Neutrophil lymphocyte ratio as a predictor of stroke.

BACKGROUND: The aim of this study is to investigate the relationship of the neutrophil to lymphocyte ratio (NLR) with short-term mortality in acute stroke. METHODS: This retrospective study included 255 patients with acute cerebral infarction who presented within 24 hours of symptom onset. A hemogram from peripheral venous blood samples was taken at the time of admission. The NLR was calculated as the ratio of neutrophils to lymphocytes. Duration of follow-up was defined as 60 days. RESULTS: Seventy-one of 255 patients died during the follow-up period. The median NLR was significantly increased among the mortality group compared with the survival group (median 11.50, interquartile ratio [IQR] 10.40 vs median 3.79, IQR 4.72; P = .001). In our multivariate Cox regression model, NLR >5.0 (hazard ratio [HR] 3.30; 95% confidence interval [CI] 1.35-8.07), National Institutes of Health Stroke Scale score (HR 1.11; 95% CI 1.07-1.16), glucose values at admission (HR 1.007; 95% CI 1.002-1.011), and history of coronary artery disease (HR 2.49; 95% CI 1.26-4.92) were predictors of short-term mortality. The sensitivity for short-term mortality when the NLR was >5 was 83.10%, and the specificity was 62.00%. The positive predictive value of a NLR >5 was 45.7%, and negative predictive value was 90.50%. A strong linear association between NLR and National Institutes of Health Stroke Scale score was also observed (r = 0.64; P = .001). In addition, the NLR was higher in both the atherosclerotic and cardioembolic stroke subgroups than the lacunar infarct subgroup (6.5 [IQR 7.2], 7.5 [IQR 8.9], and 3.20 [IQR 3.50], respectively; P = .001). CONCLUSIONS: The NLR at the time of hospital admission may be a predictor of short-term mortality in acute stroke patients. Because of the routine use and inexpensive nature of hemogram analysis, the NLR should be investigated in future prospective, randomized controlled trials investigating acute stroke.

P-wave dispersion for predicting paroxysmal atrial fibrillation in acute ischemic stroke.

BACKGROUND: Detection of paroxysmal atrial fibrillation (PAF) in acute ischemic stroke patients poses diagnostic challenge. The aim of this study was to predict the presence of PAF by means of 12-lead ECG in patients with acute ischemic stroke. Our hypothesis was that P-wave dispersion (P(d)) might be a useful marker in predicting PAF in patients with acute ischemic stroke. METHODS: 12-lead resting ECGs, 24-hour Holter recordings and echocardiograms of 400 patients were analyzed retrospectively. PAF was detected in 40 patients on 24-hour Holter monitoring. Forty out of 360 age and gender matched patients without PAF were randomly chosen and assigned as the control group. Demographics, P-wave characteristics and echocardiographic findings of the patients with and without PAF were compared. RESULTS: Maximum P-wave duration (p=0.002), P(d) (p<0.001) and left atrium diameter (p=0.04) were significantly higher in patients with PAF when compared to patients without PAF. However, in binary logistic regression analysis P(d) was the only independent predictor of PAF. The cut-off value of P(d) for the detection of PAF was 57.5 milliseconds (msc). Area under the curve was 0.80 (p<0.001). On a single 12-lead ECG, a value higher than 57.5 msc predicted the presence of PAF with a sensitivity of 80% and a specificity of 73%. CONCLUSION: P(d) on a single 12-lead ECG obtained within 24 hours of an acute ischemic stroke might help to predict PAF and reduce the risk of recurrent strokes.

Lumboperitoneal shunt in a patient with Behçet's disease with medically refractory intracranial hypertension.

