THE VALUE OF BLINK REFLEX IN EARLY DIAGNOSIS OF MULTIPLE SCLEROSIS.

The aim was to determine differences of blink reflex in clinically definite multiple sclerosis (CDMS) and clinically isolated syndrome (CIS) in patients presented with symptoms and signs of brainstem impairment. The study included 20 patients diagnosed with CDMS, 20 with CIS, and 20 healthy controls. We recorded latencies of early (R1) and late component ipsilaterally (R2) and contralaterally (R2'), and occurrence of irritative component (R3). We analyzed data on sex, age, signs of brainstem impairment and magnetic resonance imaging (MRI) findings for the presence of brainstem demyelinating lesions. There was no statistically significant difference between patient groups according to sex, age, symptoms of brainstem involvement and MRI findings. There was no statistically significant difference in R1 component latencies and R2 latencies on the right side. Latencies of R2 on the left and R2' on the right were statistically longer in CDMS group. There was no difference in the appearance of R3 component. In conclusion, blink reflex was found to be a very sensitive and useful diagnostic tool in the assessment of brainstem structures, especially because abnormalities are seen not only in CDMS but also in CIS. Slowing of the late component as a sign of dysfunction in the efferent part of the reflex arc is not very specific but is a highly sensitive finding.

OPTIC NERVE SHEATH SONOGRAPHY IS A PROMISING TOOL FOR ASSESSMENT OF RAISED INTRACRANIAL PRESSURE IN PATIENTS ADMITTED TO NEUROLOGICAL INTENSIVE CARE UNIT.

Optic nerve sheath diameter (ONSD) enlargement is detectable in traumatic brain injury patients with raised intracranial pressure (ICP). The aim was to assess its value in neurological patients suspected to have increased ICP. Patient clinical imaging data and hospitalization outcome were analyzed. Patients were divided into groups according to brain pathology and level of consciousness with Glasgow Coma Score (GCS). Poor hospitalization outcome was assessed by modified Rankin scale (mRS) >3. Data obtained by ocular sonography performed in acute setting were compared with data of 100 control subjects. Data were expressed as mean ± SD. Intergroup comparison was performed by Student's t-test. Data of 34 patients (63+16 years) were suitable for analysis, including 8 primary intracerebral hemorrhage (PICH), 8 subarachnoid hemorrhage (SAH), 12 PICH or SAH and intraventricular hemorrhage (IVH), 4 tumors and 2 ischemic strokes. The mean ONSD was 5.86+0.69 mm in patients versus 4.38+0.41 mm in controls (p<0.01). ONSD was 6.28+0.61 mm in patients with GCS <8 and 5.77+0.55 mm in other patients (p<0.05). ONSD was 5.72+0.59 mm in PICH versus 6.20+0.65 mm in PICH/SAH with IVH (p=0.1). ONSD was 5.73+0.38 mm in SAH in comparison to PICH/SAH with IVH (p=0.05). There was no statistically significant difference in optic nerve diameter between patients and controls (2.48+0.28 mm vs. 2.39+0.33 mm; p>0.05). Pronounced enlargement of ONSD was observed in patients with ICH or SAH with IVH, and in patients with GCS <8. Enlarged ONSD was associated with poor neurological outcome (mRS >3).

Epilepsy in patients with pineal gland cyst.

OBJECTIVE: The aim of the study is to describe types of epileptic seizures in patients with pineal gland cyst (PGC) and their outcome during follow up period (6-10 years). We wanted to determine whether patients with epilepsy differ in PGC volume and compression of the PGC on surrounding brain structures compared to patients with PGC, without epilepsy. PATIENTS AND METHODS: We analyzed prospectivelly 92 patients with PGC detected on magnetic resonance (MR) of the brain due to various neurological symptoms during the period 2006-2010. Data on described compression of the PGC on surrounding brain structures and size of the PGC were collected. RESULTS: 29 patients (16 women, 13 men), mean age 21.17 years had epilepsy and PGC (epilepsy group). 63 patients (44 women, 19 men), mean age 26.97 years had PGC without epilepsy (control group). Complex partial seizures were present in 8 patients, complex partial seizures with secondary generalization in 8 patients, generalized tonic clonic seizures (GTCS) in 10 and absance seizures in 3 patients. Mean PGC volume in epilepsy group was 855.93 mm3, in control group 651.59 mm3. There was no statistically significant difference between epilepsy and control group in PGC volume. Compression of PGC on surrounding brain structures was found in 3/29 patients (10.34%) in epilepsy group and in 11/63 patients (17.46%) in control group with no statistically significant difference between epilepsy and control group. All patients with epilepsy were put on antiepileptic therapy (AET). During the follow up period, 23 patients (79.31%) were seizure free, 3 patients (13.04%) had reduction in seizure frequency, whereas 3 patients had no improvement in seizure frequency. Two patients from epilepsy group and 3 patients from control group were operated with histologically confirmed diagnosis of PGC in 4, and pinealocytoma in 1 patient. CONCLUSIONS: In patients with PGC, epileptic seizures were classified as: complex partial seizures (with or without secondary generalization), GTCS and absance seizures. All patients were put on AET. During follow up period 79.31% patients were seizure free. There was no difference in PGC volume, nor in described compression of the PGC on surrounding brain structures between epilepsy and control group. Based on our findings, pathomechanism of epileptic seizures in patients with PGC cannot be attributable solely to PGC volume or described compression on surrounding brain structures based on MRI findings.

