COMPLETE ATRIOVENTRICULAR BLOCK AND ASYSTOLE DURING EPILEPTIC SEIZURE: A CASE REPORT.

Cardiac arrhythmias during or after epileptic seizures are one of the possible pathomechanisms of sudden unexpected death in epilepsy. These arrhythmogenic epilepsies are most commonly associated with sinus tachycardia, but atrioventricular block and asystole can also be seen. Although a rare occurrence, these arrhythmias can lead to significant morbidity and mortality, but also can be potentially preventable with pacemaker implantation. Here we describe a patient with recurrent epileptic seizures, diagnosed with ictal third-degree atrioventricular block and asystole during seizure, which required a permanent cardiac pacemaker.

SUCCESSFUL TREATMENT OF ACUTE DISSEMINATED ENCEPHALOMYELITIS (ADEM) BY PROMPT USAGE OF IMMUNOGLOBULINS - CASE REPORT AND REVIEW OF THE LITERATURE.

Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disease of the central nervous system that usually affects children and young adults. It most commonly has a monophasic course, although relapses are reported. Clinical presentation of the disease includes encephalopathy and multifocal neurological deficits. There are no established reliable criteria for diagnosis of ADEM and sometimes it is difficult to distinguish it from first attack of multiple sclerosis, especially in adults. The diagnosis of ADEM is based on clinical, radiological and laboratory findings. In the treatment of ADEM, high doses of corticosteroids, plasmapheresis and immunoglobulins are used. We report a case of a young adult female patient with ADEM who fully recovered after prompt administration of high dose methylprednisolone and immunoglobulins.

Quality of life assessment in migraine and relapsing remitting multiple sclerosis: self-perceived health is similar.

OBJECTIVE: The aim of this study was to compare self-perceived health between migraine and early stages of relapsing-remitting multiple sclerosis (RRMS) and to explore whether and how accurate those health domains predict overall quality of life. METHODS: Ninety patients aged 18-55 years were enrolled in this cross-sectional study. Thirty follow-up outpatients were recruited with migraine (with or without aura), 30 patients with RRMS, and 30 healthy subjects. They were asked to complete the Health status questionnaire (SF-36) and Personal Wellbeing Index (PWI). RESULTS: Patients with RRMS and migraine had significantly worse self-reported health regarding role limitation due to physical problems and general health than the healthy control group. Additionally, migraine patients had more bodily pain, while RRMS patients expressed more difficulties regarding physical functioning. Differences between migraine and RRMS patients were not significant. Hierarchical regression analysis revealed that role limitation due to physical problems, mental health, and general health represents significant predictors of overall quality of life. CONCLUSIONS: Migraine may affect quality of life similarly to early stages of RRMS. Bio-psycho-socio-medical understanding of the two diseases and their impact on patients QoL should be reconsidered.

Quality of life and health of patients in early stages of Multiple sclerosis.

BACKGROUND: Multiple sclerosis is a chronic neurologic condition with a variety of symptoms which have a great impact on quality of life even in the early stages. The aim of this study was to investigate, and to compare overall subjective quality of life with self-perceived health in patients with early stages of MS. SUBJECTS AND METHODS: Thirty patients with MS (22 women, 8 men; mean age 37.3±9.7years; relapsing-remitting MS; EDSS<2.5; all on immunomodulatory therapy: IFN, GA) were enrolled in the study. The QOL was assessed using the Personal well-being index (PWI) and health was measured by the Short Form 36-Item Health Survey (SF-36) questionnaire. RESULTS: Results indicate that MS patients in early stage experience similar health and quality of life, comparing to the general adult population. Analysis of self-reported change in health by categories showed that 50% patients access their health about the same as a year before, 9 rate their health as worse as one year before and 5 rate their health even better. Correlation analysis revealed that SF-36 domain Mental health correlates with most PWI domains. CONCLUSION: This study demonstrates that MS patients in early stage experience similar quality of life as general adult population. Also, it was revealed that health domain Mental health is correlated with various quality of life domains, suggesting that mental health is of great significance for subjective quality of life perception. However, it is important to emphasize the distinction between the health and quality of life, due to the fact that one can perceive his/hers own health as impaired, but at the same time can have satisfactory quality of life.

Regression of Asymmetric Upper Extremity Tremor After Liver Transplantation in a Patient With Hepatic Encephalopathy: Case Report.

