Thalamic aphasia syndrome.

Eighteen patients (11 male, 7 female) with left thalamic haemorrhage confirmed by CT-scan of the brain were investigated for their language function. Aphasia Test for Turkish Citizens modified from Mayo Clinic Aphasia Test and Boston Diagnostic Aphasia Examination were given for evaluating the language modalities. Fluent aphasia was observed in 16 subjects (with paraphasia in 8 and hypophonia in 3). Dysarthric speech output was seen in 2 cases. Repetition and naming were well preserved while comprehension was moderately affected. This type of aphasia differs considerably from the classical aphasias and its rapid recovery is a very prominent feature.

Bromocriptine is ineffective in the treatment of chronic nonfluent aphasia.

The effect of bromocriptine on chronic nonfluent aphasia was investigated in 4 patients suffering from a stroke 24 to 35 months before the onset of this study (average 29 months). Two patients had Broca, one had global and the other transcortical motor aphasia. CT-scans demonstrated anterior-posterior infarctions in 3 patients and anterior infarction in one. Bromocriptine was given initially at a dosage of 10 mg/day, and of 25 mg/day during the follow ups. By means of aphasia tests, bromocriptine was found to be ineffective for the treatment of any symptoms of chronic nonfluent aphasia.

Subcortical crossed aphasia.

A 55 year-old, right-handed, hypertensive woman with global aphasia, due to a spontaneous hemorrhage in the right putamen extending to the periventricular white matter was examined thirteen days after the acute onset of stroke. She had left hemiplegia and inability to speak. She displayed no spontaneous speech output and was capable only of occasional undifferentiated grunts in conversation. Other language modalities such as auditory and reading comprehension, naming, repetition and writing were severely impaired. Her aphasia was classified as global aphasia. Forty-five days after the onset of stroke, rapid recovery from the aphasia with mild deficits in speaking, naming, and repetition was detected. This case is a good example of crossed aphasia, favouring the importance of deep structures of the right hemisphere in this type of aphasia. Rapid recovery is an important feature.

Wegener's granulomatosis : a case with multiple symmetric cranial neuropathies.

A 47 year-old woman with Wegener's granulomatosis presented with an atypical onset of multiple symmetric cranial nerve involvement. The diagnosis was established by clinical examination and laboratory data. To our knowledge, this is the first case of Wegener's granulomatosis presenting with bilateral multiple symmetric cranial neuropathies.

Wegener's granulomatosis : a case with multiple symmetric cranial neuropathy.

We report a 47 year-old woman with Wegener's granulomatosis presenting with an atypical onset of multiple symmetric cranial neuropathies. The diagnosis was established by clinical and laboratory data. To our knowledge, this is the first case of Wegener's granulomatosis presenting with bilateral multiple symmetric cranial neuropathy.

Accuracy of bedside diagnosis versus Allen and Siriraj stroke scores in Turkish patients.

Computerized tomography and magnetic resonance imaging allow the accurate diagnosis in stroke and distinction of ischemic from hemorrhagic lesions. However, clinical diagnosis is still critical where neuroimaging techniques are not available, especially to establish first-aid measures in a stroke patient. In this prospective study of 300 patients with stroke, the diagnosis of ischemic and hemorrhagic strokes was made as an informal bedside diagnosis prior to neuroimaging. The accuracy of bedside diagnosis was also compared with the results of the Allen and Siriraj stroke scores. Then, the reliability of these scores and our informal bedside diagnosis, along with the final diagnosis, were compared with each other. Our informal bedside diagnosis was correct in 250 of the 300 patients (83.3%). The diagnostic sensitivity and positive predictive value (PPV) of bedside diagnosis for ischemic stroke were 87.8% and 86.0% and for intracerebral hemorrhage 75.7% and 78.5%, respectively. Sensitivity and PPV for every cut-off value of the Allen and Siriraj stroke scores were less than that of sensitivity and PPV of informal bedside diagnosis. When the receiver operating curves obtained from the Allen and Siriraj stroke scores were compared, the Allen stroke score was found to be a better predictor in the final diagnosis. Our data suggest that an informal bedside diagnoses is as good as diagnoses made on certain intracerebral hemorrhages and on certain ischemic strokes by the Siriraj and Allen stroke scores; when compared, the Allen score seems to be better than the Siriraj stroke score. Hence, the use of both scores is recommended in epidemiologic studies as a screening tool as suggested by previous studies employing other diagnostic tools in clinics.

