An investigation of upper extremity function in patients with multiple sclerosis, and its relation with shoulder position sense and disability level.

Purpose: The purposes of this study were to investigate upper extremity function and shoulder position sense in patients with multiple sclerosis and its relation with disability level. Materials and methods: In this study, 20 multiple sclerosis and 20 healthy subjects participated. The disability level was determined by the Expanded Disability Status Scale. Mental state was assessed using the Mini-Mental State Examination. Upper extremity function was measured with the 9-Hole Peg Test and shoulder position sense was evaluated with a Dualer IQTM digital inclinometer. The study protocol was also registered at http://clinicaltrials.gov (NCT03846336). Results: Upper extremity function scores were lower and shoulder position sense error scores were greater in patients with multiple sclerosis in comparison to healthy controls (p < .05). While disability level was associated with dominant and non-dominant upper extremity function, no relationship was found between the disability level and shoulder position sense (p < .05). Only the dominant side shoulder position senses at 30° and 60° abduction were found to be associated with upper extremity function (p < .05). Conclusions: These results indicate that shoulder position sense and upper extremity function were affected in patients with multiple sclerosis with mild to moderate disability. Upper extremity functions were associated with shoulder abduction joint sense in patients with multiple sclerosis. In the assessment of upper extremity functions, joint position sense should be taken into account even at early stages of multiple sclerosis, so it may provide guidance in planning rehabilitation programs.

Bilateral optic neuropathy, acral gangrene and visceral ischaemia as a rare presentation of calciphylaxis: A case report.

We report a case with calciphylaxis very rarely presenting with bilateral optic neuropathy, acral gangrene and visceral ischaemia. Bilateral papilloedaema was found in a 43 year-old female with chronic renal failure. Acral dry gangrene was observed. Pathological examination of her amputated thumb revealed calcification, thrombi, obstructive endovascular fibrotic areas in the walls of arteries. She was diagnosed with calciphylaxis. Bilateral optic neuropathy was defined secondary to calciphylaxis. Abdominal computerized tomography revealed prominent calcifications in mesenteric, spleen and renal arteries. She died eight months after the diagnosis. Calciphylaxis should be considered in the differential diagnosis of the optic neuropathy.

Retinal nerve fiber layer thickness in patients with Alzheimer disease.

The aim of this study was to investigate retinal nerve fiber layer (RNFL) thickness in patients with Alzheimer disease (AD) without visual impairment using spectral domain optical coherence tomography (SD-OCT) and to compare the results with healthy controls. A total of 80 subjects, including 40 patients with early untreated AD (mean age, 69.3 ± 4.9 years) and 40 healthy controls (mean age, 68.9 ± 5.1 years) were enrolled. Both eyes of patients with AD and controls were imaged using SD-OCT. The average RNFL thickness was significantly less in the AD patients than in controls (65 ± 6.2 µm vs 75 ± 3.8µm; P = 0.001). There was selective thinning of the RNFL in the superior quadrant, the mean superior quadrant RNFL thickness being 76 ± 6.7 µm in AD patients and 105 ± 4.8 µm in controls (P = 0.001). In our study, the thickness of RNFL in patient with AD was lower than that of controls. This suggests that SD- OCT has the potential to be used in the early diagnosis of AD as well as in the study of therapeutic agents. Further studies are needed to validate this technology as a viable ocular biomarker over time in AD.

Pituitary adenoma apoplexy presenting with bilateral third nerve palsy and bilateral proptosis: a case report.

OBJECTIVE: To report a case of pituitary adenoma apoplexy presenting with bilateral proptosis and bilateral third nerve palsy that developed after cardiovascular surgery. CLINICAL PRESENTATION AND INTERVENTION: A 45-year-old man developed bilateral proptosis and bilateral third nerve palsy after a coronary artery bypass grafting operation. A pituitary macroadenoma with extension into the sphenoid sinus and cavernous sinus with bilateral involvement was resected on computed tomography scan by microscopic transsphenoidal procedure. Third nerve palsy improved partially on the first postoperative day and completely improved in the fourth month after the operation. CONCLUSION: This is a rare case of pituitary adenoma apoplexy that presented with bilateral third cranial nerve palsy.

