Cerebral cortical and deep venous thrombosis without sinus thrombosis: clinical MRI correlates.

BACKGROUND: Cortical and/or deep vein thrombosis (CDVT) without dural sinus involvement is uncommon and presents diagnostic difficulty for many reasons. Our aim is to determine the relationship between magnetic resonance imaging (MRI) findings and clinical findings in patients with CDVT. METHODS: Forty-six patients with venous stroke proved on MRI included in our Registry, corresponding to 0.1% of 4650 patients with stroke, were studied. Magnetic resonance angiography (MRA) was performed in all patients, and 18 of them had follow-up MRA. Outcome was evaluated by using the Glasgow Outcome Scale at the time of discharge and during follow-up. RESULTS: Thirty-two patients presented cortical venous stroke; 21 of them had involvement of the dorsomedial venous system, six had a defect in the posteroinferior venous group, and five had a defect in the anteroinferior venous group. Thirteen patients presented simultaneous involvement of the superficial and deep venous system; seven with a defect in the parietal and internal cerebral veins (three with involvement of vein of Gallen), four with a defect in the temporooccipital (vein of Labbé) and basal vein of Rosenthal, two with a deficit in the anterior frontotemporal and uncal-pterygoid venous system. One patient had deep venous thrombosis primarily localized to the thalami bilaterally and the basal ganglia on the right because of occlusion of the thalamostriate veins. The main presenting symptoms of CDVT were headache, focal neurologic signs, partial complex or secondary generalized seizures, and consciousness disturbances in those with deep venous thrombosis, presented alone or in combination at onset. CDVT was more than twofold more frequent in women than in men. Pregnancy, puerperium, oral contraceptive use, and infections were the most common predisposing factors. CONCLUSION: Computerized tomography, conventional MRI and diffusion-weighted imaging showing ischemic and/or hemorrhagic lesion that does not follow the boundary of classical arterial boundaries without signs of sinus thrombosis, and partial or generalized seizures followed by focal neurologic signs may predict CDVT. The outcome of patients with cortical venous stroke was good, but not in those with cortical plus deep venous infarction.

Serum and cerebrospinal fluid nitrite and nitrate levels in relapsing-remitting and secondary progressive multiple sclerosis patients.

Nitric oxide (NO) has been implicated in immune mediated cellular cytotoxicity and inflammatory processes including multiple sclerosis (MS). We aimed to assess NO production in MS patients and to delineate its involvement in different stages. The stable end-products of NO; nitrite(NO2-) and nitrate(NO3-) were analysed both in serum and CSF (cerebrospinal fluid) of patients with MS and non-inflammatory neurological diseases. Nitrite levels were quantified by calorimetric assay based on the Griess reaction. Nitrate levels were examined spectrophotometrically. MS patients exhibited significantly increased serum and CSF levels of NO2-+NO3- compared with the control subjects. CSF NO2-+NO3- levels were raised significantly in MS patients with both relapsing remitting (RR) and secondary progressive (SP) course. There was no significant difference between RR and SP MS patients with regard to NO metabolites. No significant correlation was found between NO metabolites and disability score, disease progression index, MRI (magnetic resonance imaging) activity and development of cortical atrophy on MRI. This study provides further evidence for excessive NO production both in CSF and peripheral blood of MS patients. Excessive CSF NO2-+NO3- levels being more increased than the levels in sera supports pathological inflammatory process within CNS (central nervous system) in both stages of MS. Another implication for the role of NO and INOS inhibitors in the treatment of MS patients with both RR and SP courses was also suggested.

Cerebral venous thrombosis in Down's syndrome.

We report the first case of cerebral venous thrombosis (CVT) diagnosed in an adult with Down's syndrome (DS). A 25-year-old man with DS was admitted because of a generalized tonic-clonic seizure and prolonged postictal period. Cerebral magnetic resonance imaging (MRI) and MR venography revealed CVT. No particular cause of the thrombosis was identified. CVT may be an unusual cause of stroke in DS.

Increased cerebrospinal fluid and serum nitrite and nitrate levels in amyotrophic lateral sclerosis.

