One Patient, Three Providers: A Multidisciplinary Approach to Managing Common Neuropsychiatric Cases.

BACKGROUND: Neuropsychiatric cases require a multidisciplinary approach for effective management. This paper presented case-based discussions on migraine, dementia, epilepsy, mood disorders, neuralgia, and psychosis from the perspectives of a family physician, neurologist, and psychiatrist. The goal was to highlight the importance of collaboration between healthcare providers in managing these complex cases. METHODS: The paper was based on the proceedings of the Mediterranean Neuropsychiatry Symposium, where experts from family medicine, neurology, and psychiatry came together for comprehensive case-based discussions. The CARE framework (Case Report, Appraisal, Research, and Education) was developed to guide reporting and evaluation of case reports in clinical practice. RESULTS: Six cases were presented and discussed, highlighting the importance of a multidisciplinary approach in managing neuropsychiatric cases. The cases included chronic migraine with medication overuse, memory dysfunction with language and behavioral problems, refractory epileptic seizures with subjective sensory symptoms, bipolar affective disorder with normal pressure hydrocephalus, postherpetic neuralgia in a case with bipolar affective disorder, and psychosis with recurrent attacks with the abuse of several substances. CONCLUSION: A biopsychosocial multidisciplinary approach is essential for managing neuropsychiatric cases effectively on behalf of the patients and public health of the country. The CARE framework can guide the reporting and evaluation of case reports in clinical practice, ensuring that patients receive comprehensive and effective care. Healthcare providers should collaborate to provide the best possible care for patients with complex and multifaceted needs.

Headache as the sole presenting symptom of cerebral venous sinuses thrombosis: Subgroup analysis of data from the VENOST study.

OBJECTIVES: Headache is the most common complaint in cerebral venous sinus thrombosis (CVST) and it may sometimes be the only symptom in these patients. This retrospective and prospective study was an investigation of any differences in terms of clinical risk factors, radiological findings, or prognosis in patients with CVST who presented with isolated headache (IH) and cases with other concomitant findings (non-isolated headache [NIH]). METHODS: A total of 1144 patients from a multicenter study of cerebral venous sinus thrombosis (VENOST study) were enrolled in this research. The demographic, biochemical, clinical, and radiological aspects of 287 IH cases and 857 NIH cases were compared. RESULTS: There were twice as many women as men in the study group. In the IH group, when gender distribution was evaluated by age group, no statistically significant difference was found. The onset of headache was frequently subacute and chronic in the IH group, but an acute onset was more common in the NIH group. Other neurological findings were observed in 29% of the IH group during follow-up. A previous history of deep, cerebral, or other venous thromboembolism was less common in the IH group than in the NIH group. Transverse sinus involvement was greater in the IH group, whereas sagittal sinus involvement was greater in the NIH group. The presence of a plasminogen activator inhibitor (PAI) mutation was significantly greater in the IH group. CONCLUSION: IH and CVST should be kept in mind if a patient has subacute or chronic headache. PAI, which has an important role in thrombolytic events, may be a risk factor in CVST. Detailed hematological investigations should be considered. Additional studies are needed.

Patients with cerebrotendinous xanthomatosis diagnosed with diverse multisystem involvement.

Cerebrotendinous xanthomatosis (CTX) is a lipid storage disease caused by deficiency of sterol 27-hydroxylase enzyme encoded by CYP27A1 gene. This multicenter, cross-sectional descriptive study aimed to document clinical characteristics of CTX patients of different ages, clinical presentations of early-diagnosed patients, and responses to short-term chenodeoxycholic acid (CDCA) treatment. Seven of 11 CTX patients were diagnosed in childhood. Three patients (27%) had neonatal cholestasis, seven (63%) patients had a history of frequent watery defecation started in infantile period, and eight (72.7%) patients had juvenile cataract. Four patients in the adult age group had pyramidal signs and parkinsonism symptoms. The mean Mignarri score at diagnosis was significantly lower in the pediatric patients (267.8 ± 51.4) than in the adult patients (450.0 ± 64.0, p = 0.001). No significant difference was determined between pediatric patients and adult patients regarding plasma cholestanol concentration at diagnosis (p = 0.482). The frequency of defecation decreased with treatment in six children, who had diarrhea at admission. Compared to pretreatment values, patients' body weight and standardized body mass index significantly increased at the 12th month of treatment. In conclusion, Mignarri scores are lower in the pediatric patients than in adult patients since the most determinative signs of the CTX disease are not apparent yet in the childhood. The disease is frequently overlooked in routine practice as the disease presents itself with different clinical combinations both in adults and in children. CTX is potentially a treatable disease; thereby, enhanced awareness is critically important for early diagnosis particularly in children.

