Familial and single cases of restless leg syndrome

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Introduction
The syndrome was first investigated by Dr. Ekbom
in 1945 (8). Dr. Critchley (5) has reported that
Thomas Willis has denoted the syndrome as “the case
of the person having restless in the arms and legs interfering sleep in the bed” in second edition of his
textbook in 1695 (17). Ekbom (9) reported that the
same expressions had taken place in the first edition of that book published in 1685 (17). In 1861, the
same syndrome was described as “Anxietas Tibiarum”
and classified in a form of hysteria by Wittmaack (18).
George Beard examined the issue under the title of
neurasthenia and he associated it with the spinal irritation (2). Oppenheim has referred it as a syndrome
of hysterical or neurasthenic symptoms in his book
(15). Ruwak and Mussio-Fournier called attention to
the familial form of the syndrome (13). Complaints
of the syndrome are usually paresthesia or pain in
the legs. It is not easy to distinguish between the
two forms. The form with paresthesia, which is more
common can be diagnosed easily. Ekbom had called
this form “asthenia crurum paresthetica” (7). Ekbom
stated (9) that the most comprehensive review was
ever published by Jolivet since 1945 (11). However, it
is also important that Askupmark (1) and Nordlander
(14) have reported that anemia may cause the restless
leg syndrome. Moreover Ask-upmark underlined the
causal effects of the venous system enlargement in
the epidural space of spinal canal (1). Gorman et al.,
found anxiety and depression in 10 patients with the
restless leg syndrome by using the MMPI test (10).
The neurogenic origin of the syndrome has been
mentioned by Callaghan (3) and Spillane (16) in patients with uremic syndrome and chronic pulmonary
disease, respectively.
In this paper, the clinical signs, EEG in rest and sleep
and treatment methods have been examined in the
cases of the familial and single restless leg syndrome.
*Department of Neurology, Gülhane Military Medical Academy
¶ This study which was originally published in Turkish in our journal years ago (GATA Bulletin 1978;
20: 539-552) has been republished in English version in memory of expired Dr. Şevket Akpınar,
who was one of the pioneers of “restless leg syndrome” in Turkey. We gratefully thank our Executive
Editor-in-Chief and Editorial Board for their valuable contributions for the publication of the article,
and Department of Neurology for the translation of the original manuscript.78 • June 2011 • Gulhane Med J Akpınar et al.
Material and Methods
Cases: Case 1. Ş.Ö. Male, 50-year-old. He was referred by a psychiatrist from Izmir with the following
note: “the patient has some involuntary movement
in his right side in the night. I think that he has the
epilepsy but the other colleagues think that he has
conversion. The patient had no relief after the treatment of Faraday’s induction. He had symptoms even
in the deep sleep. His mother, sister and daughter
have also the same condition. His wife reported that
these movements were so severe. They had become
miserable from this condition. Could we get the information about the seizure from EEG and sleep EEG?
Could you please examine that whether the cause of
the condition was psychologic or epileptic?”
Patient history: he complained from a disturbing feeling at his legs which urged him unwillingly to move
his legs and arms, causing insomnia for 20 years.
After getting tired from these movements he could
sleep at the dawn. These movements were described
as asynchrony and asymmetric global movements in
arms and legs.
The patient described an unpleasant feeling causing
compulsion to move his extremities. In order to prevent this impulsive feeling that forced him to move
his legs, he wrapped his legs into nylons, towels, hit
his legs with his hands, got up and walked around or
snack. He had no complaint during daytime. To fall
asleep the patient was trying to lie along in various
places in the house by watching TV. When he reported that his mother, sister and daughter had the same
condition, family history were taken and the pedigree was composed (Figure 1).
Case 2. G.Ö. Female, 19-year-old (Daughter of the
patient). She had an occasional feeling that as if her
feet did not belong to her during sleep for 2 years.
This urged her to keep her feet in planter flexion.
