HPA axis function in patients with right and left focal lateralized epilepsy.

OBJECTIVES: There is a complex, reciprocal link between epilepsy and the hypothalami pituitary-adrenal (HPA) axis. This study aimed to evaluate the role of the HPA axis in individuals with focal epilepsy, including those with right- or left-hemispheric lateralized epilepsy. MATERIAL AND METHODS: The study comprised 60 individuals with focal epilepsy, ages 18 to 85, with seizures coming from a single hemisphere, no destructive lesions on cranial magnetic resonance imaging, and 32 healthy persons. Blood was drawn from the patient and control groups at 8.00 for serum cortisol level and at 23.00 for serum melatonin level. The Pittsburgh Sleep Quality Index and the Epworth Sleepiness Scale were administered to both the patient and control groups. RESULTS: Patients showed decreased melatonin levels (p < 0.001) and poorer sleep quality (p = 0.035). The cortisol level of the patients was found to be lower than the cortisol level of healthy individuals, although it was not statistically significant (p = 0.107). Cortisol and melatonin levels did not significantly differ between patients with seizures coming from the right or left hemisphere. The patients with seizures originating from the left hemisphere had a longer duration of epilepsy disease (p = 0.013), higher seizure frequency (p = 0.013), lower age of first seizure onset (p = 0.038), and a higher rate of polytherapy (p = 0.05). CONCLUSION: Low cortisol and melatonin levels in patients with focal epilepsy may be an indicator of disruption in the HPA axis. There is no significant difference in the HPA axis function between patients with focal epilepsy according to the epileptic hemisphere.

Sexual behaviour change in seronegative limbic encephalitis due to the involvement of the left amygdala.

Limbic encephalitis (LE), a rare cause of encephalitis, generally presents with neuropsychiatric manifestations, memory deficits, seizures, and movement disorders. The case of a 41-year-old female patient with LE involving the left amygdala is presented. The patient was admitted to the emergency department with complaints of unconsciousness and seizures. Paraneoplastic and limbic markers were negative. This case was diagnosed as seronegative LE. Three to four months after the diagnosis, it was observed that her sexual preference changed to the female sex. No report has been published so far, concerning any case of LE associated with changes in sexual behaviour. The patient was treated with intravenous methylprednisolone (IVP) and triple antiepileptic therapy. After treatment, changes in sexual behaviour returned to the previous state.

Is the left hemisphere more prone to epilepsy and poor prognosis than the right hemisphere?

Objective: The central nervous system is known to have asymmetric immune system modulation. Thus far, no clinical study has examined asymmetric immune modulation between hemispheres in focal epilepsy patients. We aimed to compare the prognosis of epilepsy patients lateralized to the right hemisphere with epilepsy patients lateralized to the left hemisphere using clinic and demographic data.Method: Ninety-nine patients with focal epilepsy with all seizures originating in only one hemisphere, between the ages of 18-and 86 years were included. We included patients with focal epilepsy whose seizures were lateralized to only one hemisphere. Age, gender, marital status, education, mental retardation, hand dominance, etiology, trauma, central nervous system infection, febrile convulsion, parental relationships, seizure onset age, seizure frequency (per month), systemic disease, and biochemical parameters were recorded. To evaluate lateralization, we used positron emission tomography (PET/CT), long-term video-electroencephalography (EEG), and magnetic resonance imaging (MRI) investigations.Results: Thirty-seven patients (37.4%) patients were right-lateralized, whereas 62 patients (62.6%) were left-lateralized (p = 0.01). Seizures frequency seizures were higher in patients lateralized to the left hemisphere than in the right. (p = 0.001). In patients with epilepsy lateralized to the left hemisphere, epilepsy onset age was lower (p = 0.003), numbers of antiepileptic medicines were higher (p = 0.04), and epilepsy durations and longest seizure-free periods were longer (p = 0.001 and p = 0.04, respectively).Conclusion: We have shown that compared to the right hemisphere, the left hemisphere is far more prone to seizures and has a poorer prognosis.

Herpes simplex encephalitis and pseudotumour cerebri due to isotretinoin.

Isotretinoin can have significant adverse reactions on multiple systems. We report a unique case of pseudotumour cerebri and herpes encephalitis resulting due to isotretinoin. A 19-year-old female patient was admitted to our clinic, presenting with headache, nausea, vomiting and fever since three days. She had used isotretinoin for the last two months. The patient's neurological examination revealed the presence of neck stiffnes and a body temperature of 39,0◦C. MRI showed high signal localized to the temporal lobe and insula on the right and widened cerebrospinal fluid signal intensity on either side of the optic nerve. Electroencephalogram sharp and wave paroxysms on the right temporo-parietal region. Lumbar puncture showed an opening pressure of 320 mm H2O. The cerebrospinal fluid displayed the presence of 4-5 lymphocytes. On these grounds, the diagnosis of pseudotumour cerebri and herpes encephalitis was made. It is thus suggested that the physicians must keep in mind that pseudotumour cerebri and herpes encephalitis are possible adverse effects of isotretinoin.

