Spontaneous intracranial hypotension: Exploring the viability of non-contrast FLAIR as a substitute for contrast-enhanced T1WI in assessing pachymeningeal thickening.

PURPOSE: To avoid contrast administration in spontaneous intracranial hypotension (SIH), some studies suggest accepting diffuse pachymeningeal hyperintensity (DPMH) on non-contrast fluid-attenuated inversion recovery (FLAIR) as an equivalent sign to diffuse pachymeningeal enhancement (DPME) on contrast-enhanced T1WI (T1ce), despite lacking thorough performance metrics. This study aimed to comprehensively explore its feasibility. METHODS: In this single-center retrospective study, between April 2021 and November 2023, brain MRI examinations of 43 patients clinically diagnosed with SIH were assessed using 1.5 and 3.0 Tesla MRI scanners. Two radiologists independently assessed the presence or absence of DPMH on FLAIR and DPME on T1ce, with T1ce serving as a gold-standard for pachymeningeal thickening. The contribution of the subdural fluid collections to DPMH was investigated with quantitative measurements. Using Cohen's kappa statistics, interobserver agreement was assessed. RESULTS: In 39 out of 43 patients (90.7%), pachymeningeal thickening was observed on T1ce. FLAIR sequence produced an accuracy, sensitivity, specificity, positive predictive value, and negative predictive value of 72.1%, 71.8%, 75.0%, 96.6%, and 21.4% respectively, for determining pachymeningeal thickening. FLAIR identified pachymeningeal thickening in 28 cases; however, among these, 21 cases (75%) revealed that the pachymeningeal hyperintense signal was influenced by subdural fluid collections. False-negative rate for FLAIR was 28.2% (11/39). CONCLUSION: The lack of complete correlation between FLAIR and T1ce in identifying pachymeningeal thickening highlights the need for caution in removing contrast agent administration from the MRI protocol of SIH patients, as it reveals a major criterion (i.e., pachymeningeal enhancement) of Bern score.

Exploring the "Insight Paradox" in Treatment-Resistant Schizophrenia: Correlations Between Dimensions of Insight and Depressive Symptoms in Patients Receiving Clozapine.

Objective: There remains a lack of clarity as to the possible cross talk of insight into illness and depressive symptoms in treatment-resistant schizophrenia. We therefore set our primary aim to evaluate relationship between insight dimensions and depressive symptoms in patients with treatment-resistant schizophrenia receiving clozapine. Methods: This was a cross-sectional, non-interventional study, conducted in daily clinical practice conditions. Patients in outpatient clinics between March 2020 and May 2020 with treatment-resistant schizophrenia (based on Treatment Response and Resistance in Psychosis), with no comorbid psychiatric disorder, and with no body mass index greater than 40.0 kg/m2 were included. We collected sociodemographic variables, scores of insight dimensions (treatment compliance, illness recognition, and symptom relabeling with the Schedule for Assessment of Insight), and depressive symptoms with Calgary Depression Score for Schizophrenia. Linear regression models were used to investigate variables associated with depressive symptoms as the outcome of interest. Results: The final analysis sample comprised 55 patients with treatment-resistant schizophrenia, with a mean age of 42.48 (SD = 9.18) years and a predominance of the male sex (n = 42, 76.9%). Model 1 [Calgary Depression Score for Schizophrenia ~ (Schedule for Assessment of Insight + Positive and Negative Syndrome Scale)] displayed that 48% of the variation in the Calgary Depression Score for Schizophrenia can be explained by Schedule for Assessment of Insight-composite and Positive and Negative Syndrome Scale-composite (P < .001). More effectively, model 2 [Calgary Depression Score for Schizophrenia ~ (Schedule for Assessment of Insight-illness recognition + Positive and Negative Syndrome Scale-general psychopathology)] revealed that 51% of the variation in the Calgary Depression Score for Schizophrenia can be explained by the sub-scales (P < .001). We further designed a new model in which Global Assessment of Functioning scores were the response variable to explore the link between awareness into illness and functionality (Global Assessment of Functioning ~ Schedule for Assessment of Insight-illness recognition). In this model, awareness of illness did not explain a significant proportion of variance in functionality scores (R 2 = 0.045, F(1,52) = 2.48, P = 0.121). Conclusion: The treatment compliance part of insight was not one of the significant explanatory variables of depressive symptoms, but it explained the variance in functioning, in contrast to the illness recognition dimension of insight. If our findings were replicated in treatment-resistant schizophrenia, they would suggest that promoting treatment compliance dimension of insight instead of recognition of illness could not increase depressive symptoms.