Sometimes she wrapped and squeezed her ankles
with a rope, and only through the pain due to this
squeezing she could avoid of this feeling. If she still
could not get rid of this feeling she lied down on her
abdomen and moved her legs up and down. After
getting tired, she could go to sleep. Occasionally, the
condition described by her as “leg numbness” had
came after when she thought that it would occur.
She said that she was uncomfortable when she was
flat on the back. She said that the condition occured
one a month and more frequent in summer. If she could prevent the condition, she could fall asleep. She
described that the feeling migrated to the other leg.
When she could not prevent it in 15-20 minutes, she
could sleep only 2 hours for all night. These leg movements came from the inevitable impulse when she
was conscious. She could sleep in a various position
for example she let her legs hang down. She described that she had a tic of ankle movement. For that
reason her boots were worn and twisted (Figure 2).
Case 3. N.S. Female, 47-year-old (Sister of the patient). She had given her history responding to the
letter: Occasionally, she had an unpleasant feeling
in her legs since she was 24-year-old. She mentioned
that this condition occurred when she lost weight or
at the warm air. She added that she had a treatment
for this condition but she had taken the pills for her
sleep disturbances.
Case 4. Female (1900-1956) (Mother of the patient).
She had also an unpleasant feeling in her legs and she
had sleep disturbances because of it. The patient described that every family member had migrated from
one sleep corner to another.
It has been described that a woman from the fourth
generation had restless leg in the daytime. Also a man
(72-year-old) from the third generation had described
that he had an unpleasant feeling in his left leg during falling asleep. However he had also added that
this condition had no restriction for him and he had
no treatment for this condition.
The single case (26-year-old) had some leg movements such as traction of the toes, contraction of the
thigh at night preventing to fall asleep. He felt that
he had to lift his leg and beat his foot on the ground.
This impulse could not be prevented by the pressure
of the other leg. Because of this condition he had sleep disturbance. The condition which occurred everyFigure 1. The pedigree in a family with the restless leg syndrome. The patient and his sister and daughter had the syndrome as fourth ands
fifth generations, respectively. The mentioned family is at the middle of the diagram. The family diagram has been taken from the male of 3rd
generation who had the mild syndromeVolume 53 • Issue 2 Restless leg syndrome • 79
day increased by stress and fatigue. He mentioned
that he needed to move his leg in the daytime and he
could not let his leg stabile.
In addition, from time to time during the daytime
he had some impulse of hitting or punching. He could cope with this feeling by buzzing from the environment. He had hit the trees. But he had never have
this feeling during the struggle. For example, he had
impulse to hit pointed iron fence.
In addition, the absent seizures, impaired consciousness with the growing and shrinking of the objects were described. He could not move his eyes at
that moment. EEG examination revealed the focus of
sharp wave on the right.
Methods
1. A. Clinical physical examination, neurological
examination and EEG, fasting blood glucose, SGOT,
alkaline phosphatase, peripheral blood and urine
examination were performed.
B. The patient’s movements were monitored at
night.
2. Tests of EEG:
A. Resting EEG: the Grass Model-6 16-channel
EEG device was used for resting EEG in the patient,
his daughter and in the single case. Resting EEG was
recorded with monopolar links by using the reference
electrodes placed according to 10-20 system to the
vertex and the ears and bipolar links from the electrode to electrode. The eye movement and hyperventilation tests were performed.
B. Sleep EEG: the Grass Model-6 16-channel EEG
device was used for sleep EEG. The patient slept in
laboratory without electrodes at the first night (first
adaptation day), in second night the patient slept in
laboratory with electrodes (second adaptation day).
Finally, the sleep EEG was recorded at the third night
for average 8 hours. EEG was recorded by using vertex
as a reference with electrodes placed in other cantuses
of both eyes and upper/lower orbit of the left eye for
horizontal and vertical eye movements, respectively.
