Clinical, Demographic, and Radiological Characteristics of Patients Demonstrating Antibodies Against Myelin Oligodendrocyte Glycoprotein.

Background: Optic neuritis, myelitis, and neuromyelitis optica spectrum disorder (NMOSD) have been associated with antibodies against myelin oligodendrocyte glycoprotein-immunoglobulin G (anti-MOG-IgG). Furthermore, patients with radiological and demographic features atypical for multiple sclerosis (MS) with optic neuritis and myelitis also demonstrate antibodies against aquaporin-4 and anti-MOG-IgG. However, data on the diagnosis, treatment, follow-up, and prognosis in patients with anti-MOG-IgG are limited. Aims: To evaluate the clinical, radiological, and demographic characteristics of patients with anti-MOG-IgG. Study Design: Multicenter, retrospective, observational study. Methods: Patients with blood samples demonstrating anti-MOG-IgG that had been evaluated at the Neuroimmunology laboratory at Ondokuz Mayis University's Faculty of Medicine were included in the study. Results: Of the 104 patients with anti-MOG-IgG, 56.7% were women and 43.3% were men. Approximately 2.4% of the patients were diagnosed with MS, 15.8% with acute disseminated encephalomyelitis (ADEM), 39.4% with NMOSD, 31.3% with isolated optic neuritis, and 11.1% with isolated myelitis. Approximately 53.1% of patients with spinal involvement at clinical onset demonstrated a clinical course of NMOSD. Thereafter, 8.8% of these patients demonstrated a clinical course similar to MS and ADEM, and 28.1% demonstrated a clinical course of isolated myelitis. The response to acute attack treatment was lower and the disability was higher in patients aged > 40 years than patients aged < 40 years at clinical onset. Oligoclonal band was detected in 15.5% of the patients. Conclusion: For patients with NMOSD and without anti-NMO antibodies, the diagnosis is supported by the presence of anti-MOG-IgG. Furthermore, advanced age at clinical onset, Expanded Disability Status Scale (EDSS) score at clinical onset, spinal cord involvement, and number of attacks may be negative prognostic factors in patients with anti-MOG-IgG.

Combination among VEP, OCT and TCD data in patients with relapsing-remitting multiple sclerosis during attack-free period.

AIMS: Multiple sclerosis (MS) is characterized by inflammation, demyelination, glial cell pathology and axonal injury in the central nervous system, and also progressive axonal loss of the optic nerve in cases with optic neuritis (ON). The previous transcranial Doppler (TCD) investigations suggest cortical hyperreactivity in patients with relapsing-remitting Multiple sclerosis (RRMS). We investigated the effect of ON involvement on visual reactivity. MATERIAL AND METHODS: One hundred thirty patients with RRMS during attack-free period and 12 healthy subjects were enrolled to the study. Visual evoked potential (VEP), optic coherence tomography (OCT) and TCD examinations of all subjects were performed. RESULTS: Cerebrovascular reactivity measured with breath holding (BH) test was found to be normal. VEP amplitude, visual reactivity and peripapillary retinal nerve fibre layer (pRNFL) measurements were found to be low in patients with ON involvement, whereas VEP latencies were long. Visual reactivity was negatively correlated with VEP amplitude and RFNL measurements, and positively correlated with VEP latency. CONCLUSIONS: The present study supports that cerebrovascular reactivity is preserved in patients with RRMS except for attacks, and neurovascular reactivity is increased in patients without ON involvement.

Risk factors for multiple recurrent ischemic strokes.

BACKGROUND: Cardiovascular diseases, hypertension, diabetes mellitus, dyslipidemia, and atrial fibrillation are the most common modifiable risk factors for recurrent ischemic stroke. In this study, we aimed to find the risk factors associated with more than two recurrent ischemic strokes after the first-ever stroke. METHODS: We collected the ischemic stroke patients in our stroke registry data bank, and the eligible patients were followed for recurrent ischemic stroke after 2008. Our study consisted of 927 patients who were followed up for 9 years after the first-ever stroke. RESULTS: We found that 185 (20%) patients had a recurrent ischemic stroke, and another 32 (3.5%) patients had more than one recurrence after the first-ever ischemic stroke. The mean time for the first stroke recurrence was 1 year, and the mean time for the multiple stroke recurrences was 3 years. Significant risk factors for multiple recurrences were congestive heart disease (P < 0.015) and diabetes mellitus (P < 0.006). CONCLUSIONS: We concluded that even with the appropriate treatments, patients with congestive heart disease and diabetes mellitus have a higher rate of multiple recurrences for ischemic stroke after the first-ever ischemic stroke, indicating that more attention should be paid to this issue.

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.

Migraine and cardiovascular risk factors: A clinic-based study.

