Amaurosis and transient diplopia, a rare complication secondary to mandibular nerve block: A case report.

Ocular complications are one of the rare side effects that can be seen after a mandibular nerve block and have the most dramatic results. Since the mandibular nerve block is mostly performed by dentists, this complication is mostly seen after an intraoral mandibular nerve block. The mandibular nerve is the third division of the trigeminal nerve. It is the most caudal and lateral part of Gasser's ganglion. It arises from the middle cranial fossa through the foramen ovale. In this region, a block method, which is performed by passing through the coronoid process, has been defined. This block, usually made using anatomical markers, is used in the treatment of trigeminal neuralgia. A 42-year-old female patient was admitted to our department for a maxillary and mandibular block with a diagnosis of trigeminal neuralgia. Immediately after the administration of the local anesthetic, the patient described a complete loss of vision. The complaint of vision loss lasted for about 1 minute, after which the patient's complaint of diplopia continued for 2 hours and 10 minutes. This case report presents the ocular complications after a mandibular block applied with the extraoral technique as an unexpected side effect.

Antiphospholipid antibody positive Sneddon syndrome: a case report.

Sneddon syndrome may present with neurological findings such as transient ischemic stroke, strokes, seizures and/or headaches. However, a purplish, spider web-like skin finding called livedo reticularis may accompany the skin and precede neurological findings. Sneddon syndrome often affects women. Since it is vasculopathy affecting small and medium vessels, other organ findings may accompany. We present a 44-year-old Sneddon syndrome patient with monoparesis in her left lower extremity, livedo reticularis on her back and legs, and hypertension.

Ross syndrome with chronic cough and RF positivity: a case report.

Ross syndrome is a rare disorder of unknown etiology, characterized by the triad of segmental anhidrosis, tonic pupil, and areflexia/hyporeflexia. Ross syndrome is thought to be a limited and selective ganglioneuropathy. Its etiology has not been fully elucidated. Autonomic findings may also accompany. We wanted to present our 25-year-old patient who was diagnosed with Ross syndrome and presented with complaints of inability to sweat, heat intolerance, headache, diarrhea and chronic cough. Keyword: cough, tonic pupil, anhidrosis, compensatory.

The effects of greater occipital nerve blockage with lidocaine on sleep characteristics in chronic migraine patients.

PURPOSE: The aim of our study was to determine the effects of greater occipital nerve block (GONB) with lidocaine on sleep characteristics in patients with chronic migraine. MATERIALS AND METHODS: Twenty female patients who underwent GONB with lidocaine were included in the study. The Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Insomnia Severity Index (ISI), Pre-Sleep Arousal Scale (PSAS), Dysfunctional Beliefs and Attitudes about Sleep Scale (DBAS), Restless Legs Syndrome Severity Scale (RLSSS), Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), and headache diary results before and after the treatment of the patients were compared. RESULTS: We included 20 patients (all females) in our study. The mean age was 35.80 ± 8.82 years (range 24-50). After GON blockade, the number of days with pain (p < 0.001), duration of pain (p < 0.001), and Visual Analog Scale (VAS) score (p < 0.001) were significantly lower than before. After GONB, BDI (p = 0.007), BAI (p = 0.022), ISI (p = 0.009), and PSQI (p = 0.026) scores were significantly lower than before. After GONB, sleep quality was better than before (p = 0.035). CONCLUSION: This study showed that GONB with lidocaine can improve sleep quality, insomnia, and symptoms of depression and anxiety while reducing migraine headache.

A cross-sectional study on the personality traits of episodic and chronic migraine patients.

BACKGROUND: Migraine, is a common neurological disorder that may be associated with certain personality traits. This study aims to identify and compare the personality traits accompanying the clinical and sociodemographic profiles in migraine groups. METHODS: The study included a cohort of chronic, episodic migraine (CM - EM) and healthy controls (HC). Migraine was diagnosed according to the International Classification of Headache Disorders-3ß criteria. Age, gender, migraine-related disease duration, number of days with a headache each month, and headache intensity of the patients were recorded. The Minnesota Multiphasic Personality Inventory-2 (MMPI-2) was used to determine personality traits. RESULTS: The study groups were similar in terms of sociodemographic characteristics (70 CM, 70 EM, and 70 HC). The visual analog scale (VAS) score was significantly higher in CM (p < 0.05). No statistically significant difference was found between the groups concerning symptoms of migraine such as osmophobia, photophobia, phonophobia, and nausea (p > 0.05). When the personality traits were examined, the mean scores of the MMPI test results of migraine patients were found to be higher than healthy controls in line personality disorders (p < 0.05 for all personality traits). In CM patients, the 'hysteria' score was found to be higher in subgroup evaluation (p < 0.05). CONCLUSION: EM and CM patients had more evidence of personality disorders than healthy controls. CM patients had higher hysteria scores than EM patients. In addition to pain treatment, determining personality traits and providing appropriate management with a multidisciplinary approach can benefit both in terms of treatment, cost, and time.