Core stability-based balance training and kinesio taping for balance, trunk control, fear of falling and walking capacity in patients with multiple sclerosis: A randomized single-blinded study.

BACKGROUND: Trunk performance-based therapies are important in the Multiple Sclerosis (MS) rehabilitation process since they have been associated with balance, trunk performance, fall prevention, and walking capacity. Kinesio taping (KT) is a popular approach that has recently been used to treat a variety of musculoskeletal and neuromuscular impairments. Therefore, the aim of this single-blind, randomized controlled study was to investigate the effects of KT combined trunk stabilization-based balance training on balance, trunk control, walking capacity, and fear of falling in patients with MS. MATERIAL AND METHODS: Thirty patients diagnosed with MS were randomly assigned to the KT group or the control group. The control group received core stability-based balance training and the KT group was treated with KT applied on global trunk muscles in addition to core stability-based balance training. Balance was measured with the Mini BESTest, trunk control with the Trunk Impairment Scale, fear of falling with the Falls Efficacy Scale and walking capacity with the 2-minute walk test. RESULTS: Balance, trunk control, fear of falling, and walking capacity of all the patients improved after treatment (p < 0.05). No superiority was found between the groups in terms of treatment efficacy (p > 0.05). CONCLUSION: In conclusion, core stability-based balance training was effective in patients with MS, and the addition of KT had no additional effect in terms of balance, trunk control, fear of falling, and walking capacity.

Impaired heart rate variability as a marker of cardiovascular autonomic dysfunction in multiple sclerosis.

Multiple sclerosis (MS) can cause alterations in autonomic cardiovascular functions. We aimed to investigate the correlation of disease activity and disability with heart rate variability (HRV) of cardiovascular autonomic dysfunction (CAD) demonstrated by 24-h Holter monitorization. Thirty-four patients with clinically active relapsing-remitting MS, age 33.8 +/- 7.6 years, were studied. Twenty healthy volunteers served as controls. The time domain long-term HRV parameters were recorded by a digicorder recorder calculated by ambulatory electrocardiograms. Variabilities in time domain were lower in the MS patients: SDNN (standard deviation of all R-R intervals, p = 0,019), SDANN (standard deviation of the averages of R-R intervals in all 5-minute segments of the entire recordings, p = 0,040), RMSSD (the square root of the mean of the sum of the squares of differences between adjacent R-R intervals, p = 0,026), HRVM (mean of the SDNN in all the 5-minute intervals, p = 0,029), HRVSD (standard deviation of the SDNN in all the 5-minute, p = 0,043). These results suggest that MS causes CAD manifesting as long-term HRV abnormalities. This illness seems to cause a dysfunction in parasympathetic cardiovascular tone. Depressed HRV parameters are independent from the clinicalfindings, but the illness progression partially seems to provoke a decrease in such parameters.

The Coexistence of Olfactory Groove with Optic Nerve Sheath Meningioma Presenting with Anosmia: A Case Report.

INTRODUCTION: Meningiomas are the third most common intracranial tumors in adults after glial tumors and metastases. Olfactory groove meningiomas often grow without symptoms due to their slow growth rates and location in the frontal lobe. Optic nerve sheath meningiomas are benign neoplasms of the meninges surrounding the optic nerve. The coexistence of olfactory groove and optic nerve sheath meningiomas without any history of neurofibromatosis or radiotherapy has never been reported in the literature. CASE REPORT: A 36-year-old female patient was reported with anosmia, headache, memory disturbance, and visual impairment and with the diagnosis of olfactory groove meningioma. In the postoperative period, optic nerve sheath meningioma was detected in the imaging performed due to persistence of visual impairment. CONCLUSION: Olfactory groove and optic nerve sheath meningiomas are rare tumors and can be diagnosed late because they progress slowly. Early diagnosis and treatment may affect the prognosis and morbidity of these patients favorably.