A 21-year-old male presented with severe throbbing headache, nausea, vomiting and progressive visual loss. Clinical examination revealed bilateral papilledema and left abducens nerve palsy. MRI showed findings consistent with dural sinus thrombosis. Combinging the clinical findings, MRI and a positive pathergy test, the patient was diagnosed with dural sinus thrombosis associated with Behçet's disease (BD). Despite acetazolamide, prednisone, azathioprine and repeated lumbar punctures, his signs and symptoms of intracranial hypertension gradually worsened. Therefore, lumboperitoneal shunting was planned after which rapid resolution of intracranial hypertension was observed. After reviewing similar reports, we suggest that lumboperitoneal shunt placement can be an effective treatment for patients with BD with medically refractory intracranial hypertension associated with dural sinus thrombosis.

Digital neuropathy of the median and ulnar nerves caused by Dupuytren's contracture: Case report.

INTRODUCTION: Digital neuropathy is a pure sensory neuropathy of a digital nerve. It may be caused by acute or chronic local trauma or pressure, or accompany systemic illnesses such as rheumatoid disease, leprosy, Raynaud disease, dysproteinemia, or diabetes mellitus. We describe an extraordinary case of digital neuropathy of the median and ulnar nerves caused by Dupuytren contracture. CASE REPORT: A 56-year-old right-handed man was presented with numbness and tingling of the little finger of the right and ring finger of the left hand. The clinical and EMG findings in this patient were consistent with a lesion of the median and ulnar palmar digital nerves of the right and left ring and little fingers. CONCLUSION: Dupuytren tissue usually affects the palmar fascia, superficial to the digital nerves, and it may rarely affect the spiral cord in the digits. A spiral cord may cause sensory loss due to impingement of digital nerves or Dupuytren tissue may have been compressing the palmar digital nerves against the relatively inelastic deep transverse metacarpal ligament. As a result, digital neuropathy can develop in those with Dupuytren's contracture, and nerve conduction studies should also be performed to determine the condition. New studies are needed to provide better diagnostic criteria for the condition.

Spinal myoclonus associated with vitamin B12 deficiency.

We report a 85-year-old female patient with involuntary and regular movements restricted to abdominal muscles, resembling belly dance, with additional clinical features; ataxia, impaired cognition, neuropathy and glossitis. We initially excluded the possible cortical and spinal structural abnormalities with magnetic resonance imagings and performed routine blood analysis which revealed that serum vitamin B12 (vB12) level was under normal ranges. The relation of low serum vB12 level and myoclonus is speculative and very few studies have demonstrated such patients. In this case report, serum vB12 deficiency is discussed in the context of its probable role in the generation of spinal myoclonus.

Complex regional pain syndrome in stroke patients.

The objective of this study was to investigate the incidence, and the factors influencing the development, of complex regional pain syndrome-I in the upper extremity in hemiplegic patients within the first 28 weeks following a stroke. We followed up 82 stroke patients. All patients were evaluated at weeks 2, 6, 14 and 28 after suffering a stroke. Outcomes were assessed using passive range of motion of shoulder, presence of subluxation, Ashworth score, Motricity index arm score, Brunnstrom stages and depression score. The incidence of complex regional pain syndrome-I was 48.8% in the first 28 weeks. Significant correlation was found between complex regional pain syndrome-I and the presence of subluxation, Ashworth score, Motricity index arm score, Brunnstrom stage and depression score (r=0.259, P=0.019; r=0.271, P=0.014; r=-0.393, P<0.001; r=-0.385, P<0.001; r=0.293, P=0.008, respectively). In this study, there was a relationship between complex regional pain syndrome-I and subluxation, loss of range of motion, spasticity of shoulder muscles and muscle strength. In order to prevent the development of complex regional pain syndrome-I, exercises directed at increasing the range of motion for the glenohumeral joint, strengthening shoulder muscles and reduction of spasticity will establish the integrity of the shoulder joint.

Correlation of motor nerve conduction velocity and number of innervated muscle fibers.

