaviour after Deep Brain Stimulation: do we know what happens next? - read full article

By: Filipa Novais, Ricardo Prata, and Luís C. Pestana

Introduction: Deep Brain Stimulation (DBS) is widely performed in advanced Parkinson Disease and other neurological diseases. However changes in behaviour and personality have been reported. Their implications on the quality of life for patients and their families are yet to be clarified.

Objectives: The aim of this work was to search for the most significant alterations in personality and behaviour in patients submitted to DBS.

Methods: We performed a search on the Anglo-Saxon literature, the EMBASE, MEDLINE and PubMed were consulted using the following key words: "deep brain stimulation", "personality", behaviour" and "ethical".

Results: The most common cognitive and psychiatric problems that have been reported concern a decline in word fluency and verbal memory, depression, increased suicide tendencies, anxiety, emotional hyperreactivity, hypomania, increased impulsivity, lack of premeditation and lower persistence. These changes in mood, behaviour and cognition may lead to changes in “personal identity” and eventually affect others.

Discussion and Conclusion: There are medical and ethical issues concerning such a dramatic change in some patient’s identity. The increasing use of DBS will lead to discussions concerning their responsibility for their actions and ability to make decisions. More research is need in order to clarify theses changes and to establish predictors and related factors.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P71

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Hysteria: the road to extinction? - read full article

By: Henrique Prata-Ribeiro and Ana Filipa Freitas

Introduction: Hysteria is undoubtedly one of the first mental disorders attributable to human beings. It has been accurately described since the second millennium BC. Nowadays, the psychiatric terminology distinguishes two types of disorders that were previously labelled “hysteria”: dissociative and conversion disorders.

Objectives: The aim of this study is to examine the population of the General and Transcultural Psychiatry Clinic of CHPL and characterize this disorder.

Methods: The retrospective study consisted in analyzing records from 3862 patients hospitalized in the Clinic since 2007 until 2015, using descriptive statistical analysis techniques.

Results: From the analyzed population sample (n = 3862) we found that only 18 hospitalized patients were diagnosed as “Hysteria”. Most of them were female (proportion female:male = 15:3), aged between 19 and 63 years. The majority (15) were natural from Portugal, 1 from Angola, 1 from Brazil and 1 from Cape Verde. Most of them had active work, recording only 5 retired and 1 unemployed. None of them had previous drugs consumption and just 1 have had alcohol consumption. 11 of them have been followed previously in Psychiatry (consultations and hospitalizations). The hospital admissions were mostly voluntary (17) and the main reasons were: Behavior alterations (6), hetero-aggressiveness (4), psychomotor agitation (2), suicidal ideation (4), aphonia (1) and mutism (1). At the admission, only 4 patients had the probable diagnosis of “hysteria”. We also found that the majority of the patients had an admission diagnosis of Mood Disorder.

Discussion and Conclusions: From the analyzed data we were able to characterize the population that would be classifiable as hysteric, finding that the diagnosis would still represent a minority of patients (0,39%), being 80% of these females. Cultural issues were not considered as the vast majority of the studied population was natural from Portugal.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P72

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Walking through the Portuguese Forensic System - read full article

By: Joana Melim, Rafael Araújo, Sofia Fonseca, and Susana Almeida

Introduction: Forensic psychiatry is becoming progressively, as time passes by, an essential area in psychiatry, having evolved from a lawless sector to an extremely over regulated process while maintaining some grey areas in need of attention.

Methods: Review of the Portuguese law published in Diário da Repúbica, applied to the mental health sector.

Results: The European law is by no means homogeneous and different forensic systems co-exists. This report intends to summarize the Portuguese legislation on mental health that have some specificities compared to other European systems.

Discussion and Conclusions: Having the awareness on different legislation across Europe, allows us not only to improve by learning from positive expediencies and outcomes, but also by realizing some disabilities and try to optimize them trough a structured and shared learning process.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P73

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Attachment, suicide attempts and borderline personality disorder: a review by a case report - read full article

By: Joana Ramos and Paula Valente

Introduction: Borderline personality disorder (BDP) is a common and severe psychiatric disorder. It’s characterized by severe functional impairments like a pervasive pattern of instability in affect regulation, impulse control and interpersonal relationships. Clinic may include impulsive aggression, repeated self-injury, and chronic suicidal tendencies. It leads to extensive use of treatment, and high costs to society. The etiology is not yet clear but has been a source of intense clinical interest. It seems that genetic factors and adverse life events during childhood seem to interact. Likewise Adler suggested as a failure of parental affection and bonding and also, Kernberg says that excessive early aggression leads young children to excessive frustration. Therefore, studies also suggest that the manifestation for suicide attempts has been described as arising from exposure to adverse childhood trauma.

Objectives: To describe the case of a central hospital psychiatric inpatient and it’s comparison with the international available literature.

Methods: Retrospective analysis of the clinical process. Review of the international available literature, using MedLine and PubMed.

Case Report: Woman, 38 years old, inpatient at Daily Hospital of a Central Psychiatry Hospital. It was admitted for behavioral changes with suicide ideation and impulsive behaviors. History of several internments in Psychiatric facilities and suicide attempts since she was 8 years-old.

Conclusion: Theories of suicidal behavior suggest that the desire to die can arise from disruption of interpersonal relationships. And those are also preponderant to clinical course of BDP. For that, when working with BDP patients, it should be considered the patterns of attachment.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P74

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Pharmacological management of challenging behavior in people with intellectual disability - read full article

By: João M. Oliveira, Cátia Moreira, Gonçalo Sobreira, Corona Solana, and M. Amélia Aleixo

Introduction: Challenging behavior (CB), which includes aggressive behavior, is the most common cause for psychiatric consultation in people with intellectual disability (ID). Recent developments in our knowledge about the neurobiology of aggression have allowed the investigation into more targeted drug therapy for CB.

Objectives: The authors aim to review the literature about pharmacological management of CB in people with ID.

Methods: A PubMed database review, using “intellectual disabity”, “challenging behavior”, “aggressive behavior”.

Results: Drugs are particularly useful when there is an identified psychiatric illness or as adjunctive treatment until other strategies are put in place. In general it is recommended that there should be periodic attempts at dose reduction. Antipsychotics are the drugs more commonly used for CB in ID. In the general population there is evidence for the use of atypical (but not typical) antipsychotics for aggression. Although initial studies provided no evidence for the use of antipsychotics in ID, more recent controlled studies have had positive results, particularly for risperidone, but also for clozapine, olanzapine, and quetiapine. SSRIs are also commonly used, on the basis that 5HT inhibits aggressive behavior, although in the last few years this idea has been challenged. Furthermore, there is no controlled study of the use of SSRIs in people with ID, and the few studies found provide conflicting results. The other main drug class used are anticonvulsants; in the general population they seem to decrease aggressiveness, however there are no methodologically solid studies for people with ID. Other drugs that may be useful are benzodiazepines, beta-blockers, lithium and methylphenidate (if comorbid ADHD).

Discussion and Conclusions: Management of CB in ID should always begin with the exclusion of an underlying medical or psychiatric condition as well as exploration of whether or not the behavior serves any functional utility. Drug therapy should take an adjunctive role to psychological management as it is unusual for the former to be sufficient. Unfortunately there is an overwhelming lack of evidence for the use of any drug other than risperidone, despite the large number of positive case reports. Future options may target oxytocin, vasopressin and other neurotransmitters.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P75

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Longitudinal diagnosis and comorbidity in Psychiatry – a clinical challenge - read full article

By: L. Carvalhão Gil, M. Amélia Aleixo, and André Ponte

Introduction: The longitudinal diagnosis is an important tool in Psychiatry. Mental disorders are complex and may have different courses, not showing the precise diagnosis at the beginning. This could imply different therapeutic approaches and diverse prognosis. The co-occurrence of different mental disorders in a patient is also frequent. It increases morbidity and may cause disability and makes management more challenging than in a single disorder.

Objectives: Clinical case report concerning a young female with a psychotic disorder and theme review on psychosis. The author’s aim is to highlight the relevance of clinical presentation over time and the need of modifying psychiatric diagnosis and its impact on the management of different mental disorders in a patient.

Methods: A literature search was performed on PubMed database using the key words psychosis, psychotic disorder, bipolar disorder, conversion and hysteria and retrieved papers were selected according to their relevance. The patient clinical record was reviewed.

Results: The authors report a case of a 25 year old female who presented a first episode of psychotic symptoms of religious content four years ago, in an apparent histrionic personality. At the time there was no previous psychiatric history. After two inpatient treatments under antipsychotic medication there was a fast and good therapeutic response. In the following two years there was complete remission with progressive reduction of the psychopharmacs. Two months later, without any medication, there was a single episode of agitation, euphoria and insomnia that ended in a defenestration of the 3rd floor. She became severely injured and is currently on mood stabilizer.

Discussion and Conclusions: The clinical presentation initially led to the diagnosis of brief psychotic disorder. After treated with an atypical antipsychotic, the patient remained apparently stable for two years but soon after the medication was stopped she developed severe symptoms of mania. The diagnosis was changed to bipolar disorder. This case illustrates the importance of following the course of the disease and reconsidering, occasionally, the disorder diagnosis, concerning therapeutic and prognostic implications.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P76

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Anorexia Nervosa in men: nuclear similarities and essential differences - read full article

By: M. Bernardo and E. Trigo

Introduction: For many decades the topic of eating disorders (ED) in males was largely neglected and there are actually very limited epidemiological data about this subject. Historical studies have examined Anorexia Nervosa (AN) from an almost entirely female focus, creating stigmatizing suppositions which have all failed to fully encapsulate the condition. The construction of AN as a woman’s illness has also been rooted in clinical practice, with the International Classification Diseases (ICD) 10 and DSM IV (up to 2013) including amenorrhea as a diagnostic criterion of AN. This view has fundamentally shaped the identity and status of male sufferers who bear the added burden of a feminised diagnosis.

Objectives: To study the male cases of AN as a way to enhance the knowledge on aetiology and patophisiology of this complex and multifactorial disease.

Methods: First, we will describe a clinical case of a young man with AN who was admitted to our Sara. Afterwards, we will briefly review the most current literature addressing the shared disease components in both genders, but also the crucial differences in male patients.

Results and Discussion: Men with AN are frequently underdiagnosed, less likely to receive treatment and treated for fewer days. Their first presentation is usually late in their illness trajectory, because they experience problems in recognizing that they may have AN as a result of the continuing cultural construction of this disease as uniquely female diagnosis. There is a lack of awareness also from health professionals, which contributes massively to the delayed diagnosis this patients have to face. At that time, the disease has already become well established and therefore, even more difficult to treat.

Conclusion: It’s imperative to decouple the experience of eating disorders from feminised cultural imagery, in order to break down the barriers men face between AN and the correct diagnosis and adequate treatment of this disease.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P77

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Perceived stress, repetitive negative thinking, and cognitive coping strategies as predictors of poor sleep - read full article

By: Ana P. Amaral, Maria J. Soares, Ana T. Pereira, Sandra C. Bos, Nuno Madeira, Carolina Roque, and António Macedo

Introduction: Stress is closely related to impaired sleep and can elicit profound and lasting effects on sleep. The cognitive representations of stressors need to be prolonged in order to extend their physiological concomitants. Elevated levels of repetitive negative thinking appear to be causally involved in the maintenance of emotional problems. An appropriate regulation of thoughts and emotions decreases the likelihood of pathogenic activation of stress response.

Objectives: To study the role of perceived stress, repetitive negative thinking, and cognitive coping strategies on sleep difficulties.

Methods: 549 students (80.1% females) from two Portuguese Universities filled in the Portuguese version of Perceived Stress Scale 10, Perseverative Thinking Questionnaire, Cognitive Emotional Regulation Questionnaire and three questions were used to access sleep difficulties (initiating sleep/DIS, sleep maintenance/DMS, and early morning awakening/EMA) and the Sleep Difficulties Index/SDI (sum of these questions scores).

Results: The significant predictors of SDI were Perceived Distress (Beta=.279); Repetitive Thought (Beta=.214), Cognitive Interference and Unproductiveness (Beta=-.198); and Rumination (Beta=.127). The predictor of reporting DIS was Perceived Distress (Beta=.144), the predictors of reporting DMS were Perceived Distress (Beta=.124), Repetitive Thought (Beta=.098) and Cognitive Interference and Unproductiveness (Beta=-.124), and the predictors of reporting EMA were Perceived Distress (Beta=.070) and Rumination (Beta=.067). The factors with significant impact on the likelihood of reporting good or poor sleep were Perceived Distress (Beta=.167), Repetitive Thought (Beta=.136); Cognitive Interference and Unproductiveness (Beta=-.106) and Positive Refocusing (Beta=-.083). The mediation analyses showed that rumination and repetitive thought partially mediated the association between perceived distress and global sleep difficulties/SDI.

Discussion and Conclusions: Perceived Distress, Repetitive Negative Thinking, Rumination and Positive Refocusing were the major predictors of poor sleep. These results may have clinical implications. They highlight the importance of cognitive-behavioral stress management interventions to promote a better sleep in students.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P78

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Chronic headaches – the hidden psychological factors - read full article

By: Mariana Marinho, Ana S. Costa, João Marques, Ricardo Moreira, and Miguel Bragança

Introduction: Chronic headaches are a group of diseases with variable prevalence and impact on patients quality of life. Until a few years ago most of the investigation and the attention on this theme was directed on the role of biological factors. Nevertheless, these are insufficient to explain all the aspects of these pathologies. Currently, chronic headaches are recognized as a group of biopsychosocial diseases in which biological, psychological and environmental/social processes are considered scientifically inseparable.

Objectives: The authors aim to summarize the influence of the psychological factors on the development, course and consequences of chronic headaches.

Methods: Literature review based on articles published on PubMed/MEDLINE, between January 2005 and January 2015, using the keywords “chronic headaches”, “psychological” and “risk factors”.

Results: Several psychological factors may significantly alter the development of headache episodes, the perception of pain severity, the disability, treatment adhesion and prognosis. However, these factors usually are only thought of on clinical situations associated with significant psychopathology. The main psychological factors are headache management locus of control beliefs, self-efficacy beliefs and negative affect/emotional states, mainly depression, anxiety and anger. The authors will describe the impact of each factor.

Discussion and Conclusions: On the management of “head pain”, the physician must be aware of this a real complaint. The biopsychosocial model turns chronic headaches on a clinical challenge and so it is crucial that the physicians are familiarized with the psychological factors involved. In fact, only then can they make a correct and early diagnosis to maximize the therapeutic benefits and to minimize the functional impact of chronic headaches.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P79

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(In)voluntary psychiatric hospitalization of geriatric patients with dementia in Portugal - read full article

By: M. Marinho, F. Vieira, and M. Cruz

Introduction: With the ageing of the population, dementia is becoming increasingly common in our communities and in health practice settings. 40-90% of patients will develop psychiatric symptoms at some point during their journey within these illnesses. Frequently, the psychiatrist is faced with clinical cases where patients with dementia exhibit behavioral symptoms and lack insight, which can lead to the refuse of treatments as hospitalization.

Objectives: To comment Portugal's state legislation, policy and practice implications.

Methods: Review of literature related with involuntary hospitalization (IH) and dementia and their legal and social consequences.

Results: In Portugal, all citizens have the right of liberty and security (Art.27). However, there are some exceptions as for involuntary placement in mental disorders. The IH is conducted by the Portuguese Mental Health Act (Law n.º 36/98), which foresees some conditions such as the presence of mental disorders that imply real danger to the patient or others, risk of further deterioration, of which the person is unaware. There are few national data about this matter.

Discussion: The only report about the reality in Portugal -Alzheimer Europe- declares that the IH of people with dementia is well regulated by the Portuguese Mental Health Act. However, Article 27 is frequently violated because the majority of them are residents in nursing homes without their consent. Nowadays, there is an increase of civil actions concerning this specific population that intend to nominate legal guardians. Conclusions: The aim of preserving and enhancing the autonomy of older adults is an important target in this specific population, often forgotten by others. More epidemiological data and research are needed, focusing the patterns, conditions and the types of diagnosis that are most commonly used in cases of IH in the elderly.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P80

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Borderline Personality Disorder: a treatable condition? - read full article

By: Sofia Marques and Daniel Barrocas

Introduction: Borderline personality disorder (BPD) is characterized by four facets of psychopathological symptoms: affective disturbance, impulsivity, disturbed cognition and intense unstable relationships. It is the most common personality disorder and has a major impact on health services consumption. APA guidelines recommend psychotherapy as the primary treatment for BPD.

Objectives: Evaluation of the efficacy of cognitive-behavioral treatment (CBT) in BPD.

Methods: A systematic review of literature was conducted, using MEDLINE and PUBMED. English-language studies published between 1991 and 2014 were included when a sample of adult patients diagnosed with BPD was present, a clear description of the cognitive behavioral intervention provided and the outcomes reported.

Results: Sixty-seven studies were included, which analyzed the efficacy of several psychotherapeutic interventions, namely dialectical behavioral therapy, cognitive behavioral therapy, schema-focused therapy, manual-assisted cognitive therapy, systems training emotional predictability and problem solving, and emotion regulation group treatment. All treatments showed beneficial effects in terms of reduction of BPD core pathology and associated general psychopathology. Some also showed reduction in the severity and frequency of self-harm behaviors, whereas others documented improvement in social and global adjustment. The effect size of CBT interventions differed among studies, but in some outcomes it was moderate to large. The psychotherapeutic interventions included in this revision have many differences, either in format, total duration, therapy structure or in strategies and techniques applied.

Discussion/Conclusions: Overall, the findings support a substantial role of cognitive-behavioral psychotherapy in the treatment of BPD. This work demystifies the idea that BPD is a chronic and intractable condition. However, none of the interventions has a very robust evidence base, since studies on effectiveness of psychotherapeutic interventions meet some special methodological restrictions inherent to psychotherapy research. In the future, more studies are needed to: 1) replicate the results submitted by independent researchers; 2) include male patients; 3) include patients with defined comorbidities; 4) compare various psychotherapeutic modalities.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P81

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From the uterus to the mind – the conceptual evolution of Hysteria - read full article

By: Tânia Abreu and Geraldo Oliveira

Introduction: The concept of Hysteria has been changing for four thousand years. Its inconstancy has been influenced by the socio-cultural context in each period of History.

Objectives: The authors aim to summarize the evolution of the concept of Hysteria from 1900 b.C. to the present.

Methods: Review of the literature.

Results: Egyptians initiated the descriptions about Hysteria, describing a uterus that wandered through the body causing the symptoms. The Wandering Womb Theory lasted for many centuries. Hippocrates spoke about the “suffocation of the womb” around 400 b.C.. In the second century, Galen refuted this theory, relating Hysteria to sexual dissatisfaction and a secretion of the uterus. In the Middle Age, Hysteria was associated with sin and demonic possession, being treated by exorcism and later leading to the execution of countless women by fire. In the 16th century, the Hippocrates and Galen’s ideas were resumed. The “Suffocation of the Mother” was caused by vapors arising from the uterus. By this time, emotional causes began to be considered, but the paradigm shifts started in the 17th century. Sydenham spoke of a common multifactorial chronic disease, determined by physical and psychological factors that could affect both sexes. In the 18th century, the uterus returned, this time associated with the theories of the cerebral and spinal irritation and reflex arcs. By the 19th century, Hysteria was epidemic and treated by genital massage. At the same time, it was starting to be considered a mental disorder with the works of Griesinger, Briquet and others. Charcot marked an important turn at the Salpêtrière Hospital, leading the way to his followers, like Freud and Janet, to explore Hysteria. Freud introduced the association to repressed child sexual conflict. Treatments were focused on hypnosis and, later, psychoanalysis. Currently, the concept of Hysteria is fragmented in different disorders: dissociative, somatic and histrionic personality disorder.

Discussion and Conclusions: After four millennia, there is no consensus about Hysteria. For some it is lost, for others it is still present, often with a negative connotation.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P82

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Paws for help animal-assisted therapy - read full article

By: Tânia Abreu and Ana R. Figueiredo

Introduction: Previous research indicates that pet ownership and animal assistance in therapy and education may have a multitude of positive effects in humans, providing physical, physiological and psychological health benefits for patients. Animal-assisted Therapy is a goal-directed intervention, led by a specialized professional, in which an animal that meets specific criteria is an integral part of the treatment process. There are specified goals and objectives for each individual and measured progress. Literature has been cementing the idea that animals’ presence, spontaneous behaviour and availability for interaction may facilitate therapy. It has been demonstrated that interactions with a friendly animal can result in reducing levels of cortisol and increasing oxytocin, dopamine, endorphins and phenethylamine.

Objectives: The authors aim to study Animal-Assisted Therapy regarding animal-human relation, characteristics of the animals, theoretical bases, definitions, types of therapies and results.

Methods: It was conducted a review of the literature about Animal-assisted Therapy.

Results: Recent research shows how interaction with animals can benefit individuals with a range of mental health issues, including affective disorders, anxiety, dementia, schizophrenia and trauma. Scientific evidence on the effects is far from being consistent. It is necessary to conduct rigorous studies to prove the efficacy of Animal-Assisted Therapy, so it could become an empirically supported treatment. It is also important to standardize terminology and methodologies.

Discussion and Conclusions: Overall, Animal-assisted Therapy is an emergent field in mental health, and it can potentially be a very useful complement for the treatment of mental disorders.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P83

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Malingering and self harm: a case study - read full article

By: Telma Santos, Ema Conde, R. Leite Almeida, João Alcafache, and Vitor Santos

Introduction: In clinical practice, malingering is not considered a form of mental illness or psychopathology, although it can occur in the context of other mental illnesses.

Objectives and Methods: The aim of this work is to expose a case study about malingering in a 44 years old female admitted in the Baixo Vouga Hospitalar Centre Psychiatric ward.

Results: She claimed being victim of several physical and pshychological attacks by neighbors and brothers which resulted in multiple burns injuries, most of all on the face. During the hospitalization she admitted the deliberate self-harm authorship. On an ongoing basis we found a severe personality disorder which conditioned all patient life.

Discussion and Conclusions: Despite of malingering is unfrequent clinicians should be aware of this possibility and be competent enough to identify it, tactfully and nonjudgmentally, presenting inconsistencies to the patient and offer a face-saving way out of the interaction.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P84

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Neurobiological aspects of personality - read full article

By: Catarina Freitas, Denis Gabriel, João Chaves, and Sandra Queirós

Introduction: Personality is an individual characteristic, result of the interaction of biological, psychological and social factors. In some circumstances during adulthood, it may occur deep and lasting personality changes, which may result from injury or organic brain disease, various psychiatric disorders or exceptionally severe stressful experience. The change most commonly perceived and reported by family members of patients with brain injury is the change in personality. The neurobiological aspects of personality have been subject of intense discussion, over time, in order to try to associate certain personality traits with areas and brain circuits, including, for example, studies with imaging exams.

Objectives and Methods: The authors propose to describe two cases of patients with lesions in the prefrontal cortex, trying to associate such lesions to characteristic personality traits of orbitofrontal dorsolateral syndromes.

Results: The frontal syndromes are associated with personality change, cognitive impairment, difficulties in interpersonal relations and social behavior and other neurological disorders.

Discussion and Conclusions: With the growing scientific advances and the high demand for neurological explanation for the personality, the question remains whether the personality changes are direct consequence of brain injury or due to other different processes such as the emotional reaction to the neurological damage.

From the 23rd EFPT Forum, Porto, Portugal. 22–27 June 2015.

International Journal of Clinical Neurosciences and Mental Health 2015; 2(Suppl. 1):P85

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The role of rehabilitation in multiple sclerosis—is it worth it? - read full article

By: Isabel Amorim, Sofia Proença, Carolina Falcão, and Daniela Pinto

Introduction: Multiple Sclerosis is a complex immune-mediated disease that causes demyelination and degeneration within the brain and spinal cord. This may result in muscle global weakness, abnormal tone, visual disturbances, decreased sensation, tremor/ataxia, bladder, bowel and sexual dysfunction, fatigue and impaired ambulation. Those symptoms cause disability and have a huge impact on quality of life (QOL). Methods: Literature review about the evidence assessing the rehabilitation interventions for maintaining functional capacity and reducing risk for losing important abilities and independence. Databases of Cochrane Library/Pubmed/Medline were search from 2005-2016. Results: Physical exercise is safe and should be encouraged. Even though rehabilitation has no direct influence on disease progression, studies have shown that this intervention reduce the limitations in order to maintain quality of life. Timing and setting of rehabilitation interventions should be selected individually. Benefits are generally higher in earlier phases of MS. A multidisciplinary approach, constitutes the basic concept of rehabilitation. The main symptoms that need to be specifically attended are spasticity, cognitive impairment, motor, sensory and visual disturbance, fatigue and bladder dysfunction. Deficits in ambulation should be addressed to improve energy efficiency and reduce falls. Compensation through appropriate prescription of assistive devices, bracing, and wheelchairs will help improve safety. Cognitive training can improve memory span, working memory, and immediate visual memory. New promising rehabilitation techniques may also be useful: impairment-oriented training, CIMT, electromyogram-triggered neuromuscular stimulation, and robotic interactive therapies. Conclusion: Rehabilitation can have significant impact on achieving and maintaining QOL improving independence in patients with MS.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P1

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A diagnostic dilemma: acute disseminated encephalomyelitis following herpetic encephalitis or multiple sclerosis (MS)? - read full article

By: Cristina Baetu, I. Buraga, G. Mihailescu, and A.M. Enachi

By definition both ADEM and MS cases must manifest disseminated disease of central nervous system. AADEM is an uncommon monophasic idiopathic inflammatory demyelinating disease; it usually develops after an acute viral infection, vaccination or organ transplantation. We present the case of a female patient , age 50 who was admitted in our hospital with abrupt onset of fever ,confusion and aphasia. Initial lab tests revealed increased levels of herpes virus (IgM and IgG). Serological tests for other common neurotropic viruses and parasites were negative. Magnetic resonance imaging showed multifocal changes in the brain parenchima mainly in the white matter so she started treatment with high doses of methilprednisolone. The CSF IgG index and oligoclonal bands were positive; Electroencephalogram revealed epileptiform activity. Is it ADEM following acute viral infection or is it atypically multiple sclerosis ? Did the herpes virus triggered ADEM or MS? We will present the differential diagnosis with the final results and outcome of our case.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P2

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Fampridine in multiple sclerosis: beyond walking - read full article

By: J. Beato-Coelho, M. Pereira, I. Correia, J. Marçal, I. Ribeiro, A. Melo, C. Nunes, L. Sousa, J. Campelo, S. Batista, and C. Macário

Introduction: Fampridine is indicated in patients with multiple sclerosis (MS) with walking disability (EDSS 4-7). It has been reported that 40% of these patients present an improvement on walking speed (WS) of at least 20%. Data regarding fampridine impact on other symptoms of MS are scarce. Objectives: To evaluate the effect of fampridine on WS, cognition and manual dexterity (MD) in MS patients. Methods: We included all MS patients who started fampridine from March to November 2015. Our evaluation protocol included Timed 25-Foot-Walk (T25-FW) to measure WS, Symbol Digit Modality Test (SDMT) for cognition and 9-Hole Peg Test for MD. Patients were evaluated at baseline and after 2 weeks of fampridine 10mg twice daily. We defined as responders those who had a faster WS of at least 20%. Results: Thirty patients were included, 73.3% females, with a mean age of 51.4 years old, and a median EDSS of 5.5. The responders were 19 (63.3%). After 2 weeks of fampridine there was a significant improvement in the WS (31.36 vs 30.66 p0.001) and MD (32.53 vs 30.66 p=0.005). For cognition, as measured by SDMT, we found no difference (32.13 vs 32.87 p=0.165). Considering only the responders population, there was a trend towards improvement in SDMT yet not significant (30.1 vs 31.9 p=0.055). Conclusion: In this population fampridine improved not only the WS but also manual dexterity. We did not confirm benefits in cognition

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P3

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Unusual expression of multiple sclerosis (case report) - read full article

By: M. Beridze, G. Chakhava, L. Shanidze, and E. Devidze

Methods: We investigated a 44 year-old male patient diagnosed with Multiple Sclerosis (MS), who in two years developed typical clinical signs of parkinsonism. Patient investigated neurologically, Brain contrast MRI (1.5 Tesla) was made two times after diagnostics with 1 year interval. Cerebrospinal Fluid (CSF) was researched for oligoclonal bands. CSF and blood were researched by ELISA method to detect IgM and IgG against Chlamydia pneumonie, Mycoplasma pneumonie, Borrelia burgdorferi, Herpes simplex 1/2, Cytomegalovirus. Results: Clinically patient expressed amiostatic face, oligobradikinesia, extrapyramidal spasticity in all limbs, resting tremor in upper limb fingers, horizontal nystagmus. Brain MRI showed multiple gadolinium enhanced demyelinization lesions in periventricular and subcortical white matter. CSF oligoclonal bands were positive without dysfunction of blood-brain barrier. Particularly, IgG C SF-Serum ratio was 4.6kA, Albumine CSF/Serum ratio -6.2kA, Tibbling CSF ratio-0.75 kA, Local IgG synthesis (Reiber)-1.3kA, Range Albumin CSF-Serum ratio-7.0kA. CSF and blood IgM, IgG were negative against Chlamydia pneumonie, Mycoplasma pneumonie, cytomegalovirus, Herpes simplex ½, while the blood IgG was strongly positive against Borrelia Burgdorferi, confirmed by following Western blot test. CSF conventional PCR (target ospA gene) showed positive result for Borrelia Burgdorferi. Patient was treated by puls-therapy with 1gr/intravenous Solumedrol (5 days) along with Rocephin treatment (2gr /iv) for 21 days followed by Antiparkin (Carbidopa 250mg, Levodopa 25mg). Conclusion: MS and even Parkinsonism should be differentiated from chronic neuroboreliosis.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P4

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Adiponectin and its fractions in newly diagnosed, treatment-naïve multiple sclerosis patients - read full article

By: Wojciech Bik, A. Baranowska- Bik, D. Uchman, J. Tomalka-Kochanowska, A. Litwiniuk, M. Kalisz, L. Martynska, B. Baranowska, and J. Kochanowski

Background: Multiple sclerosis (MS) is a chronic autoimmune, inflammatory disease of the central nervous system with exact etiology being still unclarified. MS results in neurodegeneration and demyelination. Adipose tissue is able to produce active molecules, adipokines. Adiponectin belongs to a group of anti-inflammatory adipokines. Plasma adiponectin circulates in three major forms: trimer (low molecular weight, LMW), hexamer (medium molecular weight, MMW), and high molecular weight (HMW) multimer, and additionally in proteolytically cleaved form, globular adiponectin. Different adiponectin fractions have been shown to exert distinct biological activity. Aim: We aimed to assess adiponectin and its fractions in newly diagnosed, treatment-naïve MS patients. Material and methods: The study group comprised of 32 patients (24 women/8 men) with the first time episode of MS (mean age 34.9±8.3yrs.; BMI 24.4±4.8 kg/m2). The controls included 40 individuals (34 females/6 men; mean age 32.3±8.1yrs.; BMI 24.3±4.6 kg/m2). Fasting plasma adiponectin and its fractions were evaluated with ELISA. Statistical analyses were performed. Results: Comparison between results of MS group and the controls revealed no significant differences in concentrations of all evaluated parameters. When data were adjusted to BMI we found that total adiponectin and HMW values were markedly lower in MS group (both p0.01), MMW adiponectin concentration was increased in MS subjects (p0.001) while LMW adiponectin levels remained comparable between the groups. Conclusions: Alterations of adiponectin levels, independent of BMI, in newly diagnosed MS patients may be related to autoimmune neurodegeneration and demyelination.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P5

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Biological-based complementary and alternative medicine use in multiple sclerosis patients - read full article

By: Merisanda Casar Rovazdi, V. Vidovic, S. Rendulic Slivar, and O. Kraml

Introduction and aim: People with multiple sclerosis (MS) often seek complementary and alternative medicine (CAM) to manage their disease. The aim of the study was to determine the frequency and modality of the biological-based CAM use among MS patients. Patients and methods: The study included 70 MS patients that underwent inpatient rehabilitation at the Lipik Hospital. A semi-structured questionnaire on the current usage of biological-based CAM was applied. Results: Fifty-two (74.3%) respondents reported that they were currently using biological-based CAM. Respondents most commonly used D vitamin (n=37; 52.9%), followed by vitamin B complex (n=26; 37.1%), magnesium (n=16; 22.9%), calcium (n=13; 18.6%), multivitamins/minerals (n=7; 10%), omega-3 fatty acids (n=7; 10%), hemp products (n=5; 7.1%), vitamin C (n=4; 5.7%), and Swank`s diet (n=4, 5.7%). Other types of biological-based CAM were taken by less than 5% of respondents. In the group of users there were a statistically significant higher proportion of patients with lower level of disability (p=0.047), relapsing-remitting disease course (p=0.011) and shorter duration of disease (p= 0.004) compared with the group of non-users. There were no statistically significant between-group differences according to sex (p=0.142) and age (p=0.110). Conclusion: Study results demonstrated frequent use of biological-based CAM among MS patients, despite the lack of evidence about the effectiveness of most of these therapies. There is a need for additional researches on the efficacy and safety of CAM therapies.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P6

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Efficacy of teriflunomide in achieving no evidence of disease activity from 6 months to 2 years in the TEMSO study - read full article

By: A. Chan, J. de Seze, P. Truffinet, K. Thangavelu, P. Rufi, and M. Comabella

Background: Attainment of no evidence of disease activity (NEDA) has been proposed as a therapeutic goal in MS. Treatment with teriflunomide 14mg increased the likelihood of patients achieving NEDA over a 2-year period in TEMSO (NCT00134563). Residual disease activity may occur while full therapeutic efficacy of teriflunomide becomes established. This post hoc analysis of TEMSO evaluated impact of teriflunomide on NEDA using 6 months from treatment initiation as baseline. Methods: Patients with relapsing forms of MS (N=1086) were randomized to receive teriflunomide 14mg, 7mg, or placebo for 108 weeks. We evaluated achievement of NEDA (no gadolinium-enhancing T1 lesions, no new/enlarging T2 lesions [MRI activity], no relapse, and no 12-week sustained disability progression [clinical disease activity; CDA]) and proportions free from CDA or MRI activity, from 6 months to 2 years. Results: From 6 months to 2 years, a significantly greater proportion of teriflunomide-treated patients (14mg, 28.1%, P0.0001; 7mg, 21.5%, P=0.0180) achieved NEDA vs placebo-treated patients (14.3%). The proportion CDA-free was significantly higher in the 14-mg group (61.3%, P=0.0022) vs placebo (49.2%). The proportion free of MRI activity was significantly higher with teriflunomide 14mg (45.1%, P0.0001) and 7mg (35.4%, P=0.0029) vs placebo (24.6%), with 14mg exhibiting superiority over 7mg (P=0.0141). Conclusions: Teriflunomide is associated with a significant dose-dependent increase vs placebo in proportion of patients achieving NEDA from 6 months to 2 years in the TEMSO study, providing further evidence for efficacy on key measures of CDA and MRI activity.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P7

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The relationship between the BICAMS battery, disease disability, duration and relapse rate in Lithuanian MS patients - read full article