Assessment of Patients with Intracerebral Hemorrhage or Hemorrhagic Transformation in the VENOST Study.

INTRODUCTION: Cerebral venous and sinus thrombosis (CVST) may lead to cerebral edema and increased intracranial pressure; besides, ischemic or hemorrhagic lesions may develop. Intracerebral hemorrhages occur in approximately one-third of CVST patients. We assessed and compared the findings of the cerebral hemorrhage (CH) group and the CVST group. MATERIALS AND METHODS: In the VENOST study, medical records of 1,193 patients with CVST, aged over 18 years, were obtained from 35 national stroke centers. Demographic characteristics, clinical symptoms, signs at the admission, radiological findings, etiologic factors, acute and maintenance treatment, and outcome results were reported. The number of involved sinuses or veins, localizations of thrombus, and lesions on CT and MRI scans were recorded. RESULTS: CH was detected in the brain imaging of 241 (21.1%) patients, as hemorrhagic infarction in 198 patients and intracerebral hemorrhage in 43 patients. Gynecologic causes comprised the largest percentage (41.7%) of etiology and risk factors in the CVST group. In the CH group, headache associated with other neurological symptoms was more frequent. These neurological symptoms were epileptic seizures (46.9%), nausea and/or vomiting (36.5%), altered consciousness (36.5%), and focal neurological deficits (33.6%). mRS was ≥3 in 23.1% of the patients in the CH group. DISCUSSION AND CONCLUSION: CVST, an important cause of stroke in the young, should be monitored closely if the patients have additional symptoms of headache, multiple sinus involvement, and CH. Older age and parenchymal lesion, either hemorrhagic infarction or intracerebral hemorrhage, imply poor outcome.

Epileptic seizures in cerebral venous sinus thrombosis: Subgroup analysis of VENOST study.

PURPOSE: The aim of this study is to evaluate the presence and prognostic impact of early seizures in cerebral venous sinus thrombosis patients (CVST). METHOD: VENOST is a retrospective and prospective national multicenter observational study. CVST patients with or without epileptic seizures (ES) were analyzed and compared in terms of demographic and imaging data, causative factors, clinical variables, and prognosis in a total of 1126 patients. RESULTS: The mean age of the patients in the ES group was 39.73 ± 12.64 and 40.17 ± 14.02 years in the non-ES group (p > 0.05). Epileptic seizures were more common (76.6 %) in females (p < 0.001). Early ES occurred in 269 of 1126 patients (23.9 %). Epileptic seizures mainly presented in the acute phase (71.4 %) of the disease (p < 0.001). Majority of these (60.5 %) were in the first 24 h of the CVST. The most common neurological signs were focal neurologic deficits (29.9 %) and altered consciousness (31.4 %) in the ES group. Superior sagittal sinus (SSS) and cortical veins (CV) involvement were the most common sites of thrombosis and the mostly related etiology were found puerperium in seizure group (30.3 % vs 13.9 %). Patients with seizures had worse outcome in the first month of the disease (p < 0.001) but these did not have any influence thereafter. CONCLUSIONS: In this largest CVST cohort (VENOST) reported female sex, presence of focal neurological deficits and altered consciousness, thrombosis of the SSS and CVs, hemorrhagic infarction were risk factors for ES occurrence in patients with CVST.

The neutrophil-to-lymphocyte ratio as a marker of peripheral inflammation in progressive supranuclear palsy: a retrospective study.

