Jed Noel Ong

Deep brain stimulation (DBS) requires accurate presurgical targeting, conventionally performed using magnetic resonance imaging (MRI) to identify stereotactic landmarks based on the anterior commissure–posterior commissure (AC–PC) line. However, MRI may be contraindicated in patients with retained metallic foreign bodies, making target localization challenging when relying on computed tomography (CT) alone. The tuberculum sellae–occipital protuberance (TS–OP) line has been proposed as an alternative anatomical reference to approximate the AC–PC line and facilitate CT-based targeting. A 62-year-old male police officer presented with a 7-year history of resting tremor and bradykinesia and was diagnosed with Parkinson's disease. He was initially managed with levodopa-carbidopa 300 mg/d, but despite medical therapy, his symptoms progressively worsened, with “on” periods reduced to only 2.5 to 3 hours daily, prompting referral for DBS evaluation. Baseline assessment showed a Hoehn and Yahr stage III and a Unified Parkinson's Disease Rating Scale Part III score of 51 (right: 20, left: 14). Surgical planning was complicated by a history of gunshot injury 36 years prior, resulting in two retained metallic bullets in the neck and trunk, precluding MRI acquisition. CT-based stereotactic planning was therefore performed using the TS–OP line as a surrogate to estimate the AC–PC line and guide target localization. This case demonstrates the feasibility of CT-only stereotactic planning for DBS in patients with contraindications to MRI. The use of the TS–OP line as an anatomical surrogate for the AC–PC line may provide a practical and reliable alternative for target localization in resource-limited or MRI-ineligible cases.

Background & Objectives: The objective of this study was to determine the prevalence and characteristics of movement disorders in adult patients diagnosed with various types of metabolic encephalopathies in the Philippines. Methods: This is a descriptive cross-sectional study based on a 7-year chart review of admitted adult patients diagnosed with any of the fifteen different types of metabolic encephalopathy who experienced movement disorders during their hospital stay. Movement disorders were characterized based on phenomenology, onset, and distribution. Results: Out of 9,773 neurologic referrals, 2,055 patients (17%) were diagnosed with metabolic encephalopathy, mainly the hypoxic-ischemic type. Only 4% (76) exhibited involuntary movements, primarily linked to hypoxic-ischemic encephalopathy. Three movement disorders were reported: myoclonus (64), tremor (10), and parkinsonism (2). The 6th decade was the most common age for these disorders, predominantly in males. Most cases appeared acutely within 7 days after onset of encephalopathy and were mostly diffuse and multifocal. Conclusion: The findings highlight myoclonus as the predominant movement disorder in metabolic encephalopathy, particularly in hypoxic-ischemic and uremic types.

Background: X-linked dystonia-parkinsonism (XDP) is a progressive movement disorder that predominantly affects men from the Panay Islands in the Philippines. Although patient outcomes have been well described, the effect of XDP on caregivers has received far less attention. Objectives: To evaluate caregiver strain, anxiety and depression among primary caregivers of patients with XDP and compare outcomes between caregivers of patients who had and had not undergone deep brain stimulation (DBS). Methods: We conducted a single-centre, cross-sectional study involving 52 dyads of patients with XDP and their caregivers interviewed via videocall. Socio-demographic and clinical information was collected, and caregiver strain and psychological symptoms were assessed using validated online questionnaires. Results: Caregivers (mean age, 43.3 years; 96.2% female) provided an average of 13 h of care daily, most often as spouses. Nearly one-quarter were at risk for caregiver strain, and 21.2% experienced severe strain. Anxiety and depressive symptoms were reported by 53.9% and 40.4% of caregivers, respectively. Older caregiver age was associated with lower strain. Higher strain was associated with frequent unplanned hospitalisations, greater disease severity across multiple XDP domains by the Movement Disorder Society of the Philippines, patient anxiety and depression and the presence of a secondary caregiver. Caregivers of patients who underwent DBS treatment reported fewer depressive symptoms than those caring for patients who had not undergone DBS. Conclusion: Caring for individuals with XDP is associated with substantial physical and psychological burden. These findings point to the need for targeted psychosocial support, caregiver education and better coordination of caregiving roles to reduce strain and improve both caregiver well-being and patient care.

Drug-induced parkinsonism (DIP) is the second most common cause of parkinsonism, primarily resulting from medications that block dopamine D2 receptors or reduce dopamine in the basal ganglia. While antipsychotics are most frequently linked to DIP, cases related to other agents like amiodarone are rare. We describe a 79-year-old Filipino woman with sick sinus syndrome who developed parkinsonian symptoms after two months of amiodarone therapy. A high Nanjaro score, lack of response to levodopa, and dramatic improvement following discontinuation of amiodarone all aided the diagnosis of DIP. Supporting features include acute-subacute onset, timing of symptom development and absence of non-motor signs typical of PD. In conclusion, although rare, amiodarone can be associated with parkinsonism, highlighting the importance of clinical suspicion and vigilance, as the motor features of DIP can closely mimic those of PD.

