Baseline Factors Affecting the Prognosis of Ischemic Cerebellar Stroke Patients in Turkey: A Cross-Sectional Study.

BACKGROUND: Cerebellar infarcts are encountered commonly in clinical practice; however, they are likely to be misinterpreted. They cannot be adequately evaluated on scales such as the National Institute of Health Stroke Scale (NIHSS), which can have fatal consequences. AIM: To evaluate the baseline features, prognosis, and 6-month survival in patients with cerebellar stroke. METHODS: A total of 200 patients with cerebellar ischemia were included in the study. Patients were analyzed retrospectively from 10 years of data. Both univariate and multivariate analyses were evaluated. RESULTS: Mean age was 68 years old, and men were more frequently affected. The most common symptoms were dysarthria and vertiginous sensations. Ischemic lesions were usually cortical/juxtacortical, multiple, hemispheric, and small (below 1.5 cm). The most commonly affected artery was the medial branch of the posterior inferior cerebellar artery. Cardioembolism was the more frequent etiology. Gait ataxia was associated with a more favorable prognosis and 6-month modified Rankin Scale (mRS) scores (OR: 0.15, 95% CI, P = 0.03). Older age (OR: 1.75, 95%, P = 0.02), female gender (OR: 6.72, 95%, P = 0.02), multiple (OR: 10.92, 95%, P = 0.01) and large lesions (OR: 6.56, 95% CI, P = 0.01), posterior circulation ischemic lesions extra-cerebellum (OR: 8.33, 95% CI, P = 0.01), left ventricular apical hypokinesia or AF (OR: 5.58, 95% CI, P = 0.02), and a high mRS score on admission (OR: 5.21, 95% CI, P < 0.001) was correlated with higher 6-month mRS and a lower survival rates. CONCLUSION: The study found that some baseline clinical, neurovascular imaging findings, and the mRS score on admission are useful predictors of cerebellar stroke prognosis and outcome.

Cerebral blood flow velocity in migraine and chronic tension-type headache patients.

INTRODUCTION: The present study seeks to use transcranial Doppler ultrasound to evaluate cerebral blood flow velocities in anterior and posterior circulation arteries, during an attack-free episode in migraine patients, with and without aura, as well as in chronic tension-type headache patients who were not receiving prophylactic medication. METHODS: A total of 50 patients (35 female, 15 male) were evaluated during a headache-free episode: 30 migraine patients without aura (mean age: 32±8 years), 10 migraine patients with aura (mean age: 34±4 years), and 10 patients with chronic tension-type headache (mean age: 34±5 years). RESULTS: No significant difference was present between anterior, middle, and posterior cerebral and vertebral arteries' blood flow velocities between migraine patients, with and without aura, or in patients with a tension-type headache, and normal controls (p>0.05). However, a significant increase in basilar artery cerebral blood flow velocities relative to controls was present in patients with a tension-type headache (p>0.001). CONCLUSION: It is difficult to predict the main reason for the significant increase in basilar artery blood flow velocities in patients with chronic tension-type headache. It may be due to constriction of conductance or the dilatation of the resistance vessels.

The effects of Mat Pilates and Reformer Pilates in patients with Multiple Sclerosis: A randomized controlled study.

BACKGROUND: Pilates is an exercise method which increases strength and endurance of core muscles and improves flexibility, dynamic postural control and balance. OBJECTIVE: To analyze and compare the effects of Mat and Reformer Pilates methods in Patients with Multiple Sclerosis (MS). METHODS: Thirty-eight patients with MS were included in the study. Participants were randomly divided into 3 groups as Mat Pilates, Reformer Pilates and control groups. The subjects in the Pilates groups did Mat or Reformer Pilates for 8 weeks, 2 days a week. The control group did breathing and relaxation exercises at home. Balance, functional mobility, core stability, fatigue severity and quality of life were evaluated. RESULTS: Balance, functional mobility, core stability, fatigue severity and quality of life improved after Pilates in Mat and Reformer Pilates groups (p < 0.05). On the other hand, we could not find any changing in the control group (p > 0.05). When the gain obtained in the Pilates groups is compared, it has been observed that progress has been more in trunk flexor muscle strength in the Reformer Pilates group (p < 0.05) and that the gain has been similar in the other parameters (p > 0.05). CONCLUSIONS: As a result, patients with MS have seen similar benefits in Reformer Pilates and Mat Pilates methods.