The roles of galectin-3 and galectin-4 in the idiopatic Parkinson disease and its progression.

OBJECTIVES: Idiopathic Parkinson's Disease is a neurodegenerative disease caused by the loss of cells that secrete dopamine in the basal ganglia. Galectins are multipotent, evolutionarily conserved, cell surface glycoconjugated and crosslinked carbohydrate-binding proteins. The roles of these proteins in the diagnosis of the disease have been investigated. PATIENT AND METHODS: Patients who were diagnosed with idiopathic Parkinson's disease were classified as early (stage 1-2) and advanced stage (stage 3-5) according to the Hoehn-Yahr classification. In addition, voluntary cases without parkinson disease constituted the control group. Serum samples of consecutive Parkinson patients and age and gender matched healthy controls were used to measure serum galectin-3 and serum galectin-4 levels. The levels were compared between Parkinson's patients and control groups and early and advanced stage Parkinson's groups. RESULTS: Thirty age and gender-matched healthy controls and 60 parkinson patients were enrolled in the study. Serum galectin-3 levels were lower in controls compared with patients (892.9 (168.2-2416.3) vs. 2271.8 (375.9-9673.4), respectively, P < 0.01). Serum galectin-3 levels were related to Hoehn-Yahr stages and (r: 0.691, P < 0.001). The early stage group (20 patients) had lower serum galectin-4 levels compared with advanced stages (40 patients) (197.97 ± 46.42 vs. 334.263 ± 37, respectively, P < 0.01). Serum galectin-4 levels were also lower in controls compared with patients 185.1 (116.2-313.3) vs. 282.3 (156.9-984.8), respectively, P < 0.01. ROC analysis showed that serum galectin-3 and galectin-4 were statistically significant in the identification of Parkinson disease and advanced stages. The results were significant for galectin-3 (AUC: 0.89, SE: 0.034, P < 0.001 and CI: 0.823-0.958; P < 0.001) and for galectin-4 (AUC: 0.758, SE: 0.05, P < 0.001). CONCLUSION: Serum galectin-3 and galectin-4 may be potential noninvasive markers for the identification of Parkinson disease and advanced stages.

Protective effect of sildenafil (Viagra) in transient spinal cord ischemia.

Prospective study of the neuroprotective activity of sildenafil in a rat spinal ischemia model. The present study involved 21 male Sprague-Dawley rats. The animals were divided into 3 groups. Physiological serum was administered intraperitoneally to the 8 rats in the control group at the beginning of reperfusion for a period of 20 min after abdominal aortal occlusion. Sildenafil (Viagra) was administered as a single 10-mg/kg/day intraperitoneal dose to the 8 rats in the sildenafil group at the beginning of reperfusion after 20 min of abdominal aortal occlusion. No occlusion was performed and no agent was administered to the 5 rats in the sham group, but the abdominal aorta was reached by means of surgical intervention. Before the animals were sacrificed, several physiological and biochemical parameters were investigated, preoperative and postoperative motor functions were also assessed, and somatosensory evoked potential (SEP) monitoring and histopathological examinations were carried out. No differences were found between the physiological and biochemical parameters in each of the 3 groups. Neurological scoring performed after reperfusion demonstrated a significant improvement in the neurological results relative to those of the control group over 48 h in subjects that received sildenafil. These animals also showed better 24-hour SEP results, measured in terms of extended latency and decreased amplitude, than the control animals. A histopathological study showed reduced ischemic symptoms in rats that received sildenafil compared with those in the control group. However, no anomalies were observed in the sham group with respect to the histopathological and neurological findings. These results indicate that neurological damage due to spinal-cord ischemia-reperfusion injury can be reduced by sildenafil.

Usefulness of platelet to lymphocyte and neutrophil to lymphocyte ratios in predicting the presence of cerebral venous sinus thrombosis and in-hospital major adverse cerebral events.