Bipolar electromyography (EMG) and electrocardiography (ECG) were recorded from submental and infraclavicular regions, respectively. The amplification
was 7 mm=50 mcv and rate was 15 mm/s.
The sleep periods in EEG were classified according
to Dement and Kleitman (6); first period (drowsiness)
is described the waves with the low voltage and mix
frequency (quick and slow); second period is described (mild sleep) with additional k-complex and sleep spindles, third period is described (moderate deep
sleep) as <50% of EEG is composed of the waves with
high voltage and forth period (deep sleep) is described as >% of EEG is composed of the waves with high
voltage. REM sleep (rapid eye movement sleep, paradoxal sleep (12)) EEG record is similar with the first
period and additionally EMG activity disappears and
REM appears with single or group bursts.
The sleep EEG records lasting 7-8 hours were examined visually and the percentage of REM and NREM
sleep were calculated.
C. EEG technicians examined the extremity movements in the patient and his daughter and tried to
clarify the connection between the movements and
the sleep period.
3. Electromyolographical examination was performed only in the patient. Muscles were examined by
concentric needle electrode for spontaneous and maximum contractions and nerve conduction rates were
recorded.
4. Treatment: pimozide (Norofren) 1x2 in the first
week and 1x3 in the second week, clordiazepoxide 10
mg for 1 week and 25 mg for 1 week, nitrazepam 1/2
and then 1 tablet, phenobarbital 1/2 tablet at the first
Figure 2. Worn and twisted boots of Case 2 (G.Ö) that were caused by hitting the tips onto ground in order to relieve the painful sensation in her
ankles80 • June 2011 • Gulhane Med J Akpınar et al.
week and then 1 tablet, diazepam (Nervium), 5 mg/
day at the first week and then 10 mg/day. Clonazepam
(Rivotril) 2 mg/day at the first week and then twice
a week were administrated. And then hexanicite (peripheral vasodilator 0.20 g) was administrated three
times a day for 15 days.
Results
1. A. Clinical, physical and neurological examinations and laboratory results except EEG were normal in
the patients. No anemia was found in both patients.
B. The patients were monitored along with 2
adaptation nights and 2 EEG recording until the
morning. His daughter were monitored along with
one adaptation and one EEG recording nights. The
single case was evaluated by the history. Observation
results of the patient: “The patient went to bed at
23.30. His wife informed us that he slept. He did
not have a sleeping posture. He looked anxious. He
was turning from one side to the other rapidly. At
the same time he was throwing his extremities out
of the bed. He was crying as if he was suffering. At
24.20 he was awaken suddenly and he hit to his extremities by hands. He said that he had to go around.
At 1.15 he went to bed again and slept in 10 minutes. He repeated the same movements and additionally he grasped the bedpost with his hand. He was
restless and one of his leg was extended. He pressed
his feet and hands with the sharp edge of the bed.
After 15·20 minutes he awoke and got up suddenly
extending his arm and hit proximal part of his arm
with other hand.
Observation results of the patient’s daughter at the
adaptation night: “The patient slept at 2.00. 2 hours
later she turned from one side to the other. At 4.00,
she had global contraction and there was no movement at her extremities. At 4.15, fingers of the both
hands jerked. At 5.25 she had normal posture. At 5.50
she had jerks at her right leg, she awaken and asked
the time and then she fell asleep. At 6.00, she awaked.
2. EEG results:
a. Daytime resting: The resting and activation
EEG of the patient ((20.12.1977/1730) and his daughter 1.12.1977/1674 were found normal. The patient
had short term drowsiness periods in his EEG.
b. Sleep EEG: the percentage of the periods, REM
cycles and number of REM in the sleep EEG of the
patient (9.12.1977; 15.12.1977) and her daughter
(1.12.1977) are presented in Table I, the number of
extremity movements is presented in Tables II and III.
