Erratum: Evaluation of OnabotulinumtoxinA Treatment in Patients with Concomitant Chronic Migraine and Temporomandibular Disorders.

[This corrects the article on p. 330 in vol. 55, PMID: 30622389.].

Evaluation of CSF flow metrics in patients with communicating hydrocephalus and idiopathic intracranial hypertension.

PURPOSE: To search for CSF dynamics of idiopathic intracranial hypertension (IIH) and communicating hydrocephalus and any correlation between MRI findings, CSF metrics and CSF opening pressure in IIH. MATERIALS AND METHODS: Healthy subjects (30) and subjects with IIH (29) and high-pressure communicating hydrocephalus (43) were enrolled. Nonparametric Kruskal-Wallis test (p = 0.05) was used to compare three groups, Mann-Whitney U test with Bonferroni correction to compare two groups (p = 0.016). Correlation of MRI findings of IIH with CSF metrics and CSF opening pressure was analyzed by Spearman's Rank correlation coefficient (p = 0.05). RESULTS: In IIH, no correlation between MRI findings and aqueductal stroke volume (ASV) but statistically significantly CSF opening pressure in the presence of transverse sinus compression was noted. Comparing with healthy subjects, ASV was nonsignificantly lower and standardized diastolic and sum and difference of systolic and diastolic flow durations were statistically significantly lower. Comparing with hydrocephalus, the width of prepontine cistern (PPC)/the width of aqueductus sylvii (AS) was significantly higher and other CSF metrics with standardized systolic and sum of systolic and diastolic flow durations were significantly lower. In hydrocephalus, ASV and peak velocities were significantly higher. Compared with normal group, PPC/AS and reverse/forward flow duration were significantly lower and other CSF metrics were significantly higher. CONCLUSION: In hydrocephalus, significant increase in ASV and peak velocities were noted. In IIH, CSF opening pressure was statistically significantly high in the presence of transverse sinus compression and standardized diastolic flow durations were statistically significantly short that are probably effects of increased impedance of CSF flow against increased intracranial pressure and unchanged or even decreased intraventricular CSF volume.

Patterns of Altered Corneal Sensation in Patients With Chronic Migraine.

OBJECTIVE: Migraine is a central sensitization disease characterized by recurrent unilateral headache. The aim of this study was to evaluate corneal sensitivity and associated findings in patients with migraine. METHODS: In this study, we included 58 patients with migraine (52 female and 6 male, mean age: 32.98±8.51 years) and 30 healthy control subjects (27 females and 3 males, mean age: 35.29±8.00 years). Only patients who did not have any eye disease were included in this study. Corneal sensation was evaluated with Cochet-Bonnet esthesiometer in five different regions of the cornea. RESULTS: There was no significant difference between the groups for age, sex, and visual acuity. Increased mean sensitivity of the nasal cornea in the patients with migraine was found (55.0 vs. 53.75 mm, P=0.020). There was no significant difference in mean sensitivity for central (57.5 vs. 55 mm, P=0.163), temporal (57.5 vs. 55 mm, P=0.066), superior (52.5 vs. 52.5 mm, P=0.551), and inferior cornea (48.75 vs. 47.5 mm, P=0.818), or mean overall sensation (54.0 vs. 52.75, P=0.14), although there was a trend toward increased sensitivity in the patients with migraine. Among the subgroup of patients with unilateral migraine, mean overall sensation (54.0 vs. 53.0 mm, P=0.049) and temporal sensation (57.5 vs. 55.0 mm, P=0.043) were increased on the affected side. CONCLUSION: In this study, we have demonstrated that patients with migraine have increased corneal sensation, especially in the cornea of the affected side. This finding supports the idea that corneal sensation is altered in patients with migraine.

Pontine bleeding following drainage of subdural hematoma in craniospinal hypotension.

Craniospinal hypotension is the syndrome of orthostatic headache associated with low cerebrospinal fluid pressure. Imaging findings are usually explained by Monro-Kellie hypothesis stating that the craniospinal compartment is incompressible and any increase in volume of one of the craniospinal constituents (blood, cerebrospinal fluid, and parenchyma) must be compensated by a decrease in volume of another constituent or vice versa. We report a case of craniospinal hypotension in whom drainage of subdural hematoma upon clinical impairments resulted in pontine hemorrhage, supporting Monro-Kellie hypothesis.