BACKGROUND: Platelet to lymphocyte ratio (PLR) and neutrophil to lymphocyte ratio (NLR) as recently emerging thrombo-inflammatory indicators were significantly associated with both major cerebrovascular/cardiovascular adverse events (MACE) and mortality. Therefore, we aimed to assess the effects of combinations of PLR and NLR in predicting the presence of CVST and in-hospital MACE. METHODS: A total of 277 participants comprising 80 patients with evidence of CVST and 197 controls with similar baseline characteristics were included in this retrospective study. Patients were classified into 3 groups based on the optimal cut-off values of PLR and NLR calculated with receiver operating characteristic (ROC) curve for in-hospital MACE rates. RESULTS: PLR (148±61 vs 101±50, p<0.001) and NLR (3.12±1.4 vs 1.94±1.1, p<0.001) were significantly higher in the CVST group. Furthermore, patients in the high risk group (a PLR of ≥115.0 and an NLR of ≥2.1) had the highest in-hospital MACE rates including seizure (p=0.012), papilledema (p=0.025) and diplopia or blurry vision (p=0.028). After multivariate logistic regression analysis MPV, PLR (1.052 [1.045-1.059], p=0.001) and NLR (1.442 [1.086-1.916], p=0.012) were found as independent predictors of CVST. CONCLUSION: These results suggest that PLR and NLR are easily available and cheap thrombo-inflammatory indicators, so that PLR and NLR could be used in prediction of CVST and in-hospital MACE.

Bilateral brachial plexopathy complicating Henoch-Schönlein purpura.

An 11-year-old boy presented with convulsion, fever, rash, abdominal pain, swelling on the eyelids, elbow and wrists, oliguria and hematuria. Based on the abnormal findings the patient was diagnosed with Henoch-Schönlein purpura. On the 3rd day of admission, neurological examination showed ataxic gait, loss of deep tendon reflexes, and decreased (4/5) of muscle strength on all extremities. Additionally, bilateral loss of touch, pain and temperature sensation in a glove, from the elbows to distal region (on C5-T1 level) was diagnosed. Cerebrospinal fluid examination and cranial magnetic resonance imaging (MRI) were normal. The patient was discharged with oral prednisolone on the 7th day of admission. One week after discharging from the hospital, he was re-admitted with vertigo and seizures. He was in coma. MRI of cranial, cervical and cervical plexus were normal. Electromyography showed severe bilateral brachial plexopathy. Prednisolone and intravenous immunglobulin (IVIG) therapy were given without significant improvement. He was discharged from the hospital on the 17th day of admission. On the second month of follow-up, a second cure of IVIG was given because of no clinical improvement. Now, he is on the 4th month of follow-up, unfortunately, no improvement was noted on his muscle strength and sensorial abnormalities on the upper extremities.

Hemostatic markers and platelet aggregation factors as predictive markers for type of stroke and neurological disability following cerebral infarction.

We investigated the plasma levels of D-dimer, fibrinogen, beta-thromboglobulin (BTG) and platelet factor-4 (PF-4), indices of the occurrence of platelet activation in vivo, to find out their role in pathophysiology of ischemic stroke and whether or not such a role has any effect on the disability and the prognosis of stroke patients. A total of 76 patients with AIS aged from 26 to 85 (32 men, 44 women) and 30 cases as controls with similar age (18 men, 12 women) were included in the study. The plasma levels of D-dimer, BTG and PF-4 were measured by ELISA method using a special commercial kit. The cases were allocated into two groups as non-embolic (NEI) and cardioembolic stroke (CEI). The D-dimer levels in 76% of 42 patients in NEI group (p<0.05) and 85.2% of 34 patients in CEI group (p<0.05) were outside the confidence interval (CI) defined for the control group. The levels of BTG were elevated in 81% of 42 cases with NEI (p<0.05) and in 76% of 34 cases with CEI, with reference to CI of control group. The levels of PF-4 were significantly increased in 86% of cases with NEI (p<0.05) and in 88% of cases with CEI than controls (p<0.05). It was observed that the cases with high Rankin scores had higher levels of D-dimer (p<0.005), BTG (p<0.01) and PF-4 (p<0.01) than those with lower scores. There was a correlation between hemostatic markers, platelet activation and functional disability. D-dimer levels were an important marker that determined to degree of the activation of hemostatic system, especially in CEI subtype. The platelet aggregation had an important role in pathophysiology of ischemic stroke and this condition is significant in NEI subgroup and subjects with large infarcts and high disability scores.