EEG records of the patient showed that he was awake most of the time or at the first period sleep. Also he
had passed between the periods for 20-40 s. Bilateral
diffuse delta bursts which were synchrony and 4-6
seconds were observed at the time of between the periods in both the patient and his daughter. His daughter had also the same bursts in REM period.
3. EMG. No spontaneous activity was observed in
left brachial biceps, left abductor pollisis brevis, left
extensor digitorum brevis, left anterior tibial, left and
right vastus medialis. The conduction rate, distal motor latency and amplitude and shapes of the evoked
muscles responses in the left median and left perenoal nerves were normal.
Table I. The percentage of the sleep periods and REM
parameters in sleep EEG of the father and daughter in a family
with familial restless leg syndrome. Note that the father was
awake for a long time and he had lower sleep periods
Name (age) and date
Periods of sleep G.Ö. (19) Ş.Ö. (51)
Awake 1.12.1977 9.12.1977 15.12.1977
1 6.38% 57.69% 5.7%
2 1.7% 13.34% 30.4%
3 25.2% 11.27% 15.5%
4 4.18% - 3.7%
Artifact 3.6% 8.22% 8.5%
REM % 25.2% 2.4% 10.3%
Cycled 4 1 4
Burst 64 15 63
Single 9 3 11
Table II. EEG of the father: The leg movements of the patient were observed mainly in the awake period and he hit his left leg twice*
Periods of sleep Awake 1 REM
Dates of EEG 9.12.1977 15.12.1977 9.12.1977 15.12.1977 9.12.1977 15.12.1977
Movement Rounding and body
movement
41 25 2 5 - 1
Foot movement 7 10 - 8 - 1
Arm movement 9 4 - 2 - -
Shoting left leg with
left arm
1 - - - - -
Shoting left leg with
right arm
1 - - - - -
*: Numbers indicate the number of movementVolume 53 • Issue 2 Restless leg syndrome • 81
Restless leg syndrome is one of the important cause
of sleep disturbance. Observations showed that these
patients had no healthy sleep. Our case (the father) is
an example. They were afraid of sleeping.
There is no continuous effects of the warm or cold.
But most of the patients do not like the warm environment. For example, in soldiers who have to go
to bed with their clothes, it disturbs. These patients
do not want to cover their legs in the bed. Some of
them walk on the snow. Others like the warm. They
go to bed with their socks or warm their foot. Some of
them reported that the restlessness disappeared when
they had fever. They prefer to lie on their stomach. It
was the case in our female patient.
The psychological factors are important. In some
cases, the syndrome appears after the unpleasant daily activities. Ekbom reported that his patients were
calm, balanced and they had no mental problems
(9). According to him, the signs of the syndrome are
misinterpretted as nervousness. The patients do not
want to tell their problem because of shyness. But
they like to be interested. There is no physical signs
in the patients.
The course and severity of the disease vary from
mild to severe. In mild cases, the signs of the disease
are short term, and they have the nights with normal
sleep. In severe cases, the long term leg movements
and sleep disturbance are available. As a rule, it is a
chronic condition which has intervals between the
mild and severe periods. The long term asymptomatic intervals may be observed. In pregnancy, the
syndrome may be increased. This syndrome may be
observed in all ages. The mild cases are more than
the others. The prevalence has been found as 5% in
500 healthy people. There is no gender difference.
Moderate cases are less than the mild cases. Ekbom
reported that 72 males and 103 females in his 175
severe cases (9).
Jolivet suggested that the diagnosis of the restless
leg should be based on the deep feeling between the
knee and the ankle during the sitting or lying position (11). According to Gorman, these were the criteria
which were observed in rare patients (10). Most of
the patients do not report whether the feeling was
superficial or deep. They report that they have restless on their thigh. Some of them have the feeling
when they are standing. Ekbom (9) and Jolivet (11)
suggested that there were asymptomatic “frust” and
“parcial” forms which could be detected by the investigation. Jolivet suggested that these forms cause
little symptoms such as mild paresthesia and restless
in stabile positions (11). With the frust and parcial
forms, the prevalence of the restless leg syndrome reaches to 5%.