Recurrent petrositis due to nasopharyngeal carcinoma in an adult patient: Gradenigo's syndrome.

The early diagnosis of very rare nasopharyngeal carcinoma (NPC) is so difficult, to surrounded by structures such as the orbital skull base. With the invasion of the disease, the symptoms are manifested in different ways so that it may be confusion and delay in diagnosis and treatment in this situation. Including otological symptoms (serous otitis media), Gradenigo's syndrome is a rare clinical condition. The majority of published cases involve children, and the most common etiology is otitis media. We report a case of a diabetic man who presented with repeating Gradenigo's syndrome symptoms due to NPC.

The long-term prognosis of epilepsy patients with medically treated over a period of eight years in Turkey.

OBJECTIVE: The aim of this study was to investigate the effect of demographic and clinical characteristics on temporal changes in seizure control and frequency in medically treated epilepsy patients to guide treatment modalities. METHODS: We retrospectively analyzed the association between clinical and demographic characteristics and seizure frequency in 1329 epilepsy patients who were followed up at an outpatient clinic for one to eight years, 2008-2015.. RESULTS: Younger age at first seizure (p = 0.0465) and a long disease duration (p = 0.0406) had a negative effect on seizure control in all the epilepsy patients. Febrile convulsions (FCs) (p > 0.0001), perinatal risk (PNR) (p > 0.0002), a family history of epilepsy (FHE) (p > 0.0016), antiepileptic drug (AED) use (p > 0.001), mental retardation (MR) (p > 0.001), and psychiatric disorders (p > 0.0478) were prognostic indictors of temporal changes in seizure frequency. The presence of PNR (p = 0.0416), age at onset of epilepsy (p = 0.034), central nervous system infection (CNSI) (p = 0.04), and AEDs number (p = 0.0282) were prognostic indicators of not remaining seizure free for one year. In those with partial epilepsy, a trauma history (p = 0.05), a longer epilepsy duration (p = 0.0057), and FHE (p = 0.0466) increased the frequency of seizures, whereas cerebrovascular event (CVE) history decreased the seizure frequency (p = 0.0413). In addition, FHE (p = 0.0438) and psychotic disorders (p = 0.0416) increased generalized seizures frequency. CONCLUSION: In all the epilepsy patients, a younger age at onset and longer duration of epilepsy were associated with a poor prognosis. The presence of PNR, age at onset of epilepsy, CNSI, and AEDs numbers were prognostic indicators of not remaining seizure free for one year. Increasing AEDs number was not effective in controlling seizures in partial epilepsy, but it was effective in controlling seizures in generalized epilepsy.

Osteonecrosis in the both femoral heads in a patient with Neuro-Behcet's Disease.

Neuro-Behçet's disease (NBD) is a rare clinical entity that frequently presents neuro-psychiatric symptoms, and mesodiencephalic and pontobulbar lesions. There is only one published report about osteonecrosis in NBD. We report a patient whose first presentation was neurological NBD with presenting bilateral femoral heads osteonecrosis. A 36-year-old male was hospitalized with gait disorder, diplopia and speech disorder. The past medical history of the patient was unremarkable. The MR image showed mesencephalic lesion with oedemaas a hyperintense area. The present case was diagnosed as NBD and treated with methylprednisolone (1g /day) only for five days. One year after, bilateral hip pain developed. MR image of both hips showed well-demarcated areas of osteonecrosis in the bilateral femoral heads. The patient was operated by an orthopedic surgeon. Because early diagnosis and immediate treatment of osteonecrosis is very important, the physician must bear in mind that osteonecrosis might result from impaired microvascular involvement in even NBD.

The effects of thrombomodulin and activated protein C on the pathogenesis of multiple sclerosis.