BACKGROUND AND PURPOSE: To evaluate the neutrophil-to-lymphocyte ratio (NLR) levels in the peripheral blood of patients with progressive supranuclear palsy (PSP), and to compare them with levels in patients with idiopathic Parkinson's disease (PD) and healthy controls. METHODS: Twenty-one patients with probable PSP, 42 with PD, and 40 age-matched healthy volunteers were enrolled in the study. Demographic data and duration of disease, comorbid systemic disease, and smoking status were recorded. NLR was calculated by dividing neutrophil count by the lymphocyte count. RESULTS: The mean age of patients with PSP was 68.28 ± 8.7 years and the mean duration of disease was 5.09 ± 2.52 years. The mean age in PD group was 66.59 ± 9.54 years and 65.05 ± 6.52 years in the healthy volunteer group. There were no significant differences in ages between the PSP group and the other two groups (p = 0.498; p = 0.107, respectively). The PSP group consisted of four female and 17 male patients. The PD group comprised 19 female and 23 male patients. There were 18 female and 2 male in the healthy volunteer group. The mean NLR value in the PSP group was significantly higher than in the PD group and healthy controls (p = 0.023; p = 0.001, respectively). The mean NLR value in the PD group was not significantly different from the healthy controls (p = 0.593). CONCLUSION: NLR values were found higher in the PSP group. The result of this study revealed the existence of peripheral inflammation in patients with PSP.

Randomized, controlled trial of fesoterodine fumarate for overactive bladder in Parkinson's disease.

AIMS: To evaluate short-term efficacy and safety of fesoterodine fumarate in Parkinson's disease (PD) patients with overactive bladder (OAB) symptoms. METHODS: This is a randomized, double-blind, placebo-controlled study. It also has an open-label extension phase. From May 2016 to May 2018, 63 patients were randomized to receive fesoterodine 4 mg or placebo for 4 weeks. At the end of 4 weeks of randomization phase, patients were received fesoterodine fumarate 4 mg daily for another 4 weeks at the open-label extension phase. The change in the mean number of micturition episodes per 24 h period was the primary outcome measure of the study. RESULTS: The number of micturition episodes per 24 h period significantly improved with the use of fesoterodine fumarate in the double-blind phase (p < 0.001). Also the mean number of nocturia and urgency episodes decreased in the fesoterodine group. In the open-label phase, the mean number of micturition, urgency and urgency urinary incontinence episodes were improved significantly. The number of nocturia episodes did not change in the open-label phase. Cognitive functions were stable after 4 weeks of fesoterodine 4 mg treatment. CONCLUSIONS: OAB symptoms were significantly improved in older adults with PD under fesoterodine fumarate treatment, and this advantage continued in the open-label portion in the short term. In this randomized controlled study, the cognitive functions of the participants were not affected by fesoterodine 4 mg treatment compared with placebo.

Cerebral Venous Sinus Thrombosis as a Rare Complication of Systemic Lupus Erythematosus: Subgroup Analysis of the VENOST Study.

AIM: Systemic lupus erythematosus (SLE) is an unusual risk factor for cerebral venous sinus thrombosis (CVST). As few CVST patients with SLE have been reported, little is known regarding its frequency as an underlying etiology, clinical characteristics, or long-term outcome. We evaluated a large cohort of CVST patients with SLE in a multicenter study of cerebral venous thrombosis, the VENOST study, and their clinical characteristics. MATERIAL AND METHOD: Among the 1144 CVST patients in the VENOST cohort, patients diagnosed with SLE were studied. Their demographic and clinical characteristics, etiological risk factors, venous involvement status, and outcomes were recorded. RESULTS: In total, 15 (1.31%) of 1144 CVST patients had SLE. The mean age of these patients was 39.9 ± 12.1 years and 13 (86.7%) were female. Presenting symptoms included headache (73.3%), visual field defects (40.0%), and altered consciousness (26.7%). The main sinuses involved were the transverse (60.0%), sagittal (40.0%), and sigmoid (20.0%) sinuses. Parenchymal involvement was not seen in 73.3% of the patients. On the modified Rankin scale, 92.9% of the patients scored 0-1 at the 1-month follow-up and 90.9% scored 0-1 at the 1-year follow-up. CONCLUSIONS: SLE was found in 1.31% of the CVST patients, most frequently in young women. Headache was the most common symptom and the CVST onset was chronic in the majority of cases. The patient outcomes were favorable. CVST should be suspected in SLE patients, even in those with isolated chronic headache symptoms with or without other neurological findings.

