Subthalamic Nucleus Deep Brain Stimulation in a Patient with Severe Axial Symptoms and Suboptimal Levodopa Responsive Parkinson's Disease.

AIM: Deep brain stimulation (DBS) is a well-established treatment option for improving function and quality of life (QoL) in carefully selected patients with Parkinson?s disease (PD). Patient selection is a crucial step that should be performed by an experienced multidisciplinary team according to the proposed inclusion and exclusion criteria to increase the QoL of patients. CASE REPORT: A 47-year-old bedridden woman with a 20-year history of PD presented with levodopa-unresponsive tremor and severe axial symptoms. Despite various antiparkinsonian medications, a suboptimal improvement was observed with the levodopa challenge test. After detailed evaluations, she underwent bilateral subthalamic nucleus DBS. During the 2-year follow-up, her axial symptoms improved significantly leading to a better QoL. CONCLUSION: Although levodopa-resistant axial symptoms are considered a relative contraindication to DBS surgery, this case report demonstrates that with an interdisciplinary approach and an accurate assessment of symptoms, even bedridden and latestage selected PD cases may benefit from DBS.

Deep Brain Stimulation of the Globus Pallidus Internus for Secondary Dystonia: Clinical Cases and Systematic Review of the Literature Regarding the Effectiveness of Globus Pallidus Internus versus Subthalamic Nucleus.

OBJECTIVE: Deep brain stimulation (DBS) is a frequently applied therapy in primary dystonia. For secondary dystonia, the effects can be less favorable. We share our long-term findings in 9 patients with severe secondary dystonia and discuss these findings in the light of the literature. METHODS: Patients who had undergone globus pallidus internus (GPi)-DBS for secondary dystonia were included. Burke-Fahn-Marsden Dystonia Rating Scale (BFMDRS) scores, clinical improvement rates, follow-up periods, stimulation parameters and the need for internal pulse generator replacements were analyzed. The PubMed and Google Scholar databases were searched for articles describing GPi-DBS and subthalamic nucleus (STN)-DBS only for secondary dystonia cases. Keywords were "dystonia," "deep brain stimulation," "GPi," "dystonia," "deep brain stimulation," and "STN." RESULTS: A total of 9 secondary dystonia patients (5 male, 4 female) had undergone GPi-DBS with microelectrode recording in our units. The mean follow-up period was 29 months. The average BFMDRS score was 58.2 before the surgery, whereas the mean value was 36.5 at the last follow-up of the patients (mean improvement, 39%; minimum, 9%; maximum, 63%). In the literature review, we identified 264 GPi-DBS cases (mean follow-up, 19 months) in 72 different articles about secondary dystonia. The mean BFMDRS improvement rate was 52%. In 146 secondary dystonia cases, reported in 19 articles, STN-DBS was performed. The average follow-up period was 20 months and the improvement in BFMDRS score was 66%. CONCLUSIONS: Although GPi-DBS has favorable long-term efficacy and safety in the treatment of patients with secondary dystonia, STN seems a promising target for stimulation in patients with secondary dystonia. Further studies including a large number of patients, longer follow-up periods, and more homogenous patients are necessary to establish the optimal target for DBS in the management of secondary dystonias.

Microelectrode Recording for Deep Brain Stimulation of the Subthalamic Nucleus in Patients with Advanced Parkinson's Disease: Advantage or Loss of Time?

AIM: To investigate the effect of using microelectrode recording (MER) on the length of time required to carry out a deep brain stimulation (DBS) procedure of the subthalamic nucleus in patients with Parkinson's disease (PD). MATERIAL AND METHODS: The time required to include MER in the DBS operation was calculated for the first and second sides in 24 patients with PD. The number of microelectrodes used on each trajectory for the first and second sides, and the percentage of permanent electrodes implanted on each trajectory for the first and second sides, were quantified. RESULTS: The average times taken to use MER were 23.4 ± 6.2 minutes, 17.4 ± 6.5 minutes, and 41.2 ± 6.3 minutes for the first side, second side and total procedure, respectively. In 75% of patients, the permanent electrode was implanted at the planned target site for the first side, and in 61% of patients for the second side. CONCLUSION: MER extends the time required to carry out the DBS procedure. However, during surgery, it provides real-time information on the electrodes' neurophysiological locations and helps the surgical team choose an alternative target if the planned target does not produce satisfying results.

Effect of Age and Disease Duration on the Levodopa Response in Patients with Advanced Parkinson's Disease for Deep Brain Stimulation of the Subthalamic Nucleus.