Evaluation of OnabotulinumtoxinA Treatment in Patients with Concomitant Chronic Migraine and Temporomandibular Disorders.

Introduction: Migraine and temporomandibular disorders (TMD) are both common diseases and TMD are reported as a risk factor in migraine progression. OnabotulinumtoxinA is used in the treatment of chronic migraine (CM), and also has a potential role in TMD treatment. In this study, it is aimed to compare the efficacy of onabotulinumtoxinA treatment in CM patients with and without TMD. Methods: In this retrospective study, 30 CM patients (age range: 18-65 years), satisfying the inclusion and follow-up criteria in their medical records were investigated. The PREEMPT injection protocol was taken as reference and onabotulinumtoxinA 155-195 U with fixed-dose has been administered into 31 specific sites within the head/neck muscles in included subjects. Two cycles of treatment were assessed in all patients at the baseline and 12 weeks later. The headache diaries, which were completed routinely one month before, and during 6 months follow-up after the treatment, were assessed. The effect of onabotulinumtoxinA treatment was compared between CM patients with and without TMD/bruxism. Results: Of 30 female patients, 17 had concomitant TMD. In week 24, there were significant improvement in the groups with and without TMD regarding to the mean change of frequencies in the days with migraine compared to the initial findings (p<0.001). However, there was no significant difference between the two groups. Conclusions: OnabotulinumtoxinA is an effective and safe treatment for CM. Its efficacy appears to be similar in CM patients with and without TM, speculating that the comorbidity of TMD did not play a role for the treatment response.

[Validity and Reliability Studies of Modified Mini Mental State Examination (MMSE-E) For Turkish Illiterate Patients With Diagnosis of Alzheimer Disease]. / Egitimsizler Için Modifiye Edilen Mini Mental Testin (MMSE-E) Türk Toplumunda Alzheimer Hastaligi Tanisinda Geçerlik ve Güvenilirlik Çalismasi.

OBJECTIVE: To investigate the validity and reliability of modified Mini Mental State Examination (MMSE-E) for illiterate patients in a Turkish population with Alzheimer's disease (AD). METHOD: A total of 107 illiterate patients with Alzheimer's Disease (women: 65, men: 42) and 68 illiterate healthy volunteer subjects (women: 36, men: 32) were included in the study. MMSE-I and Geriatrics Depression Scale were performed on all subjects, Alzheimer patients were also administered Basic Activities of Daily Living (B- ADL). Clinical Dementia Rating (CDR) was used to determine the severity of disease, while a receiver operating characteristic (ROC) analysis was performed to analyze the cut-off scores of MMSE-I, and the positive/negative predictive values that were calculated for the optimal cut-off scores. Internal consistency was measured using Cronbach's coefficient . Additionally, correlations between total MMSE-I score and the CDR, B-ADL, and GDS scores were examined. RESULTS: The MMSE-I scores significantly and inversely correlated with CDR (-0.82, p=0.000) and B-ADL scores (-0.051, p=0.000). The optimal cut-off points of MMSE-I were 23/24, which yielded a sensitivity of 99.0% - %100.0, a specificity of 98.5% - 97.0%, and an AUC of 1.0/1.0, respectively. Reliability of the MMSE-I was high α = 0.70). CONCLUSION: The total MMSE-I score was able to differentiate the AD group from the control group.

Volumetric differences suggest involvement of cerebellum and brainstem in chronic migraine.

BACKGROUND: Chronic migraine (CM) is a disabling neurologic condition that often evolves from episodic migraine. There has been mounting evidence on the volumetric changes detected by magnetic resonance imaging (MRI) technique in migraineurs. These studies mainly focused on episodic migraine patients and less is known about the differences in CM patients. METHOD: A total of 24 CM patients and 24 healthy control individuals (all females) were included in this study. All participants underwent neurological examination and MRI. High-resolution anatomical MRI images were processed with an automated segmentation method (FreeSurfer). White-matter abnormalities of the brain were also evaluated with the Age-Related White-Matter-Changes Scale. RESULTS: The volumes of the cerebellum and brainstem were found to be smaller in CM patients compared to healthy controls. White-matter abnormalities were also found in CM patients, specifically in the bilateral parieto-occipital areas. There was no correlation between the clinical variables and volume decrease in these regions. CONCLUSION: CM patients showed significant volume differences in infratentorial areas and white-matter abnormalities in the posterior part of the brain. It is currently unclear whether the structural brain changes seen in migraine patients are the cause or the result of headaches. Longitudinal volumetric neuroimaging studies with larger groups, especially on the chronification of migraine, are needed to shed light on this topic.