BACKGROUND: Various molecules of the coagulation cascade are thought to have varying roles in the pathophysiology of multiple sclerosis (MS). We aimed to find new information about the effects of the coagulation cascade molecules to develop new therapeutic strategies for MS. MATERIALS AND METHODS: Patients with MS were chosen from among patients who were followed up at our hospital. We examined the thrombomodulin (TM) and activated protein C (APC) serum levels in patients with MS and the healthy controls. The patient groups were determined as relapsing-remitting MS (RRMS) or secondary progressive MS (SPMS) according to the McDonald criteria and between ages of 18 and 70. RESULTS: A total of 244 participants, 122 patients with multiple sclerosis and 122 healthy volunteers were included in the study. There was no statistically significant difference in the APC and TM levels between the patients and the healthy controls (p>0.05), between the patients with RRMS and SPMS (p>0.05), and between the first day of acute relapse and 10th day of methylprednisolone therapy in the patients with RRMS (p=0.334; p=0.363). We detected a statistically positive correlation only between the expanded disability status scale (EDSS) scores and TM levels in the patient group (p=0.009). CONCLUSION: Treatment with methylprednisolone decreases EDSS score in RRMS relapse. The increase in EDSS is related to level of TM. The changes in level of TM and APC may be indicator for prognosis of MS or treatment modalities to MS.

Incidental Transient Cortical Blindness after Lung Resection.

Transient vision loss after major surgical procedures is a rare clinical complication. The most common etiologies are cardiac, spinal, head, and neck surgeries. There has been no report on vision loss after lung resection. A 65-year-old man was admitted to our clinic with lung cancer. Resection was performed using right upper lobectomy with no complications. Cortical blindness developed 12 hours later in the postoperative period. Results from magnetic resonance imaging and diffusion-weighted investigations were normal. The neurologic examination was normal. The blood glucose level was 92 mg/dL and blood gas analysis showed a PO 2 of 82 mm Hg. After 24 hours, the patient began to see and could count fingers, and his vision was fully restored within 72 hours after this point. Autonomic dysfunction due to impaired microvascular structures in diabetes mellitus may induce posterior circulation dysfunction, even when the hemodynamic state is normal in the perioperative period. The physician must keep in mind that vision loss may occur after lung resection due to autonomic dysfunction, especially in older patients with diabetes mellitus.

Cortical and cerebellar atrophy, but no lesion in a patient with neuro-Behçet's disease.

Neuro-Behçet's disease (NBD) is a rare clinical entity. There are no reports about cortical atrophy in NBD. We report a patient with NBD exhibiting only cortical and cerebellar atrophy without any lesions. A 38-year-old male was hospitalized due to gait disorder. He had experienced forgetfulness, irritability, sexual and behavioral dyscontrol, and incontinence for 5 years. Magnetic resonance imaging (MRI) showed cortical and cerebellar atrophy, but there were no lesions. In the differential diagnosis of NBD, physicians should take into account the presence of both brainstem and cerebellar and cortical atrophy even in the absence of typical lesions for NBD, particularly in the presence of cognitive dysfunctions.

Parathyroid adenoma presenting as tetraparesia.

OBJECTIVE: Parathyroid adenomas (PA) are benign tumors. We report an unusual case of delayed diagnosis of a PA and concomitant Vitamin D deficiency presenting as tetraparesia. METHODS: A 30-year-woman was admitted to our clinic with an inability to walk. Our examination revealed tetraparesia and common, severe muscular atrophy. RESULTS: Laboratory investigations showed the following: creatinine phosphokinase (CK): 37 IU/L (15-130), calcium (Ca): 11.5 mg/dL (9-11), phosphorus (P): 1.5 mg/dL (2.5-5), parathyroid hormone (PTH): 736.1 pq/mL (15-65), 25-hydroxyvitamin D (25-OHvit D): 4 ng/mL (11-43), and alkaline phosphatase (ALP): 1029.5 lU (64-300). Parathyroid scintigraphy revealed PA. A year after Vitamin D replacement, the patient's neurological status and laboratory findings improved. CONCLUSION: We suggest that the physicians always keep in mind the primary hyperparathyroidism (HPT) and concomitant Vitamin D deficiency in the differential diagnosis of hypercalcemia when facing atypical neurological symptoms such as tetraparesia.

Effects of valproate, carbamazepine, and levetiracetam on the antioxidant and oxidant systems in epileptic patients and their clinical importance.