Recurrent Transient Ischemic Attacks in a Patient with POEMS Syndrome.

A 47-year-old female with a prior history of POEMS (polyneuropathy, organomegaly, endocrinopathy, monoclonal gammopathy, and skin changes) syndrome was admitted with transient ischemic attacks complicated by dysarthria and right-sided hemiparesis. A blood survey indicated thrombocytosis and hyperfibrinogenemia while imaging of intracranial vasculature showed occlusion of the bilateral middle cerebral arteries. POEMS syndrome, of which arterial thromboses have been mentioned as a manifestation, is rarely accompanied by transient ischemic attacks. The pathophysiologic mechanism is yet unclear and needs further investigation.

Heparin-induced thrombocytopenia leading to stroke, lower extremity arterial occlusive disease, and skin necrosis: a case report.

Enoxaparin sodium is a low molecular weight heparin (LMWH) used to treat and prevent deep venous thrombosis (DVT). The common complications related to the use of heparin are bleeding, allergic reaction, and osteoporosis. A less common complications are thrombocytopenia and thromboembolism that may not be generally recognized. We present a case of low molecular weight (LMW) heparin-induced thrombocytopenia (HIT) causing stroke, lower extremity arterial occlusion, and skin necrosis. Monitoring the platelet count is essential for early diagnosis of HIT. All patients who undergo heparinization should have a baseline platelet count done before the regimen is started and should be monitored closely especially during the first weeks of treatment.

Iron-Deficiency Anemia Leading to Transient Ischemic Attacks due to Intraluminal Carotid Artery Thrombus.

Reactive thrombocytosis secondary to iron-deficiency anemia (IDA) is a rare but recognized cause of stroke. We report the case of a patient with iron-deficiency anemia presenting with multiple transient ischemic attacks (TIA) due to intraluminal thrombus of an internal carotid artery. The putative mechanisms underlying anemia and stroke syndromes are not completely understood, and it is believed that iron deficiency may cause ischemic stroke by several potential mechanisms. Thrombocytosis is often associated with iron deficiency, and microcytosis produces a reduction in the red cell deformability and could produce a hypercoagulable state. The platelet count and function observed in iron-deficiency anemia could act synergistically to promote thrombus formation, especially in the setting of an underlying atherosclerotic disease. The presence of floating thrombus in a patient with clinical and MRI evidence of stroke represents a significant therapeutic dilemma and requires immediate decision about treatment.

The role of event related potentials in evaluation of subclinical cognitive dysfunction in epileptic patients.

BACKGROUND/AIM: Cognitive dysfunction in epileptic patients may develop due to the neurophysiological changes related to seizures or antiepileptic drugs. The aim of this study was to evaluate the cognitive dysfunction in epileptic patients under antiepileptic drug therapy by the aid of event related potentials. METHOD: P300 latencies were obtained from Fz, Cz and Pz electrod positions from both epileptic patients (n=40) and age and sex matched control group (n=40). Epileptic patients were classified either idiopathic primary generalized (IPGE) (n=9) or secondary generalized epilepsy (SGE) (n=31) based on the ILAE classification. The effect of epilepsy type, treatment types (monotherapy/polytherapy), daily dosages and serum levels of antiepileptic drugs, age at onset and EEG abnormalities on P300 latencies were studied. RESULTS: P300 latencies were longer in the epileptics when compared to controls (P < 0.05). Besides, our results pointed out that P300 latencies were longer in IPGE when compared to SGE (P < 0.05). No statistically significant difference was determined between ERP parameters neither in monotherapy nor in polytherapy groups (p > 0.05). Antiepileptic drug subgroups revealed variable effects on ERP latencies. CONCLUSION: We believe P300 latencies may have an important role in the evaluation of subclinical cognitive dysfunction in epileptic patients treated with antiepileptic drugs.

Event related potentials in hypothyroidism.