Hepatic encephalopathy (HE) is a brain dysfunction caused by liver failure. Clinically, it can manifests as a wide spectrum of neurological or psychiatric abnormalities. This report presents a case of a 43-year-old male with HE and asymmetric kinetic, postural and resting tremor of upper extremities. Magnetic resonance imaging (MRI) of the brain showed signal abnormalities in numerous areas. The patient underwent liver transplantation and six months after normalization of liver function, tremor as well as brain MRI abnormalities almost completely regressed. This case re-port presents the asymmetric and reversible kinetic, postural and resting tremor of upper extremities as part of the spectrum of neurological abnormalities in HE.

A Case of Kleine-Levin Syndrome: Diagnostic and Therapeutic Challenge.

Kleine-Levin syndrome (KLS) is a rare sleep disorder mainly affecting teenage boys in which the main features are intermittent hypersomnolence, behavioral and cognitive disturbances, hyperphagia, and in some cases hyper sexuality. Etiology is unknown, and there is no specific clinical or imaging test for this syndrome even though the illness has well-defined clinical features. Also, there is no effective treatment for KLS. KLS is self-limited, so the prognosis for these patients is not so bad. This study presents our case report and comprehensive workout that led to diagnosis which is primarily clinical. Our patient is a 20-year-old man referred to our clinic because of sleeping problems. At the age of 14, he presented with complaints of the excessive duration of sleep, increased appetite, excessive daytime sleepiness, loss of interest in social activities during attendance of high school and hallucinations. The excessive diagnostic procedure does not find pathological. Kleine-Levin syndrome (KLS) is a rare sleep disorder of unknown etiology which diagnosis is clinical and diagnostic workup is mainly to exclude other similar conditions. There is no specific therapy, but the disease is self-limited and with good prognosis.

Chorea Caused by Unruptured Arteriovenous Malformation: Case Report and Review of Literature.

Chorea is a movement disorder that can be caused by a large range of degenerative, vascular, metabolic and toxic disorders in basal ganglia. Arteriovenous malformations are rare vascular malformations the clinical presentation of which depends on the malformation characteristics and localization. They are most commonly presented with intracranial hemorrhage, while focal neurological deficit is the rarest presentation. A case is reported of a 64-year-old female patient presented with hemichorea. Magnetic resonance imaging and digital subtraction angiography revealed the presence of arteriovenous malformation in the right temporal lobe.

Warfarin-Induced Skin Necrosis in Patients With Low Protein C Levels.

Warfarin-induced skin necrosis (WISN) is a rare complication of anticoagulant therapy associated with a high incidence of  morbidity and mortality requiring immediate drug cessation. At particular risk are those with various thrombophilic abnormalities, especially when warfarinisation is undertaken rapidly with large loading doses of warfarin. Cutaneous findings include petechiae that progress to ecchymosis and hemorrhagic bullae. With the increasing number of patients anticoagulated as out-patients for thromboprophylaxis, we are concerned that the incidence of skin necrosis may increase. We present a case of WISN with low protein C level. He was a 50-year-old male who came to our department because of acute infarction in irrigation area of the superior cerebellar artery. He had intermittent atrial fibrillation and was started on anticoagulant therapy.  After few day of therapy, he developed skin necrosis, and his level of protein C was low. Warfarin-induced skin necrosis is a rare but serious complication that can be prevented by routine screening for protein C, protein S or antithrombin deficiencies or for the presence of antiphospholipid antibodies before beginning warfarin therapy.

Categorization of Ischemic Stroke Patients Compared with National Institutes of Health Stroke Scale.

INTRODUCTION: Scientific guidelines recommend the National Institutes of Health Stroke Scale (NIHSS) for ischemic stroke (IS) assessment. In Clinical Department of Neurology of Split University Hospital Center nurses use the categorization of patients (COP) according to individual needs for health care. AIM: The aim of this study was to demonstrate that there is a positive correlation between the COP and the NIHSS in IS patients. METHODS: We analyzed NIHSS scores and COP findings in 325 participants (median age 77 years, min-max: 37-95 years) with acute ISs. RESULTS: There is a statistically significant correlation between the NIHSS score at admission and COP at admission (ρ=0.717; P<0.001). There is a statistically significant correlation between the NIHSS score at discharge and COP at discharge (ρ=0.762; P<0.001). Median of NIHSS scores at admission is higher in females than in males for 2 (Z=4.45, P<0.001) and at discharge is higher for 2 (Z = 4.1, P<0.001). Median of COP at admission is higher in females than in males for 1 (Z=4.7, P<0.001) and at discharge is the same (Z=4.7, P<0.001). CONCLUSION: There is a significant association of NIHSS scores and COP in IS patients. This association exists at admission and at discharge from the hospital.