MIGRAINE, CAROTID STIFFNESS AND GENETIC POLYMORPHISM.

Recently migraine has been associated with increased arterial stiffness, procoagulant state, increased incidence of cerebral white matter lesions (WML) and stroke. Our aim was to compare the characteristics of migraineurs to headache free controls regarding their functional carotid ultrasound parameters. Sixty patients (45 women) with migraine (mean age 40.42 ± 10.61 years) were compared with 45 controls (30 women) with no prior history of repeating headache (mean age 38.94 ± 5.46 years) using E-tracking software on Alpha 10 ultrasound platform. Student's t-test was used on statistical analysis with alpha < 0.05. All tested carotid vascular parameters were worse in patients with migraine including increased intima-media thickness, greater carotid diameter and carotid diameter change, as well as several arterial stiffness indices. Additionally, patients with migraine had greater incidence of homozygous mutations for procoagulant genes (MTHFR (C677T), PAI-1 and ACE I/D) than expected. Computed tomography and magnetic resonance imaging of the brain showed WML in 11 patients, four of them migraine with aura patients. Since we established increased carotid stiffness and higher frequency of procoagulant gene mutations in migraineurs, we propose prospective ultrasound monitoring in such patients, especially those with detected WML, in order to timely commence more active and specific preventive stroke management strategies.

Cerebral venous circulatory system evaluation by ultrasonography.

Venous system can be classified as pulmonary veins, systemic veins and venous sinuses that are present only within the skull. Cerebral venous system is divided into two main parts, the superficial and the deep system. The main assignment of veins is to carry away deoxygenated blood and other maleficient materials from the tissues towards the heart. Veins have thinner walls and larger lumina than arteries. Between 60% and 70% of the total blood volume is found in veins. The major factors that influence venous function are the respiratory cycle, venous tone, the function of the right heart, gravity, and the muscle pump. Venous system, in general, can be presented by selective venography, Doppler sonography, computed tomography (CT) venography and magnetic resonance (MR) venography, and cerebral venous system can be displayed by selective venography, cerebral CT venography, cerebral MR venography, and specialized extracranial and transcranial Doppler sonography. The aim of this paper is to show the possibilities of intracranial and extracranial ultrasound evaluation of the head and neck venous circulation and chronic cerebrospinal venous insufficiency as one of the most common pathologies evaluated as part of neurodegenerative processes in the central nervous system.

Quality of life in patients with multiple sclerosis.

Multiple sclerosis is a chronic, immune-mediated disease of the central nervous system that typically strikes young adults. It is often associated with a wide range of functional deficits and progressive disability. Common symptoms of multiple sclerosis include vision problems, spasticity, weakness, ataxia, bladder and bowel dysfunctions, fatigue, pain syndromes, tremors, vertigo, cognitive impairment, and mood disorders. Multiple sclerosis has a major negative impact on patient health-related quality of life (HRQoL). Quality of life (QoL) is a multidimensional construct composed of functional, physical, emotional, social and spiritual well-being. Researches have reported that individuals with multiple sclerosis have lower QoL than non-diseased and diseased populations. The inclusion of HRQoL questionnaires in the patient follow-up is a relevant issue to optimize treatment, facilitate treatment decisions and improve adherence, as well as to reduce the inconveniences derived from medication such as side effects.

The role of complementary and alternative medicine in therapy of multiple sclerosis.

