Electrodiagnostic methods to verify Guillain-Barré syndrome subtypes in Istanbul: A prospective multicenter study.

BACKGROUND AND AIMS: This study aimed to identify the clinical characteristics and electrodiagnostic subtypes of Guillain-Barré syndrome (GBS) in Istanbul. METHODS: Patients with GBS were prospectively recruited between April 2019 and March 2022 and two electrodiagnostic examinations were performed on each patient. The criteria of Ho et al., Hadden et al., Rajabally et al., and Uncini et al. were compared for the differentiation of demyelinating and axonal subtypes, and their relations with anti-ganglioside antibodies were analyzed. RESULTS: One hundred seventy-seven patients were included, 69 before the coronavirus disease 2019 pandemic (April 2019-February 2020) and 108 during the pandemic (March 2020-March 2022), without substantial changes in monthly frequencies. As compared with the criteria of Uncini et al., demyelinating GBS subtype diagnosis was more frequent according to the Ho et al. and Hadden et al. criteria (95/162, 58.6% vs. 110/174, 63.2% and 121/174, 69.5%, respectively), and less frequent according to Rajabally et al.'s criteria (76/174, 43.7%). Fourteen patients' diagnoses made using Rajabally et al.'s criteria were shifted to the other subtype with the second electrodiagnostic examination. Of the 106 analyzed patients, 22 had immunoglobulin G anti-ganglioside antibodies (14 with the axonal subtype). They had less frequent sensory symptoms (54.5% vs. 83.1%, p = 0.009), a more frequent history of previous gastroenteritis (54.5% vs. 22.9%, p = 0.007), and a more severe disease as compared with those without antibodies. INTERPRETATION: Serial electrodiagnostic examinations are more helpful for accurate subtype diagnosis of GBS because of the dynamic pathophysiology of the disease. We observed no significant increase in GBS frequency during the pandemic in this metropolis.

Treatment of multiple sclerosis-related trigeminal neuralgia with onabotulinumtoxinA.

BACKGROUND: The effectiveness of onabotulinumtoxinA (BTX-A) has been established in primary trigeminal neuralgia (TN). However, to the best of our knowledge, the efficacy of BTX-A in secondary TN has not yet been studied. OBJECTIVE: This study aimed to investigate the efficacy of BTX-A treatment in patients with multiple sclerosis-related trigeminal neuralgia (TN-MS) and compare the efficacy of BTX-A treatment between patients with primary trigeminal neuralgia (TN-P) and patients with TN-MS. METHODS: This was a retrospective medical record-review study. Demographic and clinical features and severity and frequency of pain before and 2 weeks after the BTX-A administration were extracted from the patient files. BTX-A was injected into the painful area subcutaneously and/or submucosally. BTX-A injections were performed by the same physician using the same methods. A reduction in severity and/or frequency of pain ≥50% was considered therapeutic efficacy. RESULTS: Fifty-three patients were included in this study. We classified 22 (42%) as TN-P and 31 (58%) as TN-MS. Treatment with BTX-A was effective in 16 of 31 (52%) patients with TN-MS and 10 of 22 (45%) with TN-P. BTX-A treatment was less effective in patients with a history of interventional treatments and more effective in patients with concomitant continuous pain (p = 0.007; odds ratio [OR]: 0.020-0.53 and p = 0.047; OR: 0.046-0.98, respectively). CONCLUSION: The BTX-A treatment was found to be effective in at least half of our cohort with TN-MS. Concomitant continuous pain and history of interventional treatments to the trigeminal nerve or ganglion might be predictive factors for the efficacy of BTX-A treatment.

Analysis of neurology consultations in hospitalized patients with COVID-19.

OBJECTIVE: The aim of this study was to evaluate patients who were hospitalized with a diagnosis of COVID-19 and were consulted by neurology during their hospital stay. METHODS: All files of patients with COVID-19 who were admitted to Cerrahpasa Medical Faculty Hospital between March 11th and December 31st, 2020 were retrospectively reviewed, and files of patients who consulted by neurology during their stay were included. Demographic and clinical characteristics, neurologic diagnosis, outcome and related laboratory data were extracted from electronic medical records and analyzed. Patients were categorized into the first wave and second wave according to the date of hospitalization. RESULTS: A total of 2257 patients were hospitalized for COVID-19; among them, 127 were consulted by a neurologist during their hospital stay. Fifteen patients received a consultation for possible drug interactions. Among the remaining 112 patients, the reason for neurology consultation was i. exacerbation of a neurological comorbidity vs ii. new-onset neurological manifestations. The median age was 68.5 ± 14.2 years, and 60.7% were men. Dementia and stroke were the leading neurological comorbidities. COVID-19 disease was more severe in the patients with the new-onset neurological comorbidity than in patients with exacerbation of a neurological comorbidity (p = 0.07). Serum creatinine kinase levels were higher in the new-onset patient group (p < 0.05). Exacerbation of previous neurological disease or new neurological impairment were jointly and severely related to high mortality (overall 35/112 vs 275/2145, p < 0.001; exacerbation 12/45 vs 275/2145 p < 0.01; new-onset 23/67 vs 275/2145, p < 0.001). CONCLUSION: Serious neurological involvement is relatively uncommon in hospitalized patients with COVID-19 and is associated with increased mortality.