Value of F-wave inversion in diagnosis of carpal tunnel syndrome and it's relation with anthropometric measurements.

BACKGROUND: The clinical importance of F-wave inversion in the diagnosis of Carpal Tunnel Syndrome (CTS) is not yet well known. OBJECTIVE: This study aims to investigate the value of F-wave inversion in diagnosing CTS, and to evaluate the relationship of F-wave inversion with age, gender, diabetes mellitus, body mass index (BMI), wrist or waist circumferences. METHODS: Patients (n=744) who were considered to have CTS with clinical findings were included in the study. In order to confirm the diagnosis of CTS, standard electrophysiological parameters were studied with electroneuromyography. In addition, median nerve F-wave measurements were done and we determined if F-wave inversion was present or not. Sensitivity and specificity of F-wave inversion were investigated for its value in showing CTS diagnosed by electrophysiological examination. RESULTS: CTS diagnosis was confirmed by routine electrophysiological parameters in 307 (41.3%) patients. The number of the patients with the presence of F-wave inversion was 243 (32.7%). Sensitivity of F-wave inversion was found as 56% and specificity as 83.8%. BMI and wrist circumference values were significantly higher in patients with F-wave inversion present than those with F-wave inversion absent (p=0.0033, p=0.025 respectively). CONCLUSIONS: F-wave inversion can be considered as a valuable electrophysiological measurement for screening of CTS.

Use of biperiden hydrochloride in a child with severe dyskinesia induced by phenytoin.

A 5-year-old girl was admitted with a 3-day history of speech disorder and gait abnormality. She had been diagnosed with idiopathic epilepsy and was given phenytoin 2 months before admission to our hospital. On physical examination, she had severe lingual-facial-buccal extrapyramidal movements, slurred speech, and ataxic gait. During examination, she was repetitively scratching her scalp with her right hand every 30 to 60 seconds. Serum phenytoin level was 10 microg/mL (normal 8-20 microg/mL). Electroencephalography showed diffuse slow waves. Magnetic resonance imaging of the brain was normal. During hospitalization, her abnormal findings were thought to be attributable to phenytoin; it was immediately discontinued, and biperiden was initiated. After biperiden was administered, her abnormal movements markedly decreased; later, they almost completely disappeared. In conclusion, we would like to emphasize that severe dyskinesia can be observed during phenytoin therapy and that biperiden can be successfully used in the treatment of this unpleasant condition.

Do not overlook acute isoniazid poisoning in children with status epilepticus.

A previously healthy 2-year-old girl was admitted with generalized convulsive status epilepticus. She was in a stupor and could respond only to painful stimuli. She also had severe metabolic acidosis. Although initial liver function tests were normal, they were found to be moderately high on the fifth day of admission; however, they dropped to their normal ranges on the twelfth day of admission. Initially, the patient was diagnosed as having idiopathic status epilepticus, and classic anticonvulsant agents, including diazepam, phenytoin, and then phenobarbital, were given. However, her seizures did not subside, and diazepam infusion was initiated. After initiation of diazepam infusion, the seizures were completely controlled. On the fourth day of admission, her parents said that she had accidentally received 20 tablets (a total dose of 2000 mg) of isoniazid just before admission to our hospital. Later, we injected 200 mg of pyridoxine intravenously. During follow-up, her general condition improved, and anticonvulsant agents were discontinued because an electroencephalogram was found to be norma. She was discharged from the hospital on the twelfth day of admission. At the fourth month of follow-up, she was seizure free. Because of this case, we would like to re-emphasize that acute isoniazid poisoning should also be considered in a child with unexplained status epilepticus.