Optic nerve head, retinal nerve fiber layer and macular thickness analysis in restless legs syndrome.

PURPOSE: The human retina contains dopaminergic neurons within the inner retinal layer. Several studies demonstrated dopaminergic neuronal loss in Parkinson's disease (PD) using optical coherence tomography (OCT). Hypothetically, restless legs syndrome (RLS) may have an underlying dopaminergic mechanism and a probable relation to PD is assumed. Therefore, we aimed to analyze retinal morphology in RLS patients. METHODS: In this cross-sectional study we used spectral domain OCT to measure the features of various retinal layers such as thicknesses of peripapillary retinal nerve fiber layer (RNFL), macular and foveal layers, ganglion cell complex (GCC), and optic nerve head parameters of 36 patients with idiopathic RLS, together with 36 age and sex-matched controls. Differences in the thicknesses of RNFL, macula, GCC and optic disc parameters are statistically compared between patients and controls. RESULTS: The average peripapillary RNFL thickness, mean macular volume and total retinal thickness were reduced in RLS compared with healthy controls (p = 0.032, p = 0.029, and p = 0.026, respectively). After Bonferroni correction, only the reduction in the inferior inner and outer quadrants of the macula remained significant (p = 0.0040, for both). Optic nerve head parameters (cup volume, cup/disc area ratio, rim area and disc area) and GCC thickness showed no significant difference between patients and healthy controls. CONCLUSION: Our study revealed significant retinal thinning in the macula region in RLS. Our results may support the dopaminergic dysfunction in the pathogenesis of RLS. Prospective longitudinal studies with a larger sample are needed to corroborate our results.

FPL tendon thickness, tremor and hand functions in Parkinson's disease.

INTRODUCTION: In Parkinson's disease (PD), a resting tremor of the thumb may affect the flexor pollicis longus (FPL) and influence hand functions. We investigated the relationship between FPL tendon thickness and hand function in PD patients and compared these characteristics with those in healthy controls. METHODS: The hand grip and pinch strengths were measured. The participants completed the Duruöz hand index, the Sollerman's hand function test, and the Nine Hole Peg Test. The thickness of the FPL tendon was measured using ultrasonography. RESULTS: The FPL tendon was thicker in PD patients but was not associated with tremor severity. In PD patients, despite functional performance of the hands are impaired and grip strength is decreased, pinch strengths are preserved. FPL thickness was not correlated with grip and pinch strengths. CONCLUSION: The thicker FPL tendon may be associated with greater pinch and grip strengths and manual dexterity in healthy individuals. The presence of tremor is associated with a thicker FPL tendon.

Stereological Evaluation of the Optic Nerve Volume in Alzheimer Disease.

Optic nerve damage occurs in Alzheimer disease (AD) related to the loss of the retinal ganglion cells that contribute fibers to the optic nerve and reduction of the density of axons of the optic nerve. In this study the authors evaluated optic nerve volume changes and the relation between the cerebrum and optic nerve volumes in AD patients. The study evaluated the volumetric measurements of optic nerve by applying the stereological method on magnetic resonance images (MRI). It included age-matched study and control groups, which were composed of 20 patients with probable AD and 20 healthy subjects, respectively. MRIs were analyzed by using the point-counting approach holding Cavalieri principle. There were statistically significant optic nerve volume reduction and cerebral atrophy in AD patients when compared with the age-matched control subjects (P = 0.013, P < 0.001, respectively) but there was no correlation between the optic nerve volume and cerebral volume in AD patients (r = 0.326, P = 0.160). There was a difference between optic nerve volumes of AD and control subjects. The stereological evaluation of optic nerve volume is of importance for both clinicians and anatomists and it can provide valuable information in the evaluation of morphological changes of AD in vivo.

Could Toxoplasma gondii have any role in Alzheimer disease?