By: Natasa Giedraitiene, R. Kizlaitiene, and G. Kaubrys

Background: Cognitive impairment (CI) occurs frequently in multiple sclerosis (MS). It can present in patients at any time regardless of the disease severity. Recently the Brief International Cognitive Assessment for Multiple Sclerosis (BICAMS) has been created as a brief, simple, and specific instrument for the evaluation of CI in MS patients. However, it is unknown whether the BICAMS battery has the relation with the disease disability, disease duration and relapse rate. Objectives: The purpose of the study was to assess the cognitive status of MS patients by the Lithuanian version of BICAMS and to evaluate the impact of CI on the disability, duration and relapse rate of the disease. Methods: 50 MS patients and 50 cognitively normal control subjects, matched on age, gender, and the level of education were enrolled. Cognitive functions have been assessed by the BICAMS tests. Results: MS patients performed significantly worse than controls on the three neuropsychological tests of BICAMS (p0.001). The younger and working intellectually persons performed on these tests significantly better than older persons, manual workers or unemployed persons (p0.05). MS patients with higher disability score, were tended to perform the tests worse (p0.05), but the relationships between the BICAMS tests and the duration of the disease or relapse rate were not found (p0.05). Test - retest reliability was excellent for all the three subtests (r0.8, p0.05). Conclusions: Better performance of the BICAMS tests was associated with lower severity of the disability, however the relations between BICAMS tests, disease duration and relapse rate weren’t found.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P8

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Alemtuzumab demonstrates persistent clinical efficacy outcomes over 5 years in patients with active relapsing-remitting multiple sclerosis, with most not receiving retreatment: CARE-MS I and II extension studies - read full article

By: Eva Havrdova, Douglas L. Arnold, D. Alastair S. Compston, Hans-Peter Hartung, Krzysztof W. Selmaj, Linda Kasten, and David H. Margolin on behalf of the CARE-MS I and CARE-MS II Investigators

Background: Patients with active relapsing-remitting multiple sclerosis (RRMS) who were treatment-naive (CARE-MS I; NCT00530348) or with inadequate response (?1 relapse) to prior therapy (CARE-MS II; NCT00548405) had improved outcomes with alemtuzumab versus SC IFNB-1a over 2 years. Objective: To examine alemtuzumab’s efficacy and safety over 5 years in CARE-MS patients. Methods: Patients received 2 courses of alemtuzumab 12 mg (Months 0 and 12), with as-needed retreatment for disease activity, or another disease-modifying therapy (DMT). Annualised relapse rate (ARR), 6-month confirmed disability progression (?1-point Expanded Disability Status Scale [EDSS] increase [?1.5-point if baseline EDSS=0]), and 6-month sustained reduction in pre-existing disability (SRD; ?1-point EDSS decrease [baseline ?2.0]) were assessed. Results: 349 (95%) and 393 (93%) CARE-MS I and II patients entered extension (NCT00930553), respectively; 68% and 60% received no alemtuzumab since initial 2 courses; 98% and 92% received no other DMT. ARRs remained low from Year 3 (0.19 and 0.22) to Year 5 (0. 15 and 0.18). Through Years 0–5, 80% and 75% were free from 6-month confirmed disability progression, and 33% and 43% achieved 6-month SRD. Infusion-associated reactions and infections were reduced versus core studies, and serious adverse events (AE) were low. Thyroid AEs peaked at Year 3, then declined. Conclusions: Alemtuzumab improved relapse and disability outcomes over 5 years despite most patients not receiving retreatment. Based on these findings, for the majority of RRMS patients, alemtuzumab may provide an innovative treatment approach with efficacy persisting through 5 years in the absence of continued treatment and associated treatment burden.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P9

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Multiple sclerosis and involuntary movements - read full article

By: Gabriela Mihailescu, C. Baetu, S.M. Nica, A.M. Vladila, D.A. Mitrea, G. Socoliuc, A.D. Boangiu, and I. Buraga

Introduction: Movement disorders were considered uncommon in multiple sclerosis (MS), but tremor (action, postural) can be a highly disabling symptom (transient or persistent), as well as other involuntary movements. Methods: We studied 130 patients (80 male and 50 female) with multiple sclerosis. 115 with relapsing remitting (RR-MS), 5 secondary progressive (SPMS) and 10 clinical isolated syndrome (CIS) treated and monitorised in the Neurology Department of the Colentina Clinical Hospital. 76% aged 19-39 years, 84% having EDSS score 1- 4, 16% EDSS 4.5 - 6.5. 25 patients were treated with Interferon beta-1a intramuscularly, 27 with Interferon beta-1 a subcutaneously, 18 with Interferon beta-1b, 51 with glatiramer acetate and 9 with natalizumab. We performed a clinical examination, including finger to nose testing, drinking from a cup, 9 Hole–Peg test, writing/drawing, a questionnaire regarding concomitant treatments, comorbidities and movement disorders, Brain tremor severity scale and FAMS (Functional assessment of MS scale) Results: The prevalence of tremor in our group was 31,53 %, especially for action tremor of the upper limbs. 2,3 % seemed to be linked to the specific immunomodulatory treatment. Other involuntary movements present were: Restless leg syndrome 3,84%, facial hemispasm 2,3%, ballism 0,76%, tics 3.07%, myoclonus 3, 84%. Conclusions: Movement disorders are not very rare in MS patients. The pathophysiology is various and so the treatments. Comorbidities and concomitant therapies precipitated involuntary movements, which were more frequent in women, 30-39 years of age, transient or permanent and correlated to the EDSS score. They disabling, causing psychological, social and economic problems.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P10

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Teriflunomide slows down brain volume loss in relapsing MS: a SIENA analysis of the TEMSO MRI dataset - read full article

By: E. W. Radue, T. Sprenger, L. Gaetano, N. Mueller-Lenke, J. Wuerfel, K. Thangavelu, and S. Cavalier

Background/Objectives: Two phase 3 studies, TEMSO (NCT00134563) and TOWER (NCT00751881), showed significant effects of teriflunomide on slowing disability progression in patients with relapsing MS (RMS). In TEMSO, teriflunomide significantly reduced lesional MRI disease markers, but no significant attenuation of brain volume loss (BVL) (measured by brain parenchymal fraction) was observed. Given associations of BVL and long-term disability, blinded independent analysis of the TEMSO MRI dataset was warranted using a validated alternative methodology, SIENA (structural image evaluation using normalization of atrophy), to assess effects of teriflunomide on BVL. Methods: Median annualized percentage change in brain volume from baseline was calculated (SIENA). Treatment groups were compared by rank ANCOVA, adjusted for region, age, Expanded Disability Status Scale strata, and normalized brain volume (SIENAX) at baseline. Results: 969 patients were included. Median percentage reduction from baseline in brain volume at Months 12 and 24 for placebo was 0.61 and 1.29. For teriflunomide 14mg and 7mg these reductions were 0.39 and 0.90, and 0.40 and 0.94. BVL was lower for both teriflunomide groups vs placebo at Months 12 and 24: 14mg (36.9%, P=0.0001); 7mg (34.4%, P=0.0011); and 30.6% (P=0.0001) for 14mg; 27.6% (P=0.0019) for 7mg. Conclusions: Teriflunomide was associated with significant reductions in BVL vs placebo over 2 years. These findings, using SIENA, an established measure of brain tissue loss, are consistent with effects of teriflunomide on delaying disability progression observed across studies in patients with RMS.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P11

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The prevalence of cognitive impairment among Hungarian patients with relapsing-remitting multiple sclerosis and clinically isolated syndrome - read full article

By: Daniel Sandi, T. Biernacki, D. Szekeres, J. Fuvesi, Zs. T. Kincses, Cs. Rózsa, K. Mátyás, K. Kása, J. Matolcsi, D. Zboznovits, A. Pyreschitz, É. Langane, L. Vécsei, and K. Bencsik

Introduction: Cognitive impairment (CIm) is a frequent symptom of multiple sclerosis (MS); its prevalence is reported to be 43-70%. The cognitive decline is not global: information processing speed, visual and verbal memory are the most frequently affected domains. We aimed to determine the prevalence of CIm among the relapsing-remitting MS (RRMS) and clinically isolated syndrome (CIS) patients in Hungary and to assess the differences between genders and patients with different educational levels. Patients and methods: Five-hundred and fifty-four CIS and RRMS patients were enrolled to our study, 405 was treated at the Department of Neurology of the University of Szeged; 111 at the Jahn Ferenc Dél-Pest Hospital in Budapest and 38 at the Markhot Ferenc Hospital in Eger. We used the BICAMS battery to assess their cognitive state. For statistical analysis we used Chi square and Fisher exact tests. Results: Three-hundred and eighteen (57.2%) patients had CIm. CIm was significantly (p=0.001) more frequent among men (70.1%) than women (51.6%). While among men, there was no difference between patients with different educational levels, the prevalence of CIm among women with higher education was significantly (p=0.001) less common (42.5%) than women with lower education (62.5%). Discussion: Our prevalence data is similar to those reported in the literature (43-70%). We found that men are more vulnerable to CIm than women in MS, as was reported by a recent study. We are the first to report, that the higher cognitive reserve is only a protective factor among female patients.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P12

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Alemtuzumab-treated patients with active relapsing-remitting multiple sclerosis demonstrated slowing of brain volume loss over 5 years, with most patients not receiving retreatment for 4 years - read full article

By: Krzysztof W. Selmaj, D. Alastair S. Compston, Massimo Filippi, Gavin Giovannoni, Hans-Peter Hartung, Eva Havrdova, Sven Schippling, David H. Margolin, Karthinathan Thangavelu, and Douglas L. Arnold on behalf of the CARE-MS I and CARE-MS II Investigators

Background: Patients with active relapsing-remitting multiple sclerosis (RRMS) who were treatment-naive (CARE-MS I; NCT00530348) or who had inadequate response (?1 relapse) to prior therapy at baseline (CARE-MS II; NCT00548405) demonstrated significant slowing of brain volume (BV) loss over 2 years with alemtuzumab versus SC IFNB-1a. Slowing persisted through 4 years, despite most patients not receiving retreatment. Objective: To examine alemtuzumab’s effect on BV over 5 years in patients in the CARE-MS extension (NCT00930553). Methods: Patients were randomised to 2 annual alemtuzumab courses (Months 0 and 12), with as-needed retreatment for relapse and/or magnetic resonance imaging disease activity, or another disease-modifying therapy (DMT). BV loss was measured annually by brain parenchymal fraction change. Results: 349 (95%) CARE-MS I and 393 (93%) CARE-MS II alemtuzumab patients entered the extension; 68% in CARE-MS I and 60% in CARE-MS II received no alemtuzumab treatment since Month 12, and 98% and 92% received no other DMT. Over 4 years, median annual rate of BV loss was reduced and remained low in CARE-MS I (Years 1–5: –0.59%, –0.25%, –0.19%, –0.15%, and –0.20%, respectively) and CARE-MS II (Years 1–5: –0.48%, –0.22%, – 0.10%, –0.19%, and –0.07%). Conclusions: Slowing of BV loss with alemtuzumab was maintained over 5 years in patients with RRMS, despite most not receiving additional treatment beyond 12 months. Based on these findings, for the majority of RRMS patients, alemtuzumab may provide an innovative treatment approach with efficacy persisting through 5 years in the absence of continued treatment and associated treatment burden.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P13

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Major depression in patients with multiple sclerosis - read full article

By: Viktor Vidovic, M. Casar Rovazdi, O. Kraml, and S. Rendulic Slivar

Introduction and aim: Depression is frequently underdiagnosed and undertreated in patients with multiple sclerosis (MS). The aim of the study was to determine the prevalence of major depression in MS patients and analyze the frequency of antidepressants intake among patients with major depression. Methods: The study was conducted on 73 MS patients that underwent inpatient rehabilitation at the Lipik Hospital. The diagnosis was made by use of the Patient Health Questionnaire-nine (PHQ-9) screening test, where a sum of ?10 denoted positive finding. Study patients were divided into two groups, according to the presence or absence of major depression. Results: Sixteen respondents (21.9%) met the criteria for the diagnosis of major depression. Of these 16 patients, 7 (43.8%) were taking antidepressants. We found that 12 (75%) of respondents with positive PHQ-9 criteria did not inform neurologist on the presence of mood disorder. There were no statistically significant between-group differences according to age (p=0.814), sex (p=0.167), EDDS score (p=0.710), disease duration (p=0.213) and disease course (p=0.876). Conclusion: Based on screening test results, substantial proportion of MS patients suffer from major depression. The fact that a significant proportion of patients did not inform neurologist on their mood disturbance, and low frequency of antidepressants intake among MS patients with depression, call for an active approach to diagnosis and treatment of depression.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P14

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Acute demyelination in childhood associated with TNF alpha-inhibitor therapy - read full article

By: Sara Vila-Bedmar, E. Waubant, and J. Graves

Introduction: Tumor necrosis factor-alpha inhibitors (TNFi) have revolutionized the treatment of rheumatological autoimmune disorders. We report a rare, although serious concern with TNFi usage, demyelination of the central nervous system. Material and methods: Case report. Results: A 15-year old woman with history of polyarticular juvenile idiopathic arthritis stable on methotrexate and infliximab developed blurred vision and retro-orbital pain in her right eye. She had no preceding illness or fever and her arthritis was well controlled. Her examination confirmed right optic neuritis with severely impaired visual acuity (20/200), dyschromatopsia and right afferent pupillary defect. Blood test results were within normal range, extensive infectious work-up and aquaporin-4 antibody were negative. A brain MRI performed one week after the onset of symptoms revealed asymmetric T2-hyperintensity and enlargement of the right prechiasmatic optic nerve, compatible with optic neuritis without abnormal enhancement, and the brain parenchyma appeared unremarkable. She declined to have a lumbar puncture, which had been proposed for routine studies, IgG index and oligoclonal bands. She was treated with pulse high-dose steroids and experienced rapid improvement. Infliximab was discontinued and methotrexate was increased to 25 mg weekly. After 3 years of follow-up her central acuity is 20/20 in the right eye. She has had no clinical or MRI evidence of additional demyelinating lesions. Conclusions: TNFi medications can be associated with demyelination in the central and peripheral nervous system even in childhood. Close follow-up of these patients is mandatory to determine whether they have a monophasic or recurrent CNS disorder.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P15

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ABCD2 score: help or hindrance? - read full article

By: Nuno Ribeiro and N. Beaman

Introduction: ABCD2 score is the tool used in the initial assessment of patients presenting with transient neurological symptoms of vascular origin, to determine their probability of going on to develop a stroke. It is used primarily by General Practitioners and Emergency Department staff to refer into specialist TIA clinics. Scores greater than or equal to 4 should be assessed in 24 hours, those with scores less than 4 in 7 days. Method: We reviewed the ABCD2 score for patients seen in the TIA clinic between July and November 2015. The total number of patients reviewed was 153. Patients were divided into two groups; high risk with ABCD2 score ? 4 (61) and low risk 4 (92). The diagnoses were recorded for all patients. Aids used to come to diagnosis included CT brain, MRI brain and Carotid Doppler ultrasound. Results: Of the 153 patients referred, 50 were clinically diagnosed as "definite TIA", 15 as "probable TIA" and 19 as "possible TIA" (54.9%). The remaining 69 were diagnosed with conditions unrelated to transient ischaemia. Of those with a TIA diagnosis, 44 had an ABCD2 score ? 4 and 40 an ABCD2 score 4. Conclusion: Diagnosing TIA is a complex and demanding task. ABCD2 score can be a useful aid to categorise urgency of referral. However, it is apparent when used incorrectly, it leads to inappropriate referral to TIA clinics. In our case 69 referrals based on ABCD2 score were not related to TIAs.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P16

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Unilateral intracranial arteriopathy in young adults: an etiologic and therapeutic challenge - read full article

By: F. Bernardo and P. Pita Lobo

Introduction: Arterial ischemic stroke (AIS) in young adults is uncommon. Intracranial stenosis is a possible cause of AIS and has several etiologies such as non-atherosclerotic vasculopathies and premature atherosclerosis. There is little evidence regarding AIS treatment in young adults, particularly concerning arteriopathies. Case Presentation: A 39-year-old woman, with past history of idiopathic cerebral palsy and auriculoventricular block, was admitted after onset of right facial palsy and right upper limb motor and sensory deficits associated with neck pain. Head CT scan suggested a left MCA deep infarct. Additional testing revealed left carotid siphon critical stenosis on conventional angiography without specific etiologic features. The patient was discharged with aspirin 250mg/daily. She maintained clinical fluctuation during outpatient period. SPECT scan revealed left hemisphere hypoperfusion that improved after adenosine administration. Seven months later the patient maintains clinical fluctuation with mild improvement, despite having significant better cortical perfusion on the re-evaluation SPECT scan, without additional therapy. Are we facing a pre-existing blood vessel abnormality associated with a de novo static vasculopathy (dissection) or is it a progressive arteriopathy (atherosclerotic, Moyamoya disease)? Conclusion: What should be done towards critical intracranial stenosis without an established etiology, cerebral hypoperfusion and clinical fluctuation? We must repeat intracranial vascular imaging in order to differentiate nonprogressive from progressive arteriopathies and try to establish a definitive cause. Since the later have a higher risk of stroke recurrence should we optimize medical treatment by improving hypoperfusion or avoiding stenosis progression? Could endovascular treatment and surgery play a role in selected cases?

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P17

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Pseudoathetosis associated with loss of proprioception after acute ischemic stroke - read full article

By: Kyung-Hee Cho and Young-Min Park

Background & Significance: A profound loss of proprioception leads to the pseudoathetosis resulting from the failure of proper integration of cortical sensory function. However, pseudoathetosis has rarely reported in patients with acute ischaemic stroke. We describe a patient who exhibited abrupt loss of proprioception and combined pseudoathetosis following acute cerebral infarct that involved in the postcentral gyrus. Case: A 72-year-old female was brought to the emergency department 1 hour after she suddenly had the tingling sense and involuntary movements of the left arm. She had atrial fibrillation with dual anti-platelet medications. Neurological examination shows the loss of position sense and limb-kinetic movement in the distal part of the left arm. The most remarkable sign was a dystonic posturing and pseudoathetosis of the left arm and leg, which was only reveal when the patient outstretched her extremities with the eyes closed. Diffusion-weighted MRI showed acute infarcted lesion involving right parietal cortex. There was total occlusion of the right proximal internal carotid artery and inferior branch of the right middle cerebral artery in MR angiography. Nerve conduction studies were normal. Conclusions or Comments: The proprioceptive sensory loss without overt damage to the motor system can lead to pseudoathetosis, which rarely occurs following acute ischaemic stroke on the parietal cortex lesion. Postulated that the loss of proprioception causes alterations in the cortical sensory inputs to the striatum and, finally, variable mixtures of involuntary movements. However, why only a small proportion of patients with proprioceptive sensory loss develop involuntary movements is unknown.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P18

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Neurosonology in central retinal artery occlusion—does spot sign have a prognostic value? - read full article

By: I. Correia, A.I. Martins, C. Durque, J.J. Ribeiro, J. Sargento-Freitas, G. Santo, F. Silva, and L. Cunha

Introduction: Central Retinal Artery Occlusion (CRAO), the occlusion of the central retinal artery (CRA), result in retina infarction and vision loss, generally related to cardiac or arterio-arterial embolization. Neurosonology studies are important for etiologic and diagnostic work-up. Recently, a hyperechoic signal was reported within the distal portion of the CRA – “spot sign”. Some authors consider it to be an important predictive prognostic marker for persistent loss of vision since it may indicate calcified or cholesterol emboli and explain the low therapeutic success rate to thrombolysis. Clinical Case: We report a 68-year-old female patient, with known arterial hypertension and diabetes mellitus type 2, who complained of acute, persistent, painless loss of vision in her right eye, except for the superior temporal visual field where figures could be noted. Ophthalmologic examination of right retina revealed a “cherry-red spot”. Carotid and intracranial color-coded sonography showed heterogeneous carotid plaques with irregular surface without hemodynamic significance. Ocular color-coded sonography identified sub-occlusive flow in ipsilateral CRA and “spot sign”. Thoracic angio-CT showed irregular and calcified atheromatous plaques in the ascending aorta and beginning of braquicephalic trunk. She was started on secondary vascular prevention. In clinical follow-up evaluation, two months later, no new vascular episode or visual improvement was seen. Conclusions: In this report we present a CRAO case, in which neurosonology evaluation identified a ‘‘spot sign’’ in the CRA. We hypothesise that this finding may have prognostic value and therefore, neurosonology studies should be used in CRAO evaluation.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P19

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Mild stroke with a proximal occlusion—too good to treat? - read full article

By: Francisca Costa, R. Reis, F. Gomes, L. Fonseca, T. Parreira, M. Silva, and E. Azevedo

Introduction: Mechanical thrombectomy is a recognized effective treatment of acute intracranial proximal occlusions. However, as NIHSS cut-off is a debatable issue, when should we consider an acute stroke severe enough to treat? Our aim is to discuss this issue with an illustrative case. Clinical Case: 58 year-old female, previous mRankin 0, smoker with an history of ductal breast carcinoma submitted to chemotherapy, is admitted mid-afternoon due to a inferior facial paralysis and dysartria noticed at wake-up (NIHSS 2). Brain CT revealed a spontaneous hyperdensity of proximal left M1 segment and a small caudate-capsular-lenticular acute ischemic infarct. Duplex ultrasound revealed a distal ICA occlusion. Echocardiography showed severe depression of left ventricular ejection fraction (20%). Considering the evolution time window and the mild neurologic deficits, a decision to withhold endovascular treatment was made and the patient was admitted to our stroke unit. On the third day, there was neurologic deterioration (NIHSS 14). At this time, brain CT maintained the described infarct area but had a large perfusion deficit in MCA territory, compatible with a significant perfusion mismatch. Angio-CT confirmed ICA distal occlusion. After multidisciplinary discussion, mechanical thrombectomy was performed, 53 hours after symptom onset, successfully (TICI 3). The patient was discharged with anticoagulation (heart failure), with NIHSS 2. Discussion: The decision to intervene in acute stroke events is not taken lightly, as the dynamic nature of these events is not always predictable. Hence, a multidisciplinary and individual approach of these patients might be warranted.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P20

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The outcome in patients with acute ischemic stroke associated with nonvalvular atrial fibrillation—previously on oat or without - read full article

By: Radmila Amanovic Curuvija, Dragana Kosevic, Irena Grkic, Sanja Atic, and Vesna Miletic

Background: Management of non-valvular atrial fibrillation (NVAF) focuses on the use of anticoagulation to decrease the risk of acute ischemic stroke (AIS). Until recently, vitamin K antagonist (VKA) treatment was considered the standard of care, with the emergence of non-VKA oral anticoagulants (NOACs) shifting treatment practice. The question is: what is happening in everyday practice? Methods: To assess the impact of the oral anticoagulant therapy (OAT) to stroke prevention in NVAF,we identified prospectively for six month period in 2015 year, all patients with NVAF and AIS who was previously on OAT or without. The previous clinical studies included in the systematic review of AIS risk factors identified history of AIS, increasing age, hypertension and structural heart disease to be good predictors of AIS risk in NVAF patients. Results: In our data, 199 patients was referred to our Institution due to AIS associated with NVAF, and among them were 115(57,7%) female and 84 (42,3%) male. Mean age was 77,2 years (44-102 years). Among them 49 (24,6%) patients was previously on OAT. In the group of patients who was on OAT, died 14 (7.03%) patients, and in other group-without OAT, died 36 (18.09%) patients. In group with OAT 18 patients had previously AIS. Conclusion: In everyday practice OAT prescription for NVAF in prevention of AIS is extremely low and cannot be scientifically explained in light of well known guidliness. In our data, we proved benefit with OAT in prevention AIS in patients with NVAF.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P21

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Bilateral cerebral hemorrhages: not always portentous - read full article

By: B. Das, D. Khurana, S. Mehta, V.Y. Vishnu, S.R. Bhatkar, V. Lal, and N. Khandelwal

Background: Bilateral intracerebral hemorrhages (BICH) are unusual and limited to case reports. Their presence has long been considered to be associated with worse prognosis. However with availability of newer management strategies for ICH, they may not portend a bad outcome. Observation and results: We looked for cerebral double hemorrhage (CDH) in all acute hemorrhagic stroke patients presented in the emergency department of our tertiary care centre, from January 2013 to June 2015. Six patients of cerebral double hemorrhage (CDH), associated with hypertension were noted. Four patients were over 50 years of age while two were young strokes (43 and 17 years of age) and one was female. Three patients had bilateral basal-ganglia bleed (BBB), one had bilateral thalamic bleed (BTB) while two had dual pathology. All but one was known hypertensive with poor drug compliance. Patients were managed with intensive blood pressure control. All but one patient had significant improvement in sensorium at discharge. Average hospital stay was one week. Conclusion: CDH in contrast to previous belief, may be associated with better outcomes if managed as per current ICH treatment guidelines.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P22

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Nonaneurysmal sulcal subarachnoid haemorrhage in a patient with atherosclerotic intracranial stenosis - read full article

By: A. Gouveia, A. Martins, J. Sargento-Freitas, L. Almendra, F. Silva, B. Rodrigues, C. Machado, G. Cordeiro, and L. Cunha

Background: Nonaneurysmal sulcal subarachnoid haemorrhage (sSAH) is a rare cause of cerebrovascular disease and represents a small proportion of nontraumatic SAH. A few cases of sSAH in patients with extracranial atherosclerotic disease have been reported. However, the association of sSAH with intracranial atherosclerotic stenosis is exceptional. Clinical case: A 54-year-old male patient, with active smoking, hypertension and dyslipidaemia, presents with abrupt severe headache, followed two days later by right visual field defect and fluctuating dysphasia. The initial head CT revealed left peri-rolandic sSHA and, at the fourth day, two new hypodense lesions (left cortical parieto-occipital and left subcortical parietal). Repeated transcranial color coded Doppler (TCCD) evaluations, performed in the first 10 days, found a persistent focal acceleration in distal M1 segment of middle cerebral artery (MCA) with downstream flow attenuation. The digital subtraction cerebral angiography excluded the presence of aneuryms and arteriovenous malformations and showed a severe focal stenosis in distal M1 segment of MCA, with a typical atherosclerotic morphology. Six months later, the patient remains with right inferior homonynous quadrantanopia. In TCCD evaluation there is still evidence of severe MCA stenosis and there has been complete SAH reabsortion in the CT. Conclusion: We report a patient with spontaneous sSAH and ipsilateral severe MCA atherosclerotic stenosis. We propose a causal relationship between them, and discuss its pathophysiological mechanisms.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P23

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Predictors of ischemic infarction in patients with isolated vertigo - read full article

By: Byung Kun Kim

Background and Objectives: Although isolated vertigo is common problems in emergency room (ER), the initial distinction between central and peripheral vertigo in isolated vertigo is not easy. This study aims to evaluate the predictors of ischemic infarction in patients with isolated vertigo. Materials and Methods: The definition of isolated vertigo is vertigo without focal neurologic deficit except nystagmus and postural instability with unknown etiology. Diffusion weighted images were obtained 171 isolated vertigo patients. Results: Among 170 patients, 25 patients had acute lesions on DWI. Twelve out of 25 patients with stroke were impossible of standing without assistance including 5 patients of lateropulsion. Ocular lateropulsion in 2 patients with stroke and gaze evoked nystagmus in two were observed. Central vertigo mimicking peripheral vertigo were 13 out of 25 patients and 4 of them had a catch-up saccade on head thrust test. Nine central vertigo patients had a spontaneous unidirectional horizontal nystagmus. Seventy-six out of 145 patients without stroke had a spontaneous horizontal nystagmus and 53 patients had a catch-up saccade. Three peripheral vertigo patients had GEN and 26 patients were impossible of standing including 5 lateropulsion. Lateropulsion (p=0.014), head thrust test (p=0.039) and inability to stand (p=0.005) were significantly related with differentiation between central and peripheral vertigo. Conclusions: Although lateropulsion, inability to stand and head thrust test is important differential points between central and peripheral vertigo, differential diagnosis of isolated vertigo at emergency room is not always easy.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P24

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Carotid stenosis secondary to head and neck radiation therapy: a case report - read full article

By: Ermal Kurmaku, Erion Dushi, and Jera Kruja

Background: Carotid stenosis secondary to head and neck radiation therapy is becoming increasingly recognized as a cause of stroke in cancer survivors. Although knowledge of its pathology, natural history, and medical, endovascular and surgical therapy has grown proper guidelines are lacking. Case description: We describe a case of a 63 year old man who underwent regular follow up after receiving radiotherapy for a parotid gland cancer. He was never checked for a possible carotid disease until he developed fluctuating neurological signs. At this time the disease became rampant and led to a severe watershed stroke despite medical therapy. Conclusion: It is an emergency for the oncological and stroke societies to bring in new guidelines for the vascular screening of head and neck cancer patients treated with radiotherapy.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P25

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The role of non-invasive treatment in dural arteriovenous fistulas - read full article

By: Célia Machado, J. Araújo, J. Alves, J. Rocha, J. Pinho, and C. Ferreira

Background: Dural arteriovenous fistulas (DAVF) of the cavernous sinus are acquired arteriovenous shunts between dural branches of the internal and/or external carotid arteries and the cavernous sinus. Case Report: An 82 year-old woman was admitted for left eye pain, eyelid edema and conjunctival hemorrhage which developed during the previous 15 days. She presented left periorbital ecchymosis, nonpulsatile exophthalmos, chemosis, conjunctival injection and left external ophthalmoplegia. Ophthalmological evaluation revealed elevated left intraocular pressure (32 mmHg) and normal visual acuity. Cerebral angiography confirmed a DAVF of the left cavernous sinus (Borden classification type I; Barrow classification type D) with no evidence of cortical venous drainage. Non-invasive treatment with left carotid and left eye compression and acetazolamide was decided. Transient clinical improvement of local signs after compression periods, slight improvement of eye movements and reduction of intraocular pressure (24mmHg) occurred. On day 5 of treatment, she developed a mild and transient right motor deficit and compression maneuvers were stopped. Neuroimaging revealed no new lesions. Elevation of intraocular pressure persisted and endovascular treatment was proposed. Discussion: Manual external carotid-jugular compression is an accepted treatment for DAVF of the cavernous sinus except in cases with cortical venous drainage and progressive visual decline. A 30% cure rate with this technique has been reported, with a mean time to closure of 41-123 days. Predictors of compression treatment success include short symptom onset-treatment interval and venous drainage without involvement of the inferior petrosal sinus. We discuss benefits and risks of non-invasive treatment and timing for endovascular approach.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P26

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Neurosonology: a potential diagnostic tool in central retinal vein occlusion - read full article

By: Ana Martins, J. Sargento-Freitas, F. Silva, J. Beato-Coelho, G. Cordeiro, C. Farinha, J. Figueira, and L. Cunha

Introduction: Central retinal vein occlusion (CRVO) is a common vascular retinal pathology. It produces a subacute monocular severe visual loss, usually painless. Retinal and iris neovascularization can result in vitreous hemorrhages, neovascular glaucoma and tractional retinal detachment. The diagnosis is clinical-based, through fundoscopic exam, and supported by fluorescein angiography, an invasive technic requiring intravenous contrast administration. The diagnosis becomes harder in the presence of local complications preventing ocular fundus observation, as hemovitreous, sometimes requiring clarifying surgical intervention. Neurossonology, a non-invasive and safe technic, has not yet been pointed out as a definite diagnostic tool in CRVO. Clinical Case: Female, 82 years old, with known and poorly controlled essential hypertension and type 2 diabetes mellitus, developed a subacute visual acuity impairment in her left eye, allowing solely hand movements visualization. Ophthalmoscopy reveled a total hemovitreous of the left eye. Ocular echography did not show any other lesions. Differential diagnosis stood between CRVO and ocular arterial ischemic syndrome. Transorbital colour coded Doppler identified a preserved left ophthalmic artery and a reverberant flow in the central retinal vein, suggesting CRVO. The patient underwent pars plana vitrectomy associated to endolaser as management of this secondary complication of CVRO. Conclusions: The present clinical case underlines a potential new neurossonologic application, as a diagnostic tool in CVRO, particularly useful when ocular fundus cannot be properly visualized.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P27

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Carotid ultrasound and intraluminal mobile echoes: differential diagnosis - read full article

By: Irene Mendes, Vanda Pos-de-Mina, and Mateus Sónia

Introduction: Mobile intraluminal non-artifactual echoes in the carotid artery are rare findings. The differentiation between flapping atheromatous plaque, flapping thrombus, free-floatand even a combination of these with ultrasound is potentially difficult, in part due to the lack of precise description in the literature. It`s potential embolic risk makes the diagnosis an important and urgent issue. Methods: Retrospective and descriptive study including all patients referred to our Lab (LUSCAN) to perform carotid ultrasound, since 2007 to 2015. From the 7500 exams performed we selected the reports with mobile intraluminal non-artifactual echoes in the carotid artery and reviewed image`s characteristics. Results: We found five cases – two arterial wall adherent thrombus; a `flap` associated with plaque rupture; and two thrombus adherent to atheromatous plaque. In all cases the diagnosis was made by carotid ultrasound. There was one female patient, ages between 35 and 88 years, one patient was asymptomatic. The symptoms were homolateral to carotid lesion. The two arterial wall adherent thrombus were associated with prothrombotic conditions: pregnancy and lung carcinoma. From the five patients, four had a different therapeutic approach due to ultrasound findings – were anticoagulated. We describe the five patients and compare our findings with the literature data. Conclusion: Although rare, differential diagnosis of mobile intraluminal non-artifactual echoes in the carotid artery is crucial due to the need of further investigation of inherent causes and different therapeutic approaches.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P28

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Mechanical thrombectomy in acute stroke - read full article

By: Valentina Mileusnic, Slobodan Culafic, Aleksandra Zecevic, Irena Grkic, and Vesna Miletic

Background: Thrombectomy is a method of recanalization of occluded large cerebral arteries of the head and neck in acute stroke in a specified time window. This study included 17 patients who were treated at the Special Hospital for Cerebrovascular Diseases ‘St. Sava’ in the period March 2014 - December 2015. It involved monitoring patients until they were discharged from the hospital. All were divided into 2 groups: A group - 3 patients received the thrombolytic therapy (Aktiliza faktor), after which was performed thrombectomy; B group - 14 patients who were outside of the time window for thrombolytic therapy or did not meet the criteria. Therefore, only the thrombectomy was performed. Methods: All the patients undergone CT and CTA of endocrnium, laboratory testing, and X-Ray of lungs, and were scored by NIHSS and Rankin Scale. Mechanical thrombectomy was performed by Solitaire™ stent device. Results: (After the thrombectomy), without a deficit and smaller deficits (Rankin 0-1) – group A-5 patients, group B-1 patient; Severe disability (Rankin 5) – group A-3 patients, group B-1 patient ; Exitus letalis (Rankin 6) – group A-6 patients, group B-1 patient. Conclusion: The questions remains for the next Controversy: first thrombolysis and then thrombectomy, or just thrombectomy of occluded large cerebral arteries of the head and/or neck in acute stroke.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P29

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Thalamomesenteric infarction presenting as vertical one-and-a-half syndrome with contralesional horizontal gaze palsy - read full article