Carotid Endarterectomy in a Patient with Posterior Cerebral Artery Infarction: Influence of Fetal Type PCA on Atypical Clinical Course.

Fetal type PCA may positively affect clinical outcome in patients with ischemic stroke such as protection of a reserve blood flow capacity as well as negative effect on clinical outcome such as certain atypical pathological manifestations. We presented a patient with a posterior cerebral artery territory infarction due to an unexpected etiology as stenosis of internal carotid artery (ICA) with existence of fetal type PCA.

Splinting is effective for night-only symptomatic carpal tunnel syndrome patients.

[Purpose] Carpal tunnel syndrome is the most common entrapment neuropathy of the median nerve. Splinting is one of the most used conservative treatment methods for carpal tunnel syndrome. The aim of this study was to show the effectiveness of splinting in carpal tunnel syndrome patients who were divided into two groups according to their level of symptoms. [Subjects and Methods] A total of 40 carpal tunnel syndrome patients were divided into 2 groups based on having symptoms only at night or during the day were included in this study. These two groups were compared at the end of a 3-months splinting therapy in terms of improvement of severity of symptoms, functional capacity, pain level, and electrophysiological findings. [Results] Pain levels of both groups were similar at baseline. After splinting, pain levels of night-only symptomatic patients were lower than those of sustained symptomatic ones. No differences were found in symptom severity, functional capacity, and the electrophysiological findings in either group after the splinting. [Conclusion] The results of this study show that splinting alone may be sufficient to decrease the pain for night-only symptomatic patients. Combined therapy methods may be needed for sustained symptomatic patients.

One-year follow-up in patients with brainstem infarction due to large-artery atherothrombosis.

BACKGROUND: Posterior circulation infarction accounts for approximately 25% of the ischemic strokes. A number of different conditions may be associated with the development of brainstem infarction. Prognosis and recurrence rate of brainstem infarction due to large-artery atherothrombosis is still controversial. METHODS: A total of 826 patients with ischemic stroke were admitted to our clinic during a 15-month period. Patients with clinical and radiological evidence of brainstem infarction were comprehensively assessed with appropriate vascular imaging modalities and for cardiological causes. Subjects with an established diagnosis of large-artery atherothrombosis were followed up for 1 year in terms of prognosis and recurrence rates. RESULTS: Of the 101 patients with an established brainstem infarction, the diagnostic work-up indicated the presence of large-artery atherothrombosis as the causative factor in 53. A recurrent stroke was detected in the posterior circulation within the first 3 months in 5.8% and within 1 year in 9.8% of these individuals. The 1-year mortality rate was 11.7%. All patients with recurrent stroke had intracranial vascular narrowing at baseline. CONCLUSION: Our findings demonstrate a particularly high rate of recurrence and mortality at 1 year among patients who have a brainstem infarction due to intracranial arterial stenosis.

Recurrent Ischemic Stroke Characteristics and Assessment of Sufficiency of Secondary Stroke Prevention.