Accompanying migrainous features in pediatric migraine patients with restless legs syndrome.

The present study aimed to examine the frequency of restless legs syndrome (RLS) in pediatric patients with migraine and tension-type headache (TTH) and to investigate accompanying migrainous symptoms, sleep characteristics, as well as levels of serum ferritin between the pediatric migraine patients with RLS and those without RLS. We included 65 consecutive patients diagnosed with migraine, 20 patients with TTH, and 97 headache-free children in our study. Demographic, clinical, and laboratory data were noted. The presence of a primary headache was diagnosed using the ICHD-II criteria, and RLS was determined with face-to-face interviews conducted by an experienced neurologist based on the revised International RLS Study Group criteria for pediatrics. The frequency of RLS in pediatric migraine and TTH patients was significantly higher than in the controls (p = 0.0001 and p = 0.025, respectively). The frequencies of allodynia, vertigo/dizziness, and self-reported frequent arousals were significantly higher, and serum ferritin levels were significantly lower in migraine patients with RLS compared to those without RLS (p = 0.05, p = 0.028, p = 0.02, and p = 0.038, respectively). Our study suggests that the frequency of RLS is higher in pediatric migraine and TTH patients compared to controls. Therefore, pediatric headache patients should be questioned about the presence of RLS, as this co-occurrence may lead to more frequent accompanying migrainous symptoms and sleep disturbances.

Trigeminal somatosensorial evoked potentials suggest increased excitability during interictal period in patients with long disease duration in migraine.

INTRODUCTION: Migraine pathogenesis is suggested to involve many structures in cerebral cortex, brainstem and trigeminovascular system. Electrophysiological studies revealed loss of habituation, decreased cortical preactivation, segmental hypersensitivity and reduction in control of inhibitory descending pathways. Given these information, we aimed to evaluate the excitability changes of the trigeminal pathway in the cortex and brainstem in migraine using trigeminal nerve somatosensory evoked potentials (TSEP). PATIENTS AND METHOD: Fifty-one women with migraine without aura and 32 age-matched healthy women were included. TSEPs were recorded in migraine patients during interictal period and in healthy subjects. Sensory thresholds, stimulation intensities, latencies of N1, P1, N2 and P2 waves as well as N1/P1 and N2/P1 amplitudes were measured. RESULTS: Comparisons of ipsilateral latencies with N1-P1 and N2-P1 amplitudes between migraine and control groups showed no difference. Sensory thresholds were also similar. Stimulation thresholds decreased as the attack frequency increased and ipsilateral N1/P1 amplitude increased with prolonged disease duration (p=0.043). CONCLUSION: Our study did not show significant difference between migraine patients and healthy subjects during interictal period. However, migraine with long duration affects the excitability of the cortical and brainstem trigeminal pathways even during interictal periods.

Bilateral vocal cord paralysis secondary to head and neck surgery.

Even endotracheal intubation could be considered safe in operations under general anesthesia; rarely, it could cause recurrent laryngeal nerve paralysis as a complication. As mentioned in the literature, as a possible reason for this, anterior branches of the recurrent laryngeal nerve in the larynx could suffer from compression between the posteromedial part of the thyroid cartilage and the cuff of the tube. In the literature, unilateral vocal cord paralysis due to endotracheal intubation occurs more frequently in comparison to bilateral vocal cord paralysis. These types of palsies usually totally improve in approximately 6 months. A patient who experienced bilateral vocal cord paralysis in the early postoperative period after undergoing an endotracheal intubation process for general anesthesia and primary partial lip resection and supraomohyoid neck dissection due to lower lip carcinoma is presented in our article. Although vocal cord paralysis occurring after head and neck surgery is first thought as a complication of the surgery, endotracheal intubation should be considered as a possible cause of this paralysis. In relation with this patient, causes, clinical symptoms, and treatment procedures of vocal cord paralysis due to endotracheal intubation are discussed under guidance of the literature.

Thermal effects of mobile phones on facial nerves and surrounding soft tissue.