By: B. Na, H. Rhee, Y. Kwon, and S. Yoon

Vertical one-and-a-half syndrome consists of a bilateral conjugate upgaze palsy and a unilateral downward palsy or a bilateral conjugate downward palsy and a monocular upgaze palsy. We describe concurent vertical one-and-a-half syndrome and contralesional horizontal gaze palsy in a patient with acute ischemic stroke limited to unilateral paramedian thalamus and upper midbrain. A 75-year-old man admitted to our hospital for an abrupt onset of diplopia and ptosis. on admission, neurological examination revealed bilateral ptosis, conjugate upgaze palsy, downward gaze palsy of the right eye, and conjugate gaze limitation to the left side. two hours after the onset, the patient developed the left facial palsy and mild left-sided limb weakness (MRC grade 4). The diffusion-weighted MRI of the brain showed a focal high signal intensity in the right paramedian thalamus and upper midbrain. In this case, complex combinations of vertical and horizontal ocular motor disturbances was caused by an unilateral ischemic lesion of the meso-diencephalon. The patient showed vertical one-and-a-half syndrome with bilateral ptosis, contralesional conjugate gaze palsy, and hemiparesis. The impairment of upward ocular movements can be explained by a lesion affecting the riMLF or posterior commissure. It is suggested that the horizontal gaze palsy was caused by the involvement of the descending fibres from the frontal eye fields of the cerebral cortex before decussation at the midbrain level.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P30

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Comparison of frequency of death in patients with ischemic stroke and with/without diabetes mellitus - read full article

By: V. Miletic, Katarina Savic Vujovic, V. Golubovic, I. Grkic, M. Stojanovic, A. Zecevic, V. Mileusnic, R. Curuvija, V. Petrovic, and A. Vujovic

Diabetes mellitus is a strong risk factor for atherosclerosis and cerebral ischemia. Hyperglycemia often meet with non-diabetic patients, as a reflex mechanism, or the stress response to ischemic trauma. It was found that hyperglycemia associated with stroke, had a poor outcome. It is believed that this phenomenon is due to increased permeability of the blood-brain barrier, which occurs due to anaerobic glycolysis and increase acidity in the brain tissue.There is no solid evidence that good glucose levels reduces the risk of stroke in diabetics. The aim of this study was to compare the incidence of mortality in patients with ischemic stroke and diabetes mellitus compared to mortality in patients with ischemic stroke but without diabetes mellitus. 84 patients were hospitalized with acute ischemic stroke (November, 2015. There were 45 women (53.6%) and 39 men (46.4%). Twenty patients (23.8) with CVI had diabetes mellitus. 17 patients used oral antidiabetics and 3 an insulin. Mortality rate for this period was 27 patients (32%). In diabetic patients lethal outcome occurred in 5 cases (25%), while in the group of patients who did not have diabetes mellitus exitus occurred in 22 patients (34.3%). There was no statistically significant difference in mortality between the groups with acute ischemic stroke and diabetes and those with acute stroke without diabetes, but prevention of stroke in patients with diabetes is the correction of risk factors for the development of macrovascular complications.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P31

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Laterality of deep intracerebral haemorrhage and clinical outcome - read full article

By: R. Diaconescu, C.C. Stancu, M.F. Coteanu, M. Paunescu, D.L. Gavrila, and I.E. Plesea

Background: Intracerebral haemorrhage (ICH) is a devastating form of stroke, representing one of the main cause of death nowadays. Despite the fact that the percentage of the hospitalized patients with ICH has increased lately, the mortality rate has not declined. Purpose: To investigate the relationship between hemispheric laterality of acute deep ICH and clinical outcomes. Methods: We analyzed 469 patients with brain CT scan proven deep ICH of ?30 ml volume, presenting within 6 hours of symptoms onset. Baseline and 5 days Glasgow Coma Scale and National Institutes of Health Stroke Scale scores, 30 days modified Rankin Scores and mortality data were recorded. For morphological analysis, information was obtained from brain CT scans (baseline, and at 5 days) and autopsy reports. Hematoma volume was determined by the ABC / 2 method. Hematoma expansion was defined as an increase in ICH volume ? 33% of baseline. Results: The deep ICH we analyzed showed laterality that slightly favored left side (54%). 30-day mortality was higher among patients with left side deep ICH (33%). There were no differences between right and left side deep ICH regarding the major disability. Hematoma expansion was the strongest predictor of 30-day mortality and disability for all locations of deep ICH. Conclusions: Left side deep ICH proved to be more aggressive, associated with a higher risk of death.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P32

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Substance abuse as a cause for intracerebral hemorrhage - read full article

By: Mirjana Stojanovic, I. Grkic, V. Miletic, and B. Solunac

A right-handed thirty-six year old male presented with an acute loss of function in left limbs and profound sleepiness. Cranial CT showed findings suggestive of intracranial haemorrhage in the right fronto-temporal subcortical area (dimensions 66x36x63mm) with mild perifocal oedema and mass effect; bleeding extended into the lateral ventricle. On the left side, in the fronto-temporal subcortical area a smaller intracranial bleed was noted. CT angiography did not show signs of arterio-venous malformations nor aneurysms. Past medical history was unremarkable and there were no known drug allergies. Further history revealed that the patient took amphetamine with diazepam and high energy drinks immediately before the onset of his symptoms. No other known causes of intracranial bleeding were identified. We have shown that drug abuse can be a cause for intracranial bleed, especially amongst the younger population. It should therefore be considered especially when other causes are excluded.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P33

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Hyperventilation induced hypocapnia should be avoided in cases of cerebral hypoperfursion - read full article

By: K.J. Szabó, B. Rosengarten, L. Csiba, and L. Oláh

Introduction: Previous studies proved that hypercapnia induced vasodilation does not inhibit the visually evoked flow velocity changes in the posterior cerebral arteries. Our aim was to determine whether vasoconstriction induced by hypocapnia affects the neurovascular coupling. Methods: By using visual cortex stimulation paradigm, visually evoked flow velocity changes were detected by TCD in both PCAs of young healthy adults. The control measurement was followed by the examination under hyperventilation (HV). Visual-evoked-potentials were also recorded. Results: Comparing control and HV phases, the breathing frequency significantly increased (16±2 vs. 37±3/min), resulting in significant decrease of the end-tidal CO2 (37±3 vs. 25±3 mmHg) and decrease of resting peak systolic flow velocity (58±11 vs. 48±11 cm/s). To allow comparisons between volunteers, relative flow velocity was calculated in relation to baseline. Repeated measures analysis of variance revealed significant difference between the relative flow velocity time courses during hyper- and normoventilation (p0.001). The maximum changes of visually evoked relative flow velocities were 26±7% and 12±5% during normoventilation and HV (p0.01), respectively. VEPs did not differ during control and HV phases. Conclusions: The significantly lower visually evoked flow velocity changes but preserved VEP during HV suggested that hypocapnia induced vasoconstriction significantly inhibited the neuronal activity evoked flow response. Potential vascular effects of HV should not be ignored in patients with advanced steno-occlusive lesions of the brain supplying arteries, because decreased CBF, impaired vasodilation of resistance vessels, and attenuated cortical activity induced flow response, caused by HV, may increase the risk of cerebral ischemia in hemodynamically compromised patients.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P34

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Blood pressure management in acute ischemic stroke—the lower the better? - read full article

By: Ricardo Varela, A. Martins, J. Sargento-Freitas, F. Silva, J. Ribeiro, I. Correia, J. Gomes, M. Gonçalves, L. Cardoso, C. Machado, B. Rodrigues, G. Santo, and L. Cunha

Historical stroke cohorts reported a curvilinear relationship between blood pressure (BP) and clinical outcome. However, those studies were made disregarding recanalization state and predated current revascularization strategies. We aimed to investigate the relationship between BP in the in the first 24 hours after ischemic stroke and clinical outcome in patients submitted to intravenous and/or intra-arterial recanalization treatments. Consecutive acute stroke patients treated with intra-venous thrombolysis and/or intra-arterial therapies were enrolled in a retrospective cohort study. BP measurements were performed on regular intervals during the first 24 hours after stroke onset. The mean systolic BP (SBP) and diastolic BP (DBP) during the first 24 hours post-stroke were calculated. Recanalization was assessed at 6 hours by transcranial color coded Doppler, angiography or angio-CT. Functional outcome was assessed at 3 months by modified Rankin scale. Linear and quadratic multivariate regression models were performed to determine associations between BP and functional outcome. We included 674 patients, mean age 73.28 (SD: 11.50) years, 363 (53.90%) male. Arterial recanalization was documented in 355 (52.70%) patients. In multivariate analyses SBP and DBP in the first 24 hours post-stroke show a “J”-shaped relationship with functional outcome in the whole population and in the non-recanalyzed patients. Recanalyzed patients show a linear association with functional outcome. Previous concepts remained true regarding non-recanalyzed patients, however in recanalyzed patients lower systemic BP was associated with better outcome raising questions about features of this population, if there’s any room for active treatment and if so, how low should we go.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P35

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Non stenosing floating thrombus in carotid artery—case series - read full article

By: Joanna Wojczal, P. Luchowski, K. Rejdak, and Z. Stelmasiak

Non stenosing floating thrombus (FT) in carotid artery is a rare condition causing TIA or ischemic stroke (IS). The true incidence, precipitating condition and treatment is unknown. We found 5 patients with non stenosing FT in carotid artery from about 2500 routine duplex ultrasound examinations performed in acute ischemic stroke/TIA setting in 2,5 years period (incidence about 0.2%). All the patients presented clinically as TIA and in 4 of them minor infarcts were found on brain MRI. The mean age of the patient was 42 years. In all patients no obvious cause of thrombus formation was found by transthoracic and transesophageal echocardiography, holter ECG and hypercoagulable state examinations, and atheromatous plaques were absent as well. Two patients underwent upper respiratory tract infections two weeks before TIA. The patients were treated with therapeutic doses of LMWH and all of FT were dissolved within 7 days, as diagnosed by repeated ultrasound examinations. No complication was observed. FT can be a direct cause of TIA/minor stroke in young patients, however the precipitating condition of the thrombus formation is difficult to establish. The FT in carotid artery with clinically TIA and minor infarct on brain MRI can be treated successfully by LMWH, however the true value of the treatment must be confirmed in a larger study.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P36

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MoCA vs MMSE in post stroke patients - read full article

By: Sokrat Xhaxho, Jora Xhaxho, Joana Hankollari, Brunilda Xhaxho, and Jera Kruja

Introduction: Both the MMSE and the MoCA are routine cognitive screening tests rated on a 30-point scale. Neither test is very detail oriented and both would likely be used only for initial screening. The MoCA discriminates very well between normal cognition and mild impairment or dementia, but it’s too difficult for moderate to severe conditions, while the MMSE is likely a better test for more severe conditions. Aim: To evaluate the cognition in post stroke patients. To see if there is any difference between MoCA and MMSE tests and determine which one is the best to use in order to better evaluate the cognition in those patients. Methods: We included in this study 100 patients 24-48 h post stroke that were hospitalized in Clinic of Neurology, in University Hospital Centre “Mother Teresa”, Tirana. We evaluated each of them with MoCA and MMSE test one after the other. At the end we compared the mean of the points for each test. Results: We have a mean of 21.6 points for MoCA test and 23.75 points for MMSE test (normal 26 points for MoCA test and 27 points for MMSE test). There is a difference of 2.15 points between the tests. P=0.00766 that means that the difference is statistically significant. Conclusions: Cognition is an affected function in 24-48 h post stroke patients. The best way to evaluate this is MoCA test.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P37

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Cerebral and systemic endothelial functions in leukoaraiosis - read full article

By: Marjan Zaletel, Matija Zupan, Janja Pretnar-Oblak, Katarina Surlan, and Bojana Zvan

Background: Clinical relevance of leukoaraiosis (LA), its pathophysiology is still unclear. In the present work, we are focused on answering the question whether LA patients have cerebral and/or systemic endothelial dysfunction and whether this is solely a consequence of vascular risk factors (VRF). Subjects and Methods: Thirty patients with LA (58 ± 7 years) and 30 sex- and age-matched controls without LA (55 ± 6 years) were recruited with identical VRF. The cerebral endothelial function was determined by cerebrovascular reactivity to L-arginine (CVR) using TCD measurements of mean arterial velocity in both middle cerebral arteries before and after intravenous L-arginine infusion. The systemic endothelial function was determined by flow-mediated dilatation (FMD). All participants underwent a brain magnetic resonance imaging to search for radiological signs of LA that was classified according to the Fazekas score. Results: We found a significant decrease in both CVR (9.6 ± 3.2% vs. 15.8 ± 6.1%, p0.001) and FMD (4.8 ± 3.1% vs. 7.4 ± 3.8%, p=0.004) in patients with LA compared to controls. Both CVR (7.4 ± 3.1% vs. 12.2 ± 2.6%, p=0.001) and FMD (3.0 ± 2.2% vs. 6.4 ± 3.1%, p=0.011) were significantly decreased in LA subgroup Fazekas 3 compared to the subgroup Fazekas 1. The CVR and FMD significantly positively correlated in patients with LA (b=0.192, 95% CI=0.031-0.354, p=0.02). Conclusions: The results suggest that patients with LA have a significant impairment of both cerebral and systemic endothelial function, that is larger than could be expected, based on present VRF.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P38

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A new simple score for assessing behavioral and psychological symptoms of dementia (Abe’s BPSD SCORE=ABS) - read full article

By: Koji Abe, T. Yamashita, Y. Nakano, R. Morihara, Y. Ohta, and N. Hishikawa

In addition to cognitive impairment, behavioral and psychological symptoms of dementia (BPSD) are another important aspect of most dementia patients including post-stroke dementia. We attempted to create a new BPSD score for dementia with 10 BPSD items. This new simple BPSD score was compared to a standard-detailed BPSD score neuropsychiatric inventory (NPI) for a possible correlation (n=792) and a time to complete (n=136). Based on the clinical survey for local caregivers, a new BPSD score for dementia (ABS, Abe`s BPSD score) was newly created, in which each BPSD item was allotted by an already-weighted score (maximum 1–9) based on the frequency and severity, and was finalized with taking temporal occurrences into account. ABS was filled by the main caregiver with a full score of 44, was well correlated with NPI (r = 0.716, **p 0.01) in 792 AD patients (age 78.6 ± 7.0 years, MMSE 19.0 ± 5.9), and took a shorter time as only 56.8 ± 38.8 s (**p 0.01) than NPI score (132.7 ± 94.0 s) with 136 AD patients. A high inter-rater reliability was obtained (r = 0.964, **p 0.01) with a little smaller score (0.877 time) of ABS in secondary than the main caregivers. Thus ABS provides a new simple and quick test for BPSD assessment, with a good correlation to NPI but a shorter time, and with a high inter-rater reliability (Abe K et al.: J. Neurol. Sci. 2015; 350: 14-17).

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P39

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Synaptic proteins predict cognitive decline in Alzheimer's disease and Lewy body dementia - read full article

By: Erika Bereczki, P. Francis, J. B. Pereira, A. Bogstedt, J. H. Baek, C. Ballard, and D. Aarsland

Background: Initial work suggests that the loss of synapses is more robustly correlated with cognitive decline than the traditional markers of Alzheimer`s disease (AD) pathology, Our objective was to compare the levels of three synaptic proteins involved in different steps of the synaptic transmission: Rab3A, SNAP25 and neurogranin, in three common forms of dementia: AD, dementia with Lewy bodies (DLB) and Parkinson’s disease dementia (PDD). Methods: 129 post-mortem human brain tissues from PD, DLB, AD and non-demented controls were analyzed using ELISA and Western blots in brain regional specific manner exploring their associations with morphological changes and cognitive decline. Results: We have observed robust changes reflecting synaptic dysfunction in all studied dementia groups. Decreased Rab3A and SNAP25 levels correlated with increased rate of cognitive decline in DLB and AD as well as with neuropathological markers. Discussion: Our results suggest that stabilization of synaptic protein levels such as Rab3A may represent an important treatment strategy in DLB patients, while SNAP25 could be a new marker in the progression of AD. These findings indicate that the proposition that synaptic markers can predict cognitive decline in AD, should be extended to Lewy body diseases.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P40

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Expression of regulatory proteins in choroid plexus changes in early stages of Alzheimer’s disease - read full article

By: A. Krzyzanowska, I. García-Consuegra, C. Pascual, D. Antequera, I. Ferrer, and Eva Carro

The role of choroid plexus in Alzheimer’s disease (AD) is being increasingly recognized. Recent studies suggest that the choroid plexus has a more important role in physiological and pathological brain functions than previously appreciated. To obtain additional insight on choroid plexus function, we performed a proteomic analysis of choroid plexus samples from AD stages I-II (n = 16), III–IV (n = 16), and V–VI (n = 11), and 7 age-matched control subjects. We used differential 2D electrophoresis (2-D DIGE) coupled with mass spectrometry to generate a complete picture of changes in choroid plexus protein expression occurring in AD patients. We identified 6 proteins: 14-3-3 ?/?, 14-3-3 ?, moesin, proteasome activator complex subunit 1 (PSME1), annexin V, and aldehyde dehydrogenase (ALDH), which are significantly regulated in AD pathology (p0.05, 1.5-fold variation in expression comparing with control samples), with central physiological functions, including mitochondrial dysfunction and apoptosis regulation, and able to model key pathological events. The data presented here contribute additional significance to the emerging importance of molecular and functional changes of choroid plexus function in the development of AD pathology.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P41

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Neuropsychological domains sensitive to conversion of dementia in non-demented patients with Parkinson’s disease - read full article

By: Sang-Myung Cheon, Su-Yun Lee, Jae Woo Kim, and Hye-Mi Jeong

Backgrounds and objectives: Dementia is one of the most disabling symptoms in patients with Parkinson’s disease (PD). The aims of this study were to investigate the neuropsychological and mild cognitive impairment (MCI) subtypes related to conversion of dementia in non-demented PD and PD-MCI patients. Methods: PD patients taken comprehensive neuropsychological test were recruited from outpatient clinic of referral hospital. PD with dementia (PDD) was defined according to the DSM-4 and PD-MCI by impaired performance on at least one of five cognitive domains. Five tests (forward digit span, Boston Naming Test, Rey Complex Figure, Seoul Verbal Learning Test and phonemic word test) were chosen as a baseline assessment to represent five cognitive domains; attention, language, visuospatial, memory and frontal/executive functions. Those tests were compared between PDD converters and non-converts in non-demented and PD-MCI patients. Results: Total 476 patients were recruited. Among them, 41 patients had become PDD converters and they showed older age at onset, lower education level and MMSE score, and higher MCI frequency. Dysfunction in the domains of language, visuospatial and memory were more prevalent in PDD converters at baseline. Among 205 PD-MCI patients, 27 PD-MCI patients converted to PDD, and they showed poor performance in visuospatial function. Conclusions: Visuospatial function was found to be a most sensitive domain to PDD conversion in non-demented patients with PD. This finding suggests that the performance of posterior cortical function would be more related to conversion of dementia in patients with PD.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P42

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Clinical diagnosis and biomarker constellation in AD in a clinical setting: how congruent are the biomarker findings - read full article

By: Hermann-Josef Gertz, David Weise, Solveig Tiepolt, Karl-Titus Hoffmann, Donald Lobsien, Thorsten Kaiser, Henryk Barthel, and Osama Sabri

Objectives: In clinical practice biomarkers are thought to confirm or exclude the diagnosis of AD. Methods: Cross-sectional observational study with 54 patients with mild cognitive impairment or dementia due to AD or not due to AD. Biomarkers of neuronal injury were medial temporal lobe atrophy (MTA) on magnetic resonance imaging (MRI) and tau concentration in the cerebrospinal fluid (CSF). CSF A? 1-42 and amyloid-targeting positron emission tomography (PET) were considered as biomarkers of amyloid pathology. Results: Forty cases were diagnosed as AD, 14 cases as non-AD based on clinical, neuropsychological and routine MRI assessment. In the AD group completely consistent pathological biomarkers were found in 32.5%. In 62.5% the findings were inconsistent. Congruence of biomarkers was 67.5% for neuronal injury and 75% for amyloid dysfunction. In two patients clinical diagnosis switched to non-AD due to completely consistent non-pathological biomarker findings. The criteria of the international working group (IWG-2, Dubois et al. 2014) were met in 75.0% of the clinically diagnosed AD cases. Conclusions: Different explanations of incongruent biomarker results need to be considered, including technical inaccuracies and too rigid cut off points. The different biomarker constellations represent distinct types or stages of AD.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P43

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The cholesterol oxidation products may underlie alpha-synuclein accumulation in Alzheimer’s disease and Parkinson’s disease - read full article

By: Othman Ghribi

Accumulation of alpha-synuclein (alpha-Syn) is a common hallmark of a group of brain disorders collectively known as synucleinopathies. These disorders include Parkinson`s disease (PD), the most common movement disorder; dementia with Lewy bodies (DLB), the second most common form of dementia; multiple system atrophy (MSA), a neurodegenerative disease leading to severe physical impairment; and Alzheimer’s disease (AD), the most common form of dementia. The role of alpha-Syn in the pathogenesis of synucleinopathies is not understood, but experimental studies point to a potential neurotoxic role of high levels of this protein in its soluble or aggregated forms. We found that the oxysterol 27-hydroxycholesterol (27-OHC), the major cholesterol oxidation metabolite in human plasma, causes both AD-like pathology and PD-like pathology in human neuroblastoma cells and in organotypic slices. We found that 27-OHC increases alpha-Syn transcription through activation of liver X receptors (LXR). Furthermore, we demonstrate that while activation of LXR with specific agonists increases, inhibition of LXR with specific antagonists reduces alpha-Syn accumulation. Such results suggest a possible role of oxysterols and LXR signaling in synucleinopathies. Oxysterol levels are elevated in the circulation in hypercholesterolemic individuals. Interestingly, oxidative stress can also increase conversion of cholesterol to oxysterols. Our data are significant to identifying factors that may contribute to the pathogenesis of synucleinopathies and to the underlying cellular mechanisms. Identification of such factors and signaling pathways is paramount to understanding the pathophysiology of synucleinopathies including AD.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P44

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Evidence of progressive pathogenesis in the brains of comparative normative control samples in an Alzheimer’s disease study - read full article

By: Brian Jeynes and J. Provias

Tissue samples from aging normative brains are rarely Alzheimer’s disease (AD) lesion burden free. In this study we investigate the AD lesion burden within comparative normative (NM) brain samples used in a study investigating the pathogenesis of AD. Quantitative data which included counts of NFTS, SPs, and capillaries immuno-stained for VEGF, eNOS, LRP, RAGE and P-gp from comparable and 10 randomly selected superior temporal site samples in each of 14 normative brains. The samples were taken from 8 female and 6 male brains aged 63 to 80 years. For the purposes of this study the brains were divided into two groups: those with less than 2 NFTs and / or 4 SPs (low lesion); and those with more of either lesion (high lesion). Our results demonstrate that there is a significant difference between the two groups and that the high lesion group results were quantitatively higher in every observation category (p=0.01 or less). Both LRP and P-gp expression levels were significantly negatively correlated to both NFT and SP burdens (p=0.05 or less). These results point towards underlying pathogenic blood-brain barrier microvascular alterations and dysfunction in normative brains and, further, are supportive evidence for progressive AD lesion pathogenesis in aging normative brains.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P45

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Huge intracranial tumors mimicking Alzheimer’s disease - read full article

By: S. Jung, Y.K. Minn, and S.H. Hwang

Abstract: Background & Significance: Whereas Alzheimer`s disease (AD) is degenerative disease and its clinical symptoms present with insidious onset and slow deterioration, symptomatic secondary dementia can also present slow progression of clinical symptoms mimicking AD. Case: A 73-year-old female presented with memory impairment for 2-3 years. Her symptoms progressed slowly and she could not maintain her daily routine activities by herself. Neurologic examination revealed no focal deficits, but extensive neuropsychology evaluation showed decreased attention, language, visuospatial, memory and executive functions as seen in patients with AD. Brain MRI revealed a huge meningioma compressing bilateral mesial frontal lobes and a bone tumor (cavernous hemangioma) on right anterior cranial fossa. She was referred to a neurosurgeon for surgical removal. Comments: We report a case of slowly progressing memory impairment mimicking AD caused by huge intracranial tumors.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P46

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Oxidative stress in Alzheimer's disease patients—study using d-ROM and BAP test - read full article

By: Kiyoshi Kanaya, Shine Abe, Hiroko Fujii, and Haruo Hanyu

Purpose: The oxidative stress and biological antioxidant potential of Alzheimer`s disease ( AD ) patients were measured using a free radical elective evaluator (FREE). Subjects and methods: The subjects consisted of 48 untreated AD patients examined at the Department of Geriatric Medicine of the Hachioji Medical Center. All subjects underwent an Alzheimer`s Disease Assessment Scale-cognitive component-Japanese version (ADAS-Jcog), oxidative stress was assessed by measuring serum dROM levels , BAP (biological antioxidant potential) and BAP/dROM ratio using FREE, and correlations between ADAS scores and oxidative stress indicators were tested. Degree of dementia was determined by using ADAS scores to categorize the subjects into three groups consisting of a mild (ADAS score: 0-9 ), moderate ( Score: 10-19 ) and advanced group (Score: 20 or higher) , and analyzing variance for dROM levels, BAP and BAP/d-ROM ratio among each group. Results: The average ADAS-Jcog score was 15.1. The average values for d-ROM levels, BAP and BAP/d-ROM ratio were 441.8, 2497.1 and 6.06, and when compared with each of their reference values, d-ROM levels indicated severe oxidative stress while BAP values indicated appropriate biological antioxidant potential. There was a negative correlation between ADAS scores and BAP values (r=0.313, P=0.03). An analysis of variance among the three groups yielded a relationship such that BAP/d-ROM ratio was significantly higher in the advanced group in a comparison between the mild group and advanced group (P=0.048). Conclusion: Elevated d-ROM levels and normal BAP values suggest an increase in oxidative stress accompanying chronic inflammation.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P47

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Effect of Edirex-Sanovel (pioglitazone) medication on the incidence of dementia - read full article

By: Vera Kapetivadze, R. Tabukashvili, N. Gegeshidze, Kh. Tchaava, T. Lazashvili, Z. Magapheridze, and Z. Grigorashvili

Objective: Peroxisome proliferator activated receptor ?-activating drugs show various salutary effects in preclinical models of neurodegenerative disease. The decade-long clinical usage of these drugs as antidiabetics now allows for evaluation of patient-oriented data sources. Methods: Using observational data from 2012-2015, we analyzed the association of Edirex-Sanovel (pioglitazone) and incidence of dementia in a prospective cohort study of 45 subjects aged ?60 years who, at baseline, were free of dementia and insulin-dependent diabetes mellitus. We distinguished between nondiabetics, diabetics without Edirex-Sanovel, diabetics with prescriptions of 6 calendar quarters of Edirex-Sanovel, and diabetics with ?6 quarters. Cox proportional hazard models explored the relative risk (RR) of dementia incidence dependent on edirex-sanovel use adjusted for sex, age, use of rosiglitazone or metformin, and cardiovascular comorbidities. Results: Long-term use of pioglitazone was associated with a lower dementia incidence. Relative to nondiabetics, the cumulative long-term use of Edirex-Sanovel reduced the dementia risk by 49% (RR = 0.50, p = 0.027). If diabetes patients used Edirex-Sanovel 6 quarters, the dementia risk was comparable to those of nondiabetics (RR = 1.20, p = 0.36), and diabetes patients without a Edirex-Sanovel treatment had a 25% increase in dementia risk (RR = 1.27, p 0.001). We did not find evidence for age effects, nor for selection into Edirex-Sanovel treatment due to obesity. Interpretation: These findings indicate that Edirex-Sanovel treatment is associated with a reduced dementia risk in initially non-insulin-dependent diabetes mellitus patients. Prospective clinical trials are needed to evaluate a possible neuroprotective effect in these patients in an ageing population.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P48

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Interaction of thymoquinone with alpha 7 nicotinic acetylcholine receptor in LPS-induced neuroinflammatory model - read full article

By: O.A. Heikal, Lobna Kassem, Maha Zekri, Islam Diasty, and Esraa Osama

Alzheimer’s disease (AD) is neurodegenerative disorder resulting from loss of cholinergic neurons in brain especially acetylcholine. It has been reported that alpha-7 nicotinic acetylcholine receptors (alpha-7 nAchRs) play an important role in cognitive function and can be target therapy for treating cognitive deficits. alpha-7 nAchR agonists cause memory enhancement through phosphorylation of cAMP response element binding protein (CREB). Thymoquinone (TQ) was recently considered as acetylcholine esterase inhibitor and increased alpha-7 nAchR expression in brain. However, the effect of TQ as alpha-7 agonist has not been investigated. Our aim was to investigate the mechanism of action of TQ on alpha-7 nAchR. Neuroinflammatory AD rat model was developed by injecting LPS i.p (0.8 mg/kg) once. A specific alpha-7 agonist and alpha-7 positive allosteric modulator were used. Rats were injected with TQ (10 mg/kg) i.p for 5 consecutive days with or without alpha-7 positive allosteric and another qroup with alpha-7 agonist + alpha-7 positive allosteric modulator. After one week, rat brains were subjected to immunohistochemical studies. Molecular docking studies were done in which TQ was docked on chimeric acetylcholine binding protein. Results indicate significant decrease in amyloid plaques with significant increase in p-CREB expression in TQ treated groups especially the group treated with TQ and allosteric modulator. Docking results show hydrophobic interactions of TQ similar to ligand interactions in complex with the receptors. This indicates the possible direct agonistic effect of TQ on alpha-7 nAchR and its role in modulating cognitive defects. TQ can be promising therapeutic module for treatment of AD.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P49

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Association of cerebrovascular disease with peripheral artery disease in older adults - read full article

By: Yong Soo Shim, San Jung, Bora Yoon, and Dong Won Yang

Background: Vascular disease is prevalent in older adults. Cognitive impairment and dementia may result from cerebrovascular disease. Transcranial Doppler (TCD) is a noninvasive technique for evaluating cerebral hemodynamics. Also, the ankle-brachial pressure index (ABI) and pulse wave velocity (PWV), markers of peripheral arterial disease, are known to be associated with cognitive impairment. We evaluated the association of TCD parameters, markers of cerebral microvasculopathy, with peripheral artery disease, as indicated by ABI and brachial-ankle PWV (baPWV). Methods: A total of 184 participants were included: 49 controls, 72 patients with mild cognitive impairment (MCI), and 63 patients with Alzheimer’s disease (AD). Demographic characteristics, mini-mental state examination (MMSE), and clinical dementia rating_sum of boxes (CDR_SOB) were assessed. Using TCD, cerebrovascular reactivity (CVR) was evaluated, in addition to the mean blood flow velocity (MFV), pulsatility index (PI), and resistance index (RI) of the middle cerebral artery. We also assessed baPWV and ABI. Results: The mean age of participants was different among 3 groups: controls; 66.45±6.53, MCI; 69.25±8.32, and AD; 74.56±6.07 (p=0.001). Additionally, markers of cerebral and peripheral artery disease are all different among 3 groups (all, p=0.05). After adjusting for age, ABI was associated with MFV (right; r=-0.225, p=0.005 and left; r=-0.169, p=0.035) and MMSE score (right; r=0.203, p=0.007 and left; r=0.159, p=0.048). Conclusion: There was an association of a marker of peripheral artery disease (ABI) with the impaired function of cerebral microvessels (MFV) and cognitive impairment. Management of peripheral vascular disease may help prevent the progression of cerebrovascular disease or cognitive decline.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P50

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Validation of olfactory deficit as a biomarker of Alzheimer’s disease - read full article

By: Kinga Szigeti, Muhammad Ubaid Hafeez, Matthew Woodward, Jesper Hagemeier, Ralph Benedict, and Li Yan

With increased longevity the prevalence of AD in the elderly represents a major public health problem. Olfactory identification deficit (OID) may represent a parallel neurodegenerative process preceding the AD disease trajectory. Clinical study with three components was performed: i) cross-sectional case-control study to evaluate the sensitivity and specificity of OID in differentiation normal aging from an amnestic disorder; ii) an exploratory longitudinal study of aMCI subjects (mean follow-up 477.6 ±223.3 days) to evaluate the utility of OID in predicting conversion from aMCI to AD; iii) a structural MRI subset (27 NC, 15 aMCI and 37 AD) to correlate OID with regional brain volumes. Correlation trend test between odor identification and disease status was significant after correcting for age, sex, and ApoE in the model (p=1.52x10-59). ROC/AUC was similar for the 40 item UPSIT and the top 10 smells. Smeller/non-smeller based on the 10 item subset with a cutoff of 7 ( = 7, non-smeller; 7, smeller) had a sensitivity and specificity of 88% and 71% for identifying AD. Conversion rates in the aMCI group were 36.4% in non-smellers and 17.3% in smellers (p=0.03). Volumetric analysis revealed differences in right hippocampal volumes between smellers and non-smellers in the aMCI stage. OID in the context of an episodic memory impairment reflects early right hippocampal involvement suggesting a central mechanism. Longitudinal studies exploring the time relationship between the trajectory of decline in olfactory identification and the development of an amnestic disorder are needed to further characterize the relationship.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P51

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Chronic obstructive pulmonary disease as a risk factor for dementia - read full article

By: Saule Turuspekova, D. Mitrokhin, A. Zhanayev, A. Ablayeva, G. Zhilkibayeva, and A. Umarbayeva

Relevance: Chronic obstructive pulmonary disease (COPD) remains a major public health problem. According to data released by the World Bank and the World Health Organization (WHO), it is expected that in 2020 it will be on the 5th place on the damage caused by diseases globally. It is now known that pulmonary pathology leads to disruption of cerebral blood flow. Insufficient oxygen supply to the brain at bronchial obstruction, which negatively affects the brain functions such as memory, attention, thinking. Purpose: To identify the state of the higher brain functions in patients with chronic obstructive pulmonary disease. Materials and methods: There are were studied 40 patients aged 26 to 87 years (including 28 men, 12 women) with COPD III and IV . Determined by pulse oximetry oxygen saturation of the blood. The study was conducted using the Montreal Cognitive Assessment Scale Results: The study showed a significant reduction of memory, attention, thought in 14 patients (35% -19 points), moderate decline of higher brain functions in 14 patients (35% -20 and 23 points ), a slight decrease in 8 patients (20% -25 points), and the norm in 4 patients (10%). At the same time found a direct correlation between cognitive impairment and peripheral oxygen saturation: the saturation 95% were identified cognitive impairment, with 85% dementia. Conclusion: The present study indicates a significant impact of COPD on the higher brain functions of humans.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P52

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Entorhinal cortical volume, a sensitive imaging biomarker in subjective memory impairment - read full article

By: Dong Won Yang, E. Lim, J. Cho, Y. Shim, B. Yoon, and Y. Hong

Introduction: Subjective memory impairment (SMI) has been considered as a transitional state between normal and MCI and with higher conversion risk to dementia. The aim of this study was to investigate the diagnostic sensitivity of entorhinal cortical volume, hippocampal volume and fractional anisotropy (FA) in SMI. Methods: We recruited 25 controls and 23 SMI. 3D T1 SPGR MRI and diffusion tensor image were obtained for the image analysis. Entorhinal cortical volume and hippocampal volume were measured by manual segmentation with Analyzer program. Entorhinal and hippocampal volume were divided by total intra cranial volume to correct size variation of brain. FA value was measured with ROI method at the head of hippocampus with Volume One program. Results: Age, gender, education were not different between groups (p=0.05). Mini-Mental State Examination score was lower in SMI group (28.3 vs. 26.0, p=0.05). Entorhinal cortical volume and FA value of hippocampus were lower in SMI group (p=0.001). Hippocampal volume ratio was not different between groups (0.151% VS 0.148%, p=0.44). Diagnostic accuracy of each of markers was evaluated with receiver operating characteristic curve. Area under the curve (AUC) value was highest in entorhinal cortical volume (AUC=0.939). AUC of the FA value of hippocampus were lower (AUC=0.867) and hippocampal volume had the lowest AUC value (AUC=0.533). Diagnostic accuracy of MMSE was higher than the hippocampal volume (AUC=0.769). Conclusions: Structural changes start earlier in the entorhinal cortex than in the hippocampus of SMI. Measurement of entorhinal cortical volume may be a sensitive imaging biomarker for the early detection of SMI.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P53

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Awareness and its relation to psychiatric symptoms in early-onset Alzheimer’s disease - read full article

By: Bora Yoon, Dong Won Yang, Seong Hye Choi, Yong S. Shim, and San Jung

Background: Anosognosia in patients with Alzheimer’s disease (AD) appears differently by various conditions such as disease severity or neuropsychiatric symptoms (NPS). However, it remains uncertain how anosognosia is related to disease severity or NPS in early-onset (EO) AD. We investigated the incidence of anosognosia and associating factors especially NPS by disease severity. Methods: We recruited 616 EOAD patients. We subdivided participants into 3 groups by awareness for disease: full/ partial/ no, and by clinical dementia rating (CDR): 0.5/ 1/ 2. We compared the difference in neuropsychiatric inventory (NPI) according to the degree of awareness and the disease severity. Results: The percentage of anosognosia steadily increased as CDR worsened (8.6% vs 13.6% vs 26.2%). NPI total score was statistically high in anosognosia patients of CDR 0.5 and 1 group, by contrast, it was not associated with patients with anosognosia in CDR 2 group. Overall, anosognosia patients demonstrated delusion(P=0.015), hallucination(P=0.005), agitation(P=0.001), aberrant motor behavior(P=0.001), sleep(P=0.016), and appetite(P=0.040) statistically high. After stratification of CDR, anosognosia patients showed sleep(P=0.023) and appetite(P=0.025) among CDR 0.5 significantly high while delusion(P=0.035) and hallucination(P=0.049) among CDR 1. In CDR 2, there was no difference among 3 groups by awareness. Discussion: Anosognosia differs the incidence and associating factors by disease severity in EOAD patients. It is associated with specific NPS in very mild and mild stage rather than moderate stage. It would be recommended to confirm sleep and appetite problems in very mild group, and delusion and hallucination in mild group with anosognosia patients.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P54

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Immunocytochemical studies of the neurodegenerative diseases the ubiquitin proteasome system - read full article

By: Mohamed Zouambia

The present study is related to the immunoreactivities of the sub-units of 26S proteasome for the principal forms of tauo- and synucleinopathies. Several cerebral diseases were studied. Many studies showed that the weakening of the function of the proteasome is associated with the cellular senescence. However, the data available are reduced in fragments and are contradictory. Six tauopathies were studied. All showed the immunoreaction of ATPase S6b in the hippocampus and the temporal cortex. For the Alzheimer and Down Syndrome patients, the pyramidal cells of the CA1 and CA3 of the hippocampus were the most positive zones. CA4, dentate gyrus and subiculum were less reactive with ATPase S6b. Of the two synucleinopathies studied (LBD and MSA), Lewy bodies were less immunoreactive as visualized in some brains of patients having Lewy Body Disease. Our data suggest that the degree of weakening of the ubiquitin-proteasome system is much more dramatic in tauopathies than in the synucleinopathies. The evidence accumulates more and more for a participation of the ubiquitin-proteasome system in the degradation of abnormal proteins in a variety of neurological disorders.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P55

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The effect of intraperitoneal and intrathecal cobalt chloride administration on formalin-induced orofacial pain - read full article

By: T. Alexa, A. Luca, A. Negru, and C.R. Bohotin

Introduction: The exact mechanism by which cobalt chloride (CoCl2) exerts its effects is unclear. Suggested hypothesis include mitochondrial toxicity, ATP synthesis inhibition and reactive oxygen species production, mechanisms that are implicated in migraine and chronic pain. The aim of this study was to assess the effect of single-dose CoCl2 administered via central (intrathecal i.t.) versus peripheral (intraperitoneal -i.p.) route on formalin-induced orofacial pain (OFP). Materials and methods: Male BALB/c mice were divided in two groups that received CoCl2 (i.p. - 25mg/kg b.w. or i.t. - 0.025mg/kg b.w. administration) and two groups that received saline. Three hours later, mice received 20?L formalin into the right whisker pad; the time mice spent rubbing/liking the injected area was recorded. The results are expressed as percentages of inhibition. Results: Both routes of CoCl2 administration induced a significant decrease in pain behavior in phase one of the OFP test, with percentages of inhibition (PCIs) of over 30%. In the second phase, the decrease remained significant for both i.t. and i.p. CoCl2 groups, but the decrease after central administration was more important than after systemic administration (55.8% vs. 27.4% PCIs). For both administrations the CoCl2 groups were statistically different from control groups (p0.005). Conclusions: Our initial hypothesis was that CoCl2 would increase pain-related behavior. However, CoCl2 had a pronounced central effect on orofacial pain, with anti-inflammatory-like consequences. This may be secondary to CoCl2’s ability to induce neurotransmission inactivation by reducing Ca2+ pre-synaptic influx (synaptic blockade).