Onset of generalized seizures after intrathecal interferon therapy of SSPE.

An 11-year-old male was admitted with inability to walk and speech abnormality. He was diagnosed with subacute sclerosing panencephalitis on the basis of clinical and laboratory findings. Therapy with inosiplex (100 mg/kg/day orally) plus intrathecal interferon-alpha (3 million units/dose twice per week) and ribavirin (15 mg/kg/day orally) was initiated. Ribavirin was given orally because of a lack of parenteral form in our country. During follow-up, he complained about fever and widespread body pains after intrathecal therapy. On the sixth month of follow-up, generalized tonic-clonic seizures, associated with high fever, and lasting approximately 1-2 minutes occurred about 6 hours after giving interferon-alpha. Four days after the first seizures, a similar seizure attack reoccurred after intrathecal IFN-alpha. An antiepileptic agent was not administered because electroencephalogram results did not indicate epileptic discharges. At the current time, he is in the ninth month of follow-up and remains seizure-free. In conclusion, our case demonstrated that standard dose intrathecal interferon-alpha might cause seizures in children. We think that this unfortunate condition was more common in subacute sclerosing panencephalitis children treated with intrathecal interferon-alpha.

Report of a Turkish child with Sjören-Larsson syndrome associated with peripheral nerve involvement.

Sjören-Larsson syndrome is a rare hereditary neurocutaneous disorder characterized by ichthyosis, spastic di- or tetra-plegia, and mild to moderate mental retardation. In this article, we present a nine-year-old girl with the classical features of the syndrome associated with peripheral nerve involvement because of its rare presentation. To the best of our knowledge, only three cases of Sjören-Larsson syndrome with peripheral nerve involvement have been previously reported in the literature. We assume that Sjören-Larsson syndrome involves extensive disorders of the ectodermal tissues, including the peripheral nerves as well as the skin and the central nervous system.

Left hemisphere and male sex dominance of cerebral hemiatrophy (Dyke-Davidoff-Masson Syndrome).

Although radiological findings of cerebral hemiatrophy (Dyke-Davidoff-Masson Syndrome) are well known, there is no systematic study about the gender and the affected side in this syndrome. Brain images in 26 patients (mean aged 11) with cerebral hemiatrophy were retrospectively reviewed. Nineteen patients (73.5%) were male and seven patients (26.5%) were female. Left hemisphere involvement was seen in 18 patients (69.2%) and right hemisphere involvement was seen in eight patients (30.8%). We conclude that male gender and left side involvement are frequent in cerebral hemiatrophy disease.

Relationship of age, body mass index, wrist and waist circumferences to carpal tunnel syndrome severity.

Carpal tunnel syndrome (CTS) has a multifactorial etiology involving systemic, anatomical, idiopathic, and ergonomic characteristics. In this study, an investigation of the relationship between the CTS degree established by electrophysiological measurements in patients with clinical CTS prediagnosis, and age, gender, body mass index (BMI), hand wrist circumference, and waist circumference measurements has been done. On 547 patients included in the study, motor and sensory conduction examinations of the median and ulnar nerve were done on one or two upper extremities thought to have CTS. In terms of CTS severity, the patients were divided into four groups (normal, mild, medium, and severe CTS). A total of 843 electrophysiological examinations were done consisting of 424 on the right hand wrist and 419 on the left hand wrist. When the age group of 18-35 years is taken as the reference group, the CTS development risk independent of BMI has been found to have increased by a factor of 1.86 for ages 36-64 years, and by 4.17 for ages 65 years and higher after adjustment for BMI. With respect to normal degree CTS group, the BMI were significantly different in groups with mild, medium, and severe CTS. The waist circumferences of groups with mild, medium, and severe CTS severity were found to be significantly higher in comparison to the normal reference group. When this value was corrected with BMI and re-examined the statistically significant differences persisted. The study identified a significant relationship between the CTS severity and age, BMI, waist circumference.