Decreased cerebral vasomotor reactivity in patients with obstructive sleep apnea syndrome.

OBJECTIVE: In obstructive sleep apnea syndrome (OSAS), any of the activated neural, vascular, hemodynamic, metabolic, inflammatory, and thrombotic mechanisms may be related to increased cerebrovascular disease and risk of death; however, the possible pathophysiological process between obstructive sleep apnea syndrome and stroke has not been clearly explained. We hypothesize that alterations in vasomotor reactivity in patients may be responsible for their altered cerebral blood flow, and may contribute to the increased risk of ischemic stroke. METHODS: A total of 30 untreated patients with severe obstructive sleep apnea and 26 control subjects were included in the study. The mean blood flow velocity and breath holding index were measured in middle cerebral artery bilaterally in both patient and control groups by using transcranial Doppler ultrasound. We compared the values between two groups. RESULTS: The mean blood flow velocity and breath holding indexes were significantly decreased in the patient group when compared with the control group. There were no correlations between cerebral hemodynamic parameters and polysomnographic findings in patients. CONCLUSION: Our findings suggest that there was a deteriorated vasodilator response to hypercapnia in patients with OSAS. This deterioration may stem from chemoreceptors or endothelial damages that lead to vascular relaxation and vasodilatation in cerebrovascular circulation. This impaired cerebral vascular regulation may contribute to the increased risk of stroke in patients with OSAS.

Is overactive bladder a nervous or bladder disorder? Autonomic imaging in patients with overactive bladder via dynamic pupillometry.

PURPOSE: To evaluate the changes in dynamic pupillometry in patients with idiopathic overactive bladder (OAB). METHODS: The study included 40 female patients with idiopathic OAB and 40 healthy female volunteers as a control group. Demographic and clinical data were recorded. Dynamic pupillometric parameters were measured with a commercially available unit (MonPack One, Metrovision, France) at baseline and on the 30th day of treatment with an antimuscarinic treatment (drug-agent) (solifenacin 5 mg daily). Initial, minimum, maximum and mean pupil diameters, the latency and duration of contraction and dilatation of the pupil, the amplitude of contraction and dilatation velocity were automatically measured and compared between the groups. RESULTS: There were no significant differences between two groups with respect to age and body mass index (p = 0.288, 0.755, respectively). The measurements of initial, minimum and mean pupil diameters were significantly lower in patients with OAB compared to healthy controls (p = 0.007, 0.002, 0.001, respectively). OAB patients had significantly longer latency of pupil dilatation, latency of pupil contraction and shorter duration of pupil contraction than control group (p = 0.028, 0.029, 0.021, respectively). After the antimuscarinic treatment, latency of pupil contraction, latency of pupil dilatation and duration of pupil contraction shortened significantly (all p < 0.001). Pupil dilatation velocity increased significantly during the treatment (p < 0.001). CONCLUSIONS: The dynamic pupillometric findings in this study imply impaired autonomic dysfunction, mostly the increased parasympathetic action, in OAB patients and the modulatory effects of antimuscarinic treatment.

Association of nerve conduction impairment and insulin resistance in children with obesity.

AIM: The objective of our study was to investigate nerve conduction in normoglycemic obese children. METHODS: A total of 60 children with obesity (30 female and 30 male) and 30 healthy children (15 female and 15 male) were enrolled in the study. Insulin resistance (IR) and other metabolic disturbances were investigated and nerve conduction was measured in all participants. Obese children were divided into groups according to the presence of IR. All results were compared between these subgroups. RESULTS: The nerve conduction velocity (NCV) of motor median nerves in the IR+ group was significantly higher than that in the IR- group and lower than that in the control group. The NCV of the motor peroneal nerve in the IR+ group was significantly lower than that in the IR- group. The sensory nerve action potential (SNAP) of the sensory median nerve was significantly lower in the IR+ group compared to that in the IR- group. The sensory sural nerve's SNAP was significantly lower in the IR+ group than that in the control group. CONCLUSION: Nerve conduction tests may help to detect early pathologies in peripheral nerves and to decrease morbidities in obese children.