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P56

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Use of botulinum neurotoxin in painful trigeminal neuropathy attributed to a multiple sclerosis plaque: a case report - read full article

By: Rui Araújo, Sónia Batista, Isabel Luzeiro, and Beatriz Santiago

Introduction: Painful trigeminal neuropathy attributed to a multiple sclerosis (MS) plaque is a disabling and difficult to manage condition. Recent evidence suggests a potential role for botulinum neurotoxin (BoNT) in trigeminal neuralgia (TN). We present a case of refractory painful trigeminal neuralgia attributed to a MS plaque with a good response to BT. Case report: 48, male, presents with recurrent daily episodes of electric shock-like pain on the right mandibular division of the trigeminal nerve, triggered by innocuous stimuli, with persistent background facial pain since 2012. Brain MRI revealed multiple lesions fulfilling the McDonald criteria for MS diagnosis, with one lesion on the pons adjacent to the trigeminal nucleus. Patient began immunomodulatory therapy with glatiramer acetate and for the neuralgia, he was prescribed carbamazepine (CBZ) and gabapentine (GP), which were progressively increased up to CBZ 400mg 3id and GP 300mg 3id. Due to side effects his medication was progressively altered to GP 800mg 3id and oxcarbamazepine 600mg 3id. Due to inadequate pain control, it was further added baclofen 25mg 2id, misoprostol 0.2mg 3id, phenytoin 100mg 3id, without achieving pain remission. Other drugs were initiated and then suspended due to intolerance or inefficacy (venlafaxine, lamotrigine, lacosamide). Abobotulinum toxin-A (Dysport®) was initiated (60 units, 20u/site intramuscular, 30G needle, 3/3 months). The patient reported significant reduction in pain frequency ( 80%) and on the intensity of the background facial pain and is currently reducing pain medication. Conclusion: Whilst BoNT remains a controversial option for TN, there is growing evidence supporting its use.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P57

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The effects of intrathecal methylene blue and glyceryl trinitrate administration on orofacial pain in mice - read full article

By: Catalina Roxana Bohotin, Teodora Alexa, Andrei Luca, Andrei Dondas, Adriana Negru, and Radu Iliescu

Purpose: Nitric oxide (NO) is involved in several types of pain processes. In patients with migraine, glyceryl trinitrate, a pro-drug for NO, produces a delayed migraine episode. In this study, we decided to evaluate the effects of intrathecal administration of a NO pro-drug (glyceryl trinitrate-GTN) and a NO scavenger (methylene blue–MB) on orofacial pain (OFP). Methods: 24 BALB/c mice were divided in 3 groups as follows: GTN group (0.1mg/kg, n=8), MB group (0.05mg/kg, n=8) and control group (NaCl, n=8). All groups received the substances intrathecally. Two hours after drug/saline administration, formalin was injected into the upper lip and the time mice spent rubbing/liking the injected area was recorded. The results for each phase are presented in seconds. ANOVA and Dunnett post-hoc test were used for statistical evaluation. Results: Intrathecal administration of MB and NTG had no effect on the acute phase of OFP when compared with control. In the second phase, however, both drugs had an analgesic tendency; for GTN, this was statistically significant (p=0.025), and for MB the effect was less important (p=0.083). Conclusions: By centrally administering a NO pro-drug and a NO scavenger, we expected to modulate NO production in formalin-induced OFP. Our results demonstrated that the acute phase of OFP does not depend on NO (neither of the drugs had any effect) and that both substances diminish pain perception in the persistent/inflammatory phase but only the NO pro-drug had a clear-cut antinociceptive effect.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P58

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Magnetic resonance imaging in patients with conventional cardiac devices—a case report - read full article

By: P. Brás, A. Sousa, G. Januário, C. Perry da Câmara, and R. Pedrosa

Introduction: It is estimated that during their lifetime, up to 75% of patients with cardiac pacemaker (PM) develop a medical condition, such as a neurological disorder, for which an MRI may be necessary for optimal diagnosis and treatment. The evidence around conventional PM being a contraindication to MRI is controversial. Case report: A 73 years-old man with a cardiac permanent pacemaker for atrial flutter with slow ventricular response, presented with a 12-month history of worsening neck pain radiating to both arms, associated with paraesthesias and bilateral arm weakness. Initial neurological examination revealed bilateral brachial paresis with upper limb hyporeflexia, pyramidal signs present in lower limbs, positive Lhermitte sign and no sensation loss. A week later he became quadriparetic, losing the ability to walk, and developed urinary retention. A CT-myelogram showed an abnormally expanded cervical spinal cord, requiring further imaging by MRI. With the collaboration of a cardiologist and an anesthesiologist, the pacemaker was programed to an asynchronous mode and the patient was successfully submitted to a 1,5T MRI scan. The device was then reprogrammed to original settings. The MRI revealed an intramedullary lesion suggestive of a spinal cord neoplasm and the patient was submitted to neurosurgical intervention. Conclusions: With the broad number of already existing implanted cardiac components, MRI in patients with conventional pacemaker will remain a dilemma over the next years. Based on findings from several clinical studies the risk may be lower than previously thought if a number of conditions are met and appropriate precautions are taken.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P59

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Disability of headache according to the presence of exercise - read full article

By: Soo-Jin Cho, M. Chu, H.S. Moon, and J.W. Park

Exercise or physical activity is not only a trigger of headache but also a recommended behavioral therapy in migraine. We want to know the influence of exercise on the severity and disability of headache and investigated it using smartphone application-based electronic headache diary (SHD). Migraine patients with average 2-14 headache days per month were recruited and were ask to write the occurrence, severity, duration, triggers of headache, and intensity and duration of exercise on SHD. Disability of headache by HIT-6 was assessed at the baseline and 3 months after initial visit. From 62 participants who kept the diary until the end of the study, diary data for 4,579 days were analyzed. Of these, 1,099 headache days (336 migraine, 763 non-migraine headaches) were recorded. Exercise as a risk factor for headache was listed in 3 patients on baseline survey and in 7 patients upon SA-E dairy. Headaches on the day with exercise were less impaired (disability 34% vs 50%, p=0.001) and less usage of abortive medication (51% vs 65%, p=0.0002), but had similar intensity and duration compared to the headache day without exercise by analysis using 1099 headache days. Worsening of HIT-6 score more than 1 point was present in 19.0% (8/42). Proportion of worsening of HIT-6 was less frequent among patient with GPA than those without GPA (14% vs. 20%, p0.001). GPA was not well performed among episodic migraineurs. This study suggested protective effect of exercise on disability of headache and no influence of headache on the exercise time.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P60

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Unmet sleep need is prevalent among migraineurs - read full article

By: Min Kyung Chu and Kyungmi Oh

Background: sleep disturbance is common among subjects with headache, especially migraine. Sleep disturbance is closely associated with sleep need, which may vary person to person. However, the association between individuals’ sleep need and migraine has not been reported. This study is to assess the association between migraine and unmet sleep need (USN) Methods: We selected a stratified random population sample of Koreans aged 19-69 and evaluated them by face-to-face interview using questionnaire. Sleep need was evaluated using a question “How many hours of sleep do you think is enough?” If a participant’s sleep need was more than her/his sleep duration, she/he was classified as having USN. Results: In a representative sample of 2,695 individuals, 1130 (41.9%) subjects and 143 (5.3%) subjects were classified as having non-migraine headache and migraine, respectively. 848 (31.5%) subjects were identified as having USN. The proportion of USN among migraineurs (48.3%) was significantly higher compared to non-headache controls (38.8%, p=0.031) or non-migraine headache (23.9%, p0.001). Among migraineurs, the proportion of USN was not significantly different among headache frequency of 1 attack per month (23/47, 48.9%), 1-10 attacks per month (44/80, 45.0%, p = 0.668) and 10 attacks per month (10/16, 62.5%, p = 0.351). Headache frequency, Visual Analogue Scale for headache intensity and Headache Impact Test Score were not significantly different between migraineurs with UNS and migraineurs without USN. Conclusions: Unmet sleep need is prevalent among migraineurs and is more frequently associated with migraine compared to non-migraine headache or non-headache controls.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P61

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Subjective cognitive symptoms during the migraine attack: a prospective study of a clinic based sample - read full article

By: Raquel Gil-Gouveia, A. Oliveira, and I. Martins

Background: A migraine attack aggregates a range of different symptoms, besides pain, that contribute to attack-related disability. Cognitive dysfunction is an unacknowledged part of the migraine attack. Objective: To provide a profile of the frequency and character of migraine attack-related cognitive symptoms occurring during the headache phase of the attack. Methods: We performed a cross-sectional survey of a clinic-based sample of sequential episodic migraine patients that were screened about the occurrence of cognitive symptoms during migraine attacks using an open-ended question followed by a self-fulfilled symptom checklist. Results: Of 165 migraine patients (15 males, age average 37.3 ± 10.7 years), 89.7% described cognitive symptoms during the headache phase of the migraine attack. On average 2.5±1.6 symptoms were reported per patient, uninfluenced by demographic or disease-related variables. The most common spontaneous symptoms related to executive functions, such as poor ability to concentrate (37%), difficulty in reasoning (25%) and thinking (23%). The pattern of responses on the symptoms checklist corroborated those reported spontaneously and quantitative scores of the checklist were higher in patients with spontaneous symptoms. Conclusions: This study detailed the frequency and characteristics of migraine attack-related subjective cognitive symptoms and found its frequency to be similar to reports of other migraine defining symptoms (e.g. nausea, photophobia) in recent clinical series. Patients’ reports were consistent and dominated by complaints of attention difficulties, diminished cognitive efficiency and processing speed impairment.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P62

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Evaluation of headache in children - read full article

By: Deniz Yilmaz, Didem Gokkurt, and Asli Celebi Tayfur

Objective: Although the majority of headaches are benign in children, they are still frightening for parents. The aim of this study was to determine headache types, associated symptoms, incidence of various triggers and the necessity of brain imaging techniques. Material and Methods: This study was performed on 3-17 year-old children with headaches from November 2014 to January 2015 who presented at a pediatric neurology clinic in Keçiören Education Hospital. The criteria defined by International Headache Society were used to classify the headache types. Results: One hundred patients were enrolled in this prospective study, 59 girls and 41 boys. The mean age on admission was 12.835±3.2084 years. The duration of headache was more than 2 years in 31% of patients. The types of headaches were comprised as follows: 58 cases of migraines, 26 cases of tension-type headaches, 15 cases of secondary headaches. Family history was present in 37 patients (44%) with primary headache. Six patients had cerebral magnetic resonance abnormalities. Conclusion: Headache is a very common complaint in children. The evaluation should include not only detailed history of children but also detailed general and neurological examinations. Brain imaging techniques are of limited value in the routine evaluation of headache.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P63

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Medicated photoprotective anticephalgic mask - read full article

By: Morton Hyson

A pre-medicated mask would serve not only as a delivery system for benign topical medication, but simultaneously provide photo relief and exert external pressure which may alleviate vascular headaches by collapsing painfully distended extracranial arteries and reducing peripheral sensitization. Thirty-three patients were given masks and tubes of topical medication containing the bryonia and rhus toxicodendron. They were instructed to apply the medication to their frontalis and/or temporalis regions in the event they should suffer a headache and apply a photoprotective mask. Furthermore, they were instructed to take their usual oral or parenteral medications if required for the relief of the headache. They subsequently filled out forms rating the degree of relief which they attributed to the topical medication and the mask using a 0-10 scale. At the interview following the completion of their participation in the study, the patients were also simply asked if this form of treatment helped or not. Thirty out of 33 patients stated the medication and the mask were effective over and above the normal degree of relief they were receiving from their oral and/or parenteral medications. This study demonstrated a significant efficacy rate (91%) in the treatment of migraine and/or tension headache with the anticephalgic mask in conjunction with a topical cream containing bryonia and rhus toxicodendron. This study demonstrated a significant efficacy rate in the treatment of migraine and/or tension headache with the anticephalgic mask in conjunction with a topical cream containing bryonia and rhus toxicodendron.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P64

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Clinical characteristics associated with the initial visits to emergency department in patients with migraine: a headache clinic-based study - read full article

By: Byung-Su Kim

Background: Migraine attack is common cause of the visits to emergency department (ED). The aim of this study is to investigate clinical characteristics associated with the initial visits to ED for migraine. Methods: This was a cross-sectional study using an outpatient headache-clinic registry from September 2014 to August 2015. Consecutive first-visit migraine patients aged ? 19 years were dichotomously classified according to visiting patterns: referral from ED vs. direct visit to headache clinic groups (ED vs. HC groups). Logistic regression analysis was conducted to evaluate the association of clinical characteristics of migraine patients referred from ED. Results: Of 257 patients (mean age: 43.6 ± 13.8 years, female: 76.7%) in this study, 38 (14.8%) were referred from ED during a 1-year period. Univariate analysis found that headache intensity (0–10 NRS), vomiting, and vestibular symptoms were associated with ED group, compared to HC group. In a multivariate-adjusted model, the odds ratios (95% CI) of headache intensity, vomiting, and vestibular symptoms for ED group were 1.31 (1.06–1.63), 2.60 (1.20–5.66), and 4.29 (1.84-10.00), respectively. Conclusions: Patients of ED group were likely to have more severe headache intensity, vomiting, and vestibular symptoms. Our study suggests that disabling characteristics of severe headache intensity or troublesome associated symptoms could be independent predictors for the initial visits to ED among migraine patients.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P65

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Electroacupuncture pretreatment at GB20 exerts anti-nociceptive effects via peripheral and central serotonin mechanism in conscious migraine rats - read full article

By: Lu Liu, P. Pei, L. Zhao, Z. Qu, and L. Wang

Background: While electroacupuncture (EA) pretreatment in migraine has been found to attenuate pain and frequencies of attacks, the mechanism of its anti-nociceptive effect remain poorly understood. Emerging evidence suggests that peripheral and central serotonin system may be involved in migraine. We hypothesized that EA would exert anti-nociceptive effects via modulation of serotonin system. Methods: We used a conscious migraine model induced by repeated electrical stimulation on the dural mater. Forty rats were randomly assigned to one of four groups: an EA group, which received EA at GB20 following dural stimulation; a sham acupuncture group, which received manual acupuncture at a non-acupuncture point following dural stimulation; a Model group, which received dural stimulation but no acupuncture; and a Control group, which received neither dural stimulation nor acupuncture. HomeCageScan was used to measure effects on the spontaneous nociceptive behaviors, radioimmunoassay and HPLC were used to investigate the expression of 5-HT in peripheral plasma and in the periaqueductal gray (PAG), rostroventromedial medulla (RVM), and trigeminal nucleus caudalis (TNC), three key structure of the descending pain modulatory system. Results: Our study showed that EA pretreatment could produce a significant reduction in resting, freezing and grooming, and a significant increase in exploration behavior. We found that the level of 5-HT in plasma were significantly increased, while significantly reduced in RVM, TNC in Model group. Furthermore, the above results were significantly reversed in EA at GB20. Conclusions: EA pretreatment exerts anti-nociceptive effects in a rat model of recurrent migraine, possibly via modulation of the serotonin system.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P66

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The effects of single and multiple curcumin doses on oro-facial pain in mice - read full article

By: A. Luca, T. Alexa, A. Negru, and C.R. Bohotin

Introduction: Curcumin protects from mitochondrial dysfunction and modulates endogenous antioxidant enzymes, by scavenging the ROS and NO-based radicals. The aim of our study was to assess if on the formalin-induced orofacial pain (OFP) in mice a single dose has the same efficiency as sub chronic administration. Materials and methods: 32 mice were divided into four groups group Cac received one dose curucmin, group C2w received curcumin daily for 2 weeks and two groups served as control and received an equal volume of olive oil (Group Oac and O2w). The curcumin (120 mg/kg b.w, dissolved in oil) and the oil were administrated by gastric gavage. After 2h in acute groups respectively 24h in subchronic groups 20?L formalin were injected into the whisker pad and the time mice spent rubbing/liking the injected area was recorded. The results for each phase was expressed as percentage of pain inhibition (PI). Results: For both OFP phases a single dose of curcumin had a strong analgesic effect when compared with control group (p=0.01). PI was 79% (phase I) respectively 51% (phase II). Subchronic treatment maintained curcumin analgesic effect for both phases (p=0.01 respectively p=0.01) with a PI of 34% respectively 45%. Conclusions: Our data demonstrates that curcumin has a strong analgesic effect on OFP induced by formalin but the long term treatment does not improve its analgesic propriety.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P67

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Botulinum toxin a for prophylaxis in chronic migraine in Korean patients - read full article

By: H.S. Moon, D.W. Namgung, W.T. Yoon, B.C. Suh, P.W. Chung, Y.B. Kim, Y.G. Jung, and W.H. Son

Botulinum toxin type A (BoNT-A) for the treatment of patients with chronic migraine (CM) has been studied, but there is a paucity of data in Korean patients. Our study was conducted to evaluate the efficacy of BoNT-A for the prophylaxis of CM in Korean adult patients. We retrospectively analyzed 65 patients who underwent BoNT-A treatment for CM at Kangbuk Samsung Hospital from Jan 2014 to Mar 2015. An injection in 31 sites according to the protocol of the PREEMPT study at the total dosage of 155 U/treatment. The efficacy analyses were based on the change from baseline in headache days/month, number of medication intake/month and Headache Impact Test (HIT)-6 score at week 12. Total 65 patients (mean age: 45.1.2±13.2, female/male ratio: 4.4:1) received BoNT-A injection for CM and 41 patients (63.1%) of them had medication overuse headache (MOH). Patients reported a significant decrease in headache days/month (pre 21.8± 5.5, post 12.8±7.1, P=0.001) and the number of medication intake (pre 21.8±5.5, post 11.9±6.9 P=0.001) after BoNT-A injections. Total HIT-6 score was decreased significantly after BoNT-A treatment (62.1± 10.0 vs 52.9±11.3 P=0.001). Thirty-five patients (53.8%) were 50% responder that at least a 50% decrease from baseline in the headache frequency. No difference were observed in a reduction in headache days/month and total HIT-6 score between patients with MOH and without MOH (p=0.635 and p=0.997). These results demonstrated that BoNT-A may be an effective treatment for CM in Korean patients. We can also expect the efficacy of BoNT-A treatment for patients with MOH.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P68

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Multidisciplinary approach to a common complaint—a rare cause of diplopia - read full article

By: A. Ponciano, C. Faria, J. Leite, and C. Fernandes

The etiology diagnosis of patient with diplopia is a clinical challenge. The presence of accompanying symptoms may also help in the investigation. Constant or intermittent pain and defects in visual acuity should be investigated and may correlate with neuromuscular dysfunction third cranial nerve injury, or orbital disease. A 82-year-old woman consulted the Emergency Department with a complaint of progressive binocular diplopia and proptosis with a 3-week evolution, with intermittent ocular pain episodes. There was no history of fever, weight loss or nocturnal sweating. Ophthalmologic examination revealed mild restriction of left eye abduction. External examination demonstrated proptosis of the left eye, soft tissue swelling in the upper and lower lids. The rest of the anterior and posterior segment examinations were unremarkable in both eyes. Enlarged, matted, and non-tender left axillary lymphadenopathy was also found. Further neurological and physical examination were completely normal. Brain Computed Tomography revealed a bilateral intra orbital mass suggestive of lymphoma and body Tomography showed multiple enlarged lymph nodes. Biopsy of the left axillary lymphadenopathy was performed and confirmed the diagnosis of follicular lymphoma, with immunohistochemical stains positive to CD20, CD79-?, Bcl-2 and Bcl-6. Follicular lymphoma is a subset of Non-Hodgkin’s lymphoma, characterized by B-cell proliferation, commonly affecting middle-aged to older adults. It is rare for this type of systemic non-Hodgkin`s lymphoma to infiltrate the ocular tissues and present with ocular complaints at presentation, mainly painless diplopia. With this case the authors want to give attention to the importance of multidisciplinary approach to diplopia.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P69

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Efficacy of LY2951742 in subgroups of patients with migraine of different frequency - read full article

By: V. Skljarevski, J. Martinez, T. Oakes, Y. Tanaka, Q. Zhang, M. Due, and A. Schacht

Background: In a recently reported study, LY2951742 significantly reduced the number of migraine headache days (MHD). The baseline frequency of MHD was 4 to 14 MHD per month. Objectives: To examine mean change in the number of MHD from baseline in subgroups of patients based on their baseline monthly frequency of MHD. Methods: The post-hoc analyses were conducted using data from a double-blind, phase 2a study in adult patients randomly assigned to LY2951742 or placebo for 12 weeks (NCT01625988). The primary endpoint was the mean change in the number of MHD during the last 28-day period. Subgroups were examined based on the number of MHD during the baseline period from 5 (i.e. ? 5 vs. 5 MHD) to 10. 50% response rates based on the number of MHD were also examined for the same subgroups. Findings: A total of 217 patients were randomized and received LY2951742 (n=107) or placebo (n=110). A significant difference from placebo was observed at month 3 from 1.5 days reduction from baseline in the number of MHD for the ? 5 MHD subgroup and continued to increase to 2.4 days reduction from baseline in the number of MHD for the ? 8 MHD subgroup. The increase in reduction of MHD failed to continue past the ? 8 MHD subgroup. Similarly, this trend was also observed when 50% response rates were examined for the same subgroups. Conclusion: LY2951742 effect appeared maximized for the high-frequency subgroup (? 8 MHD).

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P70

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The association of cluster headache and symptomatic trigeminal neuralgia—case report - read full article

By: Zoran Vukojevic

Introduction: Cluster headache is characterised by unilateral, intermittent, recurrent, short-lived severe pain in orbito-temporal area along with unilateral autonomic symptoms (lacrimation, rhinorrhea). Painful attacks usually have circadian and circannual rhythmicity and they are rarely associated with trigeminal neuralgia. Case report: A 46-year old female patient had three episodes of cluster headaches which lasted for a month and were repeated biannually. The pain was in right orbitotemporal area, it was strong, sharp, occurred around 16:30 min., lasted for 15-30 min., repeated at 6-8 occasions and stopped around 23:30. During the pain attacks patient was experiencing ipsilateral lacrimation and nasal congestion (autonomic dysfunction). Patient was restless and constantly in motion. She was treated with prednisone and verapamil until the symptoms were gradually removed. Three months after the last episode she experienced severe, sharp pain in right side trigeminal nerve innervation (first and second branch) which intensified during speaking, chewing, face washing and touching. MRI and MRI angiography of the brain showed aberrant superior cerebellar artery which irritates proximal segments of right trigeminal nerve. She was successfully treated with oxcarbazepine and her pain was significantly reduced. Conclusion: Cluster headache has a characteristic clinical features and specific treatment in regard to other headaches. Occasionally cluster headaches are associated with symptomatic trigeminal neuralgia which makes them challenging in terms of differentiation and treatment.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P71

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Calcifying pseudotumor of the neuroaxis—a case report - read full article

By: R. Andrade Carmello, V. Rodrigues da Silva, M. Coutinho Studart, P.T. Galvão, J. Marcondes, L.M. Cardão Chimelli, and N. Henriques Silva Canedo

The calcifying pseudotumor of the neuroaxis (CAPNON) is a rare lesion affecting the central nervous system, still without a clear origin, both neoplastic and/or reactional processes being under consideration and investigation. It is considered benign and non-infiltrative, symptoms being associated with compression of the surrounding tissue. There are less than 60 cases reported worldwide, only one fourth located at the spinal cord. Our objective is to describe one of such cases due to its rarity and important differential diagnosis with neoplasia, where adjuvant treatment is eventually necessary, unlike CAPNON where excision is curative. A 31-year-old male with progressive paresis of the lower limbs for 9 years. CT at the beginning of the symptoms showed calcified intramedullar nodule at T8 level, measuring 1,9 x 0,9 x 0,6 cm. The lesion showed no growth in the period, but symptoms worsen and exeresis was performed. Gross appearance was of a soft mass covered by a calcified shell, and microscopic examination showed fibrous stroma surrounding highly pleomorphic epithelioid cells although no mitosis was identified. Osseous metaplasia was also extensively observed. Immunostaining showed EMA positivity and negative GFAP, CK pool and PR, eliminating carcinomas, gliomas and meningiomas as candidates. CAPNON must be considered a possible candidate when dealing with extensively calcified lesions of the SNC. Its morphology is extremely variable, and only a few of the aspects are generally present in every case. Immunohistochemistry and a benign evolution are fundaments of the diagnosis and help differentiating from neoplastic lesions.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P72

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Somatoform disorder presenting as psychogenic gait disorder - read full article

By: Hulya Apaydin and G. Benbir Senel

Introduction: Psychogenic movement disorders (PMD) could imitate any type of movement disorder (MD). Although MD specialists usually encounter less difficulty in recognizing patients with PMD, most patients seek medical help from different physicians and are exposed to many unnecessary treatments. PMD diagnosis is based on the exclusion of organic disorders. Detailed medical history and neurological examination usually aid the correct diagnosis./h2 Case report: A 27-year-old man was admitted to our outpatient MD clinics complaining of difficulty in maintaining his posture due to involuntary movements of the right leg. His symptoms have started almost 10 years ago with a sudden-onset, showed gradual increase during his military service. He also complained of sudden jerky tremor-like movements in his arms and legs, which appear and disappear periodically. He was diagnosed to have parkinsonism and chorea in different centers and given multiple drugs including levodopa, dopamine agonists, antipsychotics and benzodiazepines with no benefit. Neurological examination revealed bizarre atypical right leg movement occurring randomly with partial distractibility and exaggerated postural tremor. When he was asked to imitate his tremor-like movements he mentioned, he performed tic-like jerky erratic movements all over his body. He was diagnosed as having PMD, and consulted with psychiatry and had the diagnosis of somatoform disorder. Discussion: Bizarre, unusual or uneconomic movements performed with exaggerated efforts, together with distractibility, should suggest psychogenic origin. Currently, based on the detailed evaluation of PMD patients’ history and clinical signs, clinicians should be aware of specific clinical properties of PMD that differentiates them from other organic disorders.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P73

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Short-interval intracortical inhibition is decreased in patients with restless legs syndrome - read full article

By: Adriana Conforto, Joselisa Paiva, Gilmar do Prado, Edson Amaro Jr., Alan Eckeli, and Samir Magalhães

Introduction: GABAergic dysfunction in the motor cortex may be involved in the pathogenesis of Restless Legs syndrome. Decrease in short-interval intracortical inhibition (SICI) to transcranial magnetic stimulation (TMS) is considered a marker of GABAergic dysfunction, and has been described in patients with RLS. It is unknown if there is a correlation between abnormal SICI and severity of symptoms. Objectives: To compare SICI in patients with primary RLS and healthy subjects, and to evaluate a correlation between SICI and severity of RLS symptoms. Methods: Patients (n=33) and controls (n=24) underwent clinical evaluation and TMS testing. EMG was recorded from the dominant abductor digitus minimi (ADM). Severity of symptoms was assessed by the International RLS Severity Scale (IRLSS). RLS patients were grouped by IRLSS scores (mild/moderate [IRLSS20] or severe/very severe [IRLSS?20). SICI was compared in subjects with RLS and controls with Mann-Whiteny tests. The correlation between IRLSS and SICI in patients was investigated with Spearman´s rho. Results: There were no significant differences in age, gender, handedness, resting or active motor thresholds between patients with RLS and control subjects. Mean SICI (average ± standard deviation) was significantly deeper in controls (19.3±57.8%) than in patients (50.1±14.6%; p-value 0.001). The correlation between depth of SICI and IRLSS was not statistically significant. Discussion: Our work included the largest sample of patients with RLS reported until now. The results support the presence of a dysfunction in GABAa interneurons in the motor cortex in RLS.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P74

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Psychogenic facial movement disorder: a case report - read full article

By: Eren Gozke, Boran Saracoglu, Mustafa Eser, Aylin Reyhani, and Pelin Dogan Ak

Introduction: Psychogenic facial movement disorders (PFMD) can be confused with movement disorders of organic origin. Herein, a case misdiagnosed as peripheral facial paralysis (PFP) is presented together with video demonstrations. Case: A 44-year-old female patient was evaluated because of bending of her mouth developed 4 days ago. Cranial MRI performed in another hospital did not demonstrate any abnormality, and steroid therapy was initiated with the diagnosis of PFP by them. The patient presented to us because of bending of the mouth did not resolve completely. She had hypertension, diabetes, and depression. She was using indapamide, metformin, and citalopram. Neurologic examination revealed flattening of nasolabial fold which disappeared during talking and downward retraction of the contralateral edge of the mouth. She could close her eyes completely, and other neurologic examination results were not remarkable. EMG findings were normal. Fluctuant flattening of nasolabial fold, and the impression of downward retraction of one side of the mouth suggested PFMD. Her steroid therapy was discontinued, and treatment with alprozolam was initiated. A prominent resolution of her complaints was observed during posttreatment follow-up control visits. Conclusion: In all patients with PFMD phasic or tonic muscle contractions mimicking distonia can be seen. Most frequently downward retraction of the lip is seen. In nearly half of the patients symptoms follow a paroxysmal pattern. Usually involvement of one side is seen, however affected side may change. Extreme contractions can result in painful episodes. We wanted to present this case because it is especially confused with PFP.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P75

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Substantia nigra hyperechogenicity and motor severity in Parkinson’s disease: is there an association? - read full article

By: J. Jesus-Ribeiro, J. Sargento-Freitas, M. Sousa, F. Silva, A. Freire, and C. Januário

Introduction: The evaluation of hyperechogenicity of the substantia nigra (SN) by transcranial sonography (TCS) is validated for the diagnosis of Parkinson’s disease (PD). However, its correlation with the severity of motor involvement is still uncertain. Methods: We included patients with clinical diagnosis of idiopathic PD in a cross-sectional study. All patients were evaluated with Unified Parkinson’s Disease Rating Scale-motor score (UPDRS-III) and TCS at the same day with measurement of the area of SN hyperechogenicity for each side. We analysed the association between the area of SN hyperechogenicity and the contralateral motor scores of UPDRS-III, adjusting for age and dominance of the patient (statistical significance set to p=0.05). Results: 35 patients were analysed, 3 (8.6%) were excluded due to poor temporal acoustic bone window. From a total of 32 patients, the mean age was 58.4 (±11.2) years. The mean area of hyperechogenicity was 0.31cm2 (±0.1) and the mean score of UPDRS-III was 18.9 (±6.1). There were no statistically significant correlation between the scores of the UPDRS-III (rigidity, tremor and bradykinesia) and the area of SN hyperechogenicity contralateral. Conclusion: The area of SN hyperechogenicity did not correlate with motor deterioration in Parkinson’s disease.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P76