Goormen et al., reported 27 patients (mean age: 53;
31-73) with restless leg syndrome for 5-20 years (10).
In study population, 9 patients had pain and unpleasant feeling in their legs; 5 patients had prickling,
tingling and paresthesia, 3 patients had prickling and
the others had hitting legs.
The feeling was mentioned as deep and superficial
by 8 and 2 patients, respectively. The symptoms were
bilateral in all patients but half of the patients had
more severe symptoms unilaterally. The localization
of the symptoms varied from legs to foot.
4. Treatment. The patients showed no improvement with pimozid treatment (15 days). Moreover his
complains increased. He had no sleep. He awaked frequently and developed fear. The patient reported that
there was no improvement with librium, magodon
and phenobarbital. He reported that he awaked rarely
when he took Rivotril 2 mg 1 hour before sleeping.
But he told that 4 mg dose caused ataxia. The patient
continued Hexanicite 0.20 gr x 3 treatment. However,
no expected benefit was observed. The patient preferred to use clordiazepoxide 25 mg once a day.
Discussion
Familial and single “restless leg” syndrome in our
cases showed similar clinical symptoms to 179 cases
reported by Ekbom (8,9) who described the syndrome
for the first time in 1945 (8). Ekbom describes the
syndrome: unpleasant feeling, such as insect feeling
in the legs between knee and ankle, sometimes in
Table III. EEG of the daughter: The leg movements of the patient were observed in REM period
Periods of sleep Awake 1 2 3 4 REM
Movement Body movement - - - - - 4
Arm movement - - - - - 5
Movement in both legs - - - - - 8
Moving right leg - - - - - 6
Clamping hands on chest - - - 1 - -
Loosening clamped hands 1 - - -
Right leg movement - - - - 1 -82 • June 2011 • Gulhane Med J Akpınar et al.
thigh and foot. Usually it occurs unilateral but may
also occur bilaterally. The same case can have it in the
right and sometimes in the left leg. It occurs in hands
and arms rarely. This strange feeling is felt deeply in
“muscles or bones”. The patient describes this feeling
as a withdrawal or a stress in his feet. The patient needs to move to get rid of it. He mentions this feeling
as “young wolves in my legs”, “itching in my legs”.
Patients describe it with difficulty, unlike the wellknown symptoms. They say that they could sleep
when this feeling disappears. Also they describe it as
a very bad feeling: “This is the worst simple disease so
that I do not want nobody to have it. Acroparesthesic
arms may be confused with the same feeling. In the
form of the painful syndrome, an annoying pain occurs. There is mild to moderate dull pain. Pain is a
simple stubborn pain and rarely severe. The patients
with the restless leg syndrome can be divided into
two groups: having complains of unpleasant feeling
or pain. The first group is more common. Sometimes
it may be associated with paresthesia and pain.
Symptom characteristics are the emergence of
symptom in the legs at rest, relief with moving and
the deterioration at night. In the daytime symptoms
disappears completely but it may begin at the long
term immobilization and fatigue. This is more uncomfortable in the train trips, conferences, theaters
and cinemas. Some patients say that they have never get peace and relax. It forces the patient to move.
Duration varies according to the severity of cases,
sometimes it takes all night allowing only 1-2 hours
sleep.
Following to unpleasant feelings it is not possible
to keep the legs immobile. In mild cases, people can
sleep. Otherwise, he/she hits, move or massage to the
legs. Frequently he/she walks up and acts like a bear
in a cage. They get up and eat something. Some people smoke, read, kicking. One of the patients of Ekbom
used to do Charleston dance (9).
This situation lasts from a few minutes to the hours
and then the patient goes to bed and sleeps. After a
while it starts again and the patient gets up. A 70-yearold pastor had symptoms at his hands in addition to
the symptoms of restless leg.