Genotypic and phenotypic presentation of transthyretin-related familial amyloid polyneuropathy (TTR-FAP) in Turkey.

Transthyretin-related familial amyloid polyneuropathy (TTR-FAP) is an autosomal dominant disorder caused by mutations of the transthyretin (TTR) gene. The mutant amyloidogenic transthyretin protein causes the systemic accumulation of amyloid fibrils that result in organ dysfunction. TTR-associated FAP is a progressive and fatal disease, if left untreated, and should be considered in the differential diagnosis of any person presenting with a progressive polyneuropathy, particularly with accompanying autonomic involvement. The clinical, electrophysiological, histopathological, and genetic characteristics of 17 patients from Turkey (5 female, 13 male) from nine families with polyneuropathy and mutations in TTR were evaluated. Sequence analysis of the TTR gene revealed five mutations (Val30Met, Glu89Gln, Gly53Glu, Glu54Gly and Gly47Glu). Mean age at disease onset was 40.4 ± 13.9 years (range 21-66 years). The most commonly reported initial complaint was paresthesia in the feet (asymmetric in three patients). Three patients (2 male) with the Glu89Gln mutation presented with carpal tunnel syndrome. Two patients with the Gly53Glu mutation showed episodes of dysarthria and hemiparesis, consistent with this genotype. Seven patients died during the period of follow-up as a result of systemic involvement. Our study suggests that a cohort of patients from Turkey with TTR-FAP exhibits clinical and genetic heterogeneity.

Visual and brainstem auditory evoked potentials in children with obesity.

AIMS: The aim of our study is to investigate alterations in visual evoked potentials (VEP) and brainstem auditory evoked potentials (BAEP) in children with obesity. METHODS: A total of 96 children, with a mean age of 12.1±2.0 years (range 9-17 years, 63 obese and 33 age and sex-matched control subjects) were included in the study. Laboratory tests were performed to detect insulin resistance (IR) and dyslipidemia. The latencies and amplitudes of VEP and BAEP were measured in healthy and obese subjects. RESULTS: The VEP P100, BAEP interpeak latency (IPL) I-III and IPL I-V averages of obese children were significantly longer than the control subjects. When the obese group was divided into two subgroups, those with IR and without IR, BAEP wave I, wave III and P100 wave latencies were found to be longer in the group with IR. A statistically significant correlation was observed between BAEP wave I latency, IPL I-V, IPL I-III and the homeostatic model assessment insulin resistance (HOMA IR) index and fasting insulin level. CONCLUSIONS: Our findings suggest that VEP and BAEP can be used to determine early subclinical on auditory and visual functions of obese children with insulin resistance.

Reduced breath holding index in patients with chronic migraine.

Migraine is a neurovascular disorder characterized by autonomic nervous system dysfunction and severe headache attacks. Studies have shown that changes in the intracranial vessels during migraine have an important role in the pathophysiology. Many studies have been conducted on the increased risk of stroke in patients with migraine, but insufficient data are available on the mechanism underlying the increase. This study aimed to evaluate basal cerebral blood flow velocity and vasomotor reactivity in patients with chronic migraine. We evaluated 38 patients with chronic migraine. Three of them were excluded because they had auras and four of them were excluded because of their use of medication that can affect cerebral blood flow velocity and breath holding index (beta or calcium channel blockers). Our study population consisted of 31 patients with chronic migraine without aura and 29 age- and gender-matched healthy individuals who were not taking any medication. The mean blood flow velocity and breath holding index were measured on both sides from the middle cerebral artery and posterior cerebral artery, with temporal window insonation. The breath holding index for middle cerebral artery and posterior cerebral artery was significantly lower in the migraine group compared to that of the control group (p < 0.05).The vasomotor reactivity indicates the dilatation potential of a vessel, and it is closely related to autoregulation. According to our results, the vasodilator response of cerebral arterioles to hypercapnia was lower in patients with chronic migraine. These findings showed the existence of impairments in the harmonic cerebral hemodynamic mechanisms in patients with chronic migraine. This finding also supports the existing idea of an increased risk of stroke in patients with chronic migraine due to impaired vasomotor reactivity.