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Parkinson’s disease and factors influencing the quality of the dyadic relationship - read full article

By: Michaela Karlstedt, S.M. Fereshtehnejad, D. Aarsland, and J. Lökk

Objectives: The aim of this project is to explore how the quality of the dyadic relationship (mutuality) is affected by motor and non-motor symptoms, other perceived difficulties and quality of life (HRQoL) when one person in the dyad is having Parkinson´s disease (PD). Methods: Fifty dyads (age m=70.5[SD=8.5], PD-duration m=8.6[SD=6.6], Hoehn & Yahr md=2[IQR=1]) completed validated scales measuring mutuality (MS), caregiver burden (CB), caring difficulties (CADI), depression (GDS) and HRQoL (PDQ8). Spearman´s correlations were used to evaluate univariate associations. To investigate multivariate associations between independent factors and mutuality, multiple regression analysis was used. Results: Partner mutuality score was significantly associated with CB (rho=-0.69), CADI (rho=-0.61), partner GDS (rho=-0.52), patient MS (rho=0.49), patient GDS (rho=-0.42), and PDQ8 (rho=-0.38). Partner mutuality score did not strongly correlate with motor (rho=-0.24) and non-motor symptoms (rho=-0.24) or disease duration (rho=-0.11). Instead CADI, GDS, PDQ8, CB and patient MS score explained 62 % of the variance in partner mutuality. Of the included variables CADI and patient MS score showed the largest contribution (standardized beta=-0.43, p =.043 vs beta=0.35, p=0.005). Conclusion: Findings suggest that higher experience of carer difficulties and patient experience of mutuality may exert an effect on partner mutuality in care-dyads with mild to moderate PD. This ongoing longitudinal study aims now to explore how the course of PD affects mutuality, CB and HRQoL from the perspective of the care-dyad.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P77

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Parkinson’s disease patients’ willingness to pay for a new drug - read full article

By: Johan Lökk, S. Olofsson, and U. Persson

Objective/Aim: The expected value to the consumer can be measured using willingness to pay (WTP). To assess Parkinson´s disease (PD) patients´ WTP for newly developed microtablets of levodopa in combination with a drug delivering electronic device (M/E) compared to standard treatment with levodopa in combination with the COMT-inhibitor entacapone (L/e). Method: 2000 PD patients had a questionnaire on views on medication and WTP in 3 different hypothetical scenarios:1/ no change in effects or side effects; 2/ same effect and less side effects; 3/ improved effect and less side effects. These scenarios were coupled to different costs to choose from. Results: 50 % responded, mean age of 71 years and a mean PD duration of 9 years. 50% preferred M/E before L/e in scenario one with increasing preference to scenario three. The average monthly WTP among all respondents in scenario one was SEK 230 and SEK 226 in L/e, both with an almost longitudinal doubling up to scenario three. Duration of PD related symptoms, high education and high medication intake implied a higher WTP in all scenarios in contrast to age, gender, extra doses of levodopa. Conclusion: WTP for M/E increased gradually with high medication intake and education as well as with expected increased reduction of PD symptoms.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P78

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Spinal cord imaging in spastic paraparesis: are we cutting it thin enough? - read full article

By: C. Lopes, R. Soares-dos-Reis, L. Braz, J. Dias da Costa, and J. Guimarães

Introduction: Spinal dural arteriovenous fistula (SDAVF) is a rare condition, but accounts for great disability in those affected. Despite improvements in spinal imaging, SDAVF diagnosis is often difficult or masked by more common entities. Case report: A 42 year-old-woman, with a history of ileal resection 4 years prior, presented with a 6-month course of progressive walking difficulty, denying any sensory or bladder complaints. Physical examination revealed spastic paraparesis, brisk deep-tendon reflexes in the lower limbs, bilateral Babinsky sign and bilateral foot drop. Blood chemistry was normal except for low vitamin B12 levels. Her electromyogram was compatible with sensorimotor axonal polyneuropathy and cervico-dorso-lumbar spinal MRI was normal. Parenteral cyanocobalamin supplementation was initiated and the patient was discharged with a diagnosis of polyneuropathy and probable subacute combined degeneration. In the following months, the patient’s polyneuropathic gait improved, but the spastic paraparesis was unchanged. Repeat spinal cord MRI was reported as normal. Given the lack of improvement, a SDAVF was suspected. 3T Spinal MR-angiography was performed using 0.9 mm sections, revealing dilated vessels in the spinal periphery from T11 to L2 levels. Digital subtraction angiography confirmed the diagnosis and the patient is currently waiting surgery. Conclusion: We describe a case of a SDAVF with superimposed vitamin B12 deficiency, whose diagnosis required extra-thin cuts of MR-angiography. SDAVFs are potentially reversible causes of myelopathy, thus emphasizing the importance of their early identification.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P79

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Creatine food supplementation improves the phenotype and delays disease onset of the CMVMJD135 mouse model of Machado-Joseph disease - read full article

By: S. Duarte-Silva, A. Neves-Carvalho, J. Silva, A. Silva-Fernandes, and P. Maciel

Machado-Joseph disease (MJD) is an autosomal dominant neurodegenerative disorder caused by the expansion of a polyglutamine tract (polyQ) in the C-terminus of the ATXN3 gene product, ataxin-3. Mitochondrial dysfunction has been implicated in several neurodegenerative diseases. Creatine administration increases brain concentrations of phosphocreatine and an inactivation of the mitochondrial permeability pore, exerting neuroprotective effects. Here we performed two pre-clinical trials – PCT1 and PCT2 - using the CMVMJD135 mouse model of MJD (groups of animals with a 133 and 139 CAG repeat mean respectively), to which creatine 2% supplemented food was provided either for 19 (PCT1) or 29 (PCT2) weeks. Oral administration of creatine led to an overall improvement in the motor phenotype of CMVMJD135 mice on both trials. Interestingly, in PCT1, with shorter creatine treatment duration but with less disease severity, the muscular strength deficits of the CMVMJD135 were improved, while in PCT2, corresponding to a longer treatment but a high severity disease condition those improvements were not so evident. Creatine-treated animals did, however, show improvement in both trials in motor coordination, limb strength and gait quality, as well as in other neurological parameters. Creatine chronic treatment delayed the onset of several symptoms and, in some cases, completely abolished the appearance of the phenotype. Furthermore, creatine treatment showed to be neuroprotective by increasing the calbindin staining in the Purkinje cell layer and reducing the astrogliosis in the brainstem of the CMVMJD135 mice. The present findings support creatine supplementation as a useful strategy to slow the progression of MJD.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P80

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Lower motor neuron syndrome, anti-MAG neuropathy and Waldenström macroglobulinemia: Occam’s razor versus Hickam’s dictum - read full article

By: Inês Rosário Marques and M. Grunho

Background: Diseases selectively involving lower motor neurone (LMN) dysfunction have a limited differential diagnosis, including spinal muscular atrophies and motor neuropathies. Around 8-10% of patients who are initially diagnosed with motor neuron disease (MND) will eventually be found to have a different underlying condition. Others will turn out to have more than one. Case report: A 73-year-old caucasian male presented with progressive right upper limb (RUL) paresis with muscle atrophy and fasciculations. He was diagnosed with monomelic MND and started on riluzole. In the following years he developed RUL numbness, gait unsteadiness, left foot drop, and severe weight loss. He presented to us in 2015 with ongoing worsening of the symptoms. His neurological examination revealed tongue fasciculations, dysphagia and dysphonia, shoulder girdle and RUL atrophy with fasciculations, areflexic quadriparesis (RUL and left foot predominance), hypoesthesia and hypopallesthesia of RUL and distal lower limbs, overall suggestive of LMN syndrome and peripheral neuropathy. EMG was compatible with MND and sensorimotor polyneuropathy. Blood tests revealed an IgM kappa gammopathy with positive anti-MAG antibodies, and the myelogram confirmed Waldenstrom`s Macroglobulinemia (WM). The patient currently awaits chemotherapy initiation. Discussion: We present an interesting and controversial clinical case comprising three rare disorders concurring in the same patient, in a paradigmatic example of a diagnostic conundrum. Following the principle of Hickam`s dictum, could it be just an unfortunate coincidence? Alternatively, based on Occam`s razor, and according to published data, both LMN syndrome and anti-MAG neuropathy may represent different manifestation of WM and thus constitute a single disease.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P81

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Clinical manifestations of chemoradiotherapy-induced parkinsonism - read full article

By: Yoshitaka Narita, Yasuji Miyakita, Makoto Ohno, and Masamichi Takahashi

Objectives: Parkinsonism is a rare complication of chemoradiotherapy for high-grade gliomas, but the clinical manifestations were not fully understood. We examined cases of severe Parkinsonism after chemoradiotherapy for high-grade gliomas. Methods: Chemoradiotherapy-induced Parkinsonism was defined as Parkinsonism occurring after chemoradiotherapy in glioma patients without initial presentation of Parkinsonism. Two hundred forty-three patients with high-grade gliomas have been treated in our hospital from 2006 until 2015. Our basic protocol for high-grade gliomas consists of maximum safe resection and chemoradiotherapy with temozolomide. Age, tumor location, histology, initial symptoms, KPS, treatment, radiation dose, and chemotherapy for each patient were reviewed from clinical records. Results: Two hundred forty-three patients with high-grade glioma were treated in our center using temozolomide-based chemoradiotherapy. Ten patients without any hemiparesis were diagnosed with severe Parkinsonism with Yahr stage IV. The median age at initial treatment was 62.0 years, and the male:female ratio was 7:3. The median time from initial treatment to the diagnosis of Yahr stage IV was 23.8 months. Five patients (50%) presented severe Parkinsonism within 2 years from the initial treatment, whereas 2 patients presented it 3 years after the initial treatment. Among 173 patients who survived more than one year, 10 patients (5.8%) presented severe Parkinsonism. Five patients had frontal tumors, and 4 patients had parietal tumors. Three of them received dopamine therapy, but their symptoms were not completely relieved. Conclusions: Severe Parkinsonism after chemoradiotherapy is more common than expected and there is no effective treatment. Further examination is necessary to elucidate these clinical manifestations.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P82

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Shape analysis of subcortical structures in idiopathic rapid eye movement sleep behavior disorder - read full article

By: Shady Rahayel, J. Montplaisir, C. Bedetti, R.B. Postuma, S. Brambati, J. Carrier, O. Monchi, and J.F. Gagnon

Idiopathic rapid eye movement sleep behavior disorder (iRBD) is considered as a risk factor for the development of Parkinson`s disease. Structural brain abnormalities preceding onset of motor signs in Parkinson`s disease remain poorly understood and iRBD offers one way to better understand Parkinson`s disease in its preclinical stages. In iRBD, gray matter abnormalities involve both volume and cortical thickness. Another technique, vertex-based shape analysis, allows for quantification of surface differences in subcortical structures and overcomes some limitations of voxel-based measures. No study has yet studied shape of subcortical structures involved in cortico-subcortical loops in iRBD patients. Forty-one patients with iRBD and 41 controls underwent MRI examination. Voxel-based morphometry (VBM) was used to investigate local gray matter volume. Subcortical structures (i.e., putamen, caudate nucleus, globus pallidus, and thalamus) were studied for global volume and shape. VBM shows gray matter volume reductions in the frontal and insular lobes and the basal ganglia. Surface-based volumetric analysis shows reduced volume of the right putamen and the left globus pallidus. Shape analysis shows 2 clusters of abnormal surface displacement in the left putamen on the medial and lateral surfaces representing surface contraction and surface expansion. In summary, patients with iRBD present with shape and global volume abnormalities in the putamen and globus pallidus, along with local reductions of gray matter volume in the frontal lobes.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P83

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Analysis of GTP cyclohydrolase I gene (GCH1) by multiplex ligation-dependent probe amplification (MLPA) for diagnosis of Segawa disease - read full article

By: Haruo Shintaku, Hiroki Fujioka, Satoshi Kudo, Tomoko Sakaguchi, and Takashi Hamazaki

Objective: To evaluate the efficacy in diagnosis of Segawa disease by using MLPA (Multiplex Ligation-dependent Probe Amplification) method which can detect large deletions in patients who have no mutations by the direct sequencing method. Patients and Methods: We diagnosed 25 patients with Segawa disease by clinical symptoms and pteridines analysis in cerebrospinal fluid (CSF). Among 25 patients with Segawa disease 22 patients were confirmed genetically by direct gene analysis of GCH1. In the other 3 patients we performed gene analysis by using MLPA methods. Results: All 25 patients with Segawa disease showed significantly lower levels of both neopterin (N:6.59±4.09 nM) and biopterin (B:5.20±2.85 nM) in CSF than controls (N:19.5±2.10, B:23.7±8.50 nM). Twenty-two patients diagnosed by direct sequencing method had a point mutation or two bases deletion in one allele and the other 3 patients had a large deletion in their one allele which detected by MLPA method. Both N and B levels in CSF were significantly lower in the former 22 patients (N:6.92±3.92, B:5.58±2.74 nM) than in the latter 3 patients (N:1.98±0.94, B:1.67±1.46 nM). Conclusions: All patients with Segawa disease had very low N and B levels in CSF. Especially patients who had large deletion showed significantly lower levels of both N and B in CSF than the other patients who had a point mutation or 2 bases deletion. Patients suspected to be Segawa disease who had very low N and B levels in CSF should be analyze GCH1 gene by MLPA method.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P84

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Hereditary spastic paraplegia in a Filipino family: a case report - read full article

By: P. Ruth Siongco and Raymond Rosales

This is a case of a 50 year-old, male, from Bulacan, Philippines, who consulted due to difficulty in ambulation. His symptoms started with numbness of his left lower extremity that was aggravated by prolonged standing and relieved by rest. In 2012, he had lumbosacral pain and difficulty sitting and standing requiring assistance. He had difficulty in articulation and dysphagia. His weakness progressed involving his right lower extremity. He was hesitant to initiate a step, ambulated more slowly, had smaller steps, and a slightly wide-based gait. On ambulation, he had difficulty flexing his thigh muscle. He had a reduced sense of balance and a tendency to fall. There were no bowel and bladder disturbances. He consulted a neurosurgeon, where a series of neuroimaging studies of the spine revealed normal results. On examination, his cognitive function was intact with no memory disturbances. Visual acuity: 20/50 for both eyes, there was sensorineural hearing loss on his left ear, moderate dysarthria on pharyngeal sounds. He had normal muscle bulk, with spasticity on all extremities more profound on the left. He had left-sided hemiparesis, dysdiadochokinesia on both left extremities. Romberg’s sign positive. He had a crouch gait, wide-based stance, decreased cadence, and shortened step length. He had difficulty initiating a step and flexing his thighs. He was hyperreflexive on all extremities with Babinski and ankle clonus, bilateral. **Blood samples of the family were sent for genetic workup.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P85

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The effect of propofol and fentanyl on microelectrode recording and its clinical applicability during subthalamic nucleus deep brain stimulation surgery - read full article

By: Inho Song, Sung Keun Yoo, Jin Hee Moon, and Sun Ha Paek

We investigated the influence of propofol and fentanyl on microelectrode recording (MER) and its clinical applicability during subthalamic nucleus (STN) deep brain stimulation (DBS) surgery. We analyzed 8 patients with Parkinson`s disease, underwent bilateral STN DBS with MER. Their left sides were done under awake and then their right sides were done with a continuous infusion of propofol and fentanyl under local anesthesia. The electrode position was evaluated by preoperative MRI and postoperative CT. The clinical outcomes were assessed at six months after surgery. We isolated single unit activities from the left and the right side MERs. There was no significant difference in the mean firing rate between the left side MERs (38.7±16.8 spikes/sec, n=78) and the right side MERs (35.5±17.2 spikes/sec, n=66). The bursting pattern of spikes was more frequently observed in the right STN than in the left STN. All the electrode positions were within the STNs on both sides and the off-time Unified Parkinson`s Disease Rating Scale part III scores at six months after surgery decreased by 67% of the preoperative level. In this study, a continuous infusion of propofol and fentanyl did not significantly interfere with the MER signals from the STN. The results of this study suggest that propofol and fentanyl can be used for STN DBS in patients with advanced Parkinson`s disease improving the overall experience of the patients.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P86

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The effect of botox treatment in blepharospasm—an MRI pilot study - read full article

By: N. Szabó, G. Csete, E. Tóth, A. Király, P. Faragó, K. Kocsis, L. Vécsei, P. Klivényi, and T. Kincses

The pathophysiology of the blepharospasm (BPS) and the central effect of botulinum?neurotoxin (BNT) are poorly understood. The basal ganglia-thalamocortical motor circuit is thought to have a role in BPS and we suppose that BTN might have an influence on it. Ten BPS patients went under MRI scan before and after the regular BNT treatment. High resolution T1 weighted images, diffusion-weighted images and resting state functional MRI were done. The size, the structural and functional connectivity and diffusivity parameters of the basal ganglia were investigated with new MRI analytic methods. After BNT treatment the size of the left thalamus decreased in the antero-lateral region (pcorr. =0.0144). This affected region showed connection to the motor-premotor pathways, to the frontal cortex and to the cerebellum. No microstructural alterations of the white matter were found. Using the identified regions with tractography as seeds, functional connectivity analysis showed enhanced activity in the frontal lobe after BNT treatment. Also, the whole brain resting state functional MRI showed a partial restoration in visual component coherency (p=0.0266). Diffusivity parameters of the basal ganglia showed hemispheric differences after the BNT treatment. Our study supports the hypothesis that BNT treatment could generate functional and structural changes in the brain. Furthermore these results also serve an evidence for the crucial role of the deep brain structures in the pathophysiology of the dystonia and suggest, that BNT has a central effect and might due to plastic changes.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P87

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Investigation of vitamin D receptor (VDR) gene polymorphisms in sporadic amyotrophic lateral sclerosis - read full article

By: N. Török, R. Török, P. Klivényi, J. Engelhardt, and L. Vécsei

Background: There are aberrations in vitamin D–endocrine system in sporadic amyotrophic lateral sclerosis (SALS). Vitamin D deficiency and the rise of the levels of calcium and parathormon were measured in the sera of ALS patients. Diverse proteins were identified which link vitamin D to the theories of the selective degeneration of motor neurons too, albeit alterations of the VDR gene have not been reported. Objective: Our aim was to investigate the single nucleotide polymorphisms of VDR gene in SALS patients in Hungary. Methods: 75 SALS patients and 97 healthy controls were enrolled to reveal the supposed different proportion of the alleles of the VDR receptor. Restriction fragment length polymorphism was used. For data analysis, SPSS software version 20.0 was utilized. Results: ApaI SNP was associated with the disease (?2 = 11.09; P = 0.004), the A allele of this SNP proved to be significantly associated with the ALS group (?2 = 5.352, df = 1, P = 0.021, OR = 0.600, 95% CI = 1.080–2.569) so it may be an ALS risk factor. None of the investigated alleles influenced the age at disease onset. Conclusions: One allele of the examined polymorphisms of the VDR gene (ApaI A allele) seems to be a risk factor in the Hungarian SALS population. However, due to the low number of cases, another study from the Central European region is needed. To our knowledge, this is the second described VDR SNP investigation in this devastating disease.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P88

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Vascular degeneration in Parkinson’s disease - read full article

By: Panzao Yang, H.J. Waldvogel, R.L.M. Faull, M. Dragunow, and J. Guan

We have previously reported endothelial cell degeneration in Parkinson’s disease (PD) brain. The current study examined the changes of the function of the blood brain barrier (BBB), potential impairment of vascular remodelling and their association with vascular and neuronal degeneration in PD. The present study used the grey matter of middle frontal gyrus from post-mortem human PD brain and age-matched control cases where there was a significant neuronal degeneration in PD. Immunohistochemical staining of collagen IV for basement membrane (BM), platelet-derived growth factor receptor-beta (PDGF?R) for pericytes, NeuN for neurons, proliferating cell nuclear antigen (PCNA) for proliferation of endothelial cells, vascular endothelial growth factor (VEGF), fibrinogen for BBB function and phosphorylated insulin-like growth factor 1 receptor (IGF1Rp) were observed and quantified. Compared to controls, the BM was remained in PD leading to an increase in string vessels and there was no PD associated leakage of BBB. VEGF-positive neurons and pericyte-positive capillaries in PD were reduced with significant loss of vascular PCNA-positive cells. The trend toward reduction in vascular IGF1Rp-positive cells in PD was correlated with the decrease of vascular PCNA-positive cells. In conclusion, increased string vessel formation and maintained BBB may suggest the role for hypoperfusion in disease progress of PD rather than the BBB dysfunction associated neurodegeneration. The endothelial cell degeneration may be associated with impaired vascular remodelling due to the loss of trophic support from growth factors.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P89

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Arachidoyl-2’-chloroethylamide, a selective cannabinoid cb1 receptor agonist combined with valproate stimulates hippocampal neurogenesis in a mouse pilocarpine model of epilepsy - read full article

By: Marta Andres-Mach, A. Haratym-Maj, M. Zagaja, R. Rola, M. Maj, and J.J. LuszczkI

Rational polytherapy in the treatment of refractory epilepsy has been a main therapeutic modality for several years. Considering the treatment with two or more antiepileptic drugs (AEDs) it is of particular importance that the AEDs should be selected based on their high anticonvulsant properties but also high level of neuroprotection as well as minimal side effects. The aim of the study was in vivo evaluation of the relationship between treatment with synthetic cannabinoid arachidonyl-2´-chloroethylamide (ACEA) in combination with valproate (VPA) and hippocampal neurogenesis in a mouse pilocarpine model of epilepsy. All experiments were performed on adolescent CB57/BL mice. The following drugs were used: VPA, ACEA, phenylmethylsulfonyl fluoride (PMSF), pilocarpine (PILO), methyloscopolamine. We evaluated long term response to ACEA and VPA administration (BrDU, Neun, GFAP staining). Confocal microscopy and cell counting was done using Zeiss microscope and ImageJ software. Obtained results indicated clear decrease of neurogenesis in PILO control group compare to the non-PILO control mice. Moreover, ACEA with PMSF administered alone and in combination with VPA had a significant impact on neurogenesis increasing the total number of BrDU, particularly neurons (NeUN) comparing to the control group, whereas VPA administered alone significantly reduces the total number of NeUN/BrDU-positive cells compare to the control group. ACEA combined with VPA stimulates the process of neurogenesis, while chronic administration of VPA itself decreases neurogenesis in a mouse pilocarpine model of epilepsy. Obtained results make possible in vivo determination of the neurogenesis after antiepileptic drugs treatment.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P90

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Adults with epilepsy: cognitive impairment relationships with clinical aspects and quantitative EEG - read full article

By: L. Fonseca, G. Tedrus, R. Ballarin, L. Negreiros, and T. Marques

Introduction: Cognitive impairment frequently occurs in patients with epilepsy (PWE), but its pathophysiological basis is not well known. This study assessed cognition and its correlations with the clinical aspects and EEG coherence of PWE. Methods: Eighty patients with epilepsy seen consecutively at PUC-Campinas and 40 normal subjects (CG) were assessed by neurological evaluation, Mini-mental Status Examination, immediate and delayed recall of 10 simple figures, phonemic verbal fluency (FAS), clock drawing, and EEG. The mean global inter- and intrahemispheric coherences for the delta, theta, alpha and beta bands were calculated. Cognitive functions and EEG coherence of PWE and the CG were compared, and logistic regression analysis determined the factors associated with impaired cognitive functions in PWE. The significance level was set at p=0.05. Results: Cognitively, regression analysis showed that FAS impairment (14.5±8.6 x 24.3±15.7, respectively) and delayed recall of figures in PWE (7.3±2.07 x 8.6±1.48) differed significantly between PWE and the CG (R2 Nagelkerke=0.273). Beta interhemispheric coherence was higher in PWE than in the CG (0.446±0.044 x 0.425±0.036). Logistic regression analysis evidenced a significant association between beta inter-hemispheric coherence and schooling for FAS impairment (2 subgroups with cutoff at 12) (R2 Nagelkerke=0.290), and between the presence of EEG epileptiform activity and delayed recall of figures impairment (cutoff at 8)(R2 Nagelkerke=0.074). Other variables, such as epileptic seizure control and epileptic syndromes were not associated. Conclusions: Our findings suggest the importance of studying epileptiform activity and quantitative EEG for assessing cognitive changes in PWE.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P91

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The yield of non-elective inpatient video-EEG monitoring in adults - read full article

By: J. Theitler, D. Dassa, and Revital Gandelman-Marton

Background: Inpatient video-EEG monitoring (VEM) is used for the evaluation of patients with paroxysmal events of unknown nature and aids in the differentiation between seizures, psychogenic nonepileptic seizures and physiologic nonepileptic events. Most admissions to VEM are elective and are scheduled months ahead before the monitoring session. Objective: To retrospectively evaluate the yield of non-elective VEM sessions. Methods: We retrospectively reviewed the VEM recordings and medical records of all the patients admitted to our one-bed VEM unit from June 2007 to June 2015. A VEM session was diagnostic when a seizure, an event or previously unreported interictal epileptiform discharges were recorded. Results: The study group included 304 adults aged 18 to 92 years (mean- 40.4±17.4 years), 181 (59%) women. The diagnostic yield of non-elective and elective VEM session was similar (66% and 69%, respectively). In non-elective VEM, fewer patients had known epilepsy (p=0.0001), session duration was shorter (p=0.0001), and seizures and interictal epileptiform discharges were recorded less frequently compared to elective VEM (p=0.005 and p=0.0001, respectively). Conclusions: Non-elective VEM can provide useful information in patients admitted to the neurology department with recent neurological or behavioral events. A timely and correct diagnosis in these patients can potentially reduce unnecessary use of antiepileptic drugs in patients with psychogenic nonepileptic seizures and the morbidity and mortality associated with undiagnosed seizures.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P92

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Epilepsy and psychosis: when neurology and psychiatry come together - read full article

By: Tiago Geraldes, P. Breia, P. Sales, and G. Borges

Psychotic disorders are severe mental disorders that occur with changes in thinking and perception, with repercussions at personal and social levels. It is estimated that 2-9% of epileptic patients suffer from psychotic disorders. Although pathophysiological mechanisms remain unclear and psychiatric presentation may look similar to idiopathic schizophrenia, there are important clinical distinctions. There are various proposed classifications, the most consensual is performed according to their temporal relationship with the seizure itself. We present the case reports of two patients, a 56-year-old male and a 57-year-old female, with long-term temporal lobe epilepsy due to hippocampal sclerosis. Both had frontal and temporal lobes dysfunction in neuropsychological assessment, and they were referred to psychiatric consultation for behaviour changes and important psychotic symptoms. The male patient maintained a pattern of occasional complex partial seizures, showing a steady psychotic state with a good initial response to antipsychotic therapy. The female patient maintained frequent complex partial seizures even after progressive adjustment of anti-epileptic medication, culminating in right amygdalohippocampectomy. She experienced progressive worsening of psychiatric symptoms, with acute exacerbations that prompted several hospital admissions. Our aim is to draw attention to the prevalence of psychiatric disorders, particularly psychosis, affecting patients with epilepsy. These contribute to lower quality of life in these patients, and have a significant burden in society. We consider it is important to distinguish the different types of associated psychosis, not only to improve approach and therapeutic management, but also because it would contribute to the understanding of the pathophysiology of other primarily psychiatric disorders.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P93

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Cognitive functions in children with fetal antiepileptic drug exposure—study in Georgia - read full article

By: N. Gogatishvili, T. Ediberidze, S. Mamukadze, G. Lomidze, T. Gagoshidze, N. Tatishvili, and S. Kasradze

Background and aims: Influence of in utero antiepileptic drug (AED) exposure on cognitive development is limited and conflicting. We have assessed the late effects of fetal AEDs on cognitive development in children. Methods: In this prospective cohort study children aged 3-6 years with fetal exposure to AEDs were included. Individuals from the same age range but without fetal AED exposure were enrolled as a control group. In all cases Intelligence Quotient (IQ) were assessed. A two sample T test and multiple linear regression were used. Probability less than 0.05 was considered as statistically significant. Results: In total 100 subjects were evaluated. Among them 50 (mean age – 52.5 month; SD 12.8) have experienced AED exposure in utero and remaining 50 (mean age – 54.2 month; SD 14.5;) have not (unexposed group).In overall the mean IQ for exposed population was significantly lower (mean – 84.02; SD – 13.6) than in unexposed individuals (mean – 101.4; SD – 13.4)(p=0.001). Multiple regression analysis revealed mother’s non-verbal IQ (B; 0.447; p=0.001), age of walking (B; -2.1; p=0.009) and breastfeeding (B; 10.03; p=0.009) to be independent factors associated with IQ. No particular AED alone showed significant association with IQ compared to others. Conclusions: In utero AEDs exposure can hinder cognitive development. Breastfeeding, mother’s non-verbal IQ and age of walking could independently contribute in cognitive development of individuals during early childhood.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P94

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Super-refractory nonconvulsive status epilepticus secondary to cerebral fat embolism: a case report - read full article

By: Masa Hafner, S. Steblaj, B. Lorber, and G. Granda

Introduction: Cerebral fat embolism is a manifestation of fat embolism syndrome (FES) - a complication of long-bone fractures and joint reconstruction surgeries. It can show variable clinical manifestations: focal neurological signs, headache, behavioural disturbances, delirium, convulsions, or coma. Case report: A 72 - year old woman has had a total hip replacement revision surgery. The next day she had a paroxysm of right arm paresis and dysphasia. Brain CT scan and CT perfusion revealed no abnormalities. 48 hours after surgery the patient became restless and confused, later her consciousness suddenly deteriorated. An immediate EEG showed bilateral ictal epileptiform activity and the diagnosis of nonconvulsive status epilepticus (NCSE) was made. The patient was transferred to neurointensive care unit. Treatment with levetiracetam and lacosamide did not change her clinical state. Sedation and continuous EEG monitoring were started, propofol and midazolam were used. Magnetic resonance imaging (MRI) disclosed small scattered foci of acute ischemia and diffuse petechiae in deep grey matter, subcortical white matter in cerebrum, cerebellum and brainstem. Findings were consistent with cerebral fat embolism. After two weeks of deep sedation and different regimes of anticonvulsant drugs, super-refractory SE was terminated, and a month later the patient was discharged to a rehabilitation centre. Discussion: There is only one case of super-refractory NCSE secondary to fat embolism published in the medical literature and this is the first report of successful treatment of this rare clinical entity.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P95

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Molecular and biochemical criteria of the safety evaluation during anticonvulsant therapy - read full article

By: Oleksandr Kalbus and Natalia Shastun

Background: Epilepsy is one of the most common diseases of the nervous system. The efficacy of the treatment of epilepsy should be assessed not only by seizure frequency decrease, but also by the safety profile of the anticonvulsants. Purpose: To identify the diagnostic potential of glutathione and nitrothyrosine levels for assessment of the safety of anticonvulsant therapy (in experiment). Materials and Methods: Research was conducted on non-linear rats of both sexes (weight180-220g). The influence of anticonvulsants on cognitive processes was studied on a model of one-time learning - passive avoidance (CRPA) without amnesia factor. Metrazole kindling was used as an epilepsy model to evaluate the oxidative status of anticonvulsants. Discussion: Activation of nitrosating stress reactions on the ground of the deficiency of the recovered glutathione equivalents was established. Under endogenous neurointoxication even in the early stages, the nitrosating stress is developing, leading to nitro-replication of thiols and impacting the thiol-disulfide balance, which leads to the start of neuro-apoptosis. In the control group, the index nitrothyrosine-reduced glutathione ratio increased in 6 times compared to the intact group. Conclusion: The dependence of nitrothyrosine index/educed glutathione at metrazol kindling and action of anticonvulsants on cognitive processes in normal were established: as higher index is, as more negative effects anticonvulsants on cognitive function have

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P96

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Headache as an aura of epilepsy: video-EEG monitoring study - read full article

By: Dong Wook Kim, Jun-Sang Sunwoo, and Sang Kun Lee

Background: Headache can be associated with epilepsy as pre-ictal, ictal, or post-ictal phenomenon, but there are only limited studies on the patients with headache as an epileptic aura. We performed the present study to investigate the incidence and characteristics of headache as an epileptic aura, with the confirmation of EEG change by video-EEG monitoring. Methods: Data of aura and clinical seizure episodes of 831 consecutive patients who undertook video-EEG monitoring were analyzed retrospectively. All auras described by the patients were classified into 54 categories, and the detailed features of headache were obtained in patients with headache as an aura. Video-recorded clinical seizures, EEG findings and neuroimaging data were used to determine the ictal onset areas of the patients. Results: Six out of 831 (0.7%) patients experienced headache as aura (2 men, 4 women; age range: 25-52 years), and all six patients had partial seizures. Five patients described headache as the most frequent aura, and headache was the second aura in one patient. The characteristics of headache were hemicrania epileptica in two patients, tension-type headache in another two patients, and migraine-like headache in the other two patients. No patient met the diagnostic criteria of ictal epileptic headache or migraine aura-triggered seizure. Conclusion: Our study shows that headache as an aura is uncommon in adult epilepsy patients, and the headache can present as diverse features including hemicrania epileptica, tension-type headache, and migraine-like headache. Further study is necessary to characterize the feature of headache as an epileptic aura in adult epilepsy patients.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P97

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Opercular myoclonic-anarthric status epilepticus: first manifestation of mitochondrial disorder? - read full article

By: Joana Martins, N. Vila-Chã, L. Cardoso, R. Taipa, and M. Magalhães

A 38-year-old woman presented at age of 32 with epilepsia partialis continuum characterized by spontaneous, regular and focal clonic muscular twitches, that were continuous for days and involved the right hemibody (face and distal limb muscles). Dysarthria and synchronous myoclonic movements of palate and tongue accompanied these movements. Brain MRI showed a cortico-subcortical lesion in posterior part of frontal inferior left gyrus, hyperintense on T2- weighted images with cortical restricted diffusion. Electroencephalogram was normal. She became asymptomatic with antiepileptic drugs, later tapered on. Brain MRI and PET scan were performed three months later and were both normal. Infections and inflammatory disorders were excluded. The patient remained asymptomatic until the age of 37. At that age she was readmitted with a subacute, distal and symmetrical tetraparesis with brisk reflexes without sensory or sphincter involvement. A new brain MRI showed bilateral T2 hyperintensities in both caudate and lenticular nucleus. Medullar MRI and spectroscopy were normal. Laboratory investigations including blood count, serum biochemistry and cerebrospinal fluid analysis, electromyography, evoked potentials, body CT-scan and bronchofibroscopy were normal or negative. Muscle biopsy showed rare negative COX/ SDH positive fibers. Gradually, neurological symptoms disappeared. One year later, brain MRI was almost normal. Opercular myoclonic-anarthric status epilepticus (OMASE) is an uncommon condition characterized by fluctuating cortical dysarthria associated with epileptic myoclonus involving glossopharyngeal musculature bilaterally. In the present case, OMASE was the first manifestation of the disease. Although the lack of definitive criteria for the diagnosis of mitochondrial disease, muscle findings suggest this etiology.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P98

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Focal vasogenic edema in the brainstem secondary to phenytoin toxicity - read full article

By: Gayane Melikyan, N. Mhjob, A. Tabouki, D. Deleu, V. Surjith, B. Mesraoua, and H. Al Hail