OBJECTIVE: The relation between migraine and vascular risk factors is an unclear issue. Furthermore, the reasons for chronification are still unknown. Probably, the age-related risk and other factors leading to migraine progression will also change in the future. Under these questions, we aimed to investigate whether or not there is a specific association with vascular risk factors between several age groups and subtypes of migraine and also in their families. METHODS: A dataset (the Turkish Headache Database) from four tertiary headache centres in Turkey was used. This database included headache-defining features according to ICHD criteria based on face-to-face interviews and examinations by a Neurologist. Vascular risk factors of migraine without aura (MwoA), migraine with aura (MwA) and chronic migraine (CM) were compared between three age groups (under 30 years, 30-50 years and over 50 years) and in first-degree relatives of the patients. Our study included 2712 patients comprising 1868 (68.9 %), 246 (9.1 %) and 598 (22.1 %) subjects with MwoA, MwA and CH, respectively. RESULTS: This study showed that both the patients and the first-degree relatives were more frequently associated with vascular risk factors in CM than episodic MwA and MwoA. MwoA showed a weaker association with vascular risk factors than MwA and CM. CONCLUSION: Chronic migraine was associated with vascular risk factors at all ages and first-degree relatives as well. Vascular risk factors should be investigated with greater focus on chronic migraine.

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.

Cerebral Venous Sinus Thrombosis in Women: Subgroup Analysis of the VENOST Study.

BACKGROUND: Early diagnosis of cerebral venous sinus thrombosis (CVST) associated with reproductive health-related risk factors (RHRF) including pregnancy, puerperium, and oral contraceptive (OC) use can prevent severe neurological sequelae; thus, the symptoms must be documented in detail for each group. METHODS: Out of 1144 patients with CVST, a total of 777 women were enrolled from a multicenter for the study of cerebral venous sinus thrombosis (VENOST). Demographic, biochemical, clinical, and radiological aspects were compared for 324 cases with RHRF and 453 cases without RHRF. RESULTS: The mean age of the RHRF (-) group (43.2 ± 13 years) was significantly higher than of the RHRF (+) group (34 ± 9 years). A previous history of deep venous thrombosis (3%), isolated cavernous sinus involvement (1%), cranial neuropathy (13%), comorbid malignancy (7%), and its disability scores after 12 months (9%) were significantly higher in the RHRF (-) group. The RHRF (+) group consisted of 44% cases of puerperium, 33% cases of OC users and 23% of pregnant women. The mean age was found to be higher in OC users (38 ± 9 years). A previous history of deep venous thrombosis was slightly higher in the pregnancy subgroup (4%). Epileptic seizures were more common in the puerperium group (44%). CONCLUSION: The results of our study indicate that the risk of CSVT increases parallel to age, OC use, and puerperium period. In addition, when considering the frequency of findings and symptoms, epileptic seizures in the puerperium subgroup of the RHRF (+) group and malignancies in the RHRF (-) group may accompany the CSVT. In daily practice, predicting these risks for the CSVT and early recognition of the symptoms will provide significant benefits to patients.

A Rare Clinical Antity; Pure Gerstmann Syndrome.

Gerstmann syndrome is defined as a tetrad including agraphia, acalculia, finger agnosia, and right-left disorientation. In the case studies presented in the literature, it has been reported that Gerstmann syndrome usually appears as an incomplete tetrad of symptoms or accompanied by cognitive deficits including aphasia, alexia, apraxia and some perceptual disorders. Here, we present of the patient with left angular and supramarginal gyrus infarction affecting the parietal lobe. In addition to the symptoms mentioned above, the patient had alexia and anomic aphasia as well. We discussed the clinic appearance and reviewed the current literature.

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.

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.

Behçet's disease as a causative factor of cerebral venous sinus thrombosis: subgroup analysis of data from the VENOST study.

OBJECTIVE: This study was performed to determine the rate of cerebral venous sinus thrombosis (CVST) among cases of Behçet's disease (BD) included in a multicentre study of cerebral venous sinus thrombosis (VENOST). METHODS: VENOST was a retrospective and prospective national multicentre observational study that included 1144 patients with CVST. The patients were classified according to aetiologic factors, time of CVST symptom onset, sinus involvement, treatment approach and prognosis. RESULTS: BD was shown to be a causative factor of CVST in 108 (9.4%) of 1144 patients. The mean age of patients in the BD group was 35.27 years and 68.5% were men, whereas in the non-BD CVST group, the mean age was 40.57 years and 28.3% were men (P < 0.001). Among the aetiologic factors for patients aged 18-36 years, BD was predominant for men, and puerperium was predominant for women. The onset of symptoms in the BD group was consistent with the subacute form. The transverse sinuses were the most common sites of thrombosis, followed by the superior sagittal sinuses. The most common symptom was headache (96.2%), followed by visual field defects (38%). CONCLUSIONS: BD was found in 9.4% of patients in our VENOST series. Patients with BD were younger and showed a male predominance. The functional outcome of CVST in patients with BD was good; only 12% of patients presenting with cranial nerve involvement and altered consciousness at the beginning had a poor outcome (modified Rankin Score ⩾2).

Neurovascular coupling in patients with relapsing-remitting multiple sclerosis.

