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.

Multiple sclerosis patients with and without sexual dysfunction: are there any differences?

OBJECTIVE: Sexual dysfunction (SD) severely affects the quality of life in patients with multiple sclerosis (MS). The aim of this study is to investigate the type and frequency of sexual complaints in MS patients, to analyse their relationship to various clinical and psychosocial variables and to clarify the differences between MS patients with and without SD. METHODS: Thirty-five relapsing-remitting (RR), nine secondary progressive and seven primary progressive MS patients were included in this study. A structured face-to-face interview regarding sexual function and other physical problems which may interfere with sexual functioning was administered to each patient. They also filled out Multiple Sclerosis Intimacy and Sexuality Questionnaire-19 (MSISQ-19), which includes items for primary (direct physical), secondary (indirect physical) and tertiary (psychosocial) causes of SD. Disability, cognitive functions and psychological functioning were also evaluated. RESULTS: Forty-one patients (80.4%) reported primary SD; decreased libido was the most frequent complaint (80.5%). These patients were older and more disabled, however 39% had low disability scores. SD was a common problem for both men and women. Patients with RRMS were affected less in all items of primary SD. Several items of secondary SD--problems with memory and concentration, bladder symptoms, bowel symptoms--showed correlation with different items of primary SD; these were altered genital sensation, decreased libido, increased time for arousal, decreased lubrication/difficulties with erection. Total MSISQ-19 scores were correlated with disease duration, age, disability, disease course, Beck depression scale, temporary and long-standing anxiety and low level of education. CONCLUSION: SD is an underestimated, common symptom of MS. It may occur in MS even in the absence of severe disability. Physicians' awareness of this problem may help to bring about appropriate treatments and management, and improve the quality of life for these patients.

The effects of cold stress test on vasomotor tonus in normal controls.

Plethsymographic recordings are used to evaluate changes in peripheral vascular tonus. Twenty-six volunteers (15 men, 11 women) with a mean age 31 years were included in this study. Plethsymographic recordings were done both at baseline and +40C temperatures bilaterally. Significant reductions in systemic blood flow were noted with different maneuvers. Reactive hyperemia occurring after ischemia was local, however local reduction in blood flow after cold test was systemic. As the local temperature increased, the blood flow parameters normalized, too. In normal controls these values normalized in 20 minutes. The changes in vasomotor tonus due to cold test demostrated a parallel pattern.

Vascular parkinsonism: a distinct, heterogeneous clinical entity.

OBJECTIVES: The aim of this study was to define the symptoms and signs of suspected vascular parkinsonism (VP) which is still a debatable concept. MATERIAL AND METHODS: Patients with parkinsonism were grouped into patients with suspected VP and Parkinson's disease (PD) after other causes for secondary parkinsonism, and parkinsonism-plus syndromes were excluded. The clinical features of 16 patients with suspected VP to those of 50 diagnosed with PD were compared. All patients were assessed using unified Parkinson's disease rating scale (UPDRS) and all had cerebral MRIs. RESULTS: Patients with VP had significantly older onset age and shorter duration of disease with gait disorder as the most frequent initial symptom. All PD patients had satisfactory response to levodopa treatment, whereas only 38% VP patients had satisfactory response to levodopa treatment. Vascular risk factors were more common in VP (81%) than PD (32%). Postural instability, freezing, gait disturbance, pyramidal signs, and postural tremor were significantly more prevalent in patients with VP than in PD. In VP patients these features were more prominent in the lower limbs. Twenty-five percent had acute onset VP. All patients with VP had ischemic lesions, mainly in subcortical white matter, to a lesser extent basal ganglia and brainstem, in their cerebral MRIs, while 70% of PD patients had normal MRIs. CONCLUSION: The differences in the clinical features support the concept that VP is a distinct clinical entity with heterogeneous clinical, MRI, and possibly pathophysiological features.

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 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.

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.

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.

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.

Cerebral responses elicited by stimulation of the vesico-urethral junction (VUJ) in diabetics.