OBJECTIVE: To investigate the possible thermal effects of microwaves from mobile phones on facial nerves (FN) and surrounding soft tissue. STUDY DESIGN: A prospective study. METHODS: We studied FN conduction rate and compound muscle action potentials (CMAP) on 12 rabbits before exposure to radiofrequency radiation (RFR) emitted from a mobile phone. Also, the temperature change in the soft tissues around the FN was investigated by a four channel Luxtron fiber optic system. A mobile phone with 1900 MHz frequency was placed over the ipsilateral ear of the rabbit for 25 minutes, and FN and surrounding tissues were exposed to a 1.5 watts pulse modulated (217 packets/s) electromagnetic field. During exposure to RFR, immediately after turning off the mobile phone, and 25 minutes after the exposure temperature change in the surrounding tissue of the FN was recorded and compared to preexposure values. Additionally, another recording regarding the FN functions was done and the data were compared to preexposure values. RESULTS: The average temperature of the surrounding soft tissues was 0.39 K higher than the preexposure values during the exposure and immediately after turning off the mobile phone, and decreased to normal levels 25 minutes after the exposure, which was statistically significant. The amplitudes of FN CMAP after radiofrequency radiation exposure were significantly smaller than the preexposure amplitudes and the amplitudes were normal in the 25 minute measurement. CONCLUSION: The RFR emitted from a mobile phone can cause temporary FN dysfunction that can be due to temporary temperature increase in the soft tissue around the FN.

Spinal myoclonus following a peripheral nerve injury: a case report.

Spinal myoclonus is a rare disorder characterized by myoclonic movements in muscles that originate from several segments of the spinal cord and usually associated with laminectomy, spinal cord injury, post-operative, lumbosacral radiculopathy, spinal extradural block, myelopathy due to demyelination, cervical spondylosis and many other diseases. On rare occasions, it can originate from the peripheral nerve lesions and be mistaken for peripheral myoclonus. Careful history taking and electrophysiological evaluation is important in differential diagnosis. The aim of this report is to evaluate the clinical and electrophysiological characteristics and treatment results of a case with spinal myoclonus following a peripheral nerve injury without any structural lesion.

Cerebral blood flow changes in patients with probable medication-overuse headache.

Transcranial Doppler (TCD) is a non-invasive method for measuring blood flow velocity (BFV), and a marker of vessel diameter. In this study, intracranial BFV was investigated, by means of TCD, in patients suffering from probable medication-overuse headache (PMOH). Twenty-three female patients with probable ergotamine- overuse headache (PEOH), 23 female patients with probable analgesic-overuse headache (PAOH), and 15 healthy female controls participated in the study. The mean BFVs of the bilateral middle and anterior cerebral arteries (MCA and ACA) and basilar artery (BA) were measured by TCD. The mean BFVs of the BA and MCA were found to be significantly increased in the PEOH group when compared with those of the PAOH and control groups (p<0.05). No significant differences in BFV of the ACA were observed between any groups (p>0.05). The mean BFV of all the vessels in the PAOH group was found to be lower than that of the control group but no statistical significance was found (p>0.05). Our results show that ergotamine increases BFV via vasoconstriction, especially of the BA and MCA. We also suggest that 5HT1B/1D receptors are mainly localized in the BA and MCA, and that analgesic overuse results in a functional disorder of neuronal receptor and neurovascular reflexes and may cause a reduction of intracerebral vessel tone, leading to vasodilatation.

Traumatic peripheral nerve injuries: demographic and electrophysiologic findings of 802 patients from a developing country.

OBJECTIVE: To study a series of patients with traumatic peripheral nerve injury during the past 10 years in Cerrahpasa Medical Faculty/Istanbul/Turkey. METHODS: The chart review of 802 patients was evaluated and we explored the type(s) and cause(s) of injury, and electromyographic findings. The study included 171 children and 631 adults and we excluded the patients who suffered from injuries due to the Marmara earthquakes that occurred in 1999. RESULTS: Injury was most common in the upper extremities in both children (78.36%) and adults (63.54%). The common causes of nerve injury in children were as follows: obstetric lesions (46.78%), iatrogenic lesions (16.95%), traffic accidents (15.7%), and sharp lacerations (12.8%), whereas the commonest cause of nerve injury in adults was due to sharp lacerations (27.57%), followed by iatrogenic lesions (25.67%), and traffic accidents (23.77%). The most commonly injured nerves were the brachial plexus and ulnar nerve in children and adults, respectively. Electromyography demonstrated that complete nerve injury predominated in both groups. CONCLUSIONS: If preventive measures are taken into consideration satisfactorily, the incidence of disabling peripheral nerve injury may decrease, as such injuries are often treatable.