The idea of doing something such as foot massage,
waving in the air, lying on back with pedaling motion are common in the patients.
It is easy to diagnose if the syndrome is known and
the patient describes the symptoms. The following
criteria should be considered: an unpleasant feeling
which occurs only at the early in the night when the
patient gets rest and provokes to move the legs. It is
not a skin sensation but it is felt in legs deeply.
In differential diagnosis, the restless leg syndrome
is sometimes misinterpreted as Meralgia paresthetica
but there is no similarity between them. It has been
suggested that the cause of the restless leg was myokimi. It has been associated with the fasciculation of
amyotrophic lateral sclerosis but it is more disturbing
and it has no association with ALS or acroparesthesia.
The restless leg syndrome may have atypical forms.
For example, it may occur completely one-sided and
is felt throughout the day, especially in the form of
cases with pain.
The etiology is unclear. It is thought to be hereditary. Dominant families are seen (8,13,15). Our familial cases had dominant heredity as it was seen in
the examination of the pedigree. The emergence of
various degrees of symptoms and the possibility of
the disease ignorance might have limited our ability
to show the dominant trait in all generations. The
mild restless syndrome in a twin has been reported.
Their mother also have shown signs of severe syndrome. This syndrome may be seen with poliomyelitis,
infection, avitaminosis (the foot burning syndrome
in Japanese camps at the World War 2), anemia, diabetes, long-term cold, drugs (Promethazine), abrupt
discontinuation of barbiturates and prostatitis. It
may also occur in the last half of pregnancy or the
last 3 months. As a rule, it disappears after birth. The
incidence of the syndrome during pregnancy is 11%.
Iron deficiency (<60 mg/100 ml) was found in 24%
of the patients. In most cases, symptoms are mild.
Three cases of carcinoma with restless leg have been
reported (9).
It is unknown how this unpleasant feeling occurs.
Some authors suggest that it originates from the spinal cord and others think that the cause is the limb
dysfunction.
According to Ask-Upmark, the patient wakes up
with pain and pressures at the bottom of the chest
in midnight or in the morning (1). The patient has
no lung and heart problem. This condition is seen at
night and improves after getting up and walking around the room. This situation is similar to restless leg
syndrome. In restless leg syndrome the developmental deficit in venous system of epidural space at the
level of the Th6 of spinal canal has been considered.
At Th6 level, diameter of the spinal cord is narrow. If
it is the case, it is easy to understand the relieveing
effect of lying on the stomach. Positive effects of 10%
dextran administration suggest that the etiology of
the syndrome is multifactorial.
Wittmaack has defined the syndrome as “anxietas
tibiarum” and classified as a common symptom of
hysteria in 1861. Cameron has described “leg with-Volume 53 • Issue 2 Restless leg syndrome • 83
drawal and limbs jerk” in patients with anxiety during falling asleep (4). According to Ekbom, the pathogenesis of the syndrome is unknown (9). However,
he has considered that the syndrome has no psychogenic origin because it occurs in healthy subjects and
lasts for years. While Jollvet et al. have suggested that
the syndrome occurs in patients with unstable but
they have performed no psychological examination
(11).
Gorman has demonstrated in his series that the
syndrome occurs especially in tense or depressed
patients or normal people under the stress (10).
MMPI test was applied in 27 patients and 17 patients had depression and anxiety. Patients without
any symptoms of depression or anxiety should be
examined for the masked depression or organic neurological disease. It is not clear whether the restless
leg is an etiological factor or chronic unrest in depressed patients. However it should be considered that
emotional factors may lead to restless leg syndrome
such as diarrhea or tension headaches. While the parasite infection or colon spasm may cause diarrhea,
or increased intracranial pressure may cause headache, sometimes the restless leg syndrome is caused by
peripheral neuropathy or other neurological diseases.