Common Biomarkers Associated with Delirium in Hospitalized Patients with COVID-19 at the Epicentre of Turkish Coronavirus Outbreak: A Case-Control Study.

Introduction: To investigate the differences in biochemical characteristics between Coronavirus Disease 2019 (COVID-19) patients with and without delirium in non-intensive care (IC) COVID-19 units was aimed. Methods: This study was designed as an observational, single-centered, and case-control study consisting of 43 delirious patients and matched 45 non-delirious patients admitted to non-IC COVID-19 units. Delirium was diagnosed by a consultant psychiatrist according to the DSM-5 delirium diagnostic criteria. Independent variables such as laboratory tests at the time of admission, clinical features, and patient characteristics were obtained from electronic medical records by researchers. In the primary analyses, binomial logistic regression models were used to investigate the factors associated with delirium, which was identified as the outcome variable. Multivariate logistic models were then adjusted for potential confounding factors, including age, gender, history of neurocognitive disorders and Charlson Comorbidity Index (CCI). Results: We observed higher levels of urea, d-dimer, troponin-T, proB-type natriuretic peptide, and CCI in patients with delirium compared to patients without delirium. We also observed lower levels of estimated glomerular filtration rate (eGFR), serum albumin, and O2 saturation and a decrease in the length of stay at the hospital. After adjusting for confounding factors such as gender, age, and comorbidity, we found that urea (adjusted estimate=0.015; 95% Confidence Interval [CI]=0.058-0.032, P=0.039), urea/creatinine ratio (adjusted estimate=0.008; 95% CI=0.002-0.013, P=0.011), and troponin-T (adjusted estimate=0.066; 95% CI=0.014-0.118, P=0.014) were independent biomarkers associated with delirium. Conclusion: Delirium is associated with higher urea levels and urea/creatinine ratios in COVID-19 patients. In addition, the relationship between troponin-T and delirium may help understand the potential link between the brain and the heart in COVID-19. Additional multi-centred studies with larger sample sizes are needed to generalise these results.

A study of the relationship between serum uric acid levels and pain in patients with migraine.

Serum uric acid (SUA), the end product of purine metabolism acts as an antioxidant and is related to oxidative stress. It has been reported that SUA may be involved in the pathogenesis of neurodegenerative diseases including Alzheimer disease, Huntington disease, Parkinson disease, and multiple sclerosis. However, studies evaluating SUA levels in migraine are scarce. This study aimed to explore the relationship between pain characteristics and SUA levels in patients with migraine and compare SUA levels in migraine patients during a headache attack and headache-free period with those control groups. This prospective, cross-sectional study included 78 patients with migraine and 78 healthy subjects who were randomly selected from hospital personnel as the control group. Headache characteristics (duration of attack, pain intensity, and headache frequency) and sociodemographic features were recorded. The SUA level was measured once in the control group and twice in the migraine patients, during the migraine attack and headache-free periods. Although the SUA levels of the migraine group in the headache-free period were higher than those of the control group, the difference was not statistically significant. Gender was not significantly related to the change in SUA levels between the attack and headache-free period. When the correlation between age, duration of migraine, frequency, duration, and intensity of pain was evaluated; the difference between SUA levels in female migraine patients was weakly correlated with headache intensity, whereas male patients had a moderate correlation. ( P < .05; R > 0.250, and R > 0.516, respectively). The difference in SUA level in the migraine attack period compared to the headache-free period showing a positive correlation with pain intensity suggested that SUA may have a role in migraine due to its antioxidant role.

[Assessment of serum MMP-9, TIMP-1 levels and MMP-9/TIMP-1 ratio in migraine patients with and without aura].