Distal and proximal motor (M) responses were recorded from the "Abductor Pollicis Brevis" (APB) muscle by using the collision method; median motor nerve was stimulated at distal (elbow) and proximal (wrist) regions in a concurrent manner. The delay between two stimuli (ISI: Inter-stimulus Interval), beginning at 9 ms, was decreased by 0.1 ms steps, until the proximal potential completely disappeared. Areas of M responses recorded for each ISI were calculated. Because the area difference between two subsequent ISIs is proportional to the number of muscle fibers innervated by the conduction velocity group at that interval, the relative numbers of muscle fibers for each velocity group were calculated. The results show that the motor nerve conduction velocities belonging to the innervating APB muscle vary between 38 m/s and 57 m/s; the conduction velocity of the group innervating the greatest number of muscle nerves was found to be 55-57 m/s, which comprised 10% of all fibers.

Somatosensory conduction velocity distribution of median nerve middle palmar digital component.

Collision technique is one of the methods used to obtain the relative number of fibers in a nerve bundle. In 25 normal subjects, the right median nerve has been concurrently stimulated at proximal (elbow) and distal (wrist) locations, and the resultant compound action potentials (CAP) were recorded at the middle finger via ring electrodes. The delay between the two stimuli (Inter Stimulus Interval; ISI), beginning from 7 ms, has been decreased in 0.1 ms steps, until the CAPs, elicited by proximal stimulation, totally disappeared. The obtained data have been transferred to computer medium for further analysis. In this procedure, areas under proximal CAPs have been obtained for each ISI value. Using these areas, the relative numbers of fibers (%) belonging to the middle proper palmar digital (MPPD) component of sensory median nerve have been derived. The mean conduction velocities in MPPD component of sensory median nerve ranged from 40 m/s to 68 m/s. In the histogram, a large amount of heaping of the relative number of fibers has been observed in 48-59 m/s conduction velocity interval with the ratio of 64%, although there has been a 21% group having 43-47 ms conduction velocity. These results can be a guide to future studies concerning basic and clinical nerve conduction studies.

Trigeminocervical reflex in fibromyalgia patients.

OBJECTIVE: To describe the properties of trigeminocervical reflex in normal subjects and in patients with primary fibromyalgia syndrome (PFS) having neck pain. DESIGN: Prospective testing of trigeminocervical reflex. SETTING: University hospital electromyography laboratory in Turkey. PARTICIPANTS: Patients with PFS (n=16) and healthy volunteers (n=20). INTERVENTIONS: Trigeminocervical reflex is a brainstem reflex that is evoked by stimulating the sensory branches of the trigeminal nerve and can be recorded from the neck muscles. Electric stimulation of the supraorbital nerve evokes a reflex response (C3) and early reflex response (C1). The mean latencies of C1 and C3 of patients with PFS were compared with normal values. MAIN OUTCOME MEASURE: The C1 and C3 latencies of trigeminocervical reflex. RESULTS: In healthy volunteers, C3 latency +/- standard deviation was 54.17+/-6.00ms ipsilaterally and 51.25+/-9.26ms contralaterally. The difference was not significant (P=.26). The C1 latency was 17.46+/-4.89ms. In patients with PFS, C1 latency was 13.83+/-4.48ms and the C3 latency was 62.70+/-18.22ms. The difference was not significant between the patients (P=.08) and healthy volunteers (P=.17). CONCLUSION: In patients with PFS having neck pain, trigeminocervical connections were not influenced and some other mechanisms may be responsible for pain in these patients.

Ocular neuromyotonia: a case report.

Ocular neuromyotonia is a rare clinical entity, which is characterized by spontaneous spasm of ocular muscles resulting in paroxysmal diplopia and strabismus. Inappropriate discharges from ocular motor neurons or axons with unstable cell membranes may cause the sustained contraction of their respective ocular muscles. In most cases, ocular neuromyotonia resulted from radiation therapy to the parasellar and sellar regions or compressive lesions on ocular motor nerves. Among 30 patients reported in the literatür only six patients were accepted as idiopathic. Here, we reported a patient with third nerve myotonia representing with spells of diplopia. No lesion was found and she was accepted as idiopathic ocular neuromyotonia.