Even if there is no direct evidence, the real physiological mechanism of the symptoms may be due to the
prolonged contraction of skeletal muscles because of
the anxiety.
Callaghan has reported the restless leg syndrome
in uremic neuropathy (3). The emergence of the restless leg syndrome in 5 uremic patients is considered
that the irritation and injury of peripheral nerves as
a result of uremia may cause the symptoms. The restless leg symptoms are considered as peripheral nerve
symptoms due to the specific toxin or peripheral nerve symptoms due to the peripheral nervous system
disease. In the other words, the damaged fibers cause
paresthesia or diestesia.
Diabetic neuropathy, avitaminosis, coexistence
of carcinoma suggest a defect of neuronal function.
Symptoms of the syndrome were seen in the healing
stages of alcoholic neuritis and diabetic neuropathy.
Defective peripheral nerve lesion is thought to occur as a result. Spillane has reported the restless leg
syndrome in 8 patients with chronic pulmonary disease (16). It has been suggested that the symptoms are
not the result of metabolic consequences of respiratory failure but nervous system symptoms.
The present study suggests that the restless leg
syndrome may be seen as herodofamilial or as single
case. Chronic symptoms may be from mild to very
severe intensity as seen in the pedigree. No reason could be offered in these patients. Sleep EEG study performed in 2 patients showed short deep sleep periods,
frequent transition of the periods and a long time of
awake. Motion was seen while the patient was awake
and disturbed the sleep. The patient’s daughter had
sleep periods close to normal at the examination of
the sleep and the leg movements occurred in REM
sleep. In this patient, the movements in REM sleep
may be acceptable and she had no insomnia yet. It
was confirmed by EEG in the parent that the syndrome was one of the reasons for insomnia.
Paresthesia was seen in all of our cases. As mentioned above, the painful forms are rare.
The EMG evidence of peripheral neuropathy was
not seen in the severe case of the disease.
No psychiatric disorders which required psychological testing were found. However, a patient mentioned that there was an association between the daily
life stress and night symptoms.
Vasodilator therapy in patients without anemia may be administered. Priscoline (LX3 or 2x3),
Hanieol (2 tablet x 3) or Carbachol (2 mg x 3) may
be given. Good results were reported with Hexanicit.
In some cases, response may be observed within 1
month. After a while the effect of the drug may disappear. Then it is useful to switch the drugs. 0.5-1
mg of sublingual nitroglycerin tablets are given as the
symptoms resolve in a few minutes.
In iron deficiency, intravenous iron therapy is useful. In patients with iron level <60 mg/dL symptoms
were improved with iron therapy. Iron and vasodilatator may be used together. In angina pectoris, nitroglycerin and iron should be given together. AskUpmark has reported that lying on the back relieves
symptoms since the symptoms are caused by the epidural venous congestion (1). This idea was supported
by one of our patients (daughter). Preparations mentioned above are not effective in most of the cases.
In this case, symptomatic treatment with analgesic,
sedative and hypnotics may be tried. These can be
effective in mild cases. Promethazine worsens the
symptoms.
The patients reported that the barbiturates made
walking difficult when the sleep medications were
ineffective. Codein, opium and eueodal barbiturates
have a better symptomatic effect. Because of the addiction potential, narcotics should not be used.
Spontaneous remission of subjective symptoms
may occur. In the present study, only one was examined in terms of the treatment. No drugs had a benefit, consistently. Librium taken at night was relatively
useful. Treatments mentioned above should be tried
according to the severity of the patient’s symptoms.84 • June 2011 • Gulhane Med J Akpınar et al.
Acknowledgement
We would like to thank Dr. U. Dundar who referred the cases, Dr. M. Boga who followed the patients
and F. Melikoğlu, T. Akyol, H. Eker, and E. Uysal who
recorded EEG’s. We would like to thank F. Melikoğlu
for typing the paper