Morphological and electrophysiological evaluation of median and ulnar nerve in complex regional pain syndrome type 1.

OBJECTIVE: Complex regional pain syndrome (CRPS) can be distinguished as type I without and type II with electrophysiological evidence of major nerve lesion. The pathophysiology of both subgroups is still under investigation. The aim of this research is to demonstrate the nerve morphology and electrophysiology in CRPS type I patients. MATERIALS AND METHODS: Bilateral median and ulnar nerve cross-sectional areas were evaluated with ultrasound and also median and ulnar nerve conduction studies of both hands were performed. Cross-sectional areas of median and ulnar nerves and nerve conduction studies in healthy controls were also obtained and compared with the patients. RESULTS: Twenty-five male patients and 11 healthy male controls were enrolled in the study. The mean age of the patients was 24.08 ± 5.50 years and controls was 23.18 ± 5.09 (p > 0.05). Compound muscle action potential (CMAP) and sensory nerve action potential (SNAP) amplitudes of the diseased side were found significantly lower than the healthy side (p < 0.05). Both median and ulnar nerve distal motor latency values were significantly higher in the patient group (p < 0.05). There was no significant difference in the median and ulnar nerve cross-sectional area when compared with the opposite extremity and healthy volunteers. CONCLUSION: The lower SNAP and CMAP amplitudes of the median and ulnar nerves compared to the healthy side and the prolongation of the affected side median and ulnar nerve distal motor latencies of the affected individuals may indicate axonal involvement in patients with CRPS type 1. Decreased CMAP amplitudes may also indicate muscle atrophy due to a decrease in the number of functional motor units.

Headache caused by the use of personal protective equipment in healthcare workers during the COVID-19 pandemic period.

Objective: Coronavirus 2019 disease (COVID-19), the cause of the ongoing pandemic, is an acute respiratory tract infection, which has made it necessary for healthcare personnel to use protective equipment such as N95 masks, protective goggles and visors. External compression headaches caused by the compression of the pericranial soft tissues by wearing hats, helmets, or goggles (worn during swimming or diving) have been previously described. In our study, we aimed to evaluate the presence and characteristics of personal protective equipment-associated headaches in healthcare workers during the COVID-19 pandemic period and to determine the effects of such headaches. Materials and methods: A face-to-face questionnaire was delivered to 300 male and female healthcare personnel between the ages of 18-56 working in healthcare units where COVID-19 patients were evaluated and treated. The data from 296 completed questionnaires was evaluated. Results: We included 296 participants (166 females and 130 males) in our study; the mean age was 33.98 ± 8.52 years (range 18-56). One hundred ninety-six (66.22%) participants indicated that they had new onset personal protective equipment-associated headaches. Percentages of those with newly emergent headaches because of protective equipment were higher in the following participant groups: females (p = 0.045), those with COVID-19 disease history (p < 0.001), and those diagnosed with headaches before the pandemic (p = 0.001). Conclusion: Our study showed the presence of new-onset headaches associated with personal protective equipment in healthcare workers during the COVID-19 pandemic. Personal protective equipment-related headaches were associated with the following factors: female sex, a history of COVID-19 disease, and the presence of primary headaches diagnosed before the pandemic.

Current Perspectives on the Impact of Chronic Migraine on Sleep Quality: A Literature Review.