BACKGROUND: Alzheimer disease (AD), a chronic progressive neurodegenerative disorder, has a mainly unknown multifactorial etiology. Neuroinflammatory mechanisms might contribute to the cascade of events leading to neuronal degeneration. Central nervous system infections have been previously suggested as possible etiological agents in the development of sporadic AD. Toxoplasmosis can be associated with various neuropsychiatric disorders. In this study, we aimed to investigate the possible association between toxoplasma infection and AD. METHODS: This study evaluated the serum anti-Toxoplasma gondii IgG levels. It included an age-matched and sex-matched study and control groups that consisted of 34 patients with AD and 37 healthy individuals, respectively. There were no difference between the socio economic states of the patients and control subjects. serecm anti-I-gondi IgG levels were measured by using ELISA. RESULTS: According to the statistical analysis, there were no significant differences among the patients and the control participants with respect to age (68.05±15.98, 62.91±5.89 y, P=0.072; respectively) and sex. The seropositivity rate for anti-T. gondii IgG antibodies among AD patients and control groups were 44.1% and 24.3%, respectively, and there was significant difference between the serum anti-T. gondii IgG levels (P=0.005). CONCLUSIONS: Our findings suggest that toxoplasma infection may be involved in the pathogenetic mechanisms of AD. If confirmed, a positive correlation between toxoplasmosis and AD may lead to new approaches for the management of AD.

Magnetic resonance imaging findings of shoulders in Parkinson's disease.

The aim of this study is to evaluate shoulder disturbances in Parkinson's disease (PD) patients using magnetic resonance imaging (MRI) which is the best tool in the demonstration of complex shoulder pathologies; and to determine probable relations between shoulder pathologies and PD clinical features. Twenty-eight PD patients with a total of 56 shoulders were used as the study group while 13 age-matched cases with 26 shoulders were used as the control group (CG) in the study. Both patients with PD and the CG underwent shoulder MRI. The Hoehn and Yahr (H&Y) disability scale and Unified Parkinson's Disease Rated Scale (UPDRS) were used to determine the severity of the disease. Our results showed that patients with full-thickness supraspinatus (SSP) tear have statistically significant higher UPDRS (P = 0.012), tremor (P = 0.023), rigidity (P = 0.023), and total (P = 0.002) scores. Mild group patients (P = 0.045) showed significantly higher frequency resting tremor and subcoracoid effusion than those of severe group patients (P = 0.002). Subcoracoid effusion was observed in patients with significantly higher UPDRS (P = 0.045) and rigidity (P = 0.022) scores. When the resting tremor and subcoracoid effusion groups were compared according to the severity of the resting tremor but not according to the H&Y, higher frequency of full-thickness tear in SSP tendon was detected in the group of resting tremor (P = 0.053). Longer duration of disease was also observed in patients with full-thickness SSP tear (P = 0.029) and acromioclavicular joint changes (P = 0.018). Higher UPDRS, tremor, rigidity and total scores and longer PD duration appear as the predisposing factors for the development of shoulder disturbances in PD in this study.

The probable relation between Toxoplasma gondii and Parkinson's disease.

Parkinson's disease (PD), a chronic progressive neurodegenerative disorder, has a mainly unknown multifactorial etiology. Neuroinflammatory mechanisms might contribute to the cascade of events leading to neuronal degeneration. Toxoplasmosis can be associated with various neuropsychiatric disorders. The most commonly affected central nervous system (CNS) region in toxoplasmosis is the cerebral hemisphere, followed by the basal ganglia, cerebellum and brain stem. Therefore, in this study, we aimed to investigate the possible association between Toxoplasma infection and PD by evaluating the serum anti-Toxoplasma gondii IgG antibodies. There were no difference between the socioeconomic status of the patients and control subjects and magnetic resonance images of the patients were normal. Serum anti-T. gondii IgG levels were measured using ELISA. There was no statistically significant differences among the patients and control subjects with respect to age (66.01+/-12.14 years, 62.42+/-5.93 years, p=0.089; respectively) and gender. The sero-positivity rate for anti-T. gondii IgG antibodies in PD patients and control groups were 42.3 and 22.5%, respectively, and they were statistically significant (p=0.006). These results suggest that Toxoplasma infection may be involved in the pathogenetic mechanisms of PD. If confirmed, this hypothesis would represent a valuable advancement in care of patients with Parkinson's disease.

Evaluation of cerebellar asymmetry in Alzheimer's disease: a stereological study.