Importance of cutaneous silent period in fibromyalgia and its relationship with disease characteristics, psychological disorders and quality of life of patients.

INTRODUCTION: Cutaneous silent period (CSP) is an inhibitory spinal protective reflex and its afferents consist of A-delta nerve fibers. We aimed to evaluate patients with fibromyalgia (FM) and healthy controls to determine any differences between the groups in terms of CSP duration and latency, and if present, to determine whether there is any relationship with disease characteristics, psychological disorders and quality of life. MATERIALS AND METHODS: Thirty-two patients with FM and 32 healthy volunteers were included in the study. The patient and control groups were compared in terms of CSP latency and duration in both upper and lower extremities. Disease characteristics, psychological disorders and quality of life of patients were assessed using the Fibromyalgia Impact Questionnaire (FIQ) and Short Form-36 (SF-36). Patients with CSP measurements equal to or lower than those of the control group were compared with those with higher values than controls in terms of disease characteristics, psychological status and quality of life. RESULTS: Significantly prolonged CSP latencies in both upper and lower extremities were determined in patients compared to controls. We found that prolongation of CSP latency in the lower extremity is associated with disease severity and functional disability. CONCLUSIONS: CSP latencies in both upper and lower extremities in patients with FM are longer than in healthy volunteers. Moreover, prolongation of CSP latency in the lower extremity is associated with disease severity and physical functional disability.

Efficacy of local lidocaine application on anxiety and depression and its curative effect on patients with chronic tension-type headache.

BACKGROUND: Tension-type headache (TTH) is a primary headache disorder. In this study, the efficacy of local lidocaine application on anxiety and depression and its curative effect in patients with chronic TTH was investigated. METHODS: Forty-eight patients (24 local lidocaine injection, 24 local saline injection group) with chronic TTH were enrolled in our study. Injections were applied to the trigger points of the muscles that are innervated by C1-C3 and the trigeminal nerve, exit points of the fifth cranial nerve, and around the superior cervical ganglion. Each patient underwent one session every 3 days. Patients were evaluated before and 3 months after the treatment. RESULTS: In both groups, the number of painful days in a month, visual analogue scale values, amount of analgesic use in a month, Hamilton depression score, and Hamilton anxiety score decreased after the treatment. As a result, all of the parameters were found to have improved in both groups (p < 0.05), the results were statistically significant, and the lidocaine group's response to the treatment was better than the placebo group (p < 0.001). CONCLUSION: Our findings suggest that local lidocaine administration can be an effective method in the treatment of chronic TTH.

Importância do período de silêncio cutâneo na fibromialgia e sua relação com as características da doença, distúrbios psicológicos e qualidade de vida dos pacientes / Importance of cutaneous silent period in fibromyalgia and its relationship with disease characteristics, psychological disorders and quality of life of patients

INTRODUÇÃO: O período de silêncio cutâneo (PSC) é um reflexo protetor inibitório da coluna vertebral e seus aferentes consistem em fibras nervosas A-delta. Nosso objetivo foi avaliar pacientes com fibromialgia (FM) e controles saudáveis para determinar as diferenças entre os grupos em relação à duração e latência do PSC, e quando presente, determinar se há alguma relação com as características da doença, distúrbios psicológicos e qualidade de vida. MATERIAIS E MÉTODOS: Trinta e dois pacientes com FM e 32 voluntários saudáveis foram incluídos no estudo. Os dois grupos foram comparados em relação à latência e duração do PSC em ambos os membros superiores e inferiores. Características da doença, distúrbios psicológicos e qualidade de vida dos pacientes foram avaliados utilizando o Fibromyalgia Impact Questionnaire (FIQ), e o Short Form-36 (SF-36). Os pacientes com medida de PSC igual ou inferior às do grupo controle foram comparados com aqueles com valores mais elevados do que os controles em termos de características da doença, estado psicológicos e qualidade de vida. RESULTADOS: Latências significativamente prolongadas de PSC nos membros superiores e inferiores foram determinadas em pacientes comparados com os controles. Observou-se que a prolongamento da latência do PSC no membro inferior estava associado com a gravidade da doença e incapacidade funcional. CONCLUSÕES: Latências do PCS nos membros superiores e inferiores em pacientes com FM são mais longas do que em voluntários saudáveis. Além disso, o prolongamento da latência do PSC no membro inferior está associado com a gravidade da doença e incapacidade funcional física.