Objective: Recent studies have shown that sleep problems occur in migraineurs and poor sleep causes chronification, but the mechanisms by which chronic migraine affects sleep quality are still unknown. This review aims to analyze commonly reported sleep disturbances in chronic migraine (CM) and determine the effect of CM on sleep quality. Materials and Methods: We conducted a comprehensive review of all published articles on CM and sleep quality from inception to March 2022 in the literature. Clinical trials, observational studies, and case series (≥20 cases) were included. Two reviewers and a supervisor reviewed the titles and abstracts of all search results with predefined inclusion and exclusion criteria. PubMed search for randomized controlled trials and open studies on CM and sleep quality reported in English between 1983 and 2022 was conducted using the keywords including chronic migraine, sleep, insomnia, sleep quality, polysomnography, and Pittsburgh Sleep Quality Index. Results: A total of 535 potentially relevant articles were found. A total of 455 articles and reviews, meta-analyses published in any language other than English, with other exclusion criteria, were excluded from the review. In the remaining articles, 36 clinical studies, reviewing sleep quality and its association with migraine, were identified and reviewed. Evidence from this review shows that poor sleep and migraine chronicity are intertwined with other accompanying comorbidities and dysregulation of circadian rhythm that innovative treatments promise to bring relief to both poor sleep as well as migraine. Conclusion: Sleep disorders are common in CM and the association between migraine chronification and sleep quality is bidirectional. Comorbid conditions with accompanying frequent attacks in migraine may impair sleep quality. While the maladaptive pain process worsens sleep, poor sleep quality also negatively affects migraine pain. Sleep disturbance, which is affected by worsening migraine attacks, causes deterioration in the quality of life, loss of workforce, and economic burden.

A comparison of the clinical efficacy of GON block at the C2 level and GON block at the classical distal occipital level in the treatment of migraine.

PURPOSE: The aim of this retrospective study was to compare the efficacy and complications of ultrasound-guided block (C2GON) at the level of C2 and block performed from the distal occiput level (DOGON) as the greater occipital nerve progresses superficially to the obliquus capitis inferior muscle in migraine patients. METHODS: 63 patients were included in this retrospective study. For C2GON blockade, 2 units of 4 ml 0.5% bupivacaine were prepared for bilateral administration to 32 patients. For DOGON, two 1.5 ml 0.5% bupivacaine was prepared bilaterally for each patient. The patients were evaluated in terms of pain intensity and frequency, analgesic use, and any side effects before the injection and at the 1st and 3rd months after the last treatment. RESULTS: When we compared C2GON block and DOGON block in our study, we found that both blocks were effective for 3 months. The reduction rates in the C2GON and DOGON groups were 75.3% and 59% in the number of severe attacks, 63.9% and 59.1% in the total analgesic use, 71.1% and 56.25% in the triptan use, 78% and 60% in the number of days with severe headache, 63.4% and 50.3% in the duration of headache. The decrease in the highest VAS score was 48.1% in the group with C2GON, while it was 53% in the group with DOGON. CONCLUSIONS: Current findings have shown that both C2GON and DOGON blockades are effective in the treatment of migraine for 3 months.

Comparison of the clinical efficacy of bilateral and unilateral GON blockade at the C2 level in chronic migraine.

The main purpose of this study was to retrospectively compare the unilateral and bilateral application of proximal greater occipital nerve (GON) block at the C2 level in the treatment of chronic migraine disease. In chronic migraine patients who underwent GON blockade, the average number of migrainous painful days per month, the average duration of pain in attacks, the highest visual analogue scale (VAS) score in pain intensity for one month, and total analgesic use were recorded before and after the block. According to the GON block protocol applied by our clinic, the patients were treated for GON block 4 times a month, once a week. The data obtained were recorded before the treatment, in the 1st and 3rd months after the last injection, and the results were compared using the chi-square, Fisher, Mann-Whitney U, and Wilcoxon-signed rank tests. During the 3-month follow-up, the groups did not differ significantly in terms of the number of days with headache in 30 days, the average duration of headache, the highest VAS score in 30 days, and total analgesic use in 30 days. In both groups, the findings decreased in the 1st month and increased in the 3rd month compared to pre-treatment. However, results of both the 1st and 3rd months were significantly lower than pre-treatment (p<0.05), and there was a clinical benefit compared to pretreatment. While the GON block at the C2 level was effective in the treatment of chronic migraine, the superiority of bilateral application to unilateral application was not detected.

Clinical success of greater occipital nerve blockade in improving sleep quality of chronic migraineurs: a prospective observational study.