Despite its unique pharmacological properties with potential risk for toxicity, phenytoin is still widely used in many parts of the world. Brain lesions on neuroimaging have rarely been reported following phenytoin toxicity and affect almost invariably the corpus callosum. We report a patient who presented with severe phenytoin toxicity and focal vasogenic edema in the brainstem. A 26-year-old man presented with an acute-onset confusional state. Neurological examination was suggestive of encephalopathy. Routine laboratory evaluation, brain computed tomography and cerebrospinal fluid analysis were normal. Electroencephalogram showed no evidence of epileptiform activity. Subsequent information revealed that the patient was diagnosed with epilepsy three months earlier and was treated with phenytoin. His serum phenytoin level was 259 ?mol/l (N-40-80 ?mol/l). The patient underwent 3 sessions of hemodialysis which reduced the serum phenytoin level below 15?mol/l resulting in normalization of his mental status but still presented severe cerebellar signs, absent proprioception and diminished deep tendon reflexes in lower limbs. Brain magnetic resonance imaging (MRI) revealed a focal T2 weighted and FLAIR hyperintense signal in lower medulla/craniocervical junction lesion without diffusion restriction or contrast enhancement. One week later his cerebellar syndrome and sensory deficit had improved significantly, and follow-up brain MRI demonstrated partial resolution of the lesion. Transient focal vasogenic edema has previously been associated with phenytoin toxicity. However, there are no reports of phenytoin toxicity causing such lesions in the brainstem. Awareness of the possibility of these lesions is important since it may avoid unnecessary invasive diagnostic interventions.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P99

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Selection of anti-epileptic drugs in the initial phase of the treatment of epilepsy - read full article

By: O. Mostovaya

The problem of choice of antiepileptic treatment is the ambiguity of the proposed options. Therefore, in our clinic, we have developed a system EEG - control the selection of drugs. It is the following algorithm: (1) Night video monitoring with the daily record and conducting trial before and after sleeping, (2) The analysis conducted by the EEC and the choice of the segment that contains the abnormal patterns, (3) Appointment of anti-epileptic drugs from a first-line choice in the order, as proposed in the protocols followed by the EEG—a test action of the preparation on the selected segment of EEG (usually – it is 3 drugs), (4) The choice of the drug on the basis of a concrete manifestation of the effectiveness. Clinical example: Patient Ch, Man/ 30 years old; epileptic seizures from he was 2 years old; he was treated by carbamazepine, valproate; episodically recently become frequent bouts; constantly have a headache; at this time, no drugs does not accept; seizures generalized tonic-clonic, 3 times a month; MRI without pathology. Could the patient be cured if he was treated consistently? Figures 1–3 illustrate the follow-up of this patient. The selection of AEDs in the beginning stage of long-term treatment of epilepsy should be carried out with the help of EEG control.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P100

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Hippocampal involvement in physiological deja vu: subfield vulnerability rather than temporal lobe epilepsy - read full article

By: Eva Peslova, R. Marecek, D. Shaw, T. Kasparek, M. Pail, and M. Brazdil

Introduction: Brain morphological correlates of physiological déjà vu (DV) have been recently identified. Significantly reduced gray matter volume (GMV) in subjects experiencing DV mirrors the distribution of GMV reduction in mesial temporal lobe epilepsy (MTLE) patients. These patterns of GMV reduction vary in terms of the hippocampal region, however. Another condition associated with hippocampal GMV reduction is schizophrenia (SCH). Here we tested the hypothesis that hippocampal involvement in physiological DV resembles more closely the pattern of GMV decrease in MTLE compared with that in SCH. Methods: We compared GMV within hippocampal subfields in healthy individuals that have (DV+; N=87) and have not experienced DV (DV-; N=26), and patients with MTLE (N=47) and SCH (N=29). We then evaluated the spatial distribution of GMV decrease to compare the DV+ and DV- groups, and their resemblance to the MTLE and SCH groups. Results: Significant GMV decrease was found in all hippocampal subfields except CA1 for the DV+, MTLE and SCH groups relative to the DV- group. Concerning the spatial distribution, we found significant correlations both between DV+ and SCH, and DV+ and MTLE groups with higher correlations for SCH. Conclusions: Our findings reveal structural features of hippocampal involvement in physiological DV, MTLE and SCH. The pattern of GMV reduction in the DV+ relative to the DV- group does not resemble the pattern observed in MTLE any more than that observed in SCH. Nevertheless, the highly similar patterns of the three groups suggest an increased vulnerability of certain subfields: CA4 DG, CA 2-3 and subiculum.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P101

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Leukoencephalopathy related to phenytoin in a patient with methylenetetrahydrofolate reductase C6777T polymorphism - read full article

By: Hak Young Rhee, Young Nam Kwon, Sung Sang Yoon, and Boo Suk Na

We report a patient with a heterozygous CT variant of MTHFR who developed leukoencephalopathy after phenytoin medication. A 36-year-old man was admitted to our hospital for progressive worsening of mental status over one week after phenytoin medication. The patient had been diagnosed with juvenile rheumatic arthritis and ankylosing spondylitis in his preteens and suffered recurrent convulsive seizures from the age of thirties. The patient had recurrent convulsive seizures after he stopped taking the medication and eventually had received treatment as an inpatient for status epilepticus and aspiration pneumonia three weeks before this admission. Phenytoin had been prescribed to control the seizures and the patient had been improved and discharged. The patient was stuporous on this admission and routine serum chemistry and complete blood counts were normal. MRI of the brain demonstrated new onset of extensive leukoencephalopathy which was prominent on FLAIR images. Sequence analysis of the MTHFR revealed compound heterozygous mutation for 677CT. Serum homocysteine level was within normal limits and serum folate level was decreased (4.21 ng/mL). The neurological status of the patient did not improved after discontinuing phenytoin. In individuals heterozygous for MTHFR C677T polymorphism, the enzyme activity is decreased to 60% of wild type activity of MTHFR. The patient developed subacute onset of mental deterioration and diffuse white matter lesions on MRI. It is probable that impaired folate metabolism and enhanced vulnerability of the CNS to the effect of phenytoin in our patient are related to the development of the leukoencephalopathy.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P102

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Seizures in patients with newly diagnosed glioma: frequency and determinants - read full article

By: Dima Suki

Background: Seizures are a common manifestation of gliomas. The frequency of seizures is generally reported to be inversely correlated with tumor grade. Tumor resection is a favorable predictor of seizure control in these patients. The study aims at 1- assessing the frequency of seizures in a large group of patients with newly diagnosed glioma undergoing neurosurgery and identifying the factors associated with these seizures; and 2- assessing the seizure control rate in the postoperative period and its determinants. Methods: Patients with newly diagnosed glioma undergoing a biopsy or resection at MD Anderson Cancer Center between June 1993 and December 2015 were included. Excluded were patients with missing imaging data and those with greater than 3 tumors at diagnosis. Data on tumor histology, WHO grade, location, patient age, gender, use of anticonvulsants, and other relevant patient, tumor and clinical characteristcs were obtained. The study was conducted under the auspices of an institutional review board approved protocol. Results: Data was obtained on 2,106 patients with glioma (58% WHO grade 4; 18% grade 3; 20% grades 1 or 2; and 4% unclassified). Median age was 53 years (4% pediatric patients); 58% were males. The tumor was located supratentorially in 91% and infratentorially in 8% (1% had both locations). Seizures were noted preoperatively in 735 (35%). In the 30-day postoperative period, seizures were noted in 89 patients (4%) overall (6% among those with a preoperative history of seizures and 3% among those without). The full results/conclusions will be presented at the meeting.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P103

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Major depressive episode, cognition, quality of life, and epilepsy - read full article

By: G. Tedrus, L. Fonseca, M. Augusto, and F. Trindade

Background: Major depressive episode in adult patients with epilepsy (PWE) is frequent, but the associated factors remain controversial. Objective: To study the occurrence of depression in PWE and relate it to their clinical characteristics and quality of life (QoL). Sample and procedures: The study included 200 consecutive PWE from the neurology outpatient clinic of PUC-Campinas. The association between Neurological Disorders Depression Inventory for Epilepsy (NDDI-E) data and their clinical, cognitive, and QOLIE-31 characteristics was investigated at a significance level of p=0.05. Results: The sample had the following characteristics: 52.5% females; mean schooling of 5.7 years; mean age of 47.6 (±15.1) years; mean age at first epileptic seizure (ES) of 24.1 (±18) years; and 75 (37.5%) PWE had psychiatric disorders. The mean NDDI-E score was 10.3 (±4.0). NDDI-E was negatively correlated with age (Spearman correlation; -0.204; p=0.004); age at first ES (-0.168; p=0.018), and QOLIE-31 (domain and total scores). High ES frequency was associated with higher NDDI-E score (Kruskal-Wallis; p=0.006). Twenty-six cases had NDDI-E score 15, suggestive of major depressive episode, which was associated with lower performance in semantic verbal fluency and QOLIE-31 scores. Discussion and Conclusion: Major depressive episode was found in 13% of the cases. Clinical, cognitive, and quality of life aspects were correlated with NDDI-E scores.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P104

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Monitoring brain damage using surface current injection - read full article

By: Shimon Abboud, R. Cohen, and M. Arad

Disturbance in the blood supply to the brain causes a cerebrovascular accident (CVA). This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism) or a hemorrhage. In this study, the feasibility of injected low amplitude high frequency surface current over the center line of the scalp between the Nasion and the Inion points of the 10/20 EEG system, for monitoring such damage was analyzed in a computerized model. Simulations were conducted on a realistic 3D numerical model of the head. Tissues were assumed to act as linear volume conductors and electrical potentials were calculated by solving the volume conductor problem. Left-right asymmetry over the 10/20 EEG leads system was calculated for several conductivities and volumes of the damaged region. The results were compared with the left-right asymmetry found in a head model with normal brain. A negative asymmetry was revealed for ischemia (i.e. the potential amplitude over the ischemic hemisphere was greater than that over the intact hemisphere). In case of hemorrhage, a positive asymmetry was found. Furthermore, correlation was found between the location of the damaged region and the electrodes with significant asymmetry. The 3D numerical simulations revealed that the volume and the electrical conductivity of the damaged tissue are correlated with the left-right asymmetry of the surface potentials. These findings support the hypothesis that using surface current technique for monitoring brain damage is feasible.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P105

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Sight resolution and brain integrative role during painting of miniature portrait - read full article

By: Jacek Bojakowski

The report addresses miniature painting in the context of brain function and plasticity. Summary of own experience in watercolor portrait miniature painting, its perception, and possible correlation with the integrative and selective brain activities is presented. Sight resolution and integrative function of human central nervous system is analyzed and new idea of studying this function by neuroimaging is suggested.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P106

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Benign paroxysmal positional vertigo commonly recurs in the ipsilateral ear and the same canal after successful repositioning maneuvers - read full article

By: SooHyun Cho and B. Kim

Objectives: Benign paroxysmal positioning vertigo (BPPV) is the most common cause of vertigo. Although repositioning maneuvers have been demonstrated to be useful in its treatment, half of all patients experience recurrence after successful repositioning maneuvers. Nevertheless, the clinical characteristics of recurred BPPV have not been systematically evaluated. The aim of our study was to establish possible clinical factors associated recurred BPPV after successful repositioning maneuvers. Method: We analyzed the records of 216 patients who experienced recurrence after 1 month apart from successful repositioning. Results: The posterior semicircular canal was affected in 62.1% and the horizontal in 37.9%. 78.7% of the 216 cases affected the ear ipsilateral to the first episodes of BPPV. Moreover, 109 (71.7%) of cases of all recurrences affected the same canal. Conclusion: Our data revealed that the recurrence of BPPV after repositioning maneuvers commonly affects the ipsilateral ear and same canal. This can be related to the abnormal pathology at the first episodes of BPPV leading to frequent recurrence even after successful repositioning maneuvers.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P107

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Two weeks of intraperitoneally oxytocin treatment exerts facilitatory effects on working memory and anti-depressive effects in wistar rats - read full article

By: Alin Ciobica, Radu Lefter, Iulia Antioch, Manuel Paulet, and Manuela Padurariu

Introduction: Lately, there is increased interest in understanding the roles of oxytocin in the main neuropsychiatric disorders such as Alzheimer’s disease, anxiety, depression, schizophrenia or autism and the variety of behaviours exhibited by both the administration of intransal or peripheral oxytocin on the developed animal models for the aforementioned disorders. In this way, here we present some of our preliminary data regarding the administration of oxytocin for 2 weeks in some specific behavioural tasks used to assess working memory and antidepresive behaviour. Material and methods: Male Wistar (n=20) rats were used. Oxytocin was intraperitoneally injected in a dose of 10 mg/kg/b.w. for 14 consecutive days. The control rats were also injected with saline. The treatment began 12 days before the behavioural testing. Memory functions were tested through Y-maze, while antidepressive behaviour was evaluated by forced swim test, performed during the last 2 days of treatment (13th and 14th, respectively). Results: Our initial data is showing positive effects on immediate working memory for the oxytocin administration in the hippocampal-dependent Y-maze test, as showed by the significant increase of the spontaneous alternation behavior in the oxytocin group, as compared to saline. Moreover, the administration of oxytocin resulted in a significant increase of the total swimming time in the forced-swim-test, as compared to the control rats, suggesting some anti-depressive effects. Conclusions: It seems that the administration of intraperitoneally oxytocin in a dose of 10 mg/kg for 2 weeks in rats could exert some facilitatory effects on the hippocampus-dependent working memory Y-maze test and anti-depressive behavior in forced-swim-test.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P108

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Clinical spectrum of neurosyphilis: a 9-year retrospective study at a neurology department of a tertiary care hospital in Lisbon - read full article

By: Ary De Sousa, P. Brás, J. Sequeira, S. Dias, J. Morgado, C. Capela, M. Dias, and R. Pedrosa

Background: Neurosyphilis is characterized by a broad range of neurological findings, potentially complicating its diagnosis. Although neurosyphilis is no longer a common disorder, its prevalence is rising in Western countries and its past reputation as the great imitator should not be forgotten. The objective of this study is to describe the clinical spectrum of patients with neurosyphilis admitted to a Neurology department of a tertiary care hospital in Lisbon. Methods: A retrospective database search using the International Classification of Diseases (ICD) 9 codes was performed to identify all patients with the diagnosis of neurosyphilis, admitted between 2001 and 2009. Collected data included demographics, clinical features, cerebrospinal fluid (CSF) changes, neuroimaging findings and outcome. Results: We identified 16 patients that met diagnostic criteria for definite or probable neurosyphilis. Mean age was 48.5 years, males being more frequently involved. The most frequent clinical patterns were meningovascular (37.5%), general paresis (31.3%) and meningitis (25.0%). CSF pleocytosis and elevated CSF protein were found in 81.2%. Neuroimaging findings were nonspecific. In this study, 3 patients had a past history of primary syphilis and 2 were HIV seropositive. Conclusions: Compared to the preantibiotic era, a lower frequency of late neurosyphilis was observed, mainly of tabes dorsalis, similar to that reported in other modern series. Neurosyphilis is still characterized by clinical polymorphism. Providers should maintain a high index of suspicion for neurosyphilis among patients with syphilis, particularly those with HIV infection.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P109

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Head trauma and epilepsy as medical risk factors in the development of brain tumors in Albania - read full article

By: Pavllo Djamandi and G. Kaloshi

Introduction: Several diseases and medical treatments are discussed as risk factors for the development of brain tumors, including infections, allergy, alterations of immune system, cranial trauma, hormonal factors, epilepsy, cancer family history, etc. We discuss here the role of head trauma and epilepsy as medical risk factor in development of brain tumor. Results: A total 1883 patients with brain tumors are registered from 1993 -2013, 977 (49%) of them were interviewed to review the analysis of risk factors, during the period December 2010-December 2013. We found in our study a correlation between head trauma and brain tumor (meningeoma) around 1%, not a correlation between glioma and traumatic brain injury (TBI) in male, and no correlation between meningeoma, glioma and TBI in female. The role of epilepsy in development of brain tumors in our study is unclear, this for the stigma that exist in our country on epilepsy, only 0.87 % of patients diagnosed with brain tumors referred to suffer from epilepsy from 10-15 years. Conclusion: The role of medical factors in development of brain tumors is important. The role of head trauma is more evident in male than female in our study and is unclear the role of epilepsy.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P110

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The role and effect of modafinil on normal-physilological night sleep - read full article

By: Hakan Ekmekci, M.Ü.ÖZIÇ, and S. Oztürk

Modafinil is a unique wake-providing drug approved for narcolepsy, shift work sleep-disorder and as adjunctive treatment of OSAS. Modafinil is well-tolerated drug with low predisposition for abuse, it is very effective on narcolepsy and excessive daily sleep. But the role of modafinil on normal night-sleep is obscure. We studied the effect of modafinil on normal physiological sleep. Therefore we designed 33 double-blind and 30 placebo-controlled trials. All volunteers (33 patients and 30 control group) were evaluated at outpatient unit of Selcuk University Hospital, Department of Neurology. All patients indicated with usage of modafinil for narcoleptic situation were investigated just before and 90th day with Polysomnography. All data collected from pre and post-period of medications were compared in between and with the control-group data. This showed us that modaifinil is not just effect daily awakening but also with physiological sleep at night. Another important thing is that severity of Epworth score is not affective on PSG findings. With increasing age, the effectivity of Apnea-Hypopnea Index improvement is better with modafinil usage. The role of modafinil is well known in daily sleep condition, and narcolepsy; but the role of it on the coming nights-sleep is a strange and important concept. Utilizing GABA, serotonin, glutamate, epinephrine, histamine and hypocretin, are the well-known pathway for modafinil effect. But this interactions may make different effect on night sleep other than the awakening roles and the effects are mostly related with REM period, age, Epworth score, family history for narcolepsy, daily napping relaxation.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P111

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Post stroke depression - read full article

By: Irena Grkic, A. Zecevic, V. Miletic, S. Knezevic, V. Mileusnic, and K. Kacar

Depression after brain stroke is one of the very often complication which has a long run negative consecution on recovery of motor and cognitive deficit as well as death from brain stroke. Depression is most often appearance in period 3-6 months after brain stroke. This study was conducted on 52 patients with ischemic PSD. They were classified into 2 groups (21 patients with early PSD and 31 patients with late PSD). All patients were subjected to thorough neurological examination: C.T. of brain, clinical assessment of depression, Hamilton rating scale for depression and Barthel index scale for disability. All patients were hospitalized in a Specialized hospital for CVD„Saint Sava” due to instability in gait, hemiparesis of the lower level with the present partial deficit developed, without any disturbance of consciousness. During hospitalization a slight drop change of mood was registered. In therapy was introduced antidepressant with continuous monitoring. Early PSD was more common and severe in left cerebral hemispheric lesions (in the basal ganglia and frontal lobe). Late PSD was more common in cortical lesions either on the right or left sides particularly in parietal or frontal lobe lesions. There was a significant correlation between the size of the lesion and severity of late PSD. Early PSD was more common in patients with left subcortical lesions while late PSD was more common in patients with cortical lesions. Severity of late PSD was related to the size of the lesion.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P112

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Postactivation depression changes associated with improvement of motor ability in subacute stroke: a case series of three patients - read full article

By: Yu Kawaishi and Kazuhisa Domen

Postactivation depression is a presynaptic mechanism regulating the excitability of the stretch reflex. Postactivation depression of soleus H-reflex has been found to be lower in spastic patients, and a positive correlation has been reported between the diminished postactivation depression and the severity of spasticity following stroke. However, the effects of diminished postactivation depression on motor ability in stroke patients have been unclear. The purpose of this study was to measure postactivation depression post-stroke and to examine the relationship between postactivation depression and motor ability. The study included three subacute stroke patients with lower limb hemiparesis. Postactivation depression, quiet standing balance, walking velocity, Fugl-Meyer, Ashworth, were assessed three times per 4weeks. All patients have been participated in conventional physical therapy in the rehabilitation hospital while investigating. Postactivation depression was evaluated by frequency-related changes of soleus H-reflex. It was quantified as the ratio: mean amplitude of the H-reflexes obtained at 1 Hz/mean amplitude of the H-reflexes obtained at 0.1 Hz. For all patients, postactivation depression showed increasing associated with improvement of quiet standing balance, walking velocity, and Fugl-Meyer. On the other hand, Ashworth didn’t show changing while investigating. Results suggests that the improvement of motor ability after stroke is associated with recovery of postactivation depression.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P113

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Is the role of BDNF in depression and dementia already proved? - read full article

By: L. Kruglov

The structural changes of the aging brain lead to cognitive decline which can end in dementia. But why almost the same pathological changes are often found in patients with late-life depression? Does this mean that depression and dementia are two links of one continuing process? The same concerns the issue of neurochemical changes found in patients with dementia and depression. One of the prominent neurochemical findings of last years is the fact that the concentration of the brain-derivated neurotrophical factor /BDNF/ in patients with dementia and depression is declined. It is raised again when effective treatment of depression is carried out but it seems that the same doesn`t happen during the drug treatment of patients with dementia. Perhaps it could be understood according to the fact that the results of such treatment are much poorer than in the depression cases. But still there is no understandable explanation of the raised concentration of BDNF in patients with co-morbidity of dementia and depression. Besides there is obvious data that the concentration of BDNF decreases along the aging. So further studies are needed for assessing the role of BDNF and other neurotrophic factors oscillations in patients with neurodegenerative processes and psychopathological states as well as their dynamics during the therapy.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P114

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The effects of functional electrical stimulation cycle on non-hemiplegic quadriceps in stroke patients (pilot study) - read full article

By: H.J. Lee, S.Y. Kim, B.S. Kwon, J.H. Shim, and J.H. Lee

Objective: To investigate the effect of functional electrical stimulation (FES) cycle on strengthening of non-hemiplegic limb and gait performance in stroke patients. Methods: Fourteen hemiplegic patients after stroke were recruited. They underwent FES cycle for 30 minutes (five times every week for 4 weeks) with conventional therapeutic exercise. Primary outcome was isokinetic/isometric torque in non-hemiplegic limb. Secondary outcomes were gait performance measured with walking velocity (10 meter walk test; 10 MWT) and timed up and go test (TUG), motor function with Motricity Index (MI) and Modified Motor Assessment Scale (MMAS), strength of paralyzed limb with Medical Research Council (MRC), spasticity with Modified Ashworth Scale (MAS), functional ambulation ability with Functional Ambulation Category (FAC) and activities of daily living with Modified Barthel Index (MBI). They were recorded at before and 1 month after training. Results: Isometric torque of quadriceps of non-hemiplegic limb and MRC grade of hamstring of hemiplegic limb were significantly improved after training. TUG, FAC and MBI were also significantly improved after treatment. 10 MWT, MI, MMAS, spasticity and muscle power of quadriceps and isokinetic torque of hamstring and quadriceps did not show significant difference after training. There were no adverse events during experiment. Conclusion: FES cycling improved muscle strength of quadriceps of non-hemiplegic limb and gait performance. FES cycling may be helpful for improvement of gait in stroke patient. However, randomized control study is necessary to confirm the therapeutic effect of FES cycle.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P115

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Is irritable bowel disease a neurological disorder? The oxidative stress and inflammation connection - read full article

By: Radu Lefter, Miruna Ioana Balmus, Anca Trifan, Alin Ciobica, and Carol Stanciu

Irritable bowel syndrome (IBS) is a symptom-based diagnosis with unknown organic mechanisms, mainly characterized by cramping, abdominal pain and general discomfort of bowel. Still, consistent evidences are lately suggesting that irritable bowel disease may be associated to depression, anxiety, autism, posttraumatic stress disorder, psychological stress and even dementia. Moreover, lately there is an increased interest towards the relevance of the oxidative stress modifications in IBS pathological manifestations. In this context, we will discuss here about the possible correlation between the neurological effect of oxidative stress and IBS mechanistics. As it is already known, the nervous system is highly susceptible to oxidative damage and inflamation due to its particular lipidic structures and low antioxidant defence. Also, several reports showed that an oxidative stress implication in IBS would be probable, but no mechanism is yet clear. Moreover, some reports are already suggesting a possible pathway of neuroinflammation involved in enteric nerve system impairment that would lead to hyperexcitability followed by impaired intestinal motility. Moreover, it is well possible that a close relationship between neuro-visceral impairments followed by impaired gut-brain axis and IBS gastrointestinal symptomatology to exist. Furthermore, it would be possible that these symptoms to occur in the absence of a nutritional of infectious stimuli and therefore not being characterized by direct inflammation and oxidative stress, but these to occur as collateral effect to impaired neurostimulation. Based on this information, the correlation between IBS, the neurological impairment of enteric nerve system and oxidative stress/inflammation remains to be further explained and discussed.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P116

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Terminal care in patients with multiple systemic atrophy - read full article

By: Akihisa Matsumoto, T. Harada, M. Kudo, and Y. Nakagawa

In order to investigate the palliative care in end stage of MSA (Multiple Systemic Atrophy), we investigated the details of medical care and rehabilitation in patients with MSA who admitted in our hospital.74 patients with MSA (MSA-P:45 patients, MSA-C:29 patients) who died in our hospital from 2005-2014 were analyzed as to the details of therapy especially in the end stage. These patients who admitted in our hospital had been already noticed diagnosis and prognosis. As the results, among 74 patients who received the terminal care and died in our hospital, non-invasive mechanical ventilation had been already used in 3 patients before admission to our hospital. Nutritional deficiency had also relieved by percutaneous endoscopic gastrostomy in 12 patients. They also decided not to use the tracheotomy ventilation. As to the therapy after admission to our hospital, rehabilitation was done in all patients. In the end stage of MSA with respiratory failure, 4 patients were done tracheotomy with informed concept. 7 patients used oxygen therapy. Rehabilitation had been done in all patients until the end stage of MSA. Rehabilitation in the end stage was mainly for the relaxation of pain, and continued from the day of admission to our hospital until the 3-7 days before the death in 46 patients. Details of rehabilitation in the end stage were the positioning for prevention of bedsore, relaxation of muscles by stimulating the tactile sense and training of excursion of joints without using apparatus for pain elicited by movement disorder.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P117

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Vascular and mixed dementia: immune state and effectiveness of multimodal treatment - read full article

By: N. Mikhaylova, L. Androsova, S. Zozulya, and T. Kliushnik

The aim was to study some clinical and immunological characteristics of vascular dementia (VaD) compared with mixed dementia (MD). Vascular dementia was diagnosed in 26.5% since mixed dementia was in 33.2% of all patients firstly admitted to the psychogeriatric unit. Some indices of an innate immunity including leukocyte elastase activity (LE), the functional activity of ?1-protein inhibitor (?1-PI), C-reactive protein (CRP) and interleukin-6 (IL-6) concentration were measured in blood plasma of in-patients. Both forms of dementia (VaD, MD) are characterized by the appearance of inflammatory markers (LE, ?1-PI, CRP and IL-6) in patients’ blood plasma. The level of these markers was found to depend on the severity of dementia. Increased levels of CRP and IL-6 are probable the biological markers of mild VaD. Mild MD was characterized by the significant increase in activity of ?1-PI, but not the level of CRP, IL-6 and activity of LE. The state of moderate MD was determined by the significant increase in activity/level of ?1-PI, CRP and IL-6. The significant positive correlation between the level of CRP and IL-6 were found in the groups of patients with moderate dementia MD only. An open study of multimodal long-term treatment with memantine combined with vascular risk factors correction and with course of citicoline (1000 mg N=20 i.v. infusions) was carried out in 20 in-patients. An augmented therapeutical effect was shown on CGI-I assessment in mild and moderate VaD and in mild MD. The innate immune indices are needed to study as markers of anti-dementia treatment’s effectiveness.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P118

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Late recognition of Tapia’s syndrome following orotraheal intubation leads to poor recovery - read full article

By: Mihael Misir, D. Czersky-Hafner, A. Vceva, and B. Kristek

Tapia’s syndrome is known rare complication of orotracheal intubation, until now described only in a few case reports. Pathological process consists of high cervical extracranial neuropraxia of the recurrent laryngeal nerve and the hypoglossal nerve with consequent ipsilateral paralysis of the vocal cord and the tongue. We present a case of 69 years old male, operated laparoscopically, due to the acute cholecystitis, and reoperated four days later due to the colon perforation and peritonitis, in general anesthesia. The day after second operation aphonia developed, with chewing problems because of tongue weakness. The symptoms persisted and 35 days later he was eventually sent to neurologist. Dysphonia and tongue deviation to right side was noticed with atrophy of right side of tongue, fasciculations on the same side, difficulties in chewing food and oral phase dysphagia. Oral sensation was normal as were palatal and pharyngeal reflexes. All other cranial nerves were unaffected and he had no signs of other brain, spinal or peripheral nerve lesions or other neurological deficits, so Tapia’s syndrome was diagnosed. Videolaringoscopical evaluation revealed fixated right and mobile left vocal cord on phonation and respiration, rima glottidis was sufficient. Right pyriphorm sinus was shallow and left normal. Other diagnostic tests, including MRI of brain, scull base and neck were normal as expected. Patient was treated with steroid therapy, vitamin B complex therapy and had some improvement of tongue weakness and dysphonia, but not complete resolution of neurological symptoms probably due to the late recognition of syndrome and introduction of therapy.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P119

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Advanced MRI applications for mild traumatic brain injury - read full article

By: Teena Shetty, Megan Parmenter, Lorena Loci, Kelianne Cummings, Charlotte Ching, Aashka Dalal, and Joseph Nguyen

Objective: To correlate clinical neurological symptoms with mTBI biomarkers during the acute and subacute period following mTBI. Background: Subjective assessment remains the standard of care for patients with mTBI. Methods: 86 patients enrolled in the study within 72 hours or 8(±2) days of head injury for the first encounter (E1). Two or three subsequent visits followed: 8(±2) days for E2, 22(±7) days for E3, and 90(±7) days for E4. Chi-square and linear mixed models were used to assess changes across encounters. Results: Most prevalent symptoms at E1 were “Headache” (92.5%), “Don’t feel right” (84.6%), and “Feeling slowed down” (82.5%). 26.1% of patients continued to experience headaches at E4. On average, patients reported 18.5, 19.2, 12.7, and 5.4 symptoms between each respective encounter. Significant decrease was found between E1 (p=0.017) and E4 (p=0.001), suggesting possible symptom resolution three months after injury. Neurological measures tested immediate recall and delayed concentration. There was a significant increase in word recall between E1 to E3 and E1 to E4 (p=0.002 for both). Only five digit recall demonstrated significant change between encounters (p=0.043). When comparing performance on three digit recall with symptomology, patients who incorrectly recalled three digits had prolonged symptoms. By E4 incorrect responders had almost six times as many symptoms (p=0.015). Conclusion: We can potentially identify clinical symptoms which support the natural history of TBI in patients. Advanced imaging techniques may bolster current treatment of TBI and allow objective diagnosis. Further study is necessary to determine better treatment pathways in caring for these injuries.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P120

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Magnetic resonance brain imaging in patients with visual vertigo - read full article

By: Lea Pollak

Introduction: Patients with visual vertigo (VV) report dizziness provoked by moving visual surroundings. It has been suggested that these subjects develop a compensation strategy for a vestibulo-proprioceptive deficit and rely excessively on visual input. We have postulated that patients with VV might have brain abnormalities that interfere with appropriate processing of visual stimulation and performed a brain MRI study to verify this hypothesis. Materials and methods: Patients with VV of more than three months duration were included. They were asked to complete The Situational Characteristic Questionnaire (SCQ) that scores for the symptoms of VV. Dizzy patients without VV served as controls. A brain MRI was performed with a Siemens 1.5 Tesla scanner in patients and controls. Results: Twenty four patients with VV were included. Their mean SCQ score was 1.45±0.9 (normal 0.16±0.28). In 50% abnormalities on MRI imaging were found. Thirty three percent of 27 controls demonstrated an abnormal brain MRI. The two groups were similar in respect to the prevalence of a localized hemispheric or posterior fossa lesion (p=0.13) but VV patients had more unspecific white matter brain changes than controls (p=0.009). Patients and controls did not differ in age and gender distribution (p=0.9) or the history of a neurotological event preceding their symptoms (p=0.3). Conclusions: Our study suggests that multiple white matter lesions might contribute to occurrence of the phenomenon of VV. Future prospective large scale studies by specific MR techniques are indicated to validate our preliminary findings and elucidate the pathological mechanism of VV.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P121

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Relapsing-remitting facial palsy and brachial plexopathy caused by HSV-1 - read full article

By: K. Alstadhaug, H. Kvarenes, J. Prytz, and C. Vedeler

The etiologies of Bell’s palsy and brachial neuritis remain uncertain, and the conditions rarely co-occur or reoccur. Here we present a woman in her twenties who had several relapsing-remitting episodes with left-sided facial palsy and brachial neuropathy. The episodes always started with painful left-sided oral blisters. Repeat PCRs HSV-1 DNA from oral vesicular lesions were positive. Extensive screening did not reveal any other underlying cause. Except a mannose-binding lectin (MBL) deficiency, a congenital complement deficiency that is frequently found in the general Caucasian population, no other immunodeficiency was demonstrated in our patient. In vitro resistance to acyclovir was tested negative (IC50 ? 2 ?g/ml), but despite prophylactic treatment with the drug in high doses, relapses recurred. However, the stereotype neurological symptoms, confined to the same anatomical areas during each episode, and with short latency of the HSV-1 reactivation, favors a local infectious neuropathy. Findings on MRI T2-weighted brachial plexus STIR images, using a 3.0-Tesla scanner during an episode, were compatible with brachial plexus neuritis. To our knowledge, this is the first ever reported documentation of relapsing-remitting facial and rachial plexus neuritis caused by HSV-1.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P122

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Peripheral nerve hyperexcitability syndrome: longitudinal follow up of three patients - read full article

By: Rositsa Baltadzhieva and K. Kiprovski

Introduction: Peripheral Nerve Hyperexcitability (PNH) is characterized by continuous muscle fiber activity (CMFA). PNH is the chief manifestation of Isaacs’ syndrome and cramp-fasciculations syndrome (CFS). Antibodies to voltage gated potassium channels (VGKC-Ab) can be present. We report longitudinal observation of three patients. Case presentations: A 35-year-old female with mixed connective tissue disorder treated with hydroxychloroquine and prednisone, experienced muscle twitching, stiffness, cramps, delayed muscle relaxation, numbness in toes and difficulties walking. EDX testing showed generalized CMFA, (fasciculations, myokymic discharges, neuromyotonia) and axonal neuropathy. VGKC-Ab were negative. Anti-CASPR2 antibody was equivocal. Plasmapheresis and IVIG improved her walking. Long term treatment with carbamazepine was effective in alleviating the involuntary movements. Her function status remained improved on a three year follow-up. A 65-year-old male one year following resolved Guillain-Barré syndrome developed new symptoms of progressive generalized cramps, muscle twitching and difficulties walking on an incline. EDX revealed generalized CMFA compatible with CFS. VGKC-Ab were positive. Gabapentin, but not carbamazepine alleviated the symptoms. Three year follow-up showed continuous normal functional status. A 67-year-old presented with four years history of cramps and involuntary muscle twitching in the calves. EDX revealed CMFA compatible with CFS including afterdischarges. There were no identifiable comorbidities. VGKC-Ab were negative. Brief trial of gabapentin and later of carbamazepine provided no satisfactory relief and the patient declined further treatment. His neurological status did not change over the course of ensuing two years. Conclusions: PNH syndrome is a heterogeneous disorder. Longitudinal follow-up of our three patients showed good prognosis.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P123