INTRODUCTION: Cutaneous silent period (CSP) is an inhibitory spinal protective reflex and its afferents consist of A-delta nerve fibers. We aimed to evaluate patients with fibromyalgia (FM) and healthy controls to determine any differences between the groups in terms of CSP duration and latency, and if present, to determine whether there is any relationship with disease characteristics, psychological disorders and quality of life. MATERIALS AND METHODS: Thirty-two patients with FM and 32 healthy volunteers were included in the study. The patient and control groups were compared in terms of CSP latency and duration in both upper and lower extremities. Disease characteristics, psychological disorders and quality of life of patients were assessed using the Fibromyalgia Impact Questionnaire (FIQ) and Short Form-36 (SF-36). Patients with CSP measurements equal to or lower than those of the control group were compared with those with higher values than controls in terms of disease characteristics, psychological status and quality of life. RESULTS: Significantly prolonged CSP latencies in both upper and lower extremities were determined in patients compared to controls. We found that prolongation of CSP latency in the lower extremity is associated with disease severity and functional disability. CONCLUSIONS: CSP latencies in both upper and lower extremities in patients with FM are longer than in healthy volunteers. Moreover, prolongation of CSP latency in the lower extremity is associated with disease severity and physical functional disability.

Can cortical silent period and motor threshold be practical parameters in the comparison of patients with generalized epilepsy and patients with psychogenic non-epileptic seizures?.

BACKGROUND/AIM: This study aimed to compare the cortical excitability of patients with generalized tonic-clonic seizures (GTCSs) and that of patients with psychogenic non-epileptic seizures (PNESs). METHODS: Patients were classified into groups according to their electroencephalogram (EEG) findings and seizure types: group 1 = GTCS with an abnormal EEG, group 2 = GTCS with a normal EEG and group 3 = PNES with a normal EEG. The control group included healthy volunteers with normal EEGs. Cortical silent period (CSP) and motor threshold (MT) were measured for all groups and the results were compared. RESULTS: CSPs were significantly prolonged in groups 1 and 2 when compared with group 3 and the control group. No differences were found between the MT measurements of all groups. CONCLUSION: The prolongation of CSP may demonstrate the differences between the pathophysiological mechanisms of GTCS and those of PNES.

Strength-duration time constant in peripheral nerve: no abnormality in multiple sclerosis.

Objectives. To investigate the properties of the strength-duration time constant (SDTC) in multiple sclerosis (MS) patients. Methods. The SDTC and rheobase in 16 MS patients and 19 healthy controls were obtained following stimulation of the right median nerve at the wrist. Results. SDTC and rheobase values were 408.3 ± 60.0 µs and 4.0 ± 1.8 mA in MS patients, versus 408.0 ± 62.4 µs and 3.8 ± 2.1 mA in controls. The differences were not significant in SDTC or rheobase values between the patients and controls (P = 0.988 for SDTC and P = 0.722 for rheobase). Conclusion. Our study showed no abnormality in relapsing remitting MS patients in terms of SDTC, which gives some indirect information about peripheral Na(+) channel function. This may indicate that alterations in the Na(+) channel pattern in central nervous system (CNS) couldnot be shown in the peripheral nervous system (PNS) in the MS patients by SDTC. The opinion that MS can be a kind of channelopathy might be proven by performing other axonal excitability tests or SDTC in progressive forms of MS.