OBJECTIVES: Also to the inflammatory demyelinating lesions and degenerative process, altered cerebrovascular reactivity or neurovascular coupling (NVC) might be considered as playing another role in the pathogenesis of multiple sclerosis. The objective of this study is to assess the NVC of patients with relapsing-remitting multiple sclerosis (RRMS) during the acute exacerbation period. PATIENTS AND METHODS: Four hundred fifty-eight patients with RRMS and 160 healthy subjects were screened for this study during the last 14 years. We performed transtemporal transcranial Doppler recordings from the P2-segments of both posterior cerebral arteries simultaneously during simple or complex visual stimulation. The NVC was defined as a relative increase of the blood flow velocities as a percentage change of the baseline values during visual stimulation. RESULTS: The NVC to simple visual stimulation was significantly higher in the patients on both sides (37.2±13.5% and 36.0±14.8%; right and left side, respectively) from those of the controls (30.9±9.9% and 30.0±8.8%; right and left side, respectively) (p<0.01). Similarly, the NVC to complex visual stimulation was significantly higher in the patients (43.3±14.1% and 41.7±13.5%; right and left side, respectively) from those of the controls (38.6±14.2% and 37.6±14.1%; right and left side, respectively) (p<0.05). CONCLUSION: Our results suggest that patients with RRMS during exacerbation period have more reactive neurovascular units in the occipital cortex.

Predictors for being offered epilepsy surgery: 5-year experience of a tertiary referral centre.

OBJECTIVES: To define factors that predict whether patients with pharmacoresistant focal epilepsy are offered epilepsy surgery (including invasive EEG) and the main reasons for not proceeding with these after non-invasive presurgical evaluation. METHODS: We retrospectively analysed data from 612 consecutive patients with focal epilepsy admitted to a video-EEG Telemetry Unit for presurgical evaluation, and used a multivariate logistic regression model to assess the predictive value of factors for being offered potentially curative surgery. RESULTS: In the multivariate analysis, bilateral lesions on MRI (OR: 0.10; 95% CI 0.03 to 0.24), no lesion (OR: 0.33; 95% CI 0.22 to 0.49) or extratemporal lobe epilepsy (OR: 0.30; 95% CI 0.20 to 0.45) were the only factors that significantly reduced the probability of being offered surgery. 32% of patients who were offered epilepsy surgery decided against proceeding. CONCLUSIONS: There was a low chance (<10%) of being offered surgery if there were bilateral lesions on MRI and extratemporal lobe epilepsy. Patients should be given advice on the risk/benefit ratio and of realistic outcomes of epilepsy surgery; this may help reduce the number of patients who refuse surgery after comprehensive workup.

Gender differences in older adults with chronic migraine in Turkey.

AIM: Chronic migraine is a growing and disabling subtype of migraine with different risk factors and clinical features, even in older adults. We sought to define and differentiate clinical features of chronic migraine in older adults. We also aimed to compare major clinical features of chronic migraine in older adults with those in younger people of both sexes. METHODS: We used electronic dataset (Turkish Headache Database) from 13 tertiary headache centers in Turkey. Electronic dataset included detailed headache-defining features according to ICHD-II criteria based on face-to-face interviews and examination by a headache specialist. Using statistical methods, clinical variables of chronic migraine in older adults were compared with those of younger adults. We included 915 patients with chronic migraine (mean age 43.80 ± 13.95 years); 83.3% were females. In total, 301 patients (32.9%) with chronic migraine aged >50 years were compared with 614 patients aged <50 years. RESULTS: There was no significant change in men with increasing age. However, duration of headache history, severity of attacks, previous histories of motion sickness and positive family history of headaches were significantly different in women with increasing age. Further sex-related differences have been shown in parameters such as attack duration, quality and associated nausea. CONCLUSION: Chronic migraine is an infrequent type of migraine and shows age-related changes in some phenotypic characteristics, such as severity of attacks, especially in women aged older than 50 years. Furthermore, positive family history of headaches and history of motion sickness increase the likelihood of developing chronic migraine in older women, indicating involvement of some gender-related, but as-yet unknown, genetic factors.

Relationship between pulsatility index and clinical course of acute ischemic stroke after thrombolytic treatment.

Background. The relationship between the arterial recanalization after intravenous recombinant tissue plasminogen activator (rtPA) and outcomes is still uncertain. The aim of our study was to evaluate whether there is an association between the pulsatility indexes (PI) of the middle cerebral artery (MCA) measured by transcranial Doppler (TCD) after iv rtPA treatment and short- and long-term outcomes in ischemic stroke patients. Methods. Forty-eight patients with acute ischemia in the MCA territory who achieved complete recanalization after the administration of intravenous thrombolytic treatment were included in the study. The TCD was applied to patients after the iv rtPA treatment. Clinical and functional outcomes were assessed by National Institutes of Health Stroke Scale (NIHSS) scores and modified Rankin Scores (mRS), respectively. Results. Significant positive correlations were found between the PI value and NIHSS score at 24 hours, NIHSS score at 3 months, and mRS at 3 months (P < 0.005 for all). The cut-off value for PI in predicting a favorable prognosis and a good prognosis might be less than or equal to 1.1 and less than or equal to 1.4, respectively. Conclusions. PI may play a role in predicting the functional and clinical outcome after thrombolytic therapy in acute ischemic stroke patients.