Central nervous system (CNS) dysfunction is an important consequence of thyroid hormone deficiency Several studies using objective behavioral measures reported that cognition is impaired in patients with hypothyroidism. The aim of the present study is to evaluate objectively the functional changes in the nervous system and possible cognitive effects of hypothyroidism by using event related potentials (ERP) in order to determine the frequencies of these changes in patients with hypothyroidism. Forty-two patients (3 males, 39 females) (mean age: 40 +/- 11) with newly diagnosed primary hypothyroidism were included in the study. In all patients the cause of hypothyroidism were chronic autoimmune thyroiditis. None of them had received thyroid hormone as a replacement therapy. In hypothyroid group both N2 and P300 latencies from FZ, CZ, PZ electrode positions were prolonged relative to controls and the differences were statistically significant; respectively (N200: P < 0.003, 0.003, 0.002--P300: P < 0.008, 0.02, 0.001) N100 and P200latencies from FZ, CZ, PZ electrode positions did not differed significantly from those of normal controls; respectively. (p < 0.140, 0.195, 0.153--p < 0.400, 0.185, 0.766) Latency and amplitudes of P300 did not correlated with FT3, FT4 or neither with TSH values in the patient group. We believe like other's that with the aid of this technique we are able to detect early effect on central information processing compatible with a reduction of processing resources and increased effort necessary for a given task in hypothyroid individuals.

SSR abnormalities in chronic alcoholics.

We performed sympathetic skin response (SSR) studies on 29 male patients diagnosed as chronic alcoholics according to DSM-IV criteria. The average age was 43 years and the mean duration of alcohol abuse was 21 years, with all patients having a history of alcohol abuse for a minimum of 4 years. None of the patients had any symptoms and/nor signs related to autonomic nervous system dysfunction and all demonstrated normal nerve conduction velocities. Hand and foot latencies in alcoholics were prolonged relative to controls and the difference was statistically significant: reflected by p values of 0.02 and 0.004, respectively. Forty-four percent of patients demonstrated abnormal results. The unilateral prolongation of the lower extremity latency was the most commonly found abnormality (24%). Finding abnormal SSR in this patient population has made us aware that SSR has the potential to detect subclinical autonomic nervous system dysfunction even in patients who do not have autonomic complaints or neuropathy and to provide information about a part of the peripheral nervous system small unmyelinated C fibers that can not be assessed by currently performed techniques used in clinical EMG laboratories or by physical examination.

Blink reflex abnormalities in chronic alcoholics.

PURPOSE: The aim of the present study was to evaluate the efficacy of blink reflex as a method for obtaining early diagnosis of cranial nerve involvement in alcoholic patients. MATERIALS AND METHODS: The study was conducted on 30 male alcoholics with a mean age of 43 years. They had histories of alcohol abuse for at least 6 years (mean: 25). At the time of recording, they had undergone detoxification treatment for a mean of 27 days. RESULTS: R1 (early response), R2Y (second ipsilateral response), and R2C (second contralateral response) latencies in alcoholics were prolonged relative to controls and the differences were statistically significant (p < 0.02, p < 0.001, p < 0.001, respectively). According to the defined criteria, 40% of the patients had abnormal responses, and the most common abnormality was the unilateral prolongation of R1 (13%). CONCLUSION: Finding abnormal blink reflex responses in alcoholic patients has suggested that blink reflex testing is a useful method for the evaluation of subclinical cranial nerve involvement in alcoholic patients. Blink reflex testing may be useful in detecting early changes and in the follow-up of alcoholic disorder.

The roles of blink reflex and sympathetic skin response in multiple sclerosis diagnosis.

The neurological history and examination are important in multiple sclerosis (MS) diagnosis, but early and accurate diagnosis of MS often requires judicious use of paraclinical information. Electrophysiologic techniques have an important role in demonstrating lesions that are clincally silent but magnetic resonance imaging (MRI) is accepted as the most sensitive paraclincal test for detecting asymptomatic dissemination in space for MS patients. In order to test the sensitivity of electrophysiologic techniques in diagnosing asymptomatic MS lesions, we performed blink reflex (BR) and sympathetic skin response (SSR) studies on 13 female (mean age 39 -/+ 9 years) and 8 male (mean age 35 -/+ 14 years) patients with a diagnosis of definite MS who do not have any clinical symptoms nor signs referable to brainstem or autonomic system dysfunction. Forty three percent of patients on SSR testing and 40% of patients on BR testing demonstrated abnormal results. In countries with unfavorable economic conditions, diagnosis, especially the follow-up evaluation of MS patients, poses a major dilemma. The role of diagnostic techniques in MS diagnosis when MRI is available is an economic problem. Diagnostic evaluation adds to the cost of health expenses. We usually choose to perform MRI only at the initial diagnosis of MS and perform follow-up evaluations during remissions and exacerbations with the aid of electrophysiologic techniques. We stress the importance of electrophysiologic screenings in MS patients because they provide data that cannot be obtained through clinical evaluations only with a little cost.