[Botulinum neuro-toxin aype-A in the treatment of chronic tension type headache associated with pericranial tenderness]. / Perikranial hassasiyet ile iliskili kronik gerilim tipi bas agrisinda botulinum toksin tip A tedavisi.

OBJECTIVES: Both peripheral and central nociceptive mechanisms are responsible in chronic TTH. Analgegics are used in the acute treatment of chronic TTH and antidepressants are used in prophylactic treatment. However, further studies are needed to bring out new treatment options. The aim of our study is to investigate the effectiveness of Botulinum Neuro-toxin Type-A (BoNTA) in the treatment of chronic TTH associated with pericranial tenderness (PT). METHODS: 14 patients with chronic TTH with PT were included in the study. 50 units Botox(®) injection was applied to the pericranial muscles (5 units for each muscles bilaterally: frontal, temporal, semispinalis capitis, spenius capitis and trapezius muscles) for each patient. Severity of headache was evaluated by VAS (Visual Analogue Scale) and number of days with headache per month were recorded before treatment and 2nd and 4th months after treatment. RESULTS: Number of days with headache per month were 19.57 ± 3.25 before treatment, 15.28 ± 4.37 at the 2nd month after treatment and 15.78 ± 3.90 at the 4th month after treatment. Severity of headache was 65.71 ± 9.16 before the treatment, 50.71 ± 13.56 at the 2nd month after treatment and 54.28 ± 10.35 at the 4th month after treatment (p<0.05). Frequency and severity of headache before treatment were significantly decreased at the 2nd month after treatment and this significance continued at the 4th month after treatment (p<0.05). CONCLUSION: BoNTA treatment may be usefull in the treatment of patients with chronic TTH associated with PT.

The effects of low-dose radiation in the treatment of sciatic nerve injury in rats.

AIM: Peripheral nerve regeneration is often blocked by scar formation and misdirection of axon sprouts. The aim of this study is to evaluate electrophysiological and histopathological effects of low-dose radiation therapy on the prevention of intraneural scar formation in peripheral nerve injury. MATERIAL AND METHODS: In this experimental study, twenty rats were randomly divided into two groups. Left sciatic nerves were exposed and clipped by temporary aneurysm clip for 5 minutes in both groups. In all animals, electrophysiological recordings were performed between 22-24 hours after sciatic nerve injury. The control group was not given any treatment. In the experimental group, 700 cGy low-dose radiation was administered on the left sciatic nerves 24 hours after clipping. Six weeks after injury, electrophysiological recordings were performed in both groups and animals were sacrificed to evaluate the injured nerves histopathologically. RESULTS: We observed that low-dose radiotherapy increased the amplitude and improved latency measurements in electrophysiological examinations. Histopathologically, more axonal degeneration and vacuolization was observed in the control group comparing with the experimental group. Endoneural space increased slightly more in the control group than the experimental group. CONCLUSION: It was observed that low-dose radiotherapy may prevent intraneural scar formation and may improve electrophysiological recovery in sciatic nerve injury performed in rats.

The efficacy of botulinum toxin in patients with cervicogenic headache: a placebo-controlled clinical trial.

OBJECTIVE: Botulinum toxin type-A (BoNTA) has been considered a treatment option for CH. The aim of this study was to assess the effectiveness of BoNTA treatment in patients with medically resistant CH. MATERIALS AND METHODS: Forty patients with CH were included in the study. Patients in the BoNTA group (n=20) were administered 10 U of BoNTA bilaterally to the frontal muscles, 20 U to the temporal muscles, 15 U to the semispinalis capitis, 15 U to the splenius capitis, and 15 U to the trapezius muscles (total: 150 U). Patients in the placebo group (n=20) received 0.2 mL of saline administrated to the same sites. All participations were evaluated 6 and 12 weeks after treatment; side effects, the number of painful days, severity (by visual analogue scale, VAS) and frequency of pain were evaluated. RESULTS: In the BoNTA group, the severity and frequency of pain 6 and 12 weeks post treatment were significantly lower than pre-treatment levels (p<0.05). At 12 weeks post treatment, the severity and frequency of pain in the BoNTA group were lower than in the placebo group (p<0.05). CONCLUSION: The findings suggest that BoNTA was an effective treatment for CH.