Crossed aphasia in multiple sclerosis.

Aphasia is a rare sign of multiple sclerosis (MS). Several different forms of aphasia have been reported in MS. We report, to our knowledge, the first case of a MS patient with crossed aphasia during an attack.

Friedreich's ataxia: a clinical review of 20 childhood cases.

The authors report the clinical review of 20 childhood cases with Friedreich's ataxia. The mean age at onset of symptoms was 6.1 years. The main presenting symptom was abnormal gait (100%). Ataxia of gait and limbs and depressed or absent tendon reflexes were found in all cases. Clinical findings are in accordance with the findings of Harding and Werdelin. Neurophysiological studies (especially sensory) are important in the confirmation of the diagnosis. Of the 10 cases in which sensory nerve conduction velocity measurements were performed, 7 had absent sensory action potentials, 2 had decreased potentials and one was normal. In our study, it is shown that in patients having ataxic gait, ataxia of limbs and tendon reflexes depression or loss, Friedreich's ataxia may be diagnosed with the help of electrophysiological studies.

Low prevalence of mitral valve prolapse in bipolar affective disorder.

The authors report the prevalence of mitral valve prolapse in bipolar affective disorder. 22 bipolar patients (13 men and 9 women; age 17-75 years, mean 42.3) were selected at random from 41 bipolar patients for echocardiographic examination. Diagnosis of mitral valve prolapse was made if prolapsus of the anterior or posterior valve to the left atrium was seen in the two-dimensional echocardiography and if mid-to late-systolic posterior motion of the mitral valve was greater than 2 mm in M-mode echocardiography. Of the 22 bipolar patients, only two had mitral valve prolapse. This rate does not differ significantly from the 5% rate found in the general population.

Detection of aortic plaques by transesophageal echocardiography in patients with ischemic stroke.

Twenty-eight consecutive patients, aged 34-78 years with non-cardiogenic ischemic stroke were evaluated by transesophageal echocardiography (TEE). All patients were in sinus rhythm. Six of 28 patients (21.4%) displayed protruding masses in the aortic lumen. Five of these masses were located in the ascending aorta and one in the thoracic aorta. Our study suggests that cerebral infarction may also be due to aortic atherosclerotic plaques. Although our findings do not necessarily provide a causative link between atherosclerotic lesions in the aortic lumen and cerebral infarction, they may be an alternative potential source of stroke. TEE is the method of choice in detecting such lesions at the present time.

Early-onset cerebellar ataxia with retained tendon reflexes.

The authors report a clinical review of 16 childhood cases with early-onset cerebellar ataxia with retained tendon reflexes. The preservation of tendon reflexes distinguishes this disorder from Friedreich's ataxia. The mean age of onset of symptoms was 7.1 years. The main presenting symptom was abnormal gait (100%). Ataxia of gait and limbs and normal or increased tendon reflexes were found in all cases. This disorder is associated with dysarthria, pyramidal signs in the limbs, and in some instances, sensory loss. Other important differences from Friedreich's ataxia are absence of optic atrophy, diabetes mellitus, cardiomyopathy and severe skeletal deformity. Sensory nerve conduction was found to be normal, excluding one case. This finding constitutes another aspect of the syndrome different from Freidreich's ataxia. CT scans were normal in 2 of the 4 cases. The remaining two cases showed cerebellar atrophy. Inheritance is probably autosomal recessive in the majority of cases.

Transesophageal echocardiography in various ischemic stroke subtypes.