Background and purpose: Matrix metalloproteinases (MMP) are the enzymes responsible for proteolytic ac-tivity of extracellular matrix proteins. Tissue inhibitors of metalloproteinases (TIMPs) are their endogenous inhibitors. MMP-9 acts on the basal membrane of cerebellar epithe-lium and is antagonized by TIMP-1. MMP-9/TIMP-1 ratio exhibits the net activity of MMP-9. These enzymes are thought to have a role in migraine physio-pathogenesis. Methods: Total of 50 treatment-naive migraine patients (25 with aura and 25 without aura) with no other diseases, were included. 25 healthy control subjects of cor-responding age and gender were enrolled. For MMP-9 and TIMP-1 analysis, one serum sample from control group and two samples from patients were collected (during headache and headache-free periods). The enzyme levels were quantitatively analyzed by competitive ELISA method. Duration and severity of the pain and duration of the disease were recorded. Results: There was no significant difference in MMP-9 levels between patient and control groups during headache and headache-free periods (p: 0,746, p: 0,243). TIMP-1 levels were significantly lower and MMP-9/TIMP ratios were higher comparing with the control group (p: 0.001). Positive correlation was obtained between the duration of pain and MMP-9 levels in the headache-free period for both patient groups (p<0.05). There was also a positive correlation between MMP-9/TIMP-1 ratio and severity of pain (p<0.05). Conclusion: In our study, low TIMP-1 levels of patients in both headache and headache-free periods suggest that disturbance of proteolytic protection has a role in neuro-inflammation and pain in migraine. Therefore, these enzymes could be potential targets in migraine therapies.

Evaluation of serum uric levels in migraine.

OBJECTIVE: In our study, the aim was to identify the serum uric acid levels, a marker of oxidative stress, according to migraine subtypes (aura/without aura and episodic/chronic migraine). METHOD: The study included 300 migraine patients and 150 healthy controls for a total of 450 individuals. Migraine and subtypes were diagnosed according to International Classification of Headache Disorders-2013 criteria. Patients were evaluated during attendance at the neurology clinic. RESULTS: Our patient group was 77.0% female and disease duration was 9.2 ± 7.2 years. Our control group comprised 77.3% females. The age intervals in the patient and control groups were 36.4 ± 10.4 years and 36.0 ± 8.1 years. There was no statistically significant difference between our control and patient groups in terms of age and gender (p = .937 and p = .655). The serum UA, ferritin, and urea levels in our patient group were found to be significantly low compared to the healthy control group (p < .001). The serum UA levels in the migraine and control groups were 3.7 ± 0.7 and 4.6 ± 0.7 mg/dL, respectively (p < .001). There were no statistically significant differences observed between serum uric acid levels and other blood parameters between aura/without aura and episodic/chronic migraine subtypes (p > .05). CONCLUSION: Our study supports the hypothesis that the oxidative stress marker of serum uric acid levels may be associated with migraine diagnosis, concluding that serum uric acid levels were not significant for migraine subtypes.

Cognitive Functioning and Silent Neurological Manifestations in Behçet's Disease with Ocular Involvement.

INTRODUCTION: Various reports have revealed a cognitive dysfunction in Behçet's disease (BD). In this study, we aimed to assess the silent neurological manifestations, behavioral and neuropsychiological impairments of Behçet's disease patients with ocular involvement. METHODS: Thirty BD patients with ocular involvement in the nonactive phase of their illness were applied detailed neurological examination and magnetic resonance imagining (MRI). Neuropsychological tests were performed. Patients' neuropsychological performances were compared to those of healthy, demographically matched twenty subjects. RESULTS: Neurological manifestations of patients were headache (56.6%), pyramidal signs (13.3%), behavioral changes (3.3%) and sensory symptoms (3.3%). Four patients (13.3%) had white matter hyperintensities lesions on T2/FLAIR brain MRI. Fourteen patients (46%) had impaired cognitive performances on the following tasks: verbal memory (immediate memory p=0.000, maximal learning capacity p=0.009, number of repetitions p=0.000, total learning capacity p=0.001, recall p=0.033), nonverbal memory (immediate memory p=0.029, recall p=0.001), logical memory (immediate memory p=0.001, recall p=0.001), executive (frontal) functions (clock-drawing test p=0.000, Stroop test p=0.001, verbal fluency tests p=0.000). Patients' MMSE and clock drawing test scores were significantly lower than controls (p=0.03). Attention deficit was not detected. Behçet's disease patients showed higher scores on depression scales than healthy subjects but there was no statistically significant difference between anxiety scores. CONCLUSION: Neuropsychological deficits, involving mainly memory and executive functioning, subcortical MRI lesions, and non-structural headache may be present in Behçet's disease patients with ocular involvement without overt neurological manifestations.