BACKGROUND: Deep brain stimulation (DBS) has become a preferred option for the treatment of motor symptoms in patients with advanced Parkinson's disease (PD). A good levodopa response (LR) is considered the most important criterion in determining the suitability of a patient for DBS. However, the effect of age and disease duration (DD) on the LR is still a subject of discussion. OBJECTIVE: Here, we investigated the effect of age and DD on the preoperative LR in PD patients to be selected for DBS. METHODS: From August 2011 to May 2015, 54 consecutive patients (29 men and 25 women) with advanced PD were evaluated for DBS of the STN and included in this retrospective study. RESULTS: Thirty-seven patients were found suitable for DBS of the STN and 29 of them underwent bilateral surgery. We found no significant correlation between DD and the LR. However, there was a significant negative correlation between the patients' age and the LR. CONCLUSION: The results indicate that the patients' age, rather than DD, has a negative effect on the LR. The study, therefore, indicates that PD patients with an advanced age and with a poor LR are not good candidates for DBS of the STN.

Three-year experience in the Emergency Department: the approach to patients with spinal trauma and their prognosis.

BACKGROUND: Spinal cord injuries result in critical pecuniary and/or non-pecuniary losses due to the developing neurological problems. The objective of this study was to evaluate spinal injuries in terms of clinical severity and prognosis. Spinal injuries lead to serious clinical results due to the high rates of morbidity and mortality; however, there is a lack of reliable information on spinal injuries in our country. METHODS: Following the approval of the Faculty Ethics Committee, this retrospective study was conducted on 91 patients aged ?18 (59 male, 32 female) with spinal trauma who were admitted to the Emergency Department of Ondokuz Mayis University over three years. The patients were assessed in terms of demographics, clinical severity, developing complications, and mortality. RESULTS: Forty-three patients had complete injuries, while 48 had incomplete injuries. Forty-six patients suffered spinal injuries due to fall from height, 35 patients due to traffic accidents, and 10 patients due to other reasons. Several complications were observed in 52 patients, while no complication occurred in 39 patients. We determined that 19 of 92 patients involved in this study died, while 72 were discharged from the hospital. CONCLUSION: Spinal cord injuries generally result in unfavorable clinical results. Therefore, an appropriate approach (early diagnosis and true treatment) in emergency services has great significance.

Does probe's eye subthalamic nucleus length on T2W MRI correspond with microelectrode recording in patients with deep brain stimulation for advanced Parkinson's disease?

AIM: Subthalamic nucleus (STN) deep brain stimulation (DBS) has become a well-accepted treatment for patients with advanced Parkinson's disease (PD). During surgical planning for DBS, the length of the STN is taken into account and verified during microelectrode recording (MER) intraoperatively. Here, we addressed the question to which extent the length of the STN measured with the T2 weighted MRI in the probe's eye view corresponded with the intraoperatively determined length of the STN with MER. MATERIAL AND METHODS: We included 10 consecutive Parkinson's disease patients who underwent STN DBS surgery. The length of the STN in the probe's eye view mode was calculated along the trajectory of the central MER electrode crossing the STN. RESULTS: Our analysis showed no statistical difference between the length of the STN measured with the T2 weighted probe's eye view mode and the MER (right STN length 5.8 ± 0.9 mm MRI vs. 6.3 ± 0.5 mm MER, p > 0.05; left STN length 5.6 ± 0.4 mm MRI vs 5.8 ± 1 mm MER, p > 0.05). CONCLUSION: This means that the entry and the exit of the STN can be adequately estimated using the probe's eye view preoperatively.

Conversion of local anesthesia-guided deep brain stimulation of the subthalamic nucleus to general anesthesia.

BACKGROUND: Deep brain stimulation of the subthalamic nucleus (STN) is a widely applied procedure in the treatment of patients with advanced Parkinson disease and is generally performed under local anesthesia. Here we report our experience with the conversion to general anesthesia in two patients with advanced Parkinson disease because of fear reactions intraoperatively. CASE DESCRIPTION: Patients received general anesthesia with propofol and were implanted with electrodes at the level of STN guided by multiple-microelectrode electrophysiological recordings after obtaining informed consent. During the recordings the propofol levels were reduced. Postoperative clinical assessments showed marked improvements of motor disability with significant reductions of dopaminergic medication. CONCLUSION: Our case observations document the possibility of fear reactions intraoperatively and show the possibility of conversion to general anesthesia with a successful outcome.

Isolated unilateral vagus nerve palsy secondary to trauma.