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Analysis of EEG changes in patients with neurally mediated syncope - read full article

By: Magdalena Bosak and B. Song

Rationale: Neurally-mediated syncope is a common cause of transient loss of consciousness (TLOC). It is well established that convulsive movements often accompany syncopal events. Basic diagnostic workup of TLOC includes electroencephalogram (EEG). Misinterpretation of the EEG and the association of a TLOC with involuntary motor activity often leads to the wrong diagnosis of epilepsy. EEG during syncope shows either a ‘slow-flat-slow’ or a ‘slow’ pattern. However, it is difficult to monitor the EEG during a tilt table test, therefore the two tests are done separately. The aim of this study was to asses changes in EEG in patients with vasovagal syncope. Methods: 81 patients who were confirmed via tilt table testing to have neurally-mediated syncope were enrolled in the study. EEG with 5 minutes hyperventilation (HV) was performed in patients with syncope, and in 90 healthy age and sex matched controls. Results: During HV, more abundant and pronounced delta-theta activities were found in patients than in control subjects. Delta-theta activities were found in 48.5% of patients (vs. 11% of controls, p0.001). Generalized slow activity was found in 41.3% patients, while focal slow activity was found in 7.2% patients. Slow activities consisted mainly of bilateral synchronous high amplitude delta activity. No interictal epileptiform discharges were found. Conclusion: EEG in patients with neurally mediated syncope shows pronounced “pseudoparoxysmal” slowing during HV. These distinctive EEG changes should not be confused with interictal epileptiform discharges. Further studies are needed to confirm these findings and clarify its pathophysiology.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P124

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Incidence and risk factors for neuropathy following primary total hip arthroplasty - read full article

By: J. Nguyen, E. Su, S. Lyman, E. Manning, K. Cummings, C. Ching, A. Dalal, A. Wu, M. Sasaki, and T. Shetty

Background: Post-surgical neuropathy is a rare, but potentially devastating complication following total hip arthroplasty (THA). Previous literature suggests that prevalence of post-operative neuropathy ranges from 0.2% to 1.9% in primary THA cases. Aims: This study identifies potential risk factors for neuropathy after primary THA at a tertiary orthopedic institution. Methods: Patients who developed neuropathy following THA between January 1, 1998 and December 31, 2013 were identified by electronic hospital records and matched with 2 controls. The controls were matched by surgical date. Patient and surgical variables were reviewed using data from patient charts. Results: There were 81 neuropathy cases identified out of 39,056 primary THAs (0.21%) performed at our institution during the study period. The cases were matched with 162 controls. Patients older than 50 years were found to be less at risk for developing neuropathy (OR 0.38). Conversely, patient history of smoking (OR 3.45), lumbar spine disease or surgery (OR 2.29), and spinal stenosis (OR 4.31) were associated with increased risk. Surgeries between 10AM to 1PM (OR 1.71) and 1PM or later (OR 3.98) were also found to increase risk. Conclusions: The study demonstrates neuropathy is a rare complication following primary THA at our institution. Afternoon surgeries should be investigated, as personnel fatigue or shift change may be a cause for increased risk. Spinal stenosis and lumbar spine disease, and smoking history should be closely monitored to inform the patient and surgeon for the potential increased risk of post-operative neuropathy following THA.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P125

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Long-term survival of 3000 transthyretin familial amyloid polyneuropathy patients over a century - read full article

By: T. Coelho, M. Inês, I. Conceição, P. Saramago, M. de Carvalho, and J. Costa

Background: Comprehensive long-term survival data on transthyretin familial amyloid polyneuropathy (TTR-FAP) are scarce. We aimed to estimate long-term survival in this rare disease using data from the largest and oldest cluster of patients in the world. Methods: Registry data from the Portuguese referral centres were merged encompassing 3,026 Val30Met patients until Dec2015. Patient groups analysed comprised natural disease (n=1,675), treatment with liver transplant (LTx) (n=978) and disease modifying oral treatment with tafamidis (n=373). Kaplan-Meier survival estimates and Cox proportional hazards model were used to adjusted by gender, late-onset, treatment and time until treatment. Results: Overall, long-term median survival since disease onset was 13.29 years (95%CI: 13.01-13.94): 11.55 years (95%CI: 11.01-11.99) in the natural disease and 25.07 years (95%CI: 23.23-27.25) in the LTx group. Median survival was not reached in the tafamidis group, with 5 and 10 years’ survival rate of 99.70% (95%CI: 97.91%-99.96%) and 94.55% (95%CI: 85.73%-97.98%). LTx (HR 0.15, 95%CI: 0.12-0.19) and tafamidis (HR 0.04; 95%CI: 0.02-0.12) are associated with increased survival, compared with natural disease progression. Being male (HR 1.19, 95%CI: 1.08–1.31), late-onset (HR 1.46, 95%CI: 1.27–1.68) and time until treatment (HR 1.07, 95%CI: 1.03–1.10) were found to be important risk factors associated with increased mortality. Conclusions: Long-term survival of TTR-FAP Val30Met patients is poor. Although with higher short-term mortality, LTx significantly improved long-term survival. Tafamidis is associated with higher survival though longer follow-up data is needed. Shorter time between disease onset and treatment is associated with increased survival. In case of clinical progression under drug treatment it’s important to further study how and when to cross over to other options in order to maximize long-term survival from sequential treatments.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P126

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Cerebrospinal fluid markers of neuronal and glial cell damage to monitor disease activity and predict long-term outcome in autoimmune encephalitis - read full article

By: Radu Constantinescu, D. Krysl, F. Bergquist, K. Andrén, C. Malmeström, F. Asztély, M. Axelsson, E. Ben Menachem, K. Blennow, L. Rosengren, and H. Zetterberg

Background: Clinical symptoms and long-term outcome of autoimmune encephalitis are variable. Diagnosis requires multiple investigations, and treatment strategies must be individually tailored. Better biomarkers are needed for diagnosis, to monitor disease activity, and to predict long-term outcome. We investigated the value of cerebrospinal fluid (CSF) markers of neuronal (neurofilament light chain protein = NFL, and total tau protein = T-tau) and glial cell (glial fibrillary acidic protein = GFAP) damage in patients with autoimmune encephalitis. Methods: Demographic, clinical, magnetic resonance imaging, CSF and antibody-related data of 25 patients hospitalized for autoimmune encephalitis and followed for one year were retrospectively collected. Correlations between these data and consecutive CSF levels of NFL, T-tau, and GFAP were investigated. Disability, assessed by the modified Rankin scale, was used for evaluation of disease activity and long-term outcome. Results: The acute stage of autoimmune encephalitis was accompanied by high CSF levels of NFL and T-tau, whereas normal or significantly lower levels were observed after clinical improvement one year later. NFL and T-tau reacted in a similar way but at different speeds, with T-tau reacting faster. CSF levels of GFAP were initially moderately increased, but did not change significantly later on. Final outcome (disability at one year) directly correlated with CSF-NFL and CSF-GFAP levels at all time-points and with CSF-T-tau at LP2. This correlation remained significant after age-adjustment for CSF-NFL and T-tau, but not for GFAP. Conclusion: In autoimmune encephalitis, CSF levels of neuronal and glial cell damage markers appear to reflect disease activity and long-term disability.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P127

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Monitoring brain damage using surface current injection - read full article

By: Shimon Abboud, R. Cohen, and M. Arad

Disturbance in the blood supply to the brain causes a cerebrovascular accident (CVA). This can be due to ischemia (lack of blood flow) caused by blockage (thrombosis, arterial embolism) or a hemorrhage. In this study, the feasibility of injected low amplitude high frequency surface current over the center line of the scalp between the Nasion and the Inion points of the 10/20 EEG system, for monitoring such damage was analyzed in a computerized model. Simulations were conducted on a realistic 3D numerical model of the head. Tissues were assumed to act as linear volume conductors and electrical potentials were calculated by solving the volume conductor problem. Left-right asymmetry over the 10/20 EEG leads system was calculated for several conductivities and volumes of the damaged region. The results were compared with the left-right asymmetry found in a head model with normal brain. A negative asymmetry was revealed for ischemia (i.e. the potential amplitude over the ischemic hemisphere was greater than that over the intact hemisphere). In case of hemorrhage, a positive asymmetry was found. Furthermore, correlation was found between the location of the damaged region and the electrodes with significant asymmetry. The 3D numerical simulations revealed that the volume and the electrical conductivity of the damaged tissue are correlated with the left-right asymmetry of the surface potentials. These findings support the hypothesis that using surface current technique for monitoring brain damage is feasible.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P128

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Clinical presentation and predictors of outcome in adult patients with mitochondrial diseases - read full article

By: J. Durães, C. Duque, P. Garcia, L. Diogo, M. Grazina, and M. Macário

Introduction: Mitochondrial diseases have diverse clinical, biochemical and genetic presentations. Patients can have a “classic” mitochondrial syndrome or a more heterogeneous phenotype, leading to a challenging prediction of the clinical course and long-term outcome. Aim: To describe the clinical presentations in a cohort of adults with mitochondrial disease and determine predictors of their outcome. Methods: Demographics and clinical data were collected for all patients with a probable or definite diagnosis of mitochondrial disease according to the Bernier criteria. Outcomes were defined as death related to complications of the disease and degree of dependency, evaluated with the Katz Index of Independence in Activities of Daily Living. Results: 60 patients were included, 57% had an adult-onset form and the majority were female (62%). The most common phenotype was chronic progressive external ophthalmoplegia (46%). 6 patients died within follow-up (10%). Death was significantly associated with cardiac involvement (p=0.03). The mean Katz score was 5. Patients with a younger age at onset (p=0.05), presence of generalized myopathy (p=0.002), developmental delay (p=0.005) or cardiac involvement (p=0.05) as well as a history of encephalopathy (p=0.01), epilepsy (p=0.01) or stroke-like episodes (p=0.03) had a higher degree of dependency (defined as Katz score ?2). Conclusions: Our patients had mainly mild presentations with ocular involvement. The presence of other clinical findings is important for the degree of dependency and outcome. Cardiac involvement seems to be the main clinical factor related to death in mitochondrial disease, highlighting the importance of systematic cardiac study in these patients.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P129

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Temporal trends in transthyretin familial amyloid polyneuropathy survival over a century - read full article

By: T. Coelho, M.Inês, I. Conceição, P. Saramago, M. de Carvalho, and J. Costa

Background: Comprehensive long-term data on transthyretin familial amyloid polyneuropathy (TTR-FAP) survival are scarce. We estimated disease natural long-term survival using data from the largest and oldest patient’s cluster in the world. Methods: Registry data from the Portuguese referral centres were merged until Dec2015 encompassing 1,675 Val30Met untreated patients. Kaplan-Meier survival estimates were obtained and Cox proportional hazards model used to estimate hazard ratios (HR) and 95% confidence intervals (CI). We analysed survival trends using five cohorts: born before 1934, 1934–43, 1944–53, 1954–63 and after 1963, adjusted by gender and late-onset. Results: Natural long-term median survival since disease onset is 11.55 years (95%CI: 11.01-11.99) and has increased from 10.01 years (born before 1934, 95%CI: 9.38-11.01) to 11.92 years (born after 1963, 95%CI: 9.44-12.34). Being male (HR 1.29, 95%CI: 1.15–1.43) and late-onset (HR 1.38, 95%CI: 1.18–1.61) were found to be important risk factors associated with increased mortality. The 1934–43, 1944–53, 1954–63 cohorts are associated with increased survival (p0.01) as compared with those born before 1934. The cohort born after 1963 also has a positive trend (p=0.059) however without statistical significance, possibly due to higher selection into disease modifying interventions that impacted negatively the number and characteristics of untreated patients. Conclusions: If untreated, long-term survival since TTR-FAP disease onset is very poor, particularly in males and late-onset patients. Surveillance enhancement and multidisciplinary care provided by FAP referral centres can explain part of the observed increase in survival. Improvement in early referral to specialized centres is warranted. This may be achieved through better disease awareness and definition of a well identified network of referral centres.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P130

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Controversy lies in the eye of the beholder: video-oculography in chronic inflammatory demyelinating polyneuropathy - read full article

By: I.M. Ion, A. Corlobé, M. De Verdal, D. Renard, E. Thouvenot, and G. Castelnovo

Introduction: Chronic inflammatory demyelinating polyneuropathy (CIDP) is an acquired immune-mediated inflammatory disorder of the peripheral nervous system that affects motor and sensory fibers of the limbs. Less than 5% of the patients develop symptomatic ocular movement disorders. To the best of our knowledge, quantitative analysis of both saccadic and smooth pursuit eye movements has never been studied in CIDP. Methods: Fifthteen consecutive CIDP patients followed in our neurological department were invited to undergo video-oculography (VO, Eye-Brain Tracker) in December 2015. Results: Our group included 2 cases with pure motor, 7 with pure sensitive, and 6 with motor-sensory type CIDP. The sex ratio was 9M/6F and the mean age 58 years. The mean disease duration was 10 years. Mean overall neuropathy limitations scale score (range 0 to 12) was 3.5. None of the patients had ocular movement abnormalities on clinical (including complete oculomotor) examination. VO showed at least one saccadic or pursuit abnormality in all patients. Four patients had slow vertical saccades and three patients had slow horizontal saccades. Hypometric vertical and horizontal saccades were found in 5 and 6 patients respectively. Saccadic intrusions were observed in 4 cases and horizontal smooth pursuit was impaired in 2 patients. No specific oculomotor patterns were observed in the different CIDP types. Conclusion: All CIDP patients in our study had abnormal VO despite normal bedside oculomotor examination. Hypometria and slowing of vertical saccades were the most common ocular motor disorders found in our CIDP patients.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P131

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Electomyographic (EMG) peculiarities of neuromuscular transmission damage in patients with myasthenia gravis (MG) and Lambert-Eaton syndrome (LES) - read full article

By: Nana Kvirkvelia, Roman Shakarishvili, Rusudan Nikolaishvili, Maia Jibladze, Nino Mikava, and Nino Khizanishvili

Objectives: To reveal different pathogenic mechanisms reflecting EMG correlates of MG and LES. Methods: 89 MG and LES patients were EMG investigated. The functional state of neuromuscular transmission was determined by the decrement of M-response amplitude and area during the stimulation of different frequency. While stimulating with low frequencies, the determination of the decrement of the amplitude and area of the fifth M-response has been made by comparing the appropriate parameters of the first M-response and every next M-responses with the previous. Results: In patients with MG during the stimulation of low frequencies, the most significant decrement of the M-response was found between the second and first and the third and second responses. In patients with LES the decrement of M-response was manifested in all five responses toward the previous ones. Conclusion: The EMG peculiarities manifested during the stimulation with low frequencies in MG and LES explain different pathologic mechanisms of these two diseases. In this thesis the revelation of EMG peculiarities of human synaptic diseases will promote timely diagnostic and adequate therapy of these pathologies. Key message: EMG data of MG and LES will help to correctly diagnose these diseases and timely apply adequate therapy.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P132

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Colchicine-induced myopathy with myotonia - read full article

By: Jie-Yuan Li, C. Lee, and Y. Lo

Background: Acute gastrointestinal upset from the use of colchicine in the treatment of acute gouty arthritis is common. However, routine doses of colchicine may cause severe myopathy in patients with impaired renal function. Clinical or electrophysiological myotonia secondary to colchicine has very rarely been reported. Patient: A 79-year-old man presented with progressive weakness especially in the muscles of his lower limbs for about ten days before admission. He was diabetic, hypertensive and had coronary arterial disease with congestive heart failure for many years. He also had chronic renal insufficiency with a serum creatinine of 1.9 mg/dL. He had been treated with colchicine for gouty arthritis for the past 25 days. Neurological examination revealed proximal muscles weakness of four limbs, more prominent in the legs than in the upper arms. His deep tendon reflexes were absent. Percussion myotonia was present in the thenar muscles. Results: Laboratory evaluation demonstrated an increased level of serum creatine kinase (CK), lactate dehydrogenase (LDH) and aspartate aminotransferase (AST). Serum creatinine was 2.2 mg/dL. Electromyography revealed myopathy pattern and abundant widespread myotonic discharges in all muscles examined. Fibrillations and complex repetitive discharges were also widespread. Muscle biopsy findings showed prominent vacuolar formation in the myocytes. Electron microscopy revealed subsarcolemmal vacuoles containing multiple electron-dense lysosomal granules. After withdrawal of colchicine, marked improvement of his muscle strength occurred two weeks later. Conclusions: Colchicine-induced myopathy associated with clinical and electrophysiological myotonia is very rare. Colchicine should be used with caution in elderly patients with chronic renal insufficiency.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P133

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Long-term management of anti-n-methyl-d-aspartate receptor (NMDAR) encephalitis in young children—still a matter of debate - read full article

By: Sandra Moreira, P. Pires, and C. Garrido

Anti-NMDAR encephalitis is the best-characterized and most common antibody-mediated encephalitis. With early aggressive immunosuppression, prognosis is usually good, although recurrences have been reported in up to 20-25% of patients, mostly in patients without teratoma. Guidelines for the best medical management are still lacking, especially concerning its duration, the comparative efficacy of individual treatments and the role of corticoid-sparing agents. It is also unclear if tumors should be sought after an initial negative screening in males and females younger than 18. We report the case of a 30-month boy with previous speech delay, who presented with insidious onset of irritability, asymmetric dystonia and chorea, sleep disturbance and consciousness fluctuations. Infections and metabolic disturbances were excluded. NMDAR antibodies were identified in serum and CSF. MRI showed right insular and frontal cortex T2-hyperintensity. Tumor screening was negative. He was initially treated with metilprednisolone pulses and IVIG and then kept on monthly IVIG and prednisolone 1mg/Kg/day, followed by slowly tapering after 2 months of sustained clinical improvement. Follow-up MRI disclosed some brain atrophy and the patient remains with a significant speech delay after 5 months. Despite the good response to first-line treatments, as in this case, corticoid side effects in children may be severe and irreversible. On the other hand, quick withdrawal may compromise recovery and increase relapse probability, especially in cases without associated tumor. This case is illustrative of the difficulties faced by clinicians in the long-term management of NMDAR-encephalitis, namely in respect to the need of corticoid-sparing agents and tumor screening repetition.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P134

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Neurodegeneration in TTR amyloid neuropathy: schwann cell hypothesis - read full article

By: Tatsufumi Murakami, K. Sango, K. Watabe, N. Niimi, Z. Li, Z. Yamamura, and K. Sunada

TTR amyloid neuropathy is characterized by extracellular amyloid deposits and peripheral nerve involvement. Sensory dominant polyneuropathy and autonomic neuropathy are usually observed as early features in the patients. Though axonal degeneration is the primary change in TTR amyloid neuropathy, segmental demyelination and Schwann cell abnormalities have also been described. We previously demonstrated that the TTR gene is significantly expressed in Schwann cells of the dorsal root ganglia (DRG) and peripheral nerves. Then, we established a spontaneously immortalized Schwann cell line, TgS1, derived from the transgenic mice expressing human TTR Met30 gene in a mouse null background. TgS1 cells synthesized variant TTR and secreted it into the medium. The conditioned medium (CM) derived from TgS1 cells and recombinant variant TTR inhibited neurite outgrowth from DRG sensory neurons. Immunohistochemistry revealed TTR aggregates in the cytoplasm of Schwann cells and satellite cells of the DRG of aged transgenic mice. In a few satellite cells, TTR positive inclusions were observed in the cytoplasm. TTR immunoreactivity was also detected in the cytoplasm of myelinating Schwann cells. Proteasome inhibition induced TTR aggregates as aggresomes in the TgS1 cells. Electron micrographs of the cells showed autolysosomes. These findings support the hypothesis that Schwann cells might trigger neuropathy in TTR amyloidosis.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P135

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Parsonage Turner syndrome - read full article

By: Diana Naco

Parsonage Turner Syndrome is a neurological syndrome characterized by severe pain in the shoulder and arm. Is also known as brachial neuritis or neuralgic amyotrophy, is a peripheral nerve disorder . PTS may develop after trauma, viral or bacterial infection or vaccination, but the etiology it is still unknown. Parsonage-Turner Syndrome has an incidence of 1.64 cases in 100,000 people. Case Our patient, a 55 years old male, is presented in our clinic with several in the left shoulder and left arm. Patient underwent a detailed neurological examination. The x ray (radiograph) of the neck and shoulder was ordered. The orthopedic and rheumatic etiology was excluded. MRI cervical column is normal. The electromyography test result with denervation in involved muscles, conclude diagnosis. A review of literature for Parsonage turner syndrome is done.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P136

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Neurological complications of common variable immunodeficiency: the immune system in chaos - read full article

By: Ana Novo, P. Carvalho, A. Nogueira, J. Pita, C. Constanço, F. Vieira, L. Sousa, E. Faria, and S. Batista

Introduction: Autoimmune disorders and granulomatous disease are well established complications of Common Variable Immunodeficiency (CVID). However, central nervous system (CNS) involvement is rare in these disorders. Case 1: 42-year-old woman with recurrent occipital headaches since the age of 32 (1997). Brain-MRI showed hyperintense periventricular T2-lesions. Autoimmunity, serologic and CSF tests, SACE and visual evoked potential were normal. Protein electrophoresis revealed hypogammaglobulinemia G and A. In 2006, the patient presented left hemiparesis and hemihypoesthesia with spontaneous remission after 3-4 days, and recurrent mucocutaneous infections. Brain-MRI: multiple T2 hyperintense lesions in periventricular and bilateral frontal subcortical white matter. Cerebral vasculitis associated with CVID was diagnosed. Patient started a 30gr/month dose intravenous immunoglobulin (IVIG) therapy and achieved remission of infections and neurological symptoms. Case 2: 21-year-old man with a previous severe dental abscess, megaloblastic anemia and hypogammaglobulinemia (G and A). Bone marrow biopsy showed non-caseous granulomas. Infectious and neoplastic causes were excluded. In 2014, the patient was hospitalized due to new onset headache. Brain-MRI: multiple large and enhancing brain lesions. Granulomatous disease associated with CVID with CNS involvement was diagnosed. A 35gr/month IVIG therapy was started. In 2015, patient was rehospitalized due to flaccid paraparesis and urinary retention. Neuraxis-MRI: new multiple brain lesions and active cervicothoracic lesions. Improvement was observed in response to corticotherapy. Due to persistence of lesional activity, cyclophosphamid 400mg/m2/month was initiated. Conclusion: These cases illustrate the difficulty in diagnosis and treatment of CVID with neurological complications, since they entail the approach of a paradoxically hypoactive and hyperactive immune state.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P137

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Multiple sclerosis, Sjogren and/or another autoimmune disorder? - read full article

By: Adriana Rua, J. Alves, C. Pereira, G. Carvalheiras, S. Cavaco, and A. Martins da Silva

A 28-year-old female, with prior history of peripheral facial paralysis at age 12, developed signs of depression four months after giving birth to a healthy son. In the following years, her behaviour deteriorated (e.g., carelessness with chores, childish behaviour, hypersomnia, memory difficulties, psychomotor slowness, irritability, inappropriate laughter, unawareness of behavioural changes, and occasional incontinence). At 33, the patient was referred to neurology and the neurological examination only revealed fragmented saccadic movements and horizontal-torsional nystagmus. The neuropsychological assessment showed significant impairment in multiple cognitive domains (attention, psychomotor speed, visuo-spatial functions, memory, and executive functions). MRI scans disclosed multiple T2-weighted hyperintense lesions in supratentorial region (e.g., periventricular, subcortical, juxtacortical areas, and corpus callosum), infratentorial territory (cerebellum and brainstem), and cervical medulla suggestive of inflammatory/demyelinating aetiology. There were also signs of subcortical atrophy. To exclude other causes of white matter disease, a comprehensive series of laboratory studies were carried out. CSF had elevated IgG index and oligoclonal bands. Visual evoked potentials revealed bilateral prolonged latencies. The immunological tests found ANA=1/640 and high anti-thyroid antibodies. These set of paraclinical findings were supportive of Multiple Sclerosis–cortical variant. A course of methylprednisolone did not have a significant effect. One year later, the patient developed Sicca syndrome and diarrhoea of unknown aetiology. Additional investigation revealed ANA=1/1280 and salivary gland scintigraphy and biopsy compatible with Sjogren syndrome. Neuropsychological and MRI findings did not show significant changes from prior examination. The prolonged neuropsychiatric symptoms associated with a puzzling set of clinical and paraclinical findings pose a diagnostic challenge.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P138

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Recurrent coma in patient with Hashimoto’s encephalitis: a case report - read full article

By: Ia Rukhadze, T. Kishmaraia, M. Mgaloblishvili, T. Chanishvili, and G. Kiliptari

Hashimoto's encephalitis is very rare neurological disorders. It presented of many different types of neurological features. This form of encephalitis is in many cases difficult statement of diagnosis. 53 year old woman with unknown comas was hospitalized three times in different clinics during 4 months. Each attack was repeated about one month period. In all cases patient’s relatives have found her in loss of consciousness and after this they have made patient hospitalized. Because of acute breathing problem artificial respiration of lungs was needed. In the first and second cases there were generalized and myoclonic seizures associated with deep coma. Between recurrent coma periods patient was in normal condition, but the only clinical signs were tremor of limbs. According to the following observations: MRT, CT and EEG and also to the several laboratory features, there weren’t any pathological changes. After the second comatose statement, lowp recorder was inserted. We haven’t found any pathological disorders. Only in the third episode of coma TSH was increased till 10. Also, anti TPO and anti TG parameters were higher. PET observation showed encephalitic injuries in both thalamus. After this, patient was treated with hormonotherapy. Patient was positively affected by this kind of treatment. After 10 month remission patient was again in comatose condition. Nowadays, patient is in normal condition and takes prednisolon. Rare forms of Hashimoto’s encephalitis are especially severe development forms. They need timely differential diagnosis and despite of treatments have recurrent evolvement.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P139

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Cognitive impairment in patients with autoimmune thyroiditis: an underdiagnosed entity? - read full article

By: Ricardo Soares-dos-Reis and Joana Guimarães

Introduction: Autoimmune thyroiditis with hypothyroidism is an undisputed cause of cognitive dysfunction and encephalopathy. However, attributing mild cognitive complaints to this condition, in patients under adequate T4 supplementation, remains controversial. Case: A 39 year-old woman complained of cognitive impairment when performing complex tasks or multi-tasking, accompanied by occasional dizziness and headache, which had been waxing and waning for 5 years. Prior medical history revealed an autoimmune thyroiditis with a high anti-peroxidase antibody titer (683 IU/mL), diagnosed when the symptoms started, currently under adequate T4 supplementation. Her neurological examination was normal, except for slow speech and frequent pauses, losing narrative flow. Cerebral and cervical MRI and MRA, vestibular testing, ambulatory blood pressure and 24h Holter monitoring were normal. Remaining immunological testing, insulin levels and catecholamine metabolites were within normal range. A 24h EEG consistently revealed bouts of mainly alpha, but also theta activity in a left anterior temporal location, reflecting dysfunction in those areas, during the complaints of clouding of consciousness. Formal neuropsychological testing showed mild executive dysfunction. A 3-day intravenous pulse of 1gr methylprednisolone was tried, with subjective improvement and normalization of speech. A repeat 24h EEG showed no bouts of theta waves and a marked reduction in the periods of abnormal alpha activity. Conclusion: We describe a case of subjective cognitive complaints with objective EEG findings and improvement after corticosteroids. The association of subtle cognitive deficits with autoimmune thyroiditis is seldom reported, making this a rare, or underdiagnosed, entity.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P140

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Meningitis-retention syndrome - read full article

By: Ana Luísa Sousa, Raquel Samões, Ana Trepa, and Luís F. Maia

Meningitis-retention syndrome (MRS) is a rarely reported and poorly understood entity that combines urinary retention and aseptic meningitis. The etiology remains unknown, although both infectious and inflammatory causes have been proposed. A 35-year-old female presented with a history of flu-like symptoms and fever followed by urinary retention of more than 1000ml two weeks later. On examination she had mild nuchal rigidity and generalized hyperreflexia. The CSF showed 96 leukocytes (86 lymphocytes and 10 polymorphonuclear cells), mild proteinorraquia (0,46g/L) and normal glucose (0.51g/L). Herpes simplex virus PCR was negative as were serologies for EBV, CMV, borrelia, bartonella, mycoplasma and mycobacterium tuberculosis. The neuroaxis MRI was normal and the urodynamic study revealed a hyposensitive and acontractile detrusor. She was treated with 3 weeks of antibiotics, tamsulosin and intermittent urinary catheterizations. There was only partial clinical and CSF cell count improvement. She then had a 3-day course of methylprednisolone 1gr/day with gradual but complete resolution. An uroflowmetry performed 5 months after the onset of symptoms showed significant improvement: voiding became possible without straining and the residual volume decreased dramatically. MRS should be considered in the differential diagnosis of urinary retention and meningitis. Whether this syndrome represents a sacral myeloradiculitis, a parasympathetic pelvic ganglia involvement or another lesion throughout the neuroaxis remains controversial. Corticoid pulses have been used with inconsistent results. In this case, clinical recovery coincided with high dose steroid treatment, suggesting that an immune-mediated mechanism may underlie such condition, in line with what is predicted to occur in acute disseminated encephalomyelitis (ADEM).

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P141

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Guillain Barre syndrome variant with facial diplegia and paresthesias associated with systemic lupus erythematosus - read full article

By: Sung Sang Yoon, H.Y. Rhee, B.S. Na, and Y.N. Kwon

Bilateral facial palsy is a rare clinical presentation and extensive diagnostic work-up is mandatory for identifying the cause. We present a case of variant GBS showing bilateral facial palsy, which could be a presenting manifestation of SLE. A 58-year-old woman admitted to our hospital for the development of bilateral symmetrical facial weakness. She had upper respiratory infection symptoms two weeks prior to the admission. Six days before the admission, she noticed that she could not close her right eyelid completely. One day before the admission, she was unable to close the left eyelid and move cheeks properly. High resolution CT of chest showed subpleural reticular opacities, interlobular saptal thickening, and ground glass opacities in both lung fields. Laboratory data about autoimmunity revealed that ANA (homogenous 1:640, cytoplasmic 1:160) and anti-dsDNA, nucleosome, and ribosomal P protein were positive. Nerve conduction studies showed the evidence of demyelinating sensorimotor polyneuropathy. The clinical and laboratory features of the patient, which include a history of antecedent infection, acute onset and rapidly progressive bilateral facial palsy, paresthesia in the distal limbs, electrophysiologic evidence of systemic polyneuropathy, and CSF albuminocytologic dissociation, support the diagnosis of a regional GBS “facial diplegia with limb paresthesias”. The peripheral manifestations in patients with SLE include polyneuropathy, mononeuritis multiplex, cranial neuropathy, and mononeuroapthy. It also is possible that a variant form of GBS is associated with one of neurological manifestation of SLE.

Special Issue on Controversies in Neurology. From the 10th World Congress on Controversies in Neurology (CONy), Lisbon, Portugal. 17–20 March 2016.