Assessment of serum uric acid levels in patients with restless legs syndrome.

In our study, the aim was to collect data in relation to our hypothesis that oxidative stress is effective in the etiopathogenesis of restless legs syndrome (RLS) by assessing the serum uric acid levels, an important biomarker of oxidative stress, among RLS patients. The study included a total of 281 patients with restless legs syndrome diagnosis according to the "2012 Revised International Restless Legs Syndrome Study Group Diagnostic Criteria". Disease severity was assessed according to the "International Restless Legs Syndrome Study Group Severity Scale". The control group comprised 237 healthy individuals with the same age and gender features as the control group. The result showed no statistically significant difference in the mean age and gender between RLS and control group (p = 0.923; p = 0.433). The hemoglobin, ferritin, and uric acid levels of patients with RLS were found to be low (p < 0.001). Total iron-binding capacity level was higher in patients (p < 0.01; p < 0.05). In RLS patients, the serum uric acid level was not affected by disease severity (p > 0.05). Variables affecting uric acid level in RLS patients were determined to be age, disease duration, and hemoglobin level. The hypothesis that uric acid level, accepted as a biomarker of oxidative stress, is important in the pathogenesis of restless legs syndrome is supported by our study.

Blink Reflex in Episodic and Chronic Migraine.

INTRODUCTION: Activation of the trigeminovascular system and sensitization of brainstem trigeminal nuclei play a significant role in the physiopathology of migraine. Our aim was to investigate blink reflex (BR) and its recovery in episodic and chronic migraine patients. METHODS: Twenty-eight chronic migraine patients, thirty-two episodic migraine without aura patients and thirty healthy controls were included in the study. The study was performed using a portable electromyography device with a software specifically prepared for BR. Blink reflex assessments were performed in patients during the pain-free period and in healthy controls using the 'standard method - double stimulation' technique in 200 ms, 500 ms, 1000 ms, 2000 ms, and 5000 ms intervals. RESULTS: Blink reflex recovery was significantly increased in both patient groups as compared to the control group in 200 ms interstimulus interval (ISI) on both sides (p<0.005). Moreover, when it was compared to the control group, recovery was also significantly increased in the chronic migraine group in 2000 ms ISI on the right side and in 5000 ms ISI on the left side as well as in 500 and 1000 ms ISIs on the left side in the migraine without aura group (p<0.002, p<0.003). R2 recovery curve was noted to be higher in both patient groups as compared to the control group, although could not be demonstrated statistically in all intervals. A statistically significant increase was observed in the migraine group without auras compared with the controls (p <0,037, p <0,011) in the left side at 500 and 1000 ms ISIs. For all intervals in our study, although the increase in recovery was not statistically significant, it was noted that the R2 recovery curve was higher in the patient groups, with respect to the normals. The increase in R2 recovery noted in both patient groups suggested increased sensitization of the trigeminal structures. Significantly increased recovery in low ISI (200 ms) in the two patient groups as compared to the control group raised the thought that the migraine brain goes through two different excitability periods (ictal and interictal). CONCLUSION: In conclusion, similar to the previous studies, the findings of this study suggested that there was a reduction in central inhibitory mechanisms during interictal period in migraine patients.

Exploring psychiatric comorbidities and their effects on quality of life in patients with temporal lobe epilepsy and juvenile myoclonic epilepsy.