BACKGROUND: The success of various therapy methods in the treatment of insomnia and poor quality sleep, both of which play an active role in the chronicization process of migraine, has been the subject of investigation. The aim of this research was to evaluate the success, acceptability, and efficacy of greater occipital nerve block (GON-B) therapy in chronic migraine (CM) patients in improving their sleep quality and developing their beliefs about sleep . METHODS: The study included 40 patients with CM from the general population who agreed to receive blockade therapy. Before the injection treatment, 1-week sleep diaries as well as depression and anxiety symptoms were examined. The Pittsburgh Sleep Quality Index (PSQI), Insomnia Severity Index (ISI), Pre-Sleep Arousal Scale (PSAS), Epworth Sleepiness Scale (ESS), and Dysfunctional Beliefs and Attitudes about Sleep (DBAS) scales were measured and evaluated both before and after the completion of 3 months of treatment. RESULTS: Thirty-seven patients with CM successfully completed our 12-week treatment period. The anxiety and depression scales of the patients decreased after 3 months (p < 0.001). PSQI and its subgroups ratings significantly improved after treatment (p < 0.001). Similarly, ISI, ESS, PSAS, and DBAS test scores also improved after treatment (p < 0.001). CONCLUSIONS: This study provides evidence as to the applicability and acceptability of GON-B in CM treatment in terms of increased sleep quality; improved sleep beliefs, attitudes, and behaviors; and arousals and decreased insomnia findings.

Headache and neck.

Cervicogenic headache (CEH) is currently identified with different diagnostic criteria. The latest one is the International classification of headache disorders (ICHD), 3rd edition (2018). At the present time, there are not enough published articles with reliable sensitivity and specificity that may support a classification for clinical and research purposes. Current literature suggests improvement to the classification(s). The ICHD criteria should be modified to reach an optimal sensitive and specific level to identify CEH as a secondary headache. The B, C1, and C2 criteria should be implemented with proposed suggestions. The C3 criterion should be upgraded. Criteria such as mechanical precipitation of pain by digital pressure on neck trigger points and specific movements, strictly unilateral pain without side-shift, diffuse unilateral shoulder and arm pain, pain starting posteriorly and spreading anteriorly should be integral part of the classification.

Can personality traits, obesity, depression, anxiety, and quality of life explain the association between migraine and disordered eating attitudes?

BACKGROUND: Few studies have explored the coexistence of migraine and disordered eating attitudes. Furthermore, the underlying pathophysiological mechanisms of migraine and disordered eating attitude comorbidity are not clearly understood. OBJECTIVE: This study aimed to investigate the association between migraine and disordered eating attitudes in relation to personality traits, obesity, quality of life, migraine severity, depression, and anxiety. METHODS: This study included 91 patients with episodic migraine and 84 healthy control subjects. Self-report questionnaires were used to evaluate anxiety, depression, migraine-related disability, personality traits, quality of life, and eating disorders. RESULTS: The Eating Attitude Test (EAT) showed disordered eating attitudes in 21 patients (23.1%) in the migraine group and eight patients (9.5%) in the control group. Migraine-related disability, anxiety, depression, neuroticism, and quality of life scores were significantly worse in migraine patients with disordered eating attitudes compared to migraine patients without disordered eating attitudes. In migraine patients, eating attitude test scores were positively correlated with migraine-related disability, anxiety, depression, and neuroticism scores, and negatively correlated with quality of life scores. CONCLUSION: The association of migraine and disordered eating attitudes was shown to be related to depression, anxiety, quality of life and personality traits and may also indicate a more clinically severe migraine. To the best of our knowledge, there is no literature study that deals with all these relevant data together. However, neuropsychiatry-based biological studies are required to better understand this multifaceted association.

Apilarnil: A Novel Neuroprotective Candidate.