Serum nitric oxide metabolites in patients with multiple sclerosis.

Multiple sclerosis (MS) is an autoimmune disease of the central nervous system characterized by myelin breakdown. The free radical nitric oxide (NO), which is considered to be a major metabolite in immune function and in autoimmune disorders, is among the possible mediators causing the inflammatory reactions in MS. Consequently, NO has been implicated in the pathogenesis of MS and its animal model experimental allergic encephalomyelitis (EAE). In this study, stable metabolites of NO (NO(2-)+NO(3-)) levels were determined in sera of MS patients (n=23) and control subjects (n=16). NO(2-)+NO(3-) levels were higher in MS patients when compared to control subjects. However, there was not any correlation with serum NO(2-)+NO(3-) values and clinical features of the disease such as duration of sickness, the time elapsed from the last attack and EDSS values. Our results imply that nitric oxide may be involved in the pathogenesis of MS although further studies are required to elucidate underlying mechanisms.

Pattern visual evoked potential (PVEP) evaluation in hypothyroidism.

Dysfunction of the central nervous system (CNS) is an important consequence of thyroid hormone deficiency. Evoked potentials like visual evoked potentials (VEP) provide a reliable and objective measure of function in related sensory system and tracts. In this study pattern-shift VEP (PVEP) recordings were performed on 48 newly diagnosed hypothyroid patients. Twenty-four had sub-clinical and 24 had overt hypothyroidism. None of the patients had clinical symptoms or signs referable to CNS dysfunction. Their mean age was 44+/-12 yr. The response to pattern stimulation on the normal control subjects was a triphasic response with a prominent positive wave (P100) with a peak latency of 84-105 (mean: 96+/-4) milliseconds (ms). In patients with hypothyroidism mean P100 latency was (mean: 97+/-6) ms and the difference between the 2 groups was not statistically significant. (p>0.05) Delays above the average latency +/-2.5 SD of the mean of the control subjects was defined as a criteria for an abnormality. According to defined criteria 6 (12.5%) patients demonstrated abnormal PVEP at least on one tested side. Previous studies conducted on small patient populations stated there is high percentage of VEP abnormalities in hypothyroid patients. However, this fact was not confirmed by our study. We believe abnormalities of PVEP will be more prominent in untreated patients in the advanced stage of the disease, or in patients who have a neurological involvement; such as apathy, impaired memory or cerebellar dysfunction. Consecutive studies, in a more clearly defined and selected patient population, are needed to confirm and settle this issue.

Blink reflex abnormalities in diabetes mellitus.

BACKGROUND: Damage of the peripheral nervous system is particularly frequent in diabetes mellitus (DM), but somatic cranial neuropathies usually presenting as mononeuropathies are rare. Oculomotor and facial nerves are among the most commonly affected, whereas the Vth, IXth and Xth cranial nerves are less often affected. While existing neurophysiological tests in the subclinical diagnosis of damage to the peripheral nerve in diabetic patients have advanced, the same does not hold true for the subclinical diagnosis of the central nervous system (CNS). Electrophysiological studies such as the blink reflex was shown to be an effective method for revealing subclinical involvement of cranial nerves in generalised neuropathies. The aim of the present study was to evaluate the efficacy of blink reflex as a method for obtaining early diagnosis of cranial nerve involvement in diabetic patients frequently affected with peripheral neuropathy. METHODS: Twenty diabetic patients with electrophysiologically confirmed neuropathy were included in the present study for the evaluation of blink reflex. Patients with earlier cranial nerve involvement were excluded. RESULTS: Abnormal blink reflex responses were found in 55% of patients studied. R2Y and R2C latencies in diabetic patients were prolonged relative to controls (p<0.001 and p<0.001, respectively). However R1 values in diabetic patients did not differ significantly from those of normal controls (p<0.5). R2Y and R2C prolongation showed a positive correlation with the duration of disease (p=0.015 and p=0.009, respectively). However the same correlation could not be found with R1 values. No correlations were found between R1, R2Y, R2C values and HbA(1c) nor between R1, R2Y, R2C values and patients' age. CONCLUSION: We suggest that blink reflex testing is a useful method for obtaining early diagnosis of cranial nerve compromise in diabetic patients who do not show any clinical symptoms or signs of CNS involvement.