AIM: The relation of epilepsy with psychiatric disorders is of great interest to researchers due to its behavioral, social, and cognitive outcomes. In this study, we explored psychiatric comorbidity and its effects on quality of life (QOL) in patients with mesial temporal lobe epilepsy (MTLE) and juvenile myoclonic epilepsy (JME). METHODS: Thirty patients with MTLE, 30 patients with JME, and 30 healthy controls underwent the Structured Clinical Interview for DSM-IV (SCID-I) to diagnose psychiatric disorders. None of the subjects had previously undergone psychiatric examination. The Quality of Life in Epilepsy Inventory-89 (QOLIE-89) was used to assess QOL. We compared psychiatric comorbidity among groups and evaluated its effects on QOL. RESULTS: We detected comorbid psychiatric disorders in 37% of patients with JME and in 57% of patients with MTLE. Comorbid psychiatric disorders were less frequent in healthy controls compared to the patient groups (P = 0.029). Comparing demographic and clinical features of patients with JME and MTLE and their mean QOL scores, there was no statistical difference. Furthermore, we compared QOLIE scores between patients with and without psychiatric comorbidity. JME patients with mood disorders had lower scores on the Attention/Concentration subscale (P = 0.013). MTLE patients with a psychotic disorder had lower scores on the Social Isolation, Energy, and Fatigue subscales (P = 0.045). Patients with somatoform disorders had higher Pain scores (P = 0.04). CONCLUSION: Our study suggests that comorbid psychiatric disorders negatively affect patients' QOL regardless of seizure syndrome. Comorbid psychiatric conditions should be determined to increase QOL in patients with epilepsy.

The relation of serum uric acid levels with L-Dopa treatment and progression in patients with Parkinson's disease.

In this study, we aimed to investigate the association of the serum uric acid (UA) level with disease progression and L-Dopa treatment in PD (Parkinson's disease) patients. Serum UA levels of 80 consecutive PD patients were measured and were matched according to age and sex with 80 healthy controls. The patients were divided into two subgroups according to the pharmaceutical treatment received. First group consisted of patients treated with L-Dopa and a dopamine agonist and the second group consisted of patients treated only with a dopamine agonist. The patients were divided into two other subgroups according to Hoehn and Yahr scale. First group consisted of patients at the first two stages and the second group included patients at the third and upper stages. PD patients were found to have significantly lower levels of serum UA than controls (p = 0.000). Serum UA levels were lower in the group under L-Dopa + dopamine agonist treatment and in patients at third and upper Hoehn and Yahr stages than the patients under only dopamine agonist treatment and in the patients at the first two stages (p = 0.000 and p = 0.000). Multivariate logistic regression showed that advanced stages (OR 0.65, CI 0.50-0.79, p = 0.000) and L-Dopa treatment (OR 1.08, CI 1.03-1.16, p = 0.001) were independently associated with low UA levels. Our study supports that there is an inverse relation between UA levels and L-Dopa treatment and PD stages, and high serum UA levels may decrease the oxidative stress taking part in the pathogenesis of PD.

Evaluation of interictal autonomic function during attack and remission periods in cluster headaches.

OBJECTIVE: To investigate which part of the autonomic system is mainly involved and assess the sensitivity of face sympathetic skin response in cluster headache. MATERIAL AND METHODS: The study sample consisted of 19 drug-free cluster headache patients (16 males, three females) and 19 healthy volunteers. Demographic features and pain characteristics were thoroughly identified. Dysautonomic symptoms were evaluated during attack and remission periods of cluster headache patients. Orthostatic hypotension, R-R interval variation and sympathetic skin responses obtained from the face and four extremities were evaluated and the sensitivity of face sympathetic skin responses was assessed in contrast to extremity sympathetic skin responses. RESULTS: All sympathetic skin responses of face and extremities could be obtained during attack and remission periods. On the symptomatic side, mean latency of face sympathetic skin responses was longer compared to the asymptomatic side and controls (p = 0.02, p = 0.004). There were no differences in latency or amplitude of extremity sympathetic skin responses between symptomatic and asymptomatic sides and controls. No significant relationship was determined between sympathetic skin responses, R-R interval variation, orthostatic hypotension and cluster headache clinical features. CONCLUSION: Sympathetic hypoactivity of the face seems to predominate the pathophysiology of cluster headache. Face sympathetic skin responses might be more sensitive compared to extremity sympathetic skin response in demonstrating dysautonomic symptoms in cluster headache patients.