PURPOSE: This study was carried out to determine the effects of valproate (VPA), carbamazepine, and levetiracetam (LEV) on antioxidant and oxidant enzyme activities and the clinical importance of these effects. METHODS: We enrolled 32 patients receiving VPA, 17 receiving carbamazepine, 8 receiving LEV, 11 on multidrug therapy, and 30 sex- and age-matched healthy volunteers. We measured the serum activities of paraoxonase and arylesterase and the levels of 8-hydroxyguanine (8-OHG) and oxidized low-density lipoprotein in all the subjects. We also determined the clinical features of the patients. RESULTS: The serum paraoxonase and arylesterase activities were significantly lower (P = 0.003 and P = 0.0001, respectively), and the oxidized low-density lipoprotein and 8-OHG levels were higher (P = 0.029 and P = 0.0001, respectively) in the patients than in the controls. The serum antioxidant activity was low, and the oxidant activity was high in the monotherapy patients (P < 0.05). Comparing the monotherapy with the polytherapy, only the combination of VPA-LEV was associated with a high 8-OHG level (P = 0.04). The serum 8-OHG level was higher in the patients taking antiepileptic drugs (AEDs) for the first 2 months than in the controls (P = 0.0001) and positively correlated with the duration of epilepsy (r = 0.387, P < 0.01). CONCLUSIONS: Oxidative stress is seen in each of the AEDs after the first 2 months. There was no dominance of the monotherapy over the polytherapy, except for the VPA-LEV combination. None of the patients' characteristic features were related to oxidative damage, except for the duration of the epilepsy and the AED therapy.

Prothrombin G20210A mutation, hypogonadotropic hypogonadism, and generalized vitiligo-related ischemic stroke in a young adult.

PURPOSE: Cerebral infarction is a rare neurological situation in young adults, usually caused by genetic factors. We report here a case of multiple cerebral infarctions with prothrombin G20210A mutation, hypogonadotropic hypogonadism, and generalized vitiligo as a first case report. CASE REPORT: A 17-year-old female adolescent was admitted to our clinic due to a change in mental status. The patient's neurological examination revealed loss of consciousness and the presence of tetraparesia. Generalized vitiligo was also detected. Magnetic resonance imaging (MRI) and diffusion-weighted investigations (DWIs) showed acute ischemic stroke in the bilateral cerebellum, pons and left occipital regions. Heterozygote prothrombin G20210A mutation was found upon genetic examination. She had never had a menstrual cycle. Laboratory data revealed that the level of luteinizing hormone (LH) was 0.5 mIU/mL (1.1-11.6) and follicle-stimulating hormone (FSH) was 1.7 mIU/mL (2.8-11.3). Therefore, she was diagnosed with hypogonadotropic hypogonadism. The causes of ischemic stroke are heterozygote prothrombin G20210A mutation, generalized vitiligo, and hypogonadotropic hypogonadism. After treatment, the patient's neurological deficit partially improved and she was discharged. CONCLUSION: In order to identify the etiology of ischemic stroke, we suggest physicians take into account heterozygote prothrombin G20210A mutation and endocrine abnormalities, especially hypogonadotropic hypogonadism and generalized vitiligo.

The effect of interferon beta 1B on bone mineral density in multiple sclerosis patients.

OBJECTIVE: Osteoporosis is a secondary problem in multiple sclerosis (MS) patients. There have been only a few reports about the effect of interferon beta (IFNB) 1b on bone mineral density (BMD). We aimed to determine bone mass in patients using IFNB 1b. METHODS: We enrolled 17 patients taking IFNB 1b (group I), 15 patients not taking IFNB (group II). We measured the BMD and T scores values and the patients were distinguished as normal, osteopenia and osteoporosis. RESULTS: In the lumbar spine, there was no difference between groups I and II (p=0.3). In the left femur, no significant difference was detected between groups I and II (p=1). There was an inverse correlation between the BMD at the both regions and the Expanded Disability Status Scale score (r= -0.39, p=0.03; r=-0.52, p=0.002, respectively). CONCLUSION: IFNB 1b may be used safely in MS patients, even in those undergoing pulse steroid therapies, because IFNB 1b has no effect on BMD.

Evaluation of patients with multiple sclerosis using a combination of morphometrical features and clinical scores.

Our aim was to measure cerebellum volume (CV), sclerotic plaque numbers (PN), and plaque surface area (SA) in the parietal lobe, and to investigate the relationship between CV and PN or SA in the parietal lobe, and the clinical status of patients with multiple sclerosis (MS). MRIs were performed in 14 patients with relapsing-remitting MS (RRMS), 13 patients with secondary progressive MS (SPMS), and 26 healthy control participants. The Cavalieri method was used to measure CV and SA. The cerebellum volume was significantly reduced in MS patients compared to controls (p < 0.01). In all patients, CV was negatively correlated with the duration of the disease, relapse number, and Expanded Disability Status Scale (EDSS) scores (p < 0.01). CV was related to mean PN in both the right and left parietal lobes (p < 0.01) and mean SA (p < 0.05) in RRMS patients; CV was also correlated with mean PN (p < 0.01) and mean SA (p < 0.05) in SPMS patients. The progression index (Pi) values were 2.03 +/- 0.4 in RRMS patients and 0.83 +/- 0.2 in SPMS patients (p = 0.023, t = 2.612) (where Pi = EDSS/time from onset in years). We propose that atrophy begins both in the supratentorial and infratentorial areas simultaneously in the RR stage, and that the Cavalieri method can be used to predict SPMS among patients with RRMS.