Abnormal glutamate metabolism is implied in the pathogenesis of Amyotrophic Lateral Sclerosis (ALS) and cerebrospinal fluid (CSF) glutamate levels appear to be elevated. Since nitric oxide (NO) inhibits glutamate transport, excessive amounts of nitric oxide could underlie the glutamate induced neurotoxicity in ALS. Stable metabolites of NO (NO2- + NO3-) levels were determined in serum and CSF of sporadic ALS patients and control subjects. NO2- + NO3- levels were higher in ALS, in males and in serum samples compared to controls, females and CSF, respectively. Furthermore, while the difference between serum and CSF NO2- + NO3- levels was significant in males (higher in serum) no such difference was observed in females. Our results suggest that nitric oxide may be involved in the pathogenesis of ALS directly or indirectly and in a sexually dimorphic manner.

Generalized tonic-clonic status epilepticus: causes, treatment, complications and predictors of case fatality.

We retrospectively reviewed the clinical course of 66 patients treated for generalized tonic-clonic status epilepticus at the Ege University neurological intensive care unit from 1988 to 1997. Seventy-two per cent of the study group had a pre-existing seizure disorder, and antiepileptic drug withdrawal was the most prominent cause of status epilepticus. The other causes included drug toxicity, central nervous system infection, cerebrovascular disease, tumour and trauma. Seventy-three per cent of all patients responded to the first-line therapy (diazepam and/or phenytoin), and the remainder were considered to have refractory status epilepticus and required pentobarbital anaesthesia. Overall case fatality was 21%, but death could be attributed directly to status epilepticus and/or treatment complication in 10% of the study group. Major determinants of fatal outcomes were: increasing age, longer duration of status epilepticus before initiation of therapy and central nervous system infection as a causal factor.

The Ege Stroke Registry: a hospital-based study in the Aegean region, Izmir, Turkey. Analysis of 2,000 stroke patients.

We present the profile of risk factors, etiologic and clinical data of 2,000 consecutive patients with first-ever-in-a-lifetime stroke (cerebral infarction, cerebral hemorrhage and subarachnoid hemorrhage), admitted to the Ege University Hospital between January 1, 1991, and September 31, 1995. This hospital-based registry is the first systematic epidemiologic report on the stroke profile of Turkish people The Ege University Stroke Unit is the only tertiary medical care facility which is organized for patients with different stroke subtypes in Izmir, Turkey. A prospective hospital-based registry using systematic computer coding of data of all stroke patients has been used since January 1991. All patients were evaluated by clinical examination, CT and/or MRI, color duplex and specific cardiac investigations. They were followed up for at least 6 months. The mean age was 62.3 +/- 12 years, and 44.4% were females. Ischemic stroke was found in 77%, primary intracerebral hemorrhage in 19% and subarachnoid hemorrhage in 4%. The major risk factor of ischemic stroke was hypertension (63%), followed by hypercholesterolemia (37%), diabetes mellitus (35%), ischemic heart disease (23%), atrial fibrillation (20%) and smoking (17%). The main cause of primary intracerebral hemorrhage was hypertension (88%), and the principal localization was the thalamus (38%), followed by putamen (28%), lobar(16%), pons(6%), cerebellar(4%), primary intraventricular hemorrhage (4%) and multiple hemorrhages (2%). The over- all 30-day case-fatality rate was 19.7% and the higher mortality rate was found in patients with primary intracerebral hemorrhage (29%) than in those with ischemic stroke (17%). The Ege Stroke Registry allows to estimate the stroke-related problems in patients admitted to a stroke unit and to evaluate the risk factors, etiology and clinical manifestations of stroke in Turkey.

Superior vena cava syndrome together with multiple venous thrombosis in Behçet's disease.

In this paper, we describe a 25-year-old white man with Behçet's disease who developed superior vena cava syndrome which was followed with the diagnosis of pseudotumour cerebri based on bilateral papilledema for 6 months. Complete superior vena cava obstruction was detected by magnetic resonance imaging (MRI). Secondary reasons for papilledema were all excluded. Treatment of prednisone, pulse cyclophosphamide and heparin was started and clinical symptoms and fundoscopic changes completely disappeared in 2 weeks. In conclusion, we think that Behcet's disease should always be remembered in the differential diagnosis of unidentified neurological signs especially in regions where the disease is relatively common.