Evaluation of Glutamic Acid Decarboxylase Antibody Levels in Patients with Juvenile Myoclonic Epilepsy and Mesial Temporal Lobe Epilepsy with Hippocampal Sclerosis.

INTRODUCTION: Several clinical studies have been conducted to investigate the role of autoantibodies and immunological mechanisms in the etiology of treatment-resistant epilepsy in recent years. Some immunological treatments have been suggested as a result of these studies. In this study, we aimed to investigate the role of autoimmunity in partial and idiopathic generalized epilepsy and determine the relationship between drug resistance and autoimmune antibodies. METHODS: Twenty-eight patients (24 treatment-responsive and 4 treatment-resistant) with juvenile myoclonic epilepsy (JME), 26 patients with mesial temporal lobe epilepsy with hippocampal sclerosis (MTLEHS) resistant to antiepileptic drug treatment, and 26 age-matched healthy control subjects were included in a two-year cross sectional study. Glutamic acid decarboxylase antibody (GADA) levels were measured with a radioimmunoassay method in the serum of the included subjects. RESULTS: High GADA titers were detected in 2 patients with JME (7.1%), 1 patient with MTLEHS (3.8%), and 1 healthy subject (3.8%). There was no statistically significant difference among the groups regarding the serum GADA level. Although a limited number of drug-resistant patients with JME our study did not show relationships among anti-GADAs, both epileptic syndromes and drug resistance. CONCLUSION: Because we did not determine any significant relationship between GADA levels and JME or MTLEHS, we do not recommend analysis of serum GADA levels in routine examinations where there is no evidence to suggest risk factors for autoimmunity.

Evaluation of cognitive characteristics of patients developing manifestations of parkinsonism secondary to long-term ephedrone use.

AIM: In this study, cognitive functions of 9 patients developing parkinsonism due to chronic manganese intoxication by intravenous methcathinone solution were investigated using detailed neuropsychometric tests. METHOD: Attention deficit, verbal and nonverbal memory, visuospatial function, constructive ability, language, and executive (frontal) functions of 9 patients who were admitted to our clinic with manifestations of chronic manganese intoxication and 9 control subjects were assessed using neuropsychometric tests. Two years later, detailed repeat neuropsychometric tests were performed in the patient group. The results were evaluated using the χ(2) test, Fisher's exact probability test, Student's t test and the Mann-Whitney U test. RESULTS: While there was no statistically significant difference between the two groups in language functions, visuospatial functions and constructive ability, a statistically significant difference was noted between both groups regarding attention (p = 0.032), calculation (p = 0.004), recall and recognition domains of verbal memory, nonverbal memory (p = 0.021) and some domains of frontal functions (Stroop-5 and spontaneous recovery) (p = 0.022 and 0.012). Repeat neuropsychometric test results of the patients were not statistically significant 2 years later. CONCLUSION: It has been observed that cognitive dysfunction seen in parkinsonism secondary to chronic manganese intoxication may be long-lasting and may not recover as observed in motor dysfunction.

Chronic manganese toxicity due to substance abuse in Turkish patients.

BACKGROUND: Manganese toxicity may lead to a levodopa-resistant akinetic-rigid syndrome. Pathological changes occur mostly in the pallidium and stratium. MATERIALS AND METHODS: We report seven patients with a new form of chronic manganese toxicity due to long-term intravenous use of a solution consisting of ephedrine, acetylsalicylic acid and potassium permanganate as a psycho-stimulant, popularly known as "Russian Cocktail". RESULTS: The age of the patients ranged between 19 and 31 years, and the duration of substance abuse was between nine and 106 months. The onset of symptoms from first use ranged seven to 35 months. The initial symptom was impaired speech followed by gait disturbance and bradykinesia. In addition to these symptoms, choreic movements, ataxia presenting as backward falls and dystonia were also seen. Serum and urine samples revealed high levels of manganese. Hyperintense lesions on T1-weighted magnetic resonance imaging were seen in bilateral basal ganglia and brainstem, dentate nuclei, features consistent with manganese intoxication. CONCLUSION: Manganese toxicity, which may cause a distinctive irreversible neurodegenerative disorder, can be seen frequently with "Russian Cocktail" abuse, a substance which can be accessed very easily and at a low cost.