INTRODUCTION: Disabilities due to stroke lead to a serious individual and socioeconomic burden. In this presented hospital-based study, we aimed to evaluate recurrent ischemic stroke (RIS) characteristics and the sufficiency of secondary prevention regarding the most common modifiable risk factors. METHODS: The records of patients with a diagnosis of ischemic stroke between November 2009 and November 2011 in our unit were retrospectively investigated. RESULTS: Ninety-one (18%) out of 500 patients with ischemic stroke had RIS. Hypertension, diabetes mellitus, ischemic heart disease, hyperlipidemia, atrial fibrillation, and smoking were found in 88%, 43%, 36%, 30%, 11%, and 14% of the patients, respectively. Thirty-eight percent of the patients had more than two risk factors. While 14% of the hypertensive patients did not use antihypertensive medications, antihypertensive treatment was insufficient in 39% of those who already used antihypertensive medications. Twenty-three percent of the patients received no prophylactic agents. Sixty percent of the patients with a history of atrial fibrillation were on oral anticoagulant therapy (warfarin), and the international normalized ratio was <2.0 in 73% of them. Of the diabetic patients, 87% had an HgbA1C level above 6%. The LDL level was higher than 100 mg/dL in 72% of the patients. CONCLUSION: The incidence of RIS and risk factors in our retrospective study was compatible with the results of those in literature. Secondary prophylactic treatment and modification of risk factors in the stroke patients were not satisfactory. The improvement of the patients' adherence to treatment is also very important in addition to the optimal treatment and follow-up strategy for decreasing the incidence of RIS. A multidisciplinary outpatient model of stroke care may be beneficial for decreasing the incidence of RIS.

Dual diagnosis: rheumatoid arthritis and multiple sclerosis.

Juvenile rheumatoid arthritis (JRA) is the most common rheumatologic disease in children. Moreover, multiple sclerosis (MS) is the most frequent demyelinating disease and has been associated with various chronic inflammatory diseases. However, its association with JRA has not been frequently described. Autoimmunity in both JRA and MS has been documented in the scientific literature, although there has been no definitive finding that patients with JRA are prone to the development of MS. An increasing frequency of MS resulting from an increased use of antitumor necrosis factor agents in the treatment of rheumatoid arthritis and other chronic inflammatory diseases has been reported recently. In this study, we report on the development of MS in a patient with JRA who did not have a history of antitumor necrosis factor use.

Two-point discrimination in diabetic patients.

BACKGROUND: Diabetes mellitus (DM) is a common cause of polyneuropathy. The aim of the present study was to evaluate two-point discrimination (TPD) compared with nerve conduction studies in the early stages of DM. METHODS: Forty-eight patients with early diagnosed (<5 years) type 2 DM and 17 healthy controls were evaluated. Of the patients with DM, 26 had neuropathic pain and 22 were asymptomatic. TPD and electrophysiological evaluations was obtained for all subjects. RESULTS: Nerve conduction studies in patients showed findings related to both demyelination and axonal damage. Patients with neuropathic pain had higher TPD values on the plantar surface of the foot and both groups of DM patients had higher TPD values on the outer lateral malleolus compared with the control group (P < 0.05). There was a correlation between TPD and axonal damage in patients with neuropathic pain (P < 0.05). In patients without neuropathic pain, there was a correlation between TPD values and distal latencies of motor or sensory nerves (P < 0.05). In the control group, only third digit TPD values were related to the distal motor latency of the median nerve (P < 0.05). CONCLUSION: In conclusion, the TPD method is a less painful, practical, cost-effective, and more easily applicable method that was completed in less time than nerve conduction studies. Higher TPD values in the lower extremities indicate nerve damage in patients. These findings suggest that increased TPD values can easily determine neuropathy starting in the early stages of diabetes in patients with DM.

Relationship between electrodiagnostic severity and neuropathic pain assessed by the LANSS pain scale in carpal tunnel syndrome.

OBJECTIVE: The aim of the study was to investigate the relationship between the presence of neuropathic pain assessed by the Leeds Assessment of Neuropathic Symptoms and Signs (LANSS) scale and electrophysiological findings in patients with carpal tunnel syndrome (CTS). METHODS: We studied 124 hands with idiopathic CTS with pain complaints involving hand and wrist. All hands were assessed by the LANSS with which a score of 12 or more is defined as pain dominated by neuropathic mechanisms. These hands were assigned to minimal, mild, moderate, severe, or extreme severe groups according to the results of the median nerve conduction studies. RESULTS: A LANSS score ≥ 12, suggestive of pain dominated by neuropathic mechanisms, was defined in 59 (47.6%) CTS hands. Pain intensity was significantly higher in CTS hands with a LANSS score ≥ 12 (P < 0.001). Among electrophysiological findings, compound muscle action potential amplitude was significantly lower in hands with a LANSS score ≥ 12 compared with hands with a LANSS score < 12 (P = 0.020). Severity of CTS was not significantly different between LANSS ≥ 12 and LANSS < 12 groups. Electrophysiological severity was significantly higher in CTS hands with evoked pain (P = 0.005) and allodynia (P < 0.001) in LANSS subscore analysis. CONCLUSION: We suggest that the presence of pain dominated by neuropathic mechanisms in CTS is not related to electrophysiological CTS severity. Neuropathic pain should be assessed carefully in patients with CTS, and an appropriate treatment plan should be chosen, taking into account the clinical and electrophysiological findings together with the true pain classification.