Current literature in diabetes.

In order to keep subscribers up-to-date with the latest developments in their field, John Wiley & Sons are providing a current awareness service in each issue of the journal. The bibliography contains newly published material in the field of diabetes/metabolism. Each bibliography is divided into 17 sections: 1 Books, Reviews & Symposia; 2 General; 3 Genetics; 4 Epidemiology; 5 Immunology; 6 Prediction; 7 Prevention; 8 INTERVENTION: a&rpar General; b&rpar Pharmacology; 9 Pathology: a&rpar General; b&rpar Cardiovascular; c&rpar Neurological; d&rpar Renal; 10 Endocrinology & Metabolism; 11 Nutrition; 12 Animal Studies; 13 Techniques. Within each section, articles are listed in alphabetical order with respect to author (9 Weeks journals - Search completed at 1st Aug 2001)

The correlation between cerebrospinal fluid findings and evoked potentials during an acute MS attack.

Clinically definite Multiple Sclerosis (MS) cases have an index greater than 0.7. Evoked potentials using geometrical patterns and click stimuli respectively and electrical stimulation of mixed nerve trunks evokes low level electrical impulses along a nerve. Prolonged latencies and changes in amplitude in these evoked potentials are thought to reflect sensory loss. This study is performed to determine whether there is a correlation between cerebrospinal fluid (CSF) findings and evoked potentials in MS during an acute MS attack. 10 male and 10 female patients' (20-55) mean (37.75) were included in to the study. They were diagnosed as definite MS with their clinical and MRI findings. During the acute attack 10 (50%) patients out of 20 had high Ig G index and one (10%) had oligoclonal band positivity. Of these 10 patients 8 (4 M, 4 F) had pathology in their evoked potentials while two had normal evoked potential findings. 8 of (80%) 10 patients whom had normal Ig G index during the acute attack had evoked potential pathology while (20%) had normal Ig G index and evoked potentials during the acute attack. Of the 8 patients which had high Ig G index and pathological evoked potential findings during acute attack were evaluated. VEP, BAEP latencies were found to be prolonged as Ig G index increased. (p < 0.05) However the same correlation can not be found with SEP parameters.

Facial nerve conduction in diabetic neuropathy.

Diabetes mellitus (DM) has a severe influence on the nervous system and it is more likely to occur on the nerves of the upper and lower extremities than on the cranial nerves. According to the statistics, the incidence of cranial nerve involvement ranges anywhere from 3% to 14%. The aim of this study is to perform facial nerve conduction studies in diabetic patients with peripheral neuropathy, confirmed by electrophysiological methods, to determine the frequency of affection of a cranial nerve conduction in a neuropathy which mainly occurs in a distal, symmetric fashion. The study was conducted in a group of 20 diabetics who had electrophysiologically confirmed polyneuropathy. All of the patients had type 2 DM. Sixteen of the patients were receiving insulin therapy and 4 were treated with oral hypoglycaemic agents only. We found prolonged facial nerve distal latency at least on one tested side in 70% of patients. Distal latency and amplitudes of muscle responses to facial nerve stimulation showed a statistically significant difference from controls (p < 0.001). This study has shown that proximal nerves like cranial nerves are affected in a high proportion of cases in a neuropathy which mainly occurs in a distal symmetric fashion. The facial nerve is one of the most easily accessible nerves in the proximal part of the body (head-face) and makes it suitable for routine evaluation. We believe this conduction abnormality may give us the chance to classify these neuropathies as more severe than the ones that only have limb conduction abnormalities. Further studies should be performed in order to confirm these findings.