OBJECTIVES: Alzheimer's disease (AD) is the most common cause of dementia and, as previous studies have indicated, degenerative changes in the cerebellum occur in AD. It is well known that the cerebellum does not have a symmetric morphology and some pathological disorders, such as schizophrenia, epilepsy, autism and alcoholism, can cause asymmetrical changes in the cerebellum. In this study, we aimed to evaluate whether or not patients with AD show cerebellar asymmetry. We also intended to depict the probable volumetric asymmetry by using a stereological technique. MATERIALS AND METHODS: The study evaluated the volumetric measurements of each cerebellar hemisphere by applying a stereological method to MR images. This age- and gender-matched study was composed of 15 patients with probable AD and 14 healthy subjects (controls). MR images were analyzed by using the point-counting approach, holding to Cavalieri's principle. RESULTS: Although there was significant cerebellar atrophy in AD patients, the study showed no statistically significant cerebellar asymmetry according to age and gender, both in the study and control groups (p > 0.05). CONCLUSIONS: There was no difference in cerebellar asymmetry associated with age and gender between the AD patients and control subjects. The stereological evaluation of cerebellar asymmetry correlating with gender is of importance to both clinicians and anatomists. The technique is simple, inexpensive, reliable and unbiased.

Conjunctival flora in patients with Parkinson's disease.

PURPOSE: To identify the conjunctival flora in patients with Parkinson's disease (PD) and compare it with the conjunctival flora of healthy subjects. METHODS: One hundred six eyes of 106 patients with PD and 102 eyes of 102 age-matched healthy subjects were included in the study. All subjects had a detailed anterior segment examination, including eye blink rate and conjunctival cultures. Conjunctival cultures were taken with a sterile cotton-tipped dry swab without topical anesthesia. The culture samples were inoculated onto 5% sheep blood agar and chocolate agar, as well as brain heart infusion broth. The bacterial growth was evaluated in a quantitative manner as colony-forming units (CFU). All bacterial isolates were identified, and statistical analyses were performed by chi-square test to determine if there were differences in flora between PD and control groups. RESULTS: Eighty-six (81.1%) of the 106 eyes in patients with PD and 73 (71.5%) of the 102 eyes in control group were found to have positive conjunctival cultures (p = 0.144). Coagulase-negative Staphylococcus was the most commonly isolated bacterial species in both groups, found in 45 (42.4%) and 49 (48%) of eyes in patients with PD and control group, respectively (p = 0.503). Among all bacterial isolates, only Staphylococcus aureus was found to be statistically different between the two groups, noted in 32 (30.1%) and 10 (9.8%) of eyes in patients with PD and control group, respectively (p = 0.001). CONCLUSIONS: Coagulase-negative Staphylococcus, Staphylococcus aureus, and Corynebacterium species were the most commonly isolated bacterial species in the PD group. Among all bacterial isolates, only Staphylococcus aureus was significantly higher in the conjunctival flora of patients with PD than in those in the control group.

Stereological evaluation of the volume and volume fraction of intracranial structures in magnetic resonance images of patients with Alzheimer's disease.

In this study, we describe and adapt the relevant methods of magnetic resonance (MR) and stereology to estimate total brain volume (TBV), cerebral and cerebellar volume and their volume fractions within the brain. The study included 15 (8 males, 7 females) controls and 15 (8 males, 7 females) patients with Alzheimer's disease. The patients' MR images were obtained in both sagittal and axial planes. The volume and volume fraction of the total brain, cerebrum and cerebellum were determined on MR images using the point-counting approach of stereological methods. The volume fractions of the cerebrum to TBV and cerebellum to TBV in the control group were 66.38% and 67.87% in axial and sagittal planes, and 12.05% and 12.81% in axial and sagittal planes, respectively. The volume fractions of the cerebrum to TBV and cerebellum to TBV in the Alzheimer group were 52.40% and 56.26% in axial and sagittal planes, and 10.00% and 10.38% in axial and sagittal planes, respectively. The Alzheimer subjects showed significantly lower cerebral and cerebellar volume fraction to TBV than the control subjects (p<0.001). No significant difference was found in either group with regard to gender or planes (p>0.05). The present evaluation of TBV, cerebral and cerebellar volume and volume fractions can be done on any complete set of MR imaging, in which the plane scan distance and magnification factor are known, as they are in MRI. In conclusion, the cerebral and cerebellar to TBV volume fractions can be important tools in determining brain atrophy and can be estimated by the stereological method.