PURPOSE: This study was designed to investigate the effect of apilarnil on neuronal damage and related mechanisms in a sepsis model in order to demonstrate whether or not apilarnil has neuroprotective effect. METHODS: In this study, 64 adult male Sprague-Dawley species rats were randomly divided into eight groups. The rats were administered apilarnil and/or lipopolysaccharide (LPS). Superoxide dismutase (SOD), catalase (CAT), malondialdehyde (MDA), xanthine oxidase (XOD) and testican-1 levels were measured in the brain tissue. Proinflammatory cytokines (tumor necrosis factor alpha [TNF-α], interleukin 1 beta [IL-1ß], interleukin 6 [IL-6]) were measured in brain tissue. Histological examinations were performed on hippocampus and cortex tissues in all groups. Apoptotic cell count was estimated using the Tunel method to observe the apilarnil's effect on apoptosis. Purkinje cells were counted in the hippocampus to measure the protective effect of apilarnil on the hippocampus. RESULTS: Apilarnil reduced the decrease in SOD and CAT levels in the brain developing sepsis. Apilarnil reduced the increase in MDA, XOD, and testican-1 levels in the septic brain. It was observed that the number of degenerated neurons due to sepsis decreased as apilarnil dose increased. Apilarnil reduced the elevated levels of proinflammatory cytokines (IL-6, TNF-α, IL-1ß) induced by sepsis. Apilarnil prevented sepsis-related apoptosis in the brain. CONCLUSION: The neuroprotective potential of apilarnil against brain damage in the sepsis model was demonstrated and suggested that it has the potential to contribute to new therapeutic targets against various neurological disorders.

Evaluation of sleep-related respiratory disorders in patients with multiple sclerosis.

Patients with multiple sclerosis (MS) often report fatigue, poor sleep and complaint of sleep disorders. Neurofilament light chain (NF-L) has been identified as a potential biomarker for disease progression in MS patients. In this study, we aimed to evaluate sleep characteristics in MS patients and its relationship with the level of serum NF-L. In the present study carried out as a prospective and cross-sectional study, 32 relapsing-remitting MS (RRMS) patients and 32 control subjects were included. Epworth Sleepiness Scale and Fatigue Severity Scale tests were applied to the groups and the full night polysomnography was performed. Serum samples were obtained for NF-L analysis. Apnea-hypopnea index (AHI), AHI in rapid eye movement sleep (AHI REM), percentage of NonREM stage 1 (N1) and NonREM stage 3 (N3) values were significantly different in RRMS patients (p < 0.05). There was correlation between AHI and Expanded Disability Status Scale indicating a negative directed moderate relationship (r = - 0.343 p = 0.055). Serum NF-L correlations with sleep efficiency and percentage of NonREM stage 2 (N2) were showed mild significant correlation (r = - 0.342 as - 0.535, p < 0.05). We found that sleep disorders are prevalent in RRMS patients and it has a negative effect on the clinical outcome of disease. In clinical practice, the association of these two diseases should be taken into consideration because sleep disturbances increase the disability of MS disease especially presenting with fatigue.

Electrophysiological evaluation of carpal tunnel syndrome female patients after vitamin D replacement.

OBJECTIVE: The effects of vitamin D on the central and peripheral nervous system continue to be investigated today. In the present study, we aimed to evaluate pain and electrophysiologic response in patients with carpal tunnel syndrome (CTS) who have undergone replacement therapy due to vitamin D deficiency. METHODS: Fifty female patients diagnosed with mild and moderate CTS and accompanied by vitamin D deficiency were included in this study. Nerve conduction study (NCS) was performed before and after vitamin D replacement, and the patient's pain was evaluated with Visual Analogue Scale (VAS). RESULTS: When NCS were compared before and after treatment, there was a statistically significant improvement in the median distal sensory onset latency (DSOL) and sensory conduction velocity (CV) and motor distal latencies (DML) values (p=0.001; p<0.001; p=0.001, respectively). At the same time, there was a decrease in the VAS values in patients (p<0.001). When the two groups were compared there was an improvement in DSOL and sensory CV in both groups, but in DML only in moderate CTS group. CONCLUSION: In this study, it was shown that mild and moderate CTS patients had an improvement in pain and electrophysiological parameters after vitamin D replacement. Replacing vitamin D in early stages of CTS may be beneficial.

Anger and impulsiveness in migraine patients with and without aura.