Deep brain stimulation of subthalamic nucleus (STN-DBS) is recognized as the gold standard for symptomatic treatment of advanced Parkinson's disease (PD). However, despite adherence to screening protocol, perioperative neuropsychiatric complications are increasingly being recognized. The rapid development of psychiatric symptoms within less than 24 hours is rare, and acute episodes occurring during surgery are uncommon. We present a 57-year-old female patient diagnosed with PD, with good premorbid personality. However, mild depression was detected on neuropsychological assessment. After thorough deliberation and family meeting, patient was cleared to undergo STN-DBS as the expected benefits outweighed the potential risks. Intraoperatively, during microstimulation of the left STN, patient developed sudden onset of aggressive behavior. The behavioral change lessened when the DBS lead location was adjusted to a more lateral location. The psychiatric symptoms were then controlled with quetiapine until the behavioral changes had resolved after 7 days. No recurrence was noted during follow-up consults.This case report confirms the importance of fundamental knowledge and understanding of the neuroanatomical structures affected in DBS of the STN, and their clinical implications. A thorough preoperative psychiatric evaluation is essential for comprehensive management and allows anticipation of possible adverse events.

Parasomnias are sleep disorders characterized by unusual and often distressing behaviors or experiences that occur during sleep or the transition between wakefulness and sleep. These disorders can arise in both non-rapid eye movement (NREM) and rapid eye movement (REM) sleep stages. REM sleep behavior disorder (RBD) is the most common and most studied parasomnia in movement disorders, especially among synucleinopathies. Numerous researches on RBD have established its clinical significance. Other parasomnias are less frequently reported in movement disorders, making it difficult to draw firm conclusions about their coexistence. Additionally, exploding head syndrome has not yet been documented in any movement disorders. This review summarizes current research on parasomnias, their association with movement disorders, and emphasizes the importance of increased awareness to improve diagnosis, management, and patient outcomes.

Background & Objectives: Hemifacial spasm (HFS) is a chronic disease characterized by unilateral tonic and clonic contractions of the facial muscles innervated by the facial nerve. The persistent attacks can significantly impact patients’ daily lives. The most efficacious therapy has been reported to be botulinum toxin (BTX). This study aims to investigate the factors that affect the short-term prognosis of HFS patients treated with BTX type A therapy, as well as to determine the clinic-demographic profile of such patients. Methods: This is a retrospective cohort study of patients with HFS who were treated with BTX at the Movement Disorders Clinic of Makati Medical Center (MMC). The HFS Score was used to assess the severity and frequency of the eye and cheek spasms, and the degree of suffering in health-related quality of life (HRQOL) parameters. Results: Sixty-four participants were included in the study. The patients’ characteristics were the following: mean age of 50.18 years; female predominance; most without comorbidities; mean disease duration of 7.83 years; eye as the most common location of initial spasm (96.88%); disease progression of 22.85 months; majority were previously treated with BTX (79.69%); and mean interval of 10.96 months from last BTX session. Regression analysis revealed that there were factors which influenced the short-term prognosis after treatment: (1) history of prior BTX therapy was associated with better clinical parameters, while (1) history of prior BTX therapy, (2) disease duration, and (3) location of initial spasm were associated with improvement of specific HRQOL parameters. Conclusion: BTX therapy has been established as efficacious in improving the clinical, functional and psychosocial aspects of HFS patients. The factors which influenced the botulinum response were different compared to other papers, highlighting potential differences in predictor variables across populations.

Objective Deep brain stimulation of the subthalamic nucleus (STN-DBS) in Parkinson’s disease (PD) patients does not halt disease progression, as these patients will progress and develop disabling non-levodopa responsive symptoms. These features may act as milestones that represent the overall functionality of patients after DBS. The objective of this study was to investigate the development of clinical milestones in advanced PD patients who underwent bilateral STN-DBS.Methods The study evaluated PD patients who underwent STN-DBS at baseline up to their last follow-up using the Unified Parkinson’s Disease Rating Scale and Hoehn and Yahr scale. The symptoms of hallucinations, dysarthria, dysphagia, frequent falls, difficulty walking, cognitive impairment and the loss of autonomy were chosen as the clinical milestones.Results A total of 106 patients with a mean age of 47.21 ± 10.52 years at disease onset, a mean age of 58.72 ± 8.74 years at surgery and a mean disease duration of 11.51 ± 4.4 years before surgery were included. Initial improvement of motor symptoms was seen after the surgery with the appearance of clinical milestones over time. Using the moderately disabling criteria, 81 patients (76.41%) developed at least one clinical milestone, while 48 patients (45.28%) developed a milestone when using the severely disabling criteria.Conclusion STN-DBS has a limited effect on axial and nonmotor symptoms of the PD patients, in contrast to the effect on motor symptoms. These symptoms may serve as clinical milestones that can convey the status of PD patients and its impact on the patients and their caregivers. Therefore, advanced PD patients, even those treated with bilateral STN-DBS, will still require assistance and cannot live independently in the long run.

Brain metastases are the most common central nervous system tumors. The mainstay treatment for this tumor in low to middle income countries is whole brain radiation therapy. Irreversible cognitive decline is associated with the use of whole brain radiotherapy. Several pharmacologic and nonpharmacologic options have been employed in studies focusing on the prevention of cognitive decline following whole-brain radiation therapy. Memantine use has been shown to provide some benefit in reducing the rate of decline in cognitive function and time to cognitive failure. The objective of this review article is to provide a summary on available primary literature on the therapeutic role of memantine for the prevention of cognitive decline in cancer patients with brain metastasis receiving whole brain radiotherapy.