Foramen Magnum Meningioma: a Case Report and Review of Literature.

INTRODUCTION: Meningiomas are slow-growing benign tumors that arise at any location where arachnoid cells reside. Although meningiomas account for a sizable proportion of all primary intracranial neoplasms (14.3-19%), only 1.8 to 3.2% arise at the foramen magnum. Their indolent development at the craniocervical junction makes clinical diagnosis complex and often leads to a long interval between onset of symptoms and diagnosis. CASE REPORT: We report a case of a 79-year-old male patient, presented with ataxia and sense of threatening fainting during verticalization. Magnetic resonance imaging revealed the presence of meningioma in the right side of craniospinal junction.

Spontaneous Splenic Rupture Following Intravenous Thrombolysis with Alteplase Applied as Stroke Therapy - Case Report and Review of Literature.

INTRODUCTION: Stroke is a medical emergency in neurology, and is one of the leading causes of death nowadays. At a recent time, a therapeutic method used in adequate conditions is thrombolysis, a treatment of an emerging clot in the brain vascular system by alteplase. The application of alteplase also has a high risk of life threatening conditions. CASE REPORT: This is a brief report of a case with thrombolysis complication which manifested as a spleen rupture.

MULTIPLE INTRACRANIAL SCHWANNOMAS: CASE REPORT.

Schwannomas are benign encapsulated tumors arising from the sheaths of peripheral nerves. They present as slowly enlarging solitary lumps, which may cause neurological defects. Multiple schwannomas in non-neurofi bromatosis type 2 patients are extremely rare. We report a case of a 60-year-old female patient, without any family history of neurofibromatosis or schwannomatosis, presented with trigeminal neuralgia and progressive facial nerve palsy. Magnetic resonance imaging revealed the presence of acoustic schwannoma involving facial nerve and trigeminal schwannoma of the cisternal part of the nerve involving gasserian ganglion (Meckel's cave). After gamma knife radiosurgery, trigeminal neuralgia was relieved completely with improvement of facial nerve palsy.

P300 Wave Changes in Patients with Parkinson's Disease.

INTRODUCTION: Parkinson's disease (PD) is chronic progressive neurodegenerative disease. In patients with Parkinson's disease among other symptoms occur cognitive dysfunctions, which can be shown by P300 wave changes. AIM: The aim of this study was to demonstrate that patients with Parkinson's disease have reduced amplitude and prolonged latency, longer than 300 ± 10 ms. MATERIAL AND METHODS: The study included 21 patient suffering from Parkinson's disease. After reviewing the medical records and analyzes the inclusion and exclusion criteria, patients were subjected to the same procedure examining auditory cognitive potentials (P300 wave) and the results were analyzed and compared to reference value for healthy population. RESULTS: We have shown that patients with Parkinson's disease have prolonged P300 targeted and frequent stimulus latency compared to reference value for healthy population. From 21 patient 18 had a pathological P300 target stimulus amplitude, and even 20 patients had pathological P300 frequent stimulus amplitude. CONCLUSION: People with Parkinson's disease have altered P300 which indicates the presence of cognitive dysfunction in these patients.

Morphological manifestations of the Dandy-Walker syndrom in female members of a family.

The Dandy-Walker syndrome (DWS) is a hereditary disorder, appearing somewhat more frequently in women. The most important characteristics of the DWS are the lack of the cerebellar vermis, varying from a partial lack to a complete agenesis, and enlargement of the cerebrospinal spaces, especially in the fourth ventricle. The above mentioned morphological changes clinically manifest in ataxia, increased intracranial pressure and hydrocephalus. Here is presented a family with DWS, where the disease is contracted only by female members, in two generations, whereas no signs of DWS have been noticed in male family members. DWS is clinically manifested from early childhood to middle age, with the morphological changes varying from hypoplastic cerebellar vermis to widening of the brain ventricles and hydrocephalus and arachnoid cyst in the occipital part.

