David Czell

Background: Cannabinoid oro-mucosal spray nabiximols is approved for patients with moderate to severe multiple sclerosis spasticity (MSS) resistant to other antispastic medications. Few real-world data are available on the effectiveness, safety and patients’ satisfaction in MS patients treated with nabiximols as monotherapy. Methods: To investigate the effectiveness, tolerability and satisfaction of nabiximols in a real-life multicentric Swiss cohort as monotherapy or with stable doses of other antispastic medications, and explore clinical features which may predict treatment response. The following data were collected at treatment start (baseline) and 12 weeks thereafter: Modified Ashworth scale (MAS), scores at numerical rating scales ranging from 0 (absent) to 10 (considerable) for effect on spasticity (sNRS), pain (pNRS), gait (gNRS), urinary symptoms (uNRS), tolerability (tNRS) as assessed by the treating neurologist, and overall treatment satisfaction (TsNRS) and tolerability (tNRS) as assessed by the patient. Results: Ninety-five patients (44 relapsing remitting, 37 secondary progressive and 14 primary progressive MS; median age = 53 (IQR 45–62); female 70%; median EDSS 6 (IQR 4–6), concomitant antispastic treatments in 54% of patients) were included. From baseline to week 12, median MAS score decreased from 3.0 to 2.0 (p < 0.001). Median scores of the each NRS also significantly decreased (p < 0.001 for all comparisons). At week 12, the median TsNRS and tTS scores were 8/10 (IQR: 6–9) and 9/10 (IQR: 7–10), respectively, and 93.7% of patients continued to use nabiximols at the average dose of six sprays/day. No clinical factors, including use of nabiximols as add on vs. monotherapy, were associated with responder status. Conclusions: Our first Swiss, multicentric, observational, real-life study supports and enhances previous finding of nabiximols as monotherapy and as add-on therapy, being an effective, safe and well-tolerated treatment option for resistant MS spasticity and spasticity-related symptoms (pain, bladder dysfunction and gait).

Objectives: To compare a novel 3D spiral gradient echo (GRE) sequence with a conventional 2D cartesian turbo spin echo (TSE) sequence for sagittal contrast-enhanced (CE) fat-suppressed (FS) T₁ weighted (T₁W) spine MRI. Methods: In this inter-individual comparison study, 128 patients prospectively underwent sagittal CE FS T₁W spine MRI with either a 2D cartesian TSE (“TSE”, 285 s, 64 patients) or a 3D spiral GRE sequence (“Spiral”, 93 s, 64 patients). Between both groups, patients were matched in terms of anatomical region (cervical/thoracic/lumbar spine and sacrum). Three readers used 4-point Likert scales to assess images qualitatively in terms of overall image quality, presence of artifacts, spinal cord visualization, lesion conspicuity and quality of fat suppression. Results: Spiral achieved a 67.4% scan time reduction compared to TSE. Interreader agreement was high (alpha=0.868-1). Overall image quality (4;[3,4] vs 3;[3,4], p1W spine MRI. Advances in knowledge: A 3D spiral GRE sequence allows for improved sagittal CE FS T₁W spine MRI at very short scan times.

Radiculopathy can be caused by nerve root irritation and nerve root compression at the level of the lateral recess or at the level of the intervertebral foramen. T2-weighted (T2w) MRI is considered essential to evaluate the nerve root and its course, starting at the lateral recess through the intervertebral foramen to the extraforaminal space. With the introduction of novel MRI acceleration techniques such as compressed SENSE, standard-resolution 2D T2w turbo spin echo (TSE) sequences with a slice-thickness of 3–4 mm can be replaced with high-resolution isotropic 3D T2w TSE sequences with sub-millimeter resolution without prolonging scan time. With high-resolution 3D MRI, the course of the nerve root can be visualized more precisely due to a detailed depiction of the anatomical situation and less partial volume effects, potentially allowing for a better detection of nerve root compromise. In this intra-individual comparison study, 55 patients with symptomatic unilateral singular nerve root radiculopathy underwent MRI with both 2D standard- and 3D high-resolution T2w TSE MRI sequences. Two readers graded the degree of lumbar lateral recess stenosis and lumbar foraminal stenosis twice on both image sets using previously validated grading systems in an effort to quantify the inter-readout and inter-sequence agreement of scores. Inter-readout agreement was high for both grading systems and for 2D and 3D imaging (Kappa = 0.823–0.945). Inter-sequence agreement was moderate for both lumbar lateral recess stenosis (Kappa = 0.55–0.577) and lumbar foraminal stenosis (Kappa = 0.543–0.572). The percentage of high degree stenosis with nerve root deformity increased from 16.4%/9.8% to 41.8–43.6%/34.1% from 2D to 3D images for lateral recess stenosis/foraminal stenosis, respectively. Therefore, we show that while inter-readout agreement of grading systems is high for both standard- and high-resolution imaging, the latter outperforms standard-resolution imaging for the visualization of lumbar nerve root compromise.