COST: Cognitive State Test, a brief screening battery for Alzheimer disease in illiterate and literate patients.

BACKGROUND: The aim was to develop a brief screening battery, Cognitive State Test (COST), for detecting the presence of dementia in both illiterate and literate patients and to assess its validity and reliability. METHODS: COST is a cognitive screening tool that consists of almost all cognitive domains. It takes 5-7 minutes to administer, and has a maximum score of 30. Data were obtained from 114 healthy volunteers and 74 Alzheimer dementia (AD) patients. Subjects' age divided into two groups: A1: <65 years; and A2: ≥65 years and their education level divided into three groups: E1: illiterate; E2: 1-5 years; and E3: ≥6 years. For assessing concurrent validity, total COST score was compared to the Clinical Dementia Rating (CDR), the Mini Mental State Examination (MMSE), the Montreal Cognitive Assessment (MoCA), and Basic Activities of Daily Living (BADL). Sensitivity and specificity were determined through a discriminant analysis using the Receiver Operating Characteristic (ROC) curves. Internal consistency was measured using Cronbach's coefficient α. RESULTS: For normal and AD subjects, mean age was 64.9±9.8 years (50 women and 64 men) and 67.2±13.2 years (55 women and 19 men), respectively. Schooling ranged from 0-15 years (mean 5.7±4.2 and 3.3±3.8 years, respectively), and 21 and 37 subjects were illiterate, respectively. The COST significantly and positively correlated with MMSE and MoCA, and significantly and inversely correlated with CDR, the Geriatric Depression Scale (GDS), and BADL. In the E1, E2, and E3 education groups, the optimal cut-off points of COST chosen for diagnosis of AD were 23/24 (sensitivity: 81%, specificity: 99%), 24/25 (sensitivity: 75%, specificity: 86%), and 26/27 (sensitivity: 77%, specificity: 84%), respectively. When illiterate and literate subjects were then pooled, the optimal cut-off score of COST was 24/25, which yielded a sensitivity of 81% and a specificity of 87%. Reliability of the COST was good (0.86). CONCLUSION: The COST is a valid and reliable screening battery for detection of dementia both in the illiterate and the literate Alzheimer patients.

Amlodipine-induced delirium in a patient with ischemic stroke.

Amlodipine is a dihydropyridine calcium antagonist drug with distinctive pharmacokinetic characteristics that seem to be attributable to a high degree of ionization. Delirium is a neuropsychiatric syndrome recognized as a marker for increased health care costs, morbidity, mortality, and institutionalization that often complicates acute physical illness in elderly people. This case is the first report concerning amlodipine use as a cause of delirium.

Association of mean platelet volume with DSM-IV major depression in a large community-based population: the MELEN study.

The relationship between major depression and increased platelet activity has been previously stated by several studies. This study sought to test the relationship between mean platelet volume (MPV)--an indicator of platelet activity--and major depression, in an adult Turkish population sample. Respondents were 2286 participants interviewed in a regional survey. The diagnosis of current (one month) major depression was made according to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition. MPV was measured along with total cholesterol, triglycerides, HDL-cholesterol, LDL-cholesterol, BMI, and waist circumference. Two hundred eighty-nine participants (12.5%) were diagnosed as having major depression. Patients with major depression were found to have increased MPV levels in comparison with participants without depression (p = 0.001). After excluding the subjects with risk factors capable of influencing platelet activity, MPV was still found to be elevated in patients with major depression compared with non-depressed individuals (p < 0.01). Linear regression analysis revealed a significant independent association of major depression with MPV levels (r = 0.123; p = 0.001). According to the findings of this study, increased MPV (or platelet activation) is associated with current (one month) diagnosis of major depression. Future research should investigate the effect of depression treatment on MPV.