Electrophysiologic evaluation of peripheral nerve injuries in children following the Marmara earthquake.

The aim of this study was to investigate the clinical, demographic, and electromyographic (EMG) characteristics of 12 earthquake victims in the pediatric age group and to compare the findings with those of the adult group. Following the 1999 Marmara earthquake, 75 subjects with suspected peripheral nerve injury were referred to our EMG laboratory for evaluation. In the pediatric age group, five patients had a history of short-term temporary trauma and seven had a history of being trapped under the debris for 4 to 10 hours and sustaining long-term trauma. Five patients had developed compartment syndrome and one had developed crush syndrome. The EMG examinations revealed peripheral nerve injury findings in all patients. The brachial plexus was damaged in 2 patients, and 19 peripheral nerves were damaged in 10 patients. Peroneal and posterior tibial nerves were predominantly affected. Regeneration was detected in all of the patients with brachial plexus damage at a mean follow-up of 3.5 months and in 62.5% of patients with peripheral nerve damage at a mean follow-up of 7.7 months. Being buried under the debris, compartment syndrome, peripheral nerve injuries in the lower extremities, and total axonal damage in the first EMG examinations were found to be higher in the pediatric age group. Regeneration findings were found at similar rates in both groups, with the brachial plexus being the most favorable. When it is considered that the regeneration process lasts 15 to 18 months and EMG findings mostly show pathologies in the form of neuropraxia and axonotmesis, we think that the prognosis of our patients will be good.

1999 Marmara earthquake; peripheral nerve injuries--electrophysiologic evaluation.

This study evaluated the clinical, demographic and electromyographic (EMG) findings of 75 patients referred to our EMG laboratory with the preliminary diagnosis of peripheral nerve injury (PNI) during the 1999 Marmara earthquake. Forty-two patients had single and 33 had serial EMGs. Seventy-nine percent of the patients were found to have PNI. Eighty-six percent of these had PNI of the extremities and 23.7% had brachial plexus injury. PNI were detected in the upper extremities in 39% of patients, in the lower extremities in 47.5% of patients and in both extremities in 13.5% of patients. It was observed that brachial plexus degeneration was at a higher rate in patients with compartment and crush syndromes (35.70% and 42.9%) and peripheral nerve (PN) degeneration was higher in patients remaining under the debris (37%). In control EMG examinations, regeneration findings were observed at a rate of 79.2% in the upper extremities and 55.3% in the lower extremities (mean 64.5%) in the patients with PNI of the extremities and 90.9% in the patients with brachial plexus injury. In conclusion, after a mean EMG follow-up of 4 months in 75 earthquake victims a reasonably high level of regeneration findings shows that prognosis will be good in the majority of patients.

Motor unit potential analysis in the cases with hemifacial spasm and postparalytic facial hyperactivity.

This study seeks to find an answer to whether the damage caused by the focal demyelinated focus in hemifacial spasm (HFS) causes a deviation from normal in MUP's. The study evaluated MUP parameters of orbicularis oculi (o.oc) and orbicularis oris (o.or) muscles in the total of 76 cases, 41 of whom had a history of peripheral facial paralysis (PFP) and postparalytic facial hyperactivity (PPFHA) and 35 of whom had HFS. Control data was obtained from healthy sides 22 of 76 cases. "t test" and multiple comparisons were used for statistical evaluations. For o.oc muscle; when compared with the normal group, PPFHA group had significantly increased motor unit durations (p < 0.001), phase (p < 0.05), area (p < 0.05), turn (p < 0.05) and polyphasic potential numbers (p < 0.05) and HFS group had significantly increased amplitudes (p < 0.05), area (p < 0.05) and polyphasic potential numbers (p < 0.05). When patients groups were compared for the same muscle, PPFHA group had significantly increased MUP durations (p < 0.001) and number of turns (p < 0.05) as compared to HFS group. When o.or muscle values were compared with the normal group, PPFHA group had significantly increased durations (p < 0.001), phase (p < 0.05), area (p < 0.05) and turn numbers (p < 0.001) and polyphasic potential rates (p < 0.05) and area/amplitude values (p < 0.05), HFS group had significantly increased durations (p < 0.05), phase (p < 0.05), area (p < 0.05) and turn numbers (p < 0.05). When patient groups were compared for the same muscle, MUP duration was significantly increased (p < 0.05) in the PPFHA group as compared to HFS group. In conclusion, with the quantitative method, there is neurogenic involvement in the facial muscles of upper and lower halves in cases of HFS although lesser than PFP cases. This suggests that focal demyelination causes secondary axonal loss at least in some of the cases.