Transesophageal echocardiography (TEE) is more sensitive than transthoracic echocardiography (TTE) in detecting the potential source of emboli in cardioembolic strokes (CES). To establish the prevalence of a potential cardiac source of embolism detectable on TEE and its relationship to vascular risk factors, an unselected ischemic stroke population was evaluated. Twenty-six age and sex-matched cases with normal cardiological and neurological examinations as well as normal CT-scans, TTE and ECGs were included in the study as the control group. One hundred and eight patients with cardioembolic stroke (53 patients), atherothrombotic stroke (36 patients), and lacunar stroke (19 patients) were investigated by TTE and TEE. Seven of the 26 (26.9%) controls had thoracic atherosclerotic plaques on TEE examinations. The prevalence of abnormal TEE findings in patients was higher compared to the controls (p < 0.001). TEE revealed more specific findings in every etiological group when compared to TTE (74.0% vs 10.2%, p < 0.001). Atrial fibrillation correlated with the abnormalities of TEE (p < 0.05) while other risk factors did not. Left atrial spontaneous echo contrast was the most common finding on TEE of cases with cardioembolic stroke while atherosclerotic aortic plaques were mostly encountered in patients with atherothrombotic stroke. No specific findings by TEE were seen in patients with lacunar stroke. TEE is capable of detecting definite etiologies in cardioembolic stroke and associated cardiac pathologies in atherothrombotic stroke and lacunar stroke. These observations suggest that TEE is a useful tool to guide the physician for the treatment of ischemic stroke patients.

Thromboembolism risk in patients with mitral stenosis.

A total of 168 consecutive patients with predominant rheumatic mitral stenosis were evaluated by transthoracic (TTE) and transesophageal echocardiography (TEE). Of the 168 patients, 35 had previous embolic events (group I) and 133 had no emboli (group II). A total of 77 (45.8%) patients had atrial fibrillation. The frequency of atrial fibrillation was higher in group I than group II (68.6% vs 39.8%, p < 0.001). The incidence of left atrial enlargement was greater in group I (p < 0.001). Mitral valve area was found to be smaller in group I compared to group II (p < 0.001). In group I 83.3% and 29.2% of the patients with atrial fibrillation had left atrial spontaneous echo contrast (SEC) and left atrial thrombus, respectively, and 72.7% of the patients with sinus rhythm had left atrial SEC. In group II 79.2% and 20.8% of the patients with atrial fibrillation had left atrial SEC and left atrial thrombus whereas 28.6% and 2.6% of the patients with sinus rhythm had left atrial SEC and left atrial thrombus, respectively. The incidence of left atrial thrombus was significantly different in those patients with compared to those without embolic events (20% vs 9.7%, p < 0.01). In groups I and II, 28 of 35 (80%) and 64 of 133 (48.1%) patients had left atrial SEC (p < 0.01). Patients with left atrial SEC had a greater left atrial size (p < 0.01) and smaller mitral valve area (p < 0.01). Left atrial size was normal in 2 patients with left atrial SEC and SEC was not found in 55 patients with enlarged left atrium. Multiple logistic regression analysis showed that atrial fibrillation, mitral valve area and left atrial enlargement were independent predictors of the SEC (p < 0.001) and left atrial SEC was the principal determinant of thromboembolism. These data suggest that regardless of rhythm and atrial size, left atrial SEC is a principal determinant of thromboembolic risk in mitral stenosis. TEE may be able to detect those patients with mitral stenosis at risk for emboli and guide appropriate therapy.

Silent cerebral lesions on magnetic resonance imaging in subjects with coronary artery disease.

MRI of subjects with silent intracranial damages may provide more evidence than CT. Our objectives were to determine the prevalence of silent MRI lesions in patients with coronary artery disease. The study included 72 consecutive patients with angiographically proven coronary artery disease and 26 age and sex matched controls with normal coronary angiography. All subjects were evaluated for coronary atherosclerosis (Gensini and coronary angiography scores), the number of silent cerebral lesions detected by MRI, carotid stenosis and the risk factors for stroke. Thirty one of 72 (43.0%) patients had silent brain lesions on MRI while 8 of 26 (30.7%) control subjects showed silent brain infarction. The main finding on T2-weighted MRI was white matter hyperintensities (WMH) which were seen in all patients with silent brain lesions. The mean age of the patients with coronary artery disease and with silent cerebral lesions was significantly higher than that of patients without silent brain lesions. The Gensini score, coronary angiography score and prevalence of carotid stenosis are significantly higher in patients with silent cerebral lesions than that of patients without silent cerebral lesions. There was no significant difference between silent cerebral lesions and the other risk factors for stroke. Silent brain lesions are a common complication in patients with coronary artery disease. In patients with coronary artery disease, carotid artery stenosis and age were important risk factors for the development of silent brain infarction.