The National Center for Complementary and Alternative Medicine defines complementary and alternative medicine as a group of diverse medical and health care systems, practices and products that are not generally considered part of conventional medicine. Multiple sclerosis (MS) is a chronic disabling disease of the central nervous system that affects people during early adulthood. In spite of many approved medications, the treatment options in MS are limited. Many people with MS explore complementary and alternative medicine (CAM) treatments to help control their MS and treat their symptoms. Surveys suggest that up to 70% of people with MS have tried one or more CAM treatment for their MS. People with MS using CAM generally report deriving some benefit from therapies. The CAM therapies most frequently used include diet, omega-3 fatty acids and antioxidants. The therapies with highest potential among CAM therapies that warrant further investigation are low-fat diet, omega-3 fatty acids, lipoic acid, and vitamin D supplementation as potential anti-inflammatory and neuroprotective agents in both relapsing and progressive forms of MS. There are very limited researches evaluating the safety and efficacy of CAM in MS. However, in recent years, the USA National Institutes of Health and the National Multiple Sclerosis Society have been actively supporting the researches in this very important area.

Sporadic Creutzfeldt-Jakob disease in a patient with episodes of nonconvulsive status epilepticus: case report.

Creutzfeldt-Jakob disease is the most common form of human prion diseases. A 57-year-old woman was transferred to our Department from a local hospital, where she had been treated for two weeks due to consciousness disorders and convulsive epileptic attacks that progressed to refractory status epilepticus. Electroencephalography showed diffuse spike-wave complex discharges and development of nonconvulsive status epilepticus. The causes of metabolic encephalopathy and paraneoplastic syndrome were ruled out. A combination of clinical features and findings of diagnostic procedures including electroencephalography, biomarkers in the cerebrospinal fluid and magnetic resonance imaging suggested with great probability that the patient was affected with sporadic Creutzfeldt-Jakob disease.

Tumor-like multiple sclerosis.

Multiple sclerosis is a chronic demyelinating disease of the central nervous system. Tumor-like manifestation of multiple sclerosis is one of the rare clinical variants and it is frequently misdiagnosed. This is a report on a 45-year-old man who presented with right-sided hemiparesis. Initial computed tomography and magnetic resonance imaging studies of the brain revealed a large hyperintense signal lesion in the left hemisphere surrounding the cerebral edema. Low grade glioma was among the likely differential diagnoses. The patient underwent surgery. Brain biopsy showed demyelination. Lumbar puncture was performed and cerebrospinal fluid was positive for intrathecal synthesis of immunoglobulins. Other findings were compatible with the unusual form of multiple sclerosis. This case report illustrates a demyelinating process mimicking tumor lesions of the brain and it is of high importance to consider the diagnosis of multiple sclerosis on differential diagnosis of a tumor-like lesion of the central nervous system.

Guidelines for the use of intravenous immunoglobulin in the treatment of neurologic diseases.

The use of intravenous immunoglobulin (IVIg) in the management of patients with neuroimmune disorders has shown a progressive trend over the last few years. Despite the wide use of IVIg, consensus on its optimal use is deficient. The European Federation of Neurological Societies (EFNS) guidance regulations offer consensus recommendations for optimal use of IVIg. The effectiveness of IVIg has been proven in Guillain-Barré syndrome (level A), chronic inflammatory demyelinating polyradiculoneuropathy (level A), multifocal mononeuropathy (level A), acute exacerbations of myasthenia gravis and short-term treatment of severe myasthenia gravis (level A). As a second-line treatment, the use of IVIg is recommended in dermatomyositis in combination with prednisone (level B) and is considered as a treatment option in polymyositis (level C). As a second- or even third-line therapy, the use of IVIg should be considered in patients with relapsing-remitting multiple sclerosis if conventional immunomodulatory therapies are not tolerated (level B) and in relapses during pregnancy or post-partum period (good clinical practice point). Finally, it appears that the use of IVIg has a beneficial effect also in stiff-person syndrome (level A), some paraneoplastic neuropathies (level B), and some acute-demyelinating diseases and childhood refractory epilepsy (good practice point).

Thrombolysis for acute ischemic stroke--our experiences as part of SITS-MOST.

Thrombolysis with intravenous recombinant tissue plasminogen activator (rtPA) is the first evidence based treatment for acute ischemic stroke, which aims to reduce the cerebrovascular lesion. At University Department of Neurology, Sestre milosrdnice University Hospital, Zagreb, thrombolytic therapy with intravenous rtPA (alteplase) (Actilyse) for acute ischemic stroke was introduced in 2004. We present our results referring to demographic, time logistics and clinical outcome data as part of SITS-MOST (Safe Implementation of Thrombolysis in Stroke - MOnitoring STudy) and compare them with the results from other centers in Croatia and all other participating centers. Up to now, 56 patients (61% of male and 39% of female, average age 67 years) have been treated at our department with intravenous rt-PA (0.9 mg/kg body weight, maximum 90 mg), with 10% of the dose given as a bolus followed by 60-minute infusion. Our experiences with thrombolytic therapy with intravenous rt-PA (alteplase) (Actilyse) for acute ischemic stroke confirm the safety and the efficacy of this therapy.