Nocturnal headache associated with melatonin deficiency due to a pineal gland cyst.

The cyclic nature of some of headache disorders is closely related to melatonin, which is secreted by the pineal gland. We report a 29-year-old male patient with a 2.5-year history of headaches that woke him in the middle of the night. These headaches were pulsatile and continued until sunrise. During these attacks he also suffered from allodynia over the scalp, bilateral conjunctival hyperemia, and nervousness. His brain MRI showed a 5mm by 4mm neuroepithelial cyst in the pineal gland. The peak plasma melatonin level that was measured at 2 am was 28 pg/mL. The patient underwent oral melatonin treatment (6 mg/day). After 1 month he experienced a 70% reduction in his symptoms. When the melatonin dosage was increased to 10mg/day he became headache-free, and 5 months after the treatment began, had no complaints. His 5-month follow-up plasma melatonin level at 2 am was 61 pg/mL. To our knowledge this is the first report of a patient with nocturnal headache associated with a low level of melatonin due to a neuroepithelial cyst in the pineal gland.

Cerebral venous thrombosis presenting with subarachnoid hemorrhage after spinal anesthesia.

A 22-year-old male had a meniscopathy operation using spinal anesthesia. After the operation, the patient reported a throbbing headache. His brain computed tomography (CT) showed subarachnoid hemorrhage (SAH) and hyperdense dural venous sinuses suspicious for thrombosis. Filling defects were observed in the superior sagittal and right transverse sinuses on the contrast-enhanced magnetic resonance images. The patient was diagnosed with cerebral venous sinus thrombosis (CVST). On the tenth day of his admission, his clinical findings progressed and heparin therapy was initiated after resorption of hemorrhage was observed in a second non-contrast CT scan. The patient developed decreased consciousness the day after heparin administration. A subsequent brain CT revealed intraparenchymal hemorrhage in the right anteroinferior frontal region. Heparin therapy was discontinued, and anti-edema therapy was started. The presentation of CVST with SAH is a rare condition. Furthermore, development of CVST after spinal anesthesia is very rare. In this case, CVST developed after spinal anesthesia, and its first clinical presentation was SAH. To our knowledge, this is the first case CVST presenting with SAH after spinal anesthesia.

Implications of tilt-table induced faint time in patients with reflex syncope.

OBJECTIVE: The aim of this study was to determine whether patients who faint earlier in the course of a tilt table study represent a separate population with a poorer prognosis or different pathophysiology. We analyzed differences across patients with different syncopal times on the tilt-table study to answer this question. METHODS: This was a retrospective, approved, chart review. From our database of over 6000 patients, we identified 1222 patients with syncope. After excluding patients with orthostatic hypotension, postural tachycardia syndrome and diabetes, we were left with 131 patients with pure reflex syncope. We divided fainters into an early (<20 minutes) and late (>20 minutes) faint times. Along with the tilt table test all patients underwent heart rate response for deep breathing, Valsalva maneuver and quantitative sudomotor axon reflex tests. RESULTS: By 10 minutes in the tilt study, only 18% of subjects had fainted, 65% by 20 minutes, 92% by 30 minutes and 96% by 35 minutes. Age was evenly distributed across all syncopal times. Neither the 14 abnormal cardiac responses to deep breathing nor the 20 abnormal Valsalva maneuvers, nor the 28 abnormal axon reflex responses clustered with an early or late faint time. CONCLUSION: A 10-minute tilt will miss 82% of syncopal episodes, while a 30- minute tilt increases the yield 10-fold, missing only 8%. Patients with early faint times did not differ from patients with late fainting times with regard to age or autonomic test abnormalities. Timing of syncope during the tilt table test does not associated with more severe dysautonomia. A prospective study is needed to confirm these observations.