A 41-year-old man presented to emergency service with loss of consciousness lasting 20 minutes after a piece of wood struck the right side of his face. Shortly after admission, he developed difficulty swallowing. On admission, he was alert and had normal vital findings. There was no motor, sensorial, or cerebellar deficit. Deviation of the uvula to the left side and pharyngeal reflex loss on the right side was obvious. The right vocal cord was paralyzed. Other cranial nerves were intact on examination. The patient's cranial computed tomography (CT), CT-angiogram, cranial and neck magnetic resonance (MR) imaging, MR-angiogram, and cervical and lung X-ray were normal. We evaluated this case with isolated unilateral vagus nerve palsy (VNP) secondary to trauma at the emergency department. Our case illustrated that trauma can cause isolated VNP with the absence of abnormal findings on imaging modalities.

The myopathic effects of electrical injury.

BACKGROUND: In this study, we investigated the effect of voltage levels on muscle damage in patients with electrical injuries. METHODS: This retrospective study included 36 patients with electrical injury (high voltage, 21; low voltage, 15). Initial serum creatine kinase (CK), aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were obtained from each patient on admission. RESULTS: Although CK levels were observed to be higher in the high-voltage injured patients than in those exposed to a low voltage, the difference was not statistically significant. The serum AST and ALT levels were elevated in both groups, but there was no significant difference between the groups. CONCLUSION: Skeletal muscle damage can be caused by both high-voltage and low-voltage electrical injury, and in these patients, the degree of muscle damage may be consistent with the elevated initial serum levels of muscle enzymes, especially of CK. However, further researches are necessary to determine if there is strong evidence of a direct correlation between voltage level and the degree of muscle damage.

Elevated serum hyaluronic acid and interleukin-6 levels in patients with mushroom poisoning admitted to the emergency department.

OBJECTIVE: To assess the possible use of hyaluronic acid (HA) and interleukin-6 (IL-6) together as a biochemical marker of liver damage in mushroom poisoning (MP). METHODS: We prospectively studied patients with MP who were admitted to the emergency service, between April 2005 and April 2007, Samsun, Turkey. Twenty-seven patients with MP were included in the study. Serum HA and IL-6 levels of the patients were determined using enzyme-linked immunosorbent assay daily for a total of 3 days. Ten healthy adults were included in the study to serve as controls. The patients were divided into survivors, and non-survivors. RESULTS: There was no significant difference between the patients and controls with respect to serum HA levels on admission (p>0.05). However, IL-6 levels on admission were significantly higher in the patients than the control group (p<0.01). Serum HA and IL-6 levels on admission, and the following days were significantly higher in non-surviving patients (n=5) than in surviving patients (n=22) (p<0.05). There was a significant correlation between HA and IL-6 (r=0.42, p<0.05) on admission. The HA concentration was also significantly correlated with aspartate aminotransferase, alanine aminotransferase, and creatinine levels during the observation period. Serum HA and IL-6 levels increased in non-surviving patients throughout the period of observation. CONCLUSION: Increased serum HA and IL-6 levels are associated with hepatic damage in acute MP. Hyaluronic acid may be a useful marker in the assessment of MP-induced acute liver failure in clinical practice.

[The incidence of pathologic findings of the cranial computed tomography in patients with minor head trauma and its correlation with age and clinical features]. / Hafif kafa travmali olgularin kraniyal tomografisindeki patolojik bulgu sikiliginin yas gruplari ve klinik ile korelasyonu.

BACKGROUND: Our objective was to determine the incidence of diagnosing lesions by cranial computed tomography (CT) and to evaluate prospectively whether this incidence correlated with clinical features and age in patients with minor head trauma (MHT). METHODS: This prospective study included 78 patients with MHT. All of the cases underwent CT following their clinical assessment. RESULTS: In the 34.61% of cases, there was a pathologic finding in the CT however the incidence of intracranial injury was 15.38%. There were no significant differences between children (n:22) and adults (n:56), the patients with and without a history of the loss of consciousness/amnesia and the patients with and without clinical symptoms (p>0.05). CONCLUSION: Our results support the studies which have reported that there is no non-focal clinical factor as a predictor for pathologic CT findings.

[Management of brain edema in acute head injury]. / Akut kafa travmasinda antiödem tedavi.

BACKGROUND: We aim was to review the basic concepts and to analyze the current management of cerebral edema following acute head trauma (AHT). METHOD: Cerebral edema should be recognized and treated early and aggressively to avoid disastrous results such as cerebral herniation. After clinical evaluation and early cardiorespiratory stabilization, the patients should be treated with the elevation of head, oxygen, mannitol, hyperventilation, and sedation-myorelaxation and may avoid from hypotension-hypoxia. If these treatments be unsuccessful, barbiturates may be used. There are also other possibilities such as hypothermia, ventriculostomy, hypertonic saline and neuroprotector agents. CONCLUSIONS: All patients with AHT should be evaluated early and cerebral edema should be treated with correct therapy. Therefore, the mortality and morbidity rates may reduce.