International Journal of Clinical Neurosciences and Mental Health 2016; 3(Suppl. 1):P142

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A hole in the heart - read full article

By: Teresa Salero, Sérgio Menezes Pina, Sofia Amálio, Joana Pestana, Ana Paula Fidalgo, and Ana Lopes

Background: Up to 10-40% of all acute ischemic strokes have no obvious underlying cause, being defined as cryptogenic strokes. Patent Foramen Ovale (PFO) is found in nearly 25% of general population and its prevalence among cryptogenic stroke population accounts for 40-50%. 
Case Presentation: A 42-year-old right-handed fisherman, previously Rankin 0, was referred to the Emergency Department with aphasia and right hemiplegia for one-hour. Patient was alcoholic but denied head trauma. He had been immobilized during the previous week due to a patellar dislocation. Physical, cardiologic and neurologic examinations were normal, except for the motor aphasia and right hemiplegia. Cranial computed tomography and angiotomography showed no abnormalities. He underwent fibrinolytic treatment with almost full recovery from previous focal lesions. The magnetic resonance imaging of the brain showed signs of acute (<6h) infarcts along the left middle cerebral artery territory. Laboratory tests included normal complete blood count and routine blood chemistries, serology, autoimmunity and thyroid stimulating hormone. Electrocardiogram showed normal sinus rhythm. Carotid and vertebral Doppler scans, as well as the transthoracic echocardiography, were normal. Without any apparent cause, it was requested a second transthoracic echocardiography, which revealed the presence of the PFO during Valsalva maneuver and discrete right atrium enlargement. The patient was discharged anticoagulated and referred to a Cardiology consult to discuss treatment options. 
Conclusions: PFO should be investigated especially among patients without any other obvious cause for stroke. However, larger studies need to be performed in order to support the correlation between interatrial septal abnormalities and ischemic stroke in young adults.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P1

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Delayed thrombectomy in acute vertebrobasilar occlusion—case report - read full article

By: Márcia Pacheco, Gil Nunes, Jaime Pamplona, Socorro Piñeiro, Denise Lopes, Ana Pidal, Sónia Costa, Vânia Almeida, Cândida Barroso, and Alexandre Amaral-Silva

Acute basilar thrombosis is associated with poor prognosis. Thrombolysis and thrombectomy may reduce mortality and disability. Some studies suggest that the time window for revascularization is probably longer that in anterior circulation strokes. Case description: A 73-year-old female presented to the Emergency Department complaining of 2 transient episodes of dysarthria. At admission, the only positive finding was mild gait ataxia. Brain computed tomography (CT) documented acute infarcts at the right occipital pole and posterior cerebellar area. Transcranial duplex scan showed mild stenosis (<50%) of the left vertebrobasilar (VB) junction. During the first 24h after admission, progressive neurological deterioration occurred. CT angiography documented left VB junction and proximal basilar segment occlusion with retrograde filling of the distal segment. Cerebral magnetic resonance showed DWI+/FLAIR+ right cerebral peduncle, occipital parasagital, paramedian pontic and cerebellar hemispheric acute ischemic lesions. The patient was somnolent, with dysarthria and left hemiplegia - NIHSS=12. Considering the clinical-imaging mismatch, she was referred to the interventional neuroradiology department at a Comprehensive Stroke Center. Complete recanalization was achieved 31h after hospital admission (19h after clinical deterioration). The patient´s condition improved progressively and she was discharged at day 8 (NIHSS=5, mRs=2). Close surveillance and monitoring with vascular reassessment is essential to define the correct therapeutic strategy in patients with progressive symptoms. Selected patients with neurologic deterioration, clinical-imaging mismatch and persistent basilar occlusion may benefit from delayed endovascular revascularization and still achieve good outcomes.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P2

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Multiple iatrogenic lesions after preoperative embolization of hypervascular nasal tumor - read full article

By: Ricardo Martins, Ângelo Carneiro, Viriato Alves, Rui Felgueiras, João Teixeira, and João Xavier

Introduction: Pre-surgical embolization of head and neck tumors is an established procedure, aimed to decrease the blood loss during surgery and to facilitate complete resection. However, severe complications might occur during these embolizations. 
Case Presentation: A 34-year-old woman with a vascularized benign tumor in the right nasal cavity was referred for pre-surgical embolization. Tumor was devascularized with embolic microspheres, injected at the origin of the sphenopalatine artery. After the embolization, the patient complained of loss of vision on the right (became amaurotic) and selective injections depicted a previously unseen anastomosis between the branches of the sphenopalatine and the ophthalmic artery (via ethmoidal branches). Alteplase was injected into the ophthalmic artery ostium, to try to restore flow in the central retinal artery (without success). After the procedure, left hemiparesis was observed and MRI showed cerebral infarcts in the right carotid territory secondary to iatrogenic dissection of the right internal carotid artery. Iatrogenic livedo reticularis also occurred in the glabellar and right malar region.
Discussion: The reported incidence of a severe complication associated with pre-surgical embolization of head and neck tumors is less than 2%. One of the most feared complications is central retinal artery occlusion. Arterial dissections might occur during endovascular procedures but are seldom symptomatic. During endovascular treatment of stroke, an incidence of carotid dissections between 0.25-3.5 was reported. In therapeutic procedures, the risk may be higher due to the more frequent exchange of catheters and the greater number of passages of these devices. 
Conclusion: Multiple severe iatrogenies occurred, despite the adequate technical execution. Pre-surgical embolization is not free of risks, and requires multidisciplinary discussion and rigorous technical planning.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P3

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Is there a smoking paradox in acute ischemic stroke angiographic recanalization? - read full article

By: Rita Gameiro, Yasmin Mamade, Carolina Pinheiro, Catarina Perry da Câmara, Sofia Galego, Patrícia Ferreira, and Ana Paiva Nunes

Background: The smoking paradox is a controversial phenomenon that refers to an unexpectable better outcome in smokers eligible for thrombolytic treatment. Recent studies suggest that current smokers have better recanalization rates after thrombolysis with the recombinant tissue plasminogen activator (rt-PA). However, there is no literature regarding the effect of smoking on revascularization rates after mechanical thrombectomy. Objectives: We investigated the association of smoking with successful revascularization in patients with large vessel occlusion treated with mechanical thrombectomy. 
Methods: We included 208 of 213 patients with acute ischemic stroke submitted to mechanical thrombectomy during a one-year period. Recanalization rate was defined as a score superior to 2b in the thrombolysis in cerebral infarction (TICI) scale, after endovascular therapy. Smokers were defined according to active or previous smoking habits.   
Results: Among 208 patients, 14 were smokers (n=29). Smokers were younger (median, 59 years versus 73 years; P=0.08), more often men (83 versus 42; P<0.001) and had a higher prevalence of coronary disease (59 versus 11; P<0.01). Smoking status was not associated with different arterial occlusion sites (P=0.141). Smoking did not improve recanalization rates after mechanical thrombectomy (93 versus 87; P=0.55). 
Conclusions: Smoking does not appear to cause better recanalization rates in patients submitted to endovascular therapy. Because of the small numbers, these results need to be validated at a bigger scale.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P4

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Diffusion tensor imaging in acute hemiparetic stroke patients submitted to thrombectomy—a pilot study - read full article

By: Carolina Figueira, Isabel Fragata, José Manuel Amorim, Jaime Pamplona, and João Reis

Background: Stroke is a leading cause of long-term disability in adults. Diffusion tensor imaging (DTI) parameters, fractional anisotropy (FA) and apparent diffusion coefficient (ADC) measure the integrity of white matter and cytotoxic edema, respectively. DTI quantification in subacute and chronic ischemic stroke has been shown to be related to corticospinal tract damage and to the motor outcome. Purpose: We aimed to evaluate DTI parameters in the acute phase of ischemic stroke, and compare these parameters with matched controls. Materials and Methods: We retrospectively evaluated 13 patients with anterior circulation stroke submitted to mechanical thrombectomy between January 2014 and December 2015. DTI evaluation was performed in the first 10 days after ictus. We measured the mean FA and ADC using regions of interest (ROIs) in the middle cerebral artery territory. The same analysis was repeated in matched control patients. Non-parametric tests were used to compare groups. 
Results: We analyzed a total of 13 stroke patients and 13 control patients. In the stroke group, the median age was 55 years (range 43-80) and 61.5 were female. Mean FA value in the posterior limb of the internal capsule (PLIC) was significantly lower in the affected side when compared to the normal side in the stroke group (0.68±0.11 vs 0.72 ±0.08; p=0.05). Mean ADC was significantly lower in the lenticular nucleus in the affected side in the patients group (667.0 ±171.0 mm2/s vs 745.2 ±70.6 mm2/s; p=0.013). There were no differences in the mean FA and ADC values between the affected side of patients and the same hemisphere in controls, and between the unaffected side in patients and the controls. 
Conclusions: In this exploratory study using DTI we found significantly lower mean FA in the PLIC and lower mean ADC in the lenticular nucleus on the affected side in stroke patients, when compared to the contralateral hemisphere. Further research is warranted to confirm these results and to evaluate a possible role of DTI as a prognostic tool in acute ischemic stroke.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P5

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Endovascular treatment of acute posterior circulation ischemic stroke—outcomes of a single centre 14 months experience - read full article

By: Manuel A. Correia, Francisco Raposo, Mário Mendonça, Carla Guerreiro, Pedro Teotónio, Gonçalo Basílio, Paulo Sequeira, Luísa Biscoito, Lia Lucas Neto, and Jorge Campos

Background and Objectives: Posterior circulation strokes account for 15-20% of all ischemic strokes and are associated with high disability. Variable and ill-defined symptoms may delay the diagnosis and increase morbimortality. Early recanalization seems to be associated with better clinical outcomes; however, the best management is still uncertain. Experience with stent retrievers is limited and this technique is usually combined with other therapies. In this study, we analyzed the imaging and clinical outcome after treatment with mechanical thrombectomy. 
Methods: Since our center became part of the metropolitan emergency service for stroke (January 2016), more than 130 patients were admitted in the department of interventional neuroradiology. Of these, 10 had acute posterior circulation ischemic stroke and underwent endovascular mechanical thrombectomy. Clinical and angiographic data were collected. Success of the thrombectomy was defined as Thrombolysis in Cerebral Infarction (TICI) > 2, and good clinical outcome as a value in the modified Rankin Scale (mRS) < 3. 
Results: The median age of the patients was 70.7 ± 8.86; mean National Institutes of Health Stroke Scale (NIHSS) on admission was 23.1 ± 5.7. Recanalization was successful (TICI > 2) in 7 of 10 patients (70). At 3 months, 40% of the patients had mRS < 3 (good and moderate clinical outcome), 40% had mRS 4-5 (poor clinical outcome), and 20% had mRS = 6 (dead). 
Conclusion: Mechanical thrombectomy of acute ischemic stroke of the posterior cerebral circulation was found to be associated with high successful recanalization. We also observed favorable clinical outcome in an important percentage of patients.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P6

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Relationship between density of thrombus on admission CT and mechanical thrombectomy inefficacy - read full article

By: Mário Mendonça, Francisco Raposo, Manuel A. Correia, Carla Guerreiro, Pedro Teotónio, Gonçalo Basílio, Paulo Sequeira, Luísa Biscoito, Lia Lucas Neto, and Jorge Campos

Background and Objectives: Ischemic stroke is one of the major causes of death and disability. Vessel opening is one of the goals of treatment and earlier recanalization correlates with better outcomes. During some interventions, we noticed that many of our pulls were unsuccessful, even though the same technique and devices were used. Is there any thrombus characteristic on the admission CT scan, including its density in Hounsfield Unit (HU), that can predict the failure of a recanalization (patients with Thrombolysis in Cerebral Infarction (TICI) < 1) following Mechanical Thrombectomy? 
Methods: We selected the patients that underwent Mechanical Thrombectomy in our centre for anterior circulation acute stroke (with or without previous tPA) with a final TICI < 1; and the patients with a final TICI = 3 (complete recanalization). Then, we retrospectively reviewed the admission non-contrast CT scans of these two groups, comparing the clot characteristics, including the absolute clot density in HU. 
Results: We identified 117 patients with anterior circulation stroke treated with mechanical thrombectomy. In the TICI < 1 group (11.11 of the patients), we observed lower density value of the clot (mean absolute HU 46.5 ± 7.33) vs. the TICI = 3 group (13.67) with higher density value of the clot (mean absolute HU 56.06 ± 3.57). Within the observed groups, we did not identify any other consistent thrombus characteristic. 
Conclusion: In this retrospective study, we observed that failure of recanalization during mechanical thrombectomy correlates with lower HU values of the thrombus. This aspect may be related to the composition of the thrombus, formed mostly of fibrin and platelets, as opposed to those constituted mainly by red blood cells. Such information could be used in decision making when estimating recanalization success rate with endovascular treatment approaches.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P7

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Aspiration Thrombectomy of M2 occlusions: a single center analysis - read full article

By: Carolina Pinheiro, Isabel Fragata, Mariana Diogo, Sofia Galego, Catarina Perry da Câmara, Patrícia Ferreira, Jaime Pamplona, Marcos Veiga, Ana Paiva Nunes, and João Reis

Background: Recent studies have shown that mechanical thrombectomy is safe and improves functional outcome in patients with acute ischemic stroke (AIS) due to intracranial carotid artery or proximal (M1) middle cerebral artery (MCA) occlusions. It is unclear if patients with distal MCA occlusions such as M2/M3 also benefit from endovascular treatment (EVT) without additional risks. 
Objectives: To review the occurrence of thrombectomy after IV tPA in acute ischemic stroke due to a M2/M3 occlusion, in our single center, and to assess the clinical outcomes and associated complications. 
Methods: We conducted a retrospective review of patients who underwent thrombectomy after IV tPA for treatment of an acute M2 or M3 occlusion between January and December 2016. Patient’s medical records (demographic data, endovascular treatment complications, NIH score at 24h), angiographic results and clinical outcome using the modified Rankin score (mRS) at 90 days were reviewed. 
Results: Of a total of 24 patients, 23 patients had M2 occlusions and 1 patient had an M3 occlusion. Aspiration thrombectomy was performed in 24 patients. Three patients were treated with both stent retriever and aspiration thrombectomy. There was a female prevalence (15 vs 9 male patients). The mean age was 76.2 years old. The main risk factor was hypertension in 21 patients. The rate of successful recanalization (TICI grade ?2b) was 75% (18 of 24 patients). There were no significant complications related to the thrombectomy procedure. The median NIHSS at admission was 13 (range: 4 - 23) and the median NIHSS at 24 hours was 10 (range: 1 - 26). At three months, 9 patients (37.5%) had favorable clinical outcome (mRs<2). Two patients (8%) had symptomatic hemorrhagic transformation (HI2). Mortality at 3 months was 16.6% (4 patients). 
Conclusion: EVT of M2 and M3 occlusions, in selected patients, can result in a good outcome, with a low rate of complications. Further prospective studies are necessary to confirm these observations.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P8

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Decompressive craniectomies for malignant anterior circulation infarction—evaluation of in-hospital prognosis - read full article

By: Pedro Moura Branco, Gonçalo Januário, Lino Fonseca, Dalila Forte, Ricardo Nogueira, Luís Cardoso, Ana Paiva Nunes, and Carlos Vara Luiz

Objective: Analyse the in-hospital prognosis of patients submitted to decompressive craniectomy (DC) for anterior circulation malignant stroke. 
Methods: Retrospective analysis of consecutive patients submitted to DC for anterior circulation malignant stroke, for a period of 5 years in a tertiary centre. Demographic, imagological and surgical data, as well as neurological outcome, were analysed; factors associated with in-hospital mortality were determined. 
Results: Among 41 patients, the average age was 57.46±12.1 years, 56.1% were male and 53.6% had right-sided infarction. 32 of the surviving patients achieved a Rankin score >3. Mortality was 46.3%, and associated with higher ages (62.7±10.8 vs 53.4±11.8;p=0.013). Preoperative midline shift (MDS) of >10 mm was predictor of mortality (OR 4.2;p=0.038). Presence of anisocoria was associated with 66.7% mortality versus 33.3% (p=0.058) without its presence. No postoperative MDS was associated with 33.3% mortality versus 54.5% on those that maintained MDS (p=0.093). Patients under 65 years old with isolated middle cerebral artery infarction (MCA) (n=22) presented a mortality of 31.8% versus 57.8% on those that did not fulfilled one of these criteria. Mortality in patients over 65 years old reached 77.8%, with all survivors presenting an isolated MCA infarction. On the subgroup of patients with more than one ischemic territory and under 65 years, the mortality was 40% (versus 100% over 65 years), with only one patient reaching Rankin score <3.
Conclusion: Age and preoperative midline shift were associated to in-hospital mortality. Patients >65 years and/or >1 ischemic territory presented the worst prognosis. 

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P9

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When things get complicated but are reversible… - read full article

By: Valentina Tosatto, Cristiano Cruz, Torcato Marques, Paula Nascimento, Zsófia Vesza, André Almeida, and Rita Barata Moura

Clinical Report: The patient was a 33-year-old Nepali woman, living in Portugal, previously healthy, thirty-three weeks pregnant, with second trimester gestational diabetes. She was admitted at the gynecology emergency room with preeclampsia and HELLP syndrome, and underwent urgent cesarean delivery for fetal bradycardia. She was then transferred to the intensive care unit due to clinical worsening, resistant hypertension, acute kidney injury and non-cardiogenic pulmonary edema. When a decrease of sedoanalgesia was attempted, significant psychomotor agitation ensued. Head CT scan showed signs of Posterior Reversible Encephalopathy Syndrome (PRES), namely in the bilateral parietal and occipital cortico-subcortical areas. A second CT scan showed hypodensity of the left fronto-temporo-parietal cortico-subcortical area, clinically associated with right hemiplegia. Two weeks later, hemorrhagic conversion of the left cerebral hemisphere injury ensued, without mass effect or increased extension. Electroencephalography was normal and transcranial doppler showed mild vasospasm in major arteries. Two months later, there was clinically significant improvement, with the patient showing normotensive profile and total renal function recovery, even though maintaining aphasia and moderate right hemiparesis, partially improved. MRI showed favorable evolution of PRES signs. 
Conclusions: This case represents an example of PRES associated with HELLP syndrome, with unusual involvement of anterior cerebral areas. The anterior left injury was probably multifactorial, including autoregulatory failure in a non-chronic hypertensive patient, endothelial dysfunction associated with preeclampsia and local hypoperfusion with cerebral infarction due to reactive focal vasoconstriction (described in more severe cases). Hemorrhagic conversion is also an unusual event.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P10

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Ischemic stroke in cancer patients - read full article

By: Catarina Valente Bexiga, Vilma Laís Grilo, Ana Raquel Miranda, Melanie Duarte Serra Ferreira, Ana Glória Fonseca, and Maria Francisca Delerue

Background: The association between venous thromboembolism and malignancy is well known. How arterial events and cancer are related is less clear. Objectives: To evaluate cardiovascular risk factor (CVRF) profile in cancer patients admitted for ischemic stroke (IS), as well as stroke ethology. 
Methods: A hospital-based retrospective study consisting in the analysis of admissions between January 2013 and December 2016 was conducted. Clinical files whose final diagnoses included ICD-9 codes pertaining IS and any solid neoplasia were reviewed. Variables included underlying malignancy, CVRF profile and IS etiology. For statistical analysis, we used IBM SPSS version 23. The significance level was 0.05. 
Results: We identified 109 patients, with 58.7% men and an average of 75.5 years. Gastrointestinal tract cancer was the most common (22.9%) neoplasia, and most tumors were adenocarcinomas (59.6%). At admission, 55 of the patients had active malignancy. The most frequent CVRF was hypertension (80%). One-third of the patients had atrial fibrillation, which was associated with non-adenocarcinoma histology (X2, p=0.001). Most patients had already known malignancy. In 8 of them, cancer was diagnosed during hospital admission. TOAST etiology was “undetermined” in half of IS and undetermined etiology was associated with adenocarcinoma histology (X2, p<0.001). 
Conclusion: In this study, age, hypertension and atrial fibrillation were the most relevant CVRF for IS as a first arterial thromboembolic event in patients with solid neoplasia. An important percentage of IS had “undetermined” etiology, especially in patients with adenocarcinoma, thus indicating that there is still much to unveil in the association between IS and cancer.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P11

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Hemorrhagic stroke in children: expect the unexpectable - read full article

By: Catarina Perry da Câmara, Marcos Veiga, Carolina Pinheiro, Teresa Morais, João Jacinto, Isabel Fragata, Carla Conceição, and João Reis

Background: Pediatric stroke is unexpectedly common, with an incidence in children between 28 days old and 18 years old of 2.3 to 13 per 100,000/year. Contrary to the adult population, in children, 45% of strokes are hemorrhagic and the most common cause is vascular anomalies. Albeit the incidence, median time to diagnosis is about 23 hours, impairing the prognosis. Objectives: This work aims to alert the medical community about hemorrhagic stroke in children. 
Methods: A review of our Neuroradiology database was performed for hemorrhagic stroke in children. Best imaging examples were selected. 
Results: We present a pictorial review of different presentations and etiologies of hemorrhagic stroke on CT, MRI and angiography. A systematic imaging approach to diagnosis was performed. Cases to be shown include: arteriovenous malformations, aneurysms, cavernous malformations, sickle cell disease and coagulopathies such as: leukemia, anticoagulation treatment or hemophilia. In addition to this review, we also put in perspective the delay in diagnosis, opening discussion to what needs to be done to prevent it. 
Conclusion: Hemorrhagic stroke is an important cause of morbidity in children. Doctors’ awareness and rapid neuroimaging are essential to a prompt diagnosis.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P12

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Ischaemic stroke related to chronic cannabis use—a case report - read full article

By: Sónia Almeida, Marta Cerol, Ana Alves Oliveira, Marta Valentim, Ana Gameiro, and Margarida Cabrita

Introduction: Several case reports support a causal link between cannabis use and cerebrovascular events, as cannabis may lead to reversible cerebral vasoconstriction syndrome and multifocal intracranial arterial stenosis (MIS). 
Case description: A 37-year-old male patient with no known classical vascular risk factors woke up with dizziness and numbness in the right side of the body. He avowed to be a chronic cannabis consumer. At admission, his vital signs were normal. On neurological examination, he exhibited hemiparesis (1/5 motor power) in his right upper extremity and loss of the right nasolabial sulcus, presenting a NIHSS (National Institutes of Health Stroke Scale) of 2. Cranial tomography (CT) revealed an acute ischaemic infarct over the left parietal lobe and vascular sequelae in the territory of the deep penetrating branches of the left middle cerebral artery (MCA). CT angiography of the extracranial neck vasculature and all laboratory examinations were normal. Due to the presence of multiple strokes, an embolic source was searched (24h Holter, transthoracic and transoesophageal echocardiograms). Magnetic resonance imaging detected a chronic infarct in the left temporal lobe and multiple lacunar strokes (some with increase in restriction diffusion-weighted imaging) in the left MCA territory, suggesting the existence of an underlying vasculopathy. 
Discussion: Chronic cannabis use is associated with increased cerebrovascular resistance and has been temporally associated with paroxysmal atrial fibrillation. Although this possibility could not be ruled out completely in this patient, the absence of cardiac symptoms, the normality of the echocardiographic studies, and the absence of systemic embolic events made this possibility unlikely, favouring the likelihood of a MIS.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P13

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Causes for clinical deterioration four and five days post thrombolysis - read full article

By: Rafael Nascimento, João Miguel Freitas, Patrício Freitas, José Franco, Duarte Noronha, Rafael Freitas, and Luz Brazão

A 64-year-old man was brought to the emergency department (ED) with sudden right-sided weakness and slurred speech. The patient referred a sudden onset of loss of power on his upper right limb during lunch. He went to a nearby Health Centre and was immediately sent to the local Hospital. At the Hospital, the man was examined one hour after the onset of his weakness. He was apyrexial and hemodynamically stable with a blood pressure of 164/92 mmHg. He had partial hemianopsia, dysarthria and right brachial hemiparesis. The patient had a NIHSS of 9 and the brain CT scan showed no acute lesions. He initiated thrombolysis 2 hours and 14 minutes after the onset of the symptoms with progressive clinical improvement; 4 hours later, his NIHSS was 5. The 24-hour control brain CT showed a hypodensity in the left hemisphere (temporal parietal location) consistent with an acute infarction. During his stay in the stroke care unit, the patient had a clinical deterioration (NIHSS 9) when he woke up on the 4th day. The following day, the patient suffered a transitional episode of dizziness and diaphoresis when trying to stand up slowly, with further aggravation of the NIHSS scale to 11. The neck duplex scan showed a stenosis of 70-80% in the left common carotid bifurcation and beginning of the internal carotid artery. That same day, the patient developed a pneumonic infection with a chest x-ray showing a heterogeneous infiltrate. The brain CT showed an enlargement of the initial lesion, with a small haemorrhagic transformation, 8 days after admission in the ED. The authors pretend to discuss the reason or reasons for clinical deterioration and debate the best treatment in this patient with a past story of radiotherapy in 2014, due to a throat cancer.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P14

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Direct puncture of the carotid artery for thrombectomy in acute stroke patients—back to the old Egas Moniz technique - read full article

By: Mariana Baptista, Luis Fontão, Isabel Fragata, Ana Paiva Nunes, and João Reis

Background: In the late twenties, Egas Moniz introduced cerebral angiography by injecting a radio-opaque medium directly in the cervical carotid artery. The femoral Seldinger technique replaced direct carotid access, and is the current state of art. However, in particularly difficult anatomical configurations, percutaneous access through the carotid artery may be justified. 
Material and Methods: Retrospective review of clinical and imaging data of stroke patients, submitted to Digital Subtraction Angiography (DSA) at Hospital São José by direct carotid artery puncture, between January 2014 and December 2016. 
Results: A total of 3 patients, referred to our hospital under the acute stroke protocol, were submitted to DSA by direct carotid artery puncture for large vessel occlusion stroke. Significant tortuosity and difficult anatomy did not allow selective catheterization through femoral access. Mechanical thrombectomy with aspiration system was performed in two of them, with successful recanalization, TICI 3. In the third patient, by the time the vessel was reached, spontaneous recanalization had occurred. Two of these patients were also submitted to intravenous thrombolysis, so a closure device was used; in the third, a manual compression was done to achieve hemostasis. There were no periprocedural complications. Post-procedural complications included percutaneous hematoma in one patient, which resolved spontaneously, with no need for intubation. 
Conclusions: At a time when endovascular treatment is part of the guidelines for the treatment of large vessels occlusion strokes, high-risk patients with no femoral access or difficult anatomy may benefit from direct carotid artery puncture, despite the risks involved.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P15

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How bad is a TICI 2? - read full article

By: Luís Fontão, Mariana Baptista, Jaime Pamplona, Isabel Fragata, Clara Ribeiro, and João Reis

Background: Successful reperfusion is a predictor of good outcome in acute ischemic stroke (AIS), following mechanical thrombectomy (MT) for large-vessel occlusions. Technical success in endovascular therapy has been defined as TICI score 3 or 2b in several studies, although scarce data is available on clinical outcome in patients in whom a lower TICI (0-2a) was achieved. 
Objective: To examine the functional outcome of patients subjected to MT for anterior circulation large-vessel occlusion, with TICI 0-2a recanalization score. 
Methods: Single-center retrospective analysis of the subset of TICI 0-2a, from consecutive 177 patients treated with MT for acute anterior circulation large intracranial artery occlusion, from January 2016 to December 2016.  
Results: Of 177 patients, 21 were included, with 12 women (57%) and a mean age of 64.2 years (SD 18.4). Mortality rate was 23%. Two groups were defined based on clinical outcome, defined as 3-month modified Rankin Scale (mRS) 0-2 (n=4 – 19) or >2 (n=17 - 81). The group with good clinical outcome (n=4) had younger ages (mean 47 years, SD 17.4 versus 68.2 years, SD 16.6), lower median intervention time (53 minutes versus 98.5 minutes) and no intracranial hemorrhage (versus 11.8 on the worst clinical outcome group). No difference was found on stroke etiology, site of occlusion, previous mRS or onset-reperfusion among the two groups.  
Conclusion: Most patients with incomplete or absent reperfusion had an unfavorable clinical outcome, whilst heterogeneity was found among younger patients. Further studies with larger samples are warranted to determine prognostic factors among these patients.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P16

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Looking for the culprit in stroke: what to do when the plot thickens? - read full article

By: Ricardo Soares-dos-Reis, Ana Monteiro, Marta Carvalho, Pedro Abreu, Paulo Chaves, and Elsa Azevedo, Tiago Parreira, Carina Reis, Luísa Fonseca, and Pedro Castro

Background: Stroke etiological investigation is usually a standardized process, where clinical and test findings are taken together. In a significant proportion of cases, no definite etiology is found, either because of negative findings or multiple causes. Here, diagnostic and therapeutic decisions were not straight-forward. 
Case report: 70-year-old man complained of acute left hemiparesis. He had left homonymous hemianopia, sensory extinction and mild hemiparesis. CT showed a right temporo-parietal infarction. Echocardiogram, cervical and transcranial Doppler and 24h Holter monitoring had no significant findings. After 4 months, he was enrolled in an embolic stroke of undetermined source clinical trial. After 1 month, he had self-limited episodes of left hand tingling and later was admitted for left leg paresis. His aPTT was prolonged. CT showed a new right caudate-capsular infarction. MRI showed recent right subcortical temporo-parietal ischemia; MRA revealed irregular caliber and stenosis of the internal carotid artery (ICA), compatible with dissection or other vasculopathy, which improved in follow-up MRA, 7 days later. CSF analysis, including VZV, was normal. Trial oral anticoagulant (OAC) was stopped. After 1 month, he noticed a throbbing headache and red right eye. Angiography and ultrasonography revealed right thrombotic proximal ICA occlusion. OAC was started. After 1 month, readmission due to multiple episodes of left-side weakness. Doppler monitoring showed microembolization with right ICA origin. Hypocoagulation was stopped. Aspirin was started with no recurrent events within a 2-month follow-up. 
Conclusion: Although a clear-cut etiology was elusive, the consensus was ICA dissection. Discussing safety/efficacy of novel OAC in ICA dissection is warranted.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P17

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Should you treat your elderly, demented and dependent grandmother? - read full article

By: Soraia Vaz, Patrícia Ferreira, Sofia Galego, Isabel Fragata, João Reis, and Ana Paiva Nunes

Background: Elderly patients – ?80 years old – with acute ischaemic stroke (AIS) are frequently excluded from reperfusion therapy. Pre-existing dementia and disability – modified-Rankin-scale (mRS) X2, while not absolute contraindications, are outcome predictors often considered in the decision-making process. 
Case report: A 85-year-old demented woman with a mRS score of 3, presented with acute onset global aphasia, head and conjugate eye deviation to the left, right homonymous hemianopia and right hemiparesis, scoring 23 points in the National Institutes of Health Stroke Scale (NIHSS). The emergent brain computed tomography (CT) failed to reveal early ischaemic signs, and the CT angiography uncovered a left internal carotid artery T-occlusion. Intravenous fibrinolysis (alteplase, 0.9mg/kg) was started at 139 minutes from symptom onset. An angiography was then performed, confirming a left T-occlusion, and a mechanical thrombectomy (MT) was performed, achieving total recanalization. Follow-up brain magnetic resonance imaging 24 hours after treatment revealed a recent ischaemic infarction of the left lenticulo-capsulo-caudate and corona radiata areas. Sustained clinical improvement was attained and, at the 3-month follow-up consultation, she had recovered from her motor deficits being able to walk, but kept meaningful language compromise and scored a mRS 3. 
Conclusion: We report a case of AIS in an elderly demented woman with a baseline mRS score 3, successfully treated with fibrinolysis and MT. Such examples support current beliefs that neither age, nor cognitive impairment or pre-existing disability alone or coexisting should be considered exclusion criteria for reperfusion therapy.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P18

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Multiple intracranial stenoses: can we find the guilty one? - read full article

By: Luís Fontão, Luis Ruano, and José Roriz

Patient was a 65-year-old men without relevant medical history or known vascular risk factors. He presented to the ER 2 days after a transitory episode of dysarthria and right-sided hemiparesis that lasted for less than 30 minutes. Neurological examination was normal. Brain CT showed only diffuse leucoariosis and a right lenticulo-radiate lacunar sequel. Multiple arterial stenoses were found on cervical/transcranial doppler ultrasound (C/TCD), including criteria for a 50% stenosis of the right cervical ICA, 70% stenosis of the right terminal ICA, 50% stenosis of the left terminal ICA, 70% stenosis of the basilar artery and 50% stenosis of the left PCA. Extensive workup was taken, including 24h-Holter, transthoracic echocardiography, ABPM, glycemic/lipid profile, thrombophilia, immunological and CSF screen; everything was normal. The patient was started on Atorvastatin 40mg and Clopidogrel. He was again admitted in the ER, about 4 months later, with an acute isolated left VI nerve paresis, and was discharged on dual antiplatelet treatment (AAS 150mg and Clopidogrel 75mg), with spontaneous improvement over the following weeks. The patient returned to the ER about a year later with an acute left-sided ataxic-hemiparesis syndrome persisting for the previous 24 hours. A brain MRI was performed, disclosing extensive microangiopathic brainstem and subcortical sequels, plus an acute paramedian right pontine lacunar infarct. C/TCD reevaluation suggested a progression of the stenoses previously documented in the left PCA and basilar artery, while remaining stable in the carotid axes. He remained treated with Atorvastatin 80mg, AAS and Clopidogrel, and was started on Enalapril + Amlodipine. Marked improvement was seen in the subsequent weeks, with no further events reported in a 6-month follow-up. Conclusion: Can the patient be further studied regarding etiology? Could all 3 symptomatic episodes be related to the basilar artery stenosis? Should the patient be (or have been) submitted to intracranial stenting of the basilar artery? Could the treatment plan be optimized with any other antiplatelet/statin combination?

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P19

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Stroke as an unusual manifestation of systemic diseases: three case reports - read full article

By: João Pedro Figueira, Maria Inês Ferreira, Raquel Silva, Tiago Serra, Isabel Cravo, and Fernanda Paixão Duarte

In stroke there is a sudden damage of brain cells in a localized area due to inadequate blood flow. Several pathophysiologic processes may be involved: intrinsic to the vessel or to the blood; embolic; hypoperfusion; and rupture of a vessel. Various systemic conditions may trigger these processes and cause brain ischemia. The authors present three cases of ischemic stroke: Case 1: A 26-year-old woman with systemic lupus erythematosus was admitted with headache and seizures. Cranial CT revealed left ischemic lesions. The patient then presented newly onset right hemiparesis. Cranial MRI confirmed subcortical lesions. Cyclophosphamide and corticosteroids were administered with improvement of general status and the patient was discharged with minor sequelae. Case 2: A 28-year-old pregnant woman with 34 weeks of gestation, previously healthy, was admitted with severe headache and nausea. Cranial MRI showed thrombosis of left lateral dural sinus. The patient had obstetric history of one low-weight term birth. The investigation of prothrombotic states was suggestive of antiphospholipid syndrome and treatment with metilprednisolone, aspirin and low molecular weight heparin was started. The birth occurred at 38 weeks of gestation without complications and the newborn was healthy and normal weighted. Case 3: A 36-year-old woman, with history of tuberculosis, in the third month of antibacilar therapy, was admitted with left peripheral facial paralysis and lack of strength on the right side of the body. During hospitalization, the patient presented left hemiplegia and worsening of the state of consciousness. Cranial CT scan showed right ischemic stroke and hydrocephalus. Ventriculoperitoneal shunt was performed with consciousness improvement but persistence of left hemiplegia.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P20

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Floating carotid plaque thrombus: a case of watchful waiting approach - read full article

By: Carolina Pinheiro, Patrícia Ferreira, Mariana Diogo, Isabel Fragata, Sofia Galego, Catarina Perry da Camara, Ana Paiva Nunes, and João Reis

The patient was a 51-year-old female university professor, with history of smoking, C7-D1 disc hernia surgery in 2014 and two episodes of right hemiparesis in November 2016 – interpreted as transient ischemic attacks – and under oral antiplatelet since. In February 2017, the patient had acute onset of dysarthria and left hemiparesis. In this context, the Stroke Code (Via Verde AVC) was activated. At hospital admission, the patient was conscious, without dysarthria or language deficits, facial asymmetry, visual field defects or ophthalmoparesis. She had a mild right hand paresis, but no associated sensitive deficits. Her NIHSS score was 2. Even before the brain computed tomography (CT) was performed, right hand strength was recovered. Head CT showed no acute parenchymal lesions. AngioCT of the supra-aortic vessel depicted a severe post-bulbar stenosis of the left internal carotid artery (ICA) over a short segment and was suggestive of an associated luminal thrombus. Despite the severe carotid stenosis, no intravenous fibrinolysis was administered, given the low NIHSS score. It was also decided not to perform any endovascular procedures at that time and the patient was admitted to a stroke unit for further vascular workup and vigilance. Carotid ultrasound study confirmed the endoluminal thrombus with oscillatory movements in the origin of the left ICA and the hemodynamic study was compatible with a severe stenosis of the proximal segment of the artery. Given these findings, it was decided to maintain the patient on an oral antiplatelet and start anticoagulation with enoxaparin, with posterior bridging to warfarin. Brain magnetic resonance imaging showed small acute ischemic lesions on the left: in the posterior frontal white matter, corona radiata and transition between the caudate head and body. Serial carotid ultrasound studies showed complete resolution of the thrombus, with a persistent atherosclerotic stenosis of 50-60%. The patient had a favorable clinical evolution, with a NIHSS score of 0 at hospital discharge. Diagnosis at discharge was atherosclerotic acute ischemic stroke. Conclusion: The doubt persists - was watchful best medical treatment indeed the best option, or would acute phase thrombectomy have been a better one?

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P21

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Off-label thrombolysis in simultaneous stroke and pulmonary embolism - read full article

By: Mourão Carvalho, Ana João Carvalho, Rita Moça, Helena Moreira, Inês Albuquerque, Nuno Príncipe, Pedro Castro, Paulo Chaves, Luísa Fonseca, and Jorge Almeida

Stroke and pulmonary embolism (PE) are emergent situations with specific performance guidelines. Their simultaneous occurrence is rare. We describe a case of a 20-year-old women, otherwise unremarkable past and familial medical history except for overweight and oral contraceptive use. She was admitted at the emergency room 45 min after suffering a witnessed seizure. She recovered consciousness but remained with motor aphasia, central facial and right arm paresis, scoring 7 in NIHSS. She was hemodynamically unstable, with low blood pressure and sinus tachycardia and polypnea. She was in hypoxia and respiratory alkalosis and her electrocardiogram in sinus tachycardia showed profound T-wave inversion at DII, DIII, aVF and V1-V5 plus S1Q3T3 pattern. Brain-CT and blood analysis were normal. Pulmonary angio-CT revealed extensive bilateral PE. Intravenous infusion of 100 mg of alteplase over two hours was administered. The patient progressively improved both hemodynamic, respiratory and neurologically, scoring 2 in NIHSS at the end of the treatment. A transthoracic echocardiogram revealed a patent foramen ovale with an atrial septal aneurysm and a right-to-left shunt. A lower limb Doppler revealed a recent left gastrocnemial and popliteal thrombosis. Unfractionated heparin perfusion was started. A brain-magnetic resonance showed left temporoparietal infarction. The two thrombolytic therapy protocols are quite different. In this specific case, the right protocol is not defined in the literature due to its rarity. Despite its hemorrhagic transformation risk, we opted to treat the most life-threatening condition. Discussing the best therapeutic strategy is an off-label but potentially lifesaving approach.

From the Lisbon Stroke Summit, Lisbon, Portugal. 7–8 April 2017.

International Journal of Clinical Neurosciences and Mental Health 2017; 4(Suppl. 1):P22

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