Use of levodopa to relieve pain from painful symmetrical diabetic polyneuropathy.

Levodopa has been used to treat some painful conditions and found to be effective in neuropathic pain due to herpes zoster in a double-blind study. From our anecdotal observations about the efficacy of levodopa on diabetic neuropathic pain, we designed a double-blind placebo-controlled study to test levodopa in painful diabetic neuropathy. Twenty-five out-patients with painful symmetrical diabetic polyneuropathy were admitted to the study. Fourteen patients were given 100 mg levodopa plus 25 mg benserazide to be taken three times per day for 28 days. Eleven patients were given identical placebo capsules. A blinded neurologist evaluated the patients clinically and performed Visual Analogue Scale (VAS) measurement every week from day 0 to day 28. The results seemed promising and levodopa may be a choice for the control of pain in neuropathy for which we do not have many alternative treatments.

General Health Questionnaire (GHQ12 & GHQ28): psychometric properties and factor structure of the scales in a Turkish primary care sample.

The General Health Questionnaire is a widely used screening instrument. It detects a wide range of psychological disorders, mainly the anxiety/depression spectrum, and has been shown to be a valid and reliable instrument across cultures. This study reports the psychometric properties of the 12- and 28-item versions of the questionnaire among Turkish primary care attenders, focusing mainly on the factor structures. Both questionnaires were found to be reliable and they had factor structures consistent with the original studies.

An electrophysiological investigation of deglutition in man.

This article describes a combined electrophysiological and mechanical method used to measure laryngeal movements and related submental EMG activity during swallowing. The mechanical upward and downward movements of the larynx were detected using a piezoelectric sensor while the submental integrated EMG (SM-EMG) was recorded. Measurements were performed in 29 human subjects. The interval between the onsets of the two sensor signal deflections was used as a measure of the time the larynx remained in its superior position during swallowing. In 10 subjects, the cricopharyngeus muscle (CP) of the upper esophageal spinchter showed a continuous tonic EMG activity except during swallowing. All the parameters measured were influenced by the type and volume of the bolus material. The method presented in this study proved its usefulness in the study of the physiology of deglutition as well as in its objective clinical evaluation in patients with dysphagia.

[Callosal infarction after bilateral occlusion of the internal carotid arteries with hemineglect syndrome and astasia-abasia]. / Infarctus calleux après occlusion bilatérale des artères carotides internes avec syndrome d'héminégligence et astasie-abasie.

We report a patient who had a callosal infarct, showed by Computer Tomography and Magnetic Resonance Imaging, without injury to the adjacent hemispheres. Angiography revealed an occlusion of both internal carotid arteries. Besides interhemispheric disconnection with unilateral left agraphia, left tactile anomia, left ideomotor apraxia and left ear auditivoverbal extinction, the patient showed signs of left hemineglect and astasia-abasia, both persistent.

Prognostic value of transcranial magnetic stimulation in acute stroke.

BACKGROUND AND PURPOSE: The aim of this study is to evaluate the role of motor-evoked potentials (MEPs) in predicting functional recovery of hemiparesis and hemiplegia in acute stroke patients. METHODS: Twenty-seven acute stroke patients were evaluated clinically and electrophysiologically within the first week and 3 to 6 months after the event. Clinical assessment included a quantitative evaluation of motor ability and activities of daily living. MEPs were recorded from the abductor pollicis brevis and tibialis anterior muscles bilaterally. Correlations between clinical parameters and MEPs were assessed. RESULTS: In the acute period, no MEP could be detected in 17 of 27 patients. In these 17 patients, the clinical scores were worse than in the patients whose MEPs could be elicited. However, in the follow-up period (3 to 6 months), no significant differences in motor function were observed between the two groups. CONCLUSIONS: In the acute phase of stroke, neurophysiological parameters were correlated with the clinical findings, but MEPs had no value in predicting the outcome of hemiparesis and hemiplegia.