Background and purpose: Migraine is a common primary headache disorder triggered by internal or external stimuli. Impulsitivity and anger are associated with many neurological and psychiatric disorders. The aim of this study was to investigate the anger and impulsivity in migraine patients with or without aura.Methods: A total of 55 patients aged between 18 and 55, who were diagnosed with episodic migraine (31 with aura and 24 without aura) and 40 healthy controls were enrolled in this prospective cross-sectional study.Migraine diagnosis and classification were based on criteria from the International Classification of Headache Disorders, 3rd edition (beta version). Multidimensional Anger Scale and Barratt Impulsivity Scale-11 were administered to the patient and control groups.Results:Migraine patients with aura, migraine patients without aura and control groups were compared, anger symptoms were significantly higher in migraine patients with aura (p < 0.001), but between these groups there was no significant difference in terms of impulsivity (p = 0.711).Conclusions: It was found that anger symptoms were more common in migraine patients with aura compared to migraine patients without aura and control group, but in impulsitivity there was no difference between groups.Further studies in future investigating the relation between migraine with aura and anger may pave the way for different and more specified treatment approach.

Vitamin D, vitamin D binding protein, vitamin D receptor levels and cardiac dysautonomia in patients with multiple sclerosis: a cross-sectional study / Vitamina D, proteína de ligação à vitamina D, níveis de receptores de vitamina D e disautonomia cardíaca em pacientes com esclerose múltipla: um estudo transversal

ABSTRACT Vitamin D is a pleiotropic steroid hormone that modulates the autonomic balance. Its deficiency has been described as an environmental risk factor for multiple sclerosis (MS). The aim of this study was to investigate the serum levels of vitamin D, vitamin D binding protein (VDBP) and vitamin D receptors (VDR) and to evaluate cardiac dysautonomia in MS patients due to bidirectional interaction between vitamin D and the autonomic nervous system. Methods: The current cross-sectional study was conducted on 26 patients with relapsing-remitting MS and on 24 healthy controls. Twenty-four-hour ambulatory blood pressure variability (BPV) was calculated and the participants were evaluated for orthostatic hypotension and supine hypertension. Serum levels of vitamin D, VDBP and VDR were measured. Results: The mean serum vitamin D level was significantly lower in MS patients than in controls (p = 0.044); however there was no significant difference in terms of VDR and VDBP levels between the groups. Supine hypertension and orthostatic hypotension were significant and the 24-hour systolic BPV was significantly decreased in patients with MS (p < 0.05) compared to controls. No correlation was found between vitamin D, VDBP and VDR with supine hypertension, orthostatic hypotension and systolic BPV values (p > 0.05). Also, there was a negative correlation between VDBP and the EDSS (p = 0.039, r = −0.406). Conclusion: There was no correlation between orthostatic hypotension, supine hypertension and systolic BPV values and serum vitamin D, VDBP and VDR in MS patients. Future prospective studies with large number of patients may help us to better understand the relationship between vitamin D and the autonomic nervous system.

RESUMO A vitamina D é um hormônio esteroide pleiotrópico que modula o equilíbrio autonômico. Sua deficiência tem sido descrita como fator de risco ambiental para esclerose múltipla (EM). O objetivo deste estudo foi investigar os níveis séricos de vitamina D, proteína de ligação à vitamina D (VDBP) e receptor de vitamina D (VDR) e avaliar a disautonomia cardíaca em pacientes com EM devida à interação bidirecional entre vitamina D e sistema nervoso autônomo. Métodos: O presente estudo transversal foi realizado em 26 pacientes com EM remitente-recorrente e em 24 controles saudáveis. A variabilidade da pressão arterial ambulatorial (BPV) por 24 horas foi calculada e os participantes foram avaliados quanto à hipotensão ortostática e hipertensão supina. Os níveis séricos de vitamina D, VDBP e VDR foram medidos. Resultados: O nível sérico médio de vitamina D foi significativamente menor nos pacientes com EM do que nos controles (p = 0,044); no entanto, não houve diferença significativa em termos de níveis de VDR e VDBP entre os grupos. Hipertensão supina e hipotensão ortostática foram significativas e a BPV sistólica de 24 horas diminuiu significativamente em pacientes com EM (p < 0,05) em comparação aos controles. Não foi encontrada correlação entre vitamina D, VDBP e VDR com hipertensão supina, hipotensão ortostática e BPV sistólica (p > 0,05). Também houve correlação negativa entre VDBP e EDSS (p = 0,039, r = −0,406). Conclusão: Não houve correlação entre hipotensão ortostática, hipertensão supina e valores de BPV sistólica e vitamina D sérica, VDBP e VDR em pacientes com EM. Futuros estudos prospectivos com grande número de pacientes podem nos ajudar a entender melhor a relação entre vitamina D e sistema nervoso autônomo.