Zusammenfassung. Bei der Trigeminusneuralgie kommt es zu kurzen neuropathischen Schmerzen im Versorgungsgebiet des Nervus trigeminus. Unterschieden werden eine klassische, eine symptomatische, und eine idiopathische Trigeminusneuralgie. Für die Akutbehandlung gibt es nur wenige Medikamente. In der vorgestellten Fallserie berichten wir von fünf Personen mit einer Trigeminusneuralgie unterschiedlicher Genese, die gut auf die Behandlung mit Brivaracetam ansprachen. Brivaracetam bindet an das synaptische Vesikelprotein 2A, das auch an Nerven und Nervenwurzeln vorkommt. SV2 reguliert die exozytotische Freisetzung von Neurotransmittern, was die Wirkung von Brivaracetam auf neuropathische Schmerzen erklären könnte. Der Einsatz von Brivaracetam kann bei der kurzfristigen Therapie von paroxysmalen Schmerzen im Rahmen der Trigeminusneuralgie hilfreich sein. Es sind weitere Studien erforderlich, um diese Wirkung nachzuweisen und einen Placeboeffekt auszuschliessen.

Zusammenfassung Hintergrund Muskelkrämpfe sind plötzlich auftretende, unwillkürliche, meist schmerzhafte Kontraktionen eines Muskels, selten einer Muskelgruppe. Sie können idiopathisch oder im Rahmen unterschiedlicher neuromuskulärer Erkrankungen vorkommen und teilweise aufgrund ihrer Frequenz und Dauer die Lebensqualität erheblich beeinträchtigen. Zur Behandlung gibt es bislang nur wenige gut wirksame Medikamente. Ergebnisse In dieser Fallserie berichten wir von 5 Patienten mit Muskelkrämpfen unterschiedlicher Genese, die gut auf die Behandlung mit Brivaracetam ansprachen. Diskussion Brivaracetam wird eigentlich zur Behandlung epileptischer Anfälle eingesetzt. Es bindet an das synaptische Vesikelprotein 2A (SV2A), welches auch an Nerven- und Nervenwurzeln vorkommt. SV2A reguliert die exozytotische Freisetzung von Neurotransmittern, was die Wirkung von Brivaracetam auf Muskelkrämpfe erklären könnte. Schlussfolgerung Es sind weitere Studien erforderlich, um die Wirkung von Brivaracetam auf Muskelkrämpfe nachzuweisen.

Cerebral nocardiosis abscess is a very rare entity in an immunocompetent patient. In this case report multiparametric and multimodality MR imaging characteristics of a pyogenic brain abscess caused by Nocardia Farcinica are discussed with a specific focus on amide proton transfer weighted imaging as a modern non-invasive, molecular MR imaging method which detects endogenous mobile protein and peptide concentration and tissue pH changes in pathologic brain lesions. The imaging characteristics are reviewed and discussed in respect to possible differential diagnoses, especially malignant tumorous lesions.

SUMMARY: Diffusion restriction is the morphologic hallmark of acute ischemic infarcts and excitotoxic brain injury in various cerebral pathologies. Diffusion restriction is visible as hyperintensity on DWI and as hypointensity on ADC maps. Due to the vicinity of multiple anatomic structures in the brain stem and hippocampus, very small lesions with diffusion restriction may result in severe clinical symptomatology, but these small lesions easily go undetected on standard cerebral DWI due to insufficient spatial resolution, T2* blurring, and image artifacts caused by susceptibility-related image distortions. Diffusion-weighted zonal oblique multislice–EPI with reduced FOV acquisition permits a considerable increase in spatial resolution and enhances the visualization of very small pathologic lesions in the brain stem and hippocampus. Improved performance in the depiction of different pathologic lesions with diffusion restriction in the brain stem and hippocampus using this sequence compared with standard DWI in selected cases is presented.