Transcranial sonography and the pocket smell test in the differential diagnosis between parkinson's disease and essential tremor.

The aim of this study was to determine the specificity and sensitivity of transcranial sonography (TCS) and the Pocket Smell Test (PST) in differing Parkinson's disease from essential tremor. The results were compared with the dopamin transporter scan (DaTSCAN) findings. Based on the DaTSCAN finding we formed a group of patients with essential tremor (51 patients) and a group with the Parkinson's disease (59 patients). The control group consisted of 26 healthy one. To evaluate the olfactory dysfunction the PST was used, whereas by TCS the substantia nigra hyperechogenicity was marked. The sensitivity and specificity of each diagnostic method was statistically calculated. In confirming Parkinson's disease the specificity of TCS was 88.2 % and the sensitivity 94.9 %. The specificity of PST was 80.4 % whereas the sensitivity was 74.6 %. TCS and PST should be performed to evaluate which patients need to be examined by DaTSCAN.

The Event-related Potential P300 in Patients with Migraine.

OBJECTIVE: Recording of event-related potentials by using oddball paradigm of auditory P300 has yielded conflicting results in migraine. The aim of this study was to demonstrate that migraine patients have reduced P300 amplitude and prolonged P300 latency, suggesting alterations of the cognitive-evaluative component. METHODS: We recruited 29 migraine patients (24 females; median age 40 years) and 29 healthy age- and gender-matched participants. Participants were subjected to the same testing procedures of auditory P300 by discrimination the target auditory stimulus from the frequent stimulus, and analyzing P300 target/frequent stimulus amplitudes, and P300 target/frequent stimulus latencies. RESULTS: Patients with migraine don't have prolonged P300 target stimulus latency, but have a longer P300 frequent stimulus latency for 17.5ms. Out of 29 participants with migraine 8 had pathological P300 target stimulus amplitude, and 19 had pathological P300 frequent stimulus amplitude. CONCLUSION: People with migraine have altered the P300 which indicates the presence of cognitive dysfunction in these patients and importance of early diagnosis and intervention to preventing any deterioration in cognitive functions.

Functional Changes of P300 Values among Young Football Players as a Measure of a Cognitive Function.

Numerous studies have shown that evaluation of evoked potentials (EP) is an excellent estimation tool for a cognitive function. During daily practices footballers are exposed to headers that can leave mild head traumas. In this study, young footballers were examined, while the control group included their coevals who don't practice contact sports. Results of the study have shown that footballers have longer latency value of the P300 wave when target stimulus is presented on N1, N2 and P3, but not on P2. Also, they have longer latency values when non-target stimulus is presented. Amplitude values of target stimulus are not different, but footballers have lower amplitudes of non-target stimulus. This study suggests that EP evaluation method can be used to detect first and mild changes of the brain function.

How severe is depression in low back pain patients?

The aim of the present study was to determine the prevalence of depression among low back pain (LBP) patients and to investigate the sociodemographic characteristics of pa- tients with LBP and relationship between depression and pain intensity in LBP patients. The study was conducted on 99 patients treated at Clinical Department of Neurology, Split University Hospital Center. There were 36 (36%) men and 63 (64%) women. Some degree of depression was present in 73 (74%) study patients, including all patients with severe LBP. In the group of patients with severe LBP, the rate of moderate, severe and very severe depression was 1.36-fold that recorded in the gro- up of patients with moderate LBP and 2.58-fold that found in the group of patients with mild LBP (χ2 = 16.2; p = 0.003). The most common symptoms were general physical symptoms 70 (71%), psychic anxiety 69 (70%) and depressed mood 66 (67%). It is concluded that depression was more severe in LBP patients with severe disease compared to patients with mild or moderate LBP.

MTHFR C677T and prothrombin G20210A mutations in a woman from Dalmatia with silent brain infarction. .

A 55-year-old, previously healthy woman, presented with frequent headaches. She had no neurological disturbances, but had a positive family history; her father died from stroke. Magnetic resonance imaging showed brain infarction; therefore detailed diagnostic evaluation of thrombophilia markers and genetic testing were performed. The patient was found to be homozy- gous for the C677T mutation of the methylenetetrahydrofolate reductase gene and heterozygous for the mutation of the prothrombin G20210A gene. No other cause of cerebral infarction was found in the patient.