Prognostic values of lesion volume and biochemical markers in ischemic and hemorrhagic stroke: a stereological and clinical study.

PURPOSE: Our aim was to evaluate the relationship between lesion volume, serum level of biochemical markers, and clinical situation in ischemic and hemorrhagic stroke. METHODS: MRI was obtained on 33 ischemic and 28 hemorrhagic strokes. The Cavalieri method was used to measure the volume. To evaluate neurological situation of the patients, we used the National Institutes of Health Stroke Scale (NIHSS) and Rankin Disability Scores at the first, third, seventh, and thirtieth days. We measured the level of leptin, high sensitivity C-reactive protein (hs-CRP), insulin, cortisol, fibrinogen, protein C, protein S, von Willebrand factor, D-dimer, Antitrombin III, and Factor VIII (F VIII) at the same time intervals. RESULTS: In ischemic events, cortisol level at third and seventh days, and fibrinogen level at the first day were correlated with lesion volumes (r = 0.5, p = .02; r = 0.4, p = .02; r = 0.5, p = .005, respectively). In hemorrhagic events, only fibrinogen level was correlated with lesion volumes at third day (r = 0.6, p = .04). No significant differences were found among all these biochemical parameters, neurological situation (p > .05), and lesion volumes at all times. CONCLUSION: In the prediction of stroke prognosis, lesion volume and all of the evaluated biochemical parameters are not deterministic factors.

Na VPA-induced acute ischemic stroke in an epileptic patient with methylenetetrahydrofolate reductase gene polymorphism.

A 23-year-old man using Na-Valproic acid (VPA) was admitted to our clinic due to convulsion. The neurological examination revealed right hemiparesis. From the exitus notes, we learned that his two siblings had died from status epilepticus. Magnetic resonance imaging (MRI), MRI spectroscopy, and diffusion-weighted investigations (DWI) showed acute-subacute ischemic stroke in the left temporo-parieto-occipital region. The patient had an ischemic stroke. Heterozygote methylenetetrahydrofolate reductase (MTHFR) 677C/T polymorphism was determined on genetic examination. The homocysteine (Hcy) level was 18.2 mmol/l (5-15 mmol/l). So VPA treatment was stopped and oxcarbazepine treatment was started. MTHFR 677C/T polymorphism is associated with the risk of vascular diseases due to hyperhomocysteinemia. Heterozygote (MTHFR) 677C/T polymorphism has not been reported to be associated with epilepsy. In patients with heterozygote (MTHFR) 677C/T polymorphism and under long-term use of certain drugs the determination of Hcy plasma levels may be useful to prevent the development of atherothrombotic disease.

Prognosis of patients with mesial temporal lobe epilepsy due to hippocampal sclerosis.

PURPOSE: Hippocampal sclerosis (HS) is the most common pathology in mesial temporal lobe epilepsy (MTLE). There are a few reports concerning prognosis in patients with MTLE-HS treated medically. The study was carried out to determine the clinical risk factors affecting prognosis. METHODS: We enrolled 287 patients with MTLE-HS treated medically. Gender, age at onset of epilepsy, history of trauma, infection, febrile convulsion, status epilepticus, mental retardation, handedness, consanguinity, side of hippocampal sclerosis, additional extrahippocampal temporal lesion, aura, seizures types, antiepileptic drugs, psychiatric disturbances and seizure frequency were noted. All patients were divided into three groups. Group I: patients seizure-free during follow up, Group II: patients with improved seizure control whose seizure frequency had decreased >50% after the treatment, and Group III: patients with poor seizure control whose seizure frequency had no change or increased. Each clinical feature was also compared among three subgroups statistically. RESULTS: Early age of seizure onset [Group II-III (p=0.000) and Group I-III (p=0.0004)], age of head trauma [Group II-III (p=0.04)], the presence of mental retardation (p=0.04) and female sex (p=0.03) were risk factors for poor prognosis. However, the other parameters did not affect prognosis. CONCLUSION: Recognizing bad prognostic features such as the presence of mental retardation, early age of seizure onset, age of head trauma and female gender may help physicians to identify risk groups with MTLE-HS and drug resistance seizures for epilepsy surgery.