To investigate the involvement of the visceral afferent nerves in diabetes mellitus, we enrolled 46 male patients in a study, examining the cerebral potentials evoked by stimulation of the vesico-urethral junction (VUJ CEP) and the pudendal (penile CEP) and posterior tibial nerves (tibial CEP). The age range was 23-67 (mean 45.8) years. The epithelial surface of the vesico-urethral junction was stimulated bipolarly with an electrode attached to a specially produced Foley catheter. Cerebral responses were recorded bipolarly at vertex. VUJ CEPs were absent (27 patients) or protracted and/or of low amplitude (4 patients) (total 31 patients; 67.8%). Penile CEP and/or tibial CEP could be obtained in all cases; however, protracted P1 peak latencies were detected in 15 (32.8%). The abnormalities of VUJ CEP did not correlate with the presence of peripheral neuropathy, while the abnormalities of penile CEP and/or tibial CEP invariably coincided with the presence of peripheral neuropathy. Although neither age nor the duration of diabetes correlated with abnormal CEPs as determined by any of the tests, insulin dependence correlated with abnormal penile CEP and to a lesser extent with VUJ CEP. We conclude that VUJ CEP is informative in evaluating the physiological condition of visceral afferents, and can be used in diagnosis of the early involvement of visceral afferents in diabetes mellitus.

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.

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.

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.

Bulbocavernosus reflex to somatic and visceral nerve stimulation in normal subjects and in diabetics with erectile impotence.

Bulbocavernosus reflex to stimulation of the vesicourethral junction and glans penis was recorded in 14 normal controls and 24 diabetic men complaining of erectile impotence. In all normal subjects the bulbocavernosus reflex to stimulation of these sites could be obtained, and mean latencies were 59.2 +/- 8.0 msec. and 33.3 +/- 3.7 msec., respectively (p less than 0.00001). A total of 66 per cent of the diabetics (16 patients) exhibited abnormal (delayed or absent) bulbocavernosus reflex to stimulation of the vesicourethral junction, while only 12.5 per cent (3 patients) had delayed response to glans penis stimulation. The latter tended to remain within normal limits, although the mean latency was significantly different from that of normal subjects (p less than 0.05). Abnormalities of the bulbocavernosus reflex to stimulation of the vesicourethral junction correlated strongly with the presence of peripheral and autonomic neuropathy, diabetes and organogenic impotence. Our results indicate that this is an informative test for the evaluation of visceral afferents arising from the bladder neck and, hence, in the differential diagnosis of organogenic versus psychogenic erectile impotence.

Cerebral responses evoked by stimulation of the vesico-urethral junction in normal subjects.

Following bipolar stimulation of the vesico-urethral junction (VUJ), evoked potentials (EPs) with a late and prominent negativity (mean latency 91.4 +/- 11.0 msec) were recorded from scalp in 22 male subjects. Although remarkable intersubject variations occurred, no peak variation could be seen in any given subject. Maximum amplitude of the EPs was recorded from Cz and CzP points. Stimuli with various frequencies did not lead to any differences in shape and latency of EPs. The differences between the EPs by bipolar stimulation of the VUJ and the responses elicited by distal urethral and pudendal nerve stimulation suggest that, during bipolar stimulation of VUJ, the somatic afferents were not excited. Therefore, these responses were most likely due to the excitement of the visceral afferents arising from the VUJ separately. This method may be a useful technique for evaluating the physiological condition of the afferent nerves arising from VUJ.

Cerebral responses evoked by stimulation of vesico-urethral junction in man: methodological evaluation of monopolar stimulation.

Cerebral responses after bipolar stimulation (BpS) and monopolar stimulation (MpS) of the vesico-urethral junction (VUJ), as well as skin surface stimulation of various hip and pelvic structures, were recorded in 13 normal control subjects. BpS of VUJ produced cerebral evoked potentials (CEPs) with a negative peak (mean latency 88.69 +/- 13.73 msec) following a smaller positive deflection, while MpS of the same sites with indifferent electrodes placed on various pelvic or hip structures resulted in different response latencies that were all significantly shorter than those of BpS. Shape and latency of responses after MpS of VUJ were similar to those elicited by skin surface stimulation of the abdominal wall and the iliac crest; those elicited by pudendal nerve stimulation at the glans were also similar in shape but significantly greater in latency. Results strongly indicate that during MpS of VUJ the somatic or muscle afferents located in the hip and pelvic region are stimulated; consequently, BpS technique should be considered the preferred technique for investigating the physiological condition of visceral afferents arising from VUJ.

Descending lumbosacral cord potentials (DLCP) evoked by stimulation of the median nerve.

In 22 normal human subjects, descending lumbosacral cord potentials (DLCP) were recorded intrathecally after stimulation of the median nerve at the elbow. The onset of DLCP is very short in latency (mean 12.1 ms) with a prominent sharp early positive peak (mean latency 13.7 ms) followed by a sharp negative peak (mean 17.6 ms). The amplitude of the first part of DLCP varied between 0.6 and 6.7 microV (mean 2.3 microV). The response was recorded most easily when the tip of intrathecal electrode was posterolaterally positioned. The threshold of the response was above or around the excitation threshold of the motor nerve fibers and it could not be produced by pure skin nerve stimulation. It resisted to subtetanic peripheral shocks. Mean peripheral conduction velocity responsible for the response was about 60.8 m/s. Some late and slower deflections appeared in many cases. It was concluded that the DLCP must have originated from the descending and very fast conducting propriospinal pathways located within the anterolateral funiculus which has an oligosynaptic anatomical organization. This response seemed to be the first direct evidence of interlimb reflex action between the arm and leg in man which is important in the coordination of movements and posture.

Somatosensory cerebral potentials evoked by stimulation of the lumbo-sacral spinal cord in normal subjects and in patients with conus medullaris and cauda equina lesions.

Somatosensory cerebral evoked potentials were recorded by intrathecal stimulation of the lumbo-sacral cord and roots in 16 normal subjects and patients having cauda/conus injury (group A, 15 cases), compressive lesions of cauda equina (group B, 13 cases) and lesions of both types covering the lumbar cord (group C, 24 cases). The shape of the intrathecally evoked cerebral potential (IECP) was basically the same as that obtained by posterior tibial nerve stimulation from 12 normal subjects except that the early components were 10-15 msec shorter in latency in the former potential, with an average of 12 msec. IECPs were easily recorded in groups A and B, but a significant delay was found in both groups, especially group A. It was difficult to obtain the IECP in group C, When it could be recorded the latency increase was apparent. These findings were explained on the basis of degeneration of the ascending spinal nerve fibers proximal to the lesion site.

Studies on the human spontaneous electromyelogram (EMyeloG). III. Spontaneous spinal cord activity of the cat relevant to the human spontaneous EMyeloG.

The spontaneous electromyelogram (EMyeloG) was investigated in 16 cats, some after laminectomy and some by a percutaneous intrathecal technique similar to the human approach. Small diphasic negative-positive waves at less than 50 microV, with short durations, were consistently recorded from the posterior aspect of the spinal cord in both laminectomized and intact cats. It was demonstrated that this kind of background activity is mainly located within the posterior halves of the spinal cord and is strictly dependent on the peripheral inputs producing excitability changes in the gray matter of the posterior horn. Monophasic positive waves of larger amplitude were often recorded from the anterior halves of the spinal cord in both types of recording. However, the amplitude of the background activity of spontaneous EMyeloG was smaller in the percutaneous approach and negative sharp waves (NSWs) of large amplitude were never seen in these intact cats. NSWs were only observed in the majority of the laminectomized cats and were facilitated after spinalization. It was proposed that when the central and peripheral nervous system are intact in awake states, it is impossible to see NSWs either in human subjects or in cats.