MULTIFOCAL MOTOR NEUROPATHY: CASE REPORTS.

- Multifocal motor neuropathy (MMN) is a chronic demyelinating neuropathy mainly characterized by multifocal distribution; affecting only motor nerve fibers of two or more peripheral nerves, with the absence of symptoms and signs of upper motor neuron; chronic, sometimes cascading progressive course; demyelination with partial block of motor conduction; immune-mediated pathogenesis and good response to intravenous immunoglobulin treatment (IVIG). The diagnosis of MMN is based on clinical, laboratory and electrophysiological characteristics. Steroids are ineffective in MMN and may lead to worsening of the disease. Similarly, therapeutic plasma exchange is negligibly effective in this neuropathy. However, more than 80% of patients with MMN experience improvement after IVIG. We present our three cases of MMN with positive response to IVIG.

One Year Outcome of Acute Stroke Patients with Sleep Apnea.

UNLABELLED: The aim of this study was to analyze one year outcome of the acute stroke patients with sleep apnea in order to gender and age. METHODS: It was analyzed 110 patients with acute stroke and sleep apnea. Among them 65(59%) were men. Average age of all participant was 65.13±9.27 years. The same number and gender distribution of participants with stroke and without apnea were in control group. Evaluation of sleep apnea has been done with: "The Sleep Disorders Questionnaire", "Berlin Questionnaire to identify patients at risk for the sleep apnea syndrome" and "The Epworth Sleepiness Scale". RESULTS: One year after stroke onset survived 91 (82.7%) out of 110 patients with apnea. Average age of survived patients was 63.66±8.78 years. Among them 52(80%) were men. In control group, without apnea survived 104 (94.5%) patients with average age of 65.00±8.62 years. Among them 62 (95.4%) were men. In men with apnea there is significantly lower survival range in order to patients without apnea (X(2)=8.22, p=0.004). In women there is no difference. Survival of both gender in patients with apnea (22; 64.7%) was the lowest in group older than 70 years of age. Sex ratio (men : women) was 15 (68.2%):7(58.3%). Survival in both gender in patients without apnea was the same in group older than 70 years of age: 27 (81.2%) out of 33. Average age of patients who died with apnea was significantly higher in order to patients without (t=1.97, p=0.03). CONCLUSION: One year after stroke, significantly more patients survived without (94.5%) than with apnea (82.7%) (p=0.01). In order to sex survived range was significantly (p=0.004) lover in men with apnea than without but in women there is no difference. Survival range of both gender in patients with apnea was the lowest in group older than 70 years (p=0.03).

Some aspects of balance disorder in patients with multiple sclerosis.

The aim of this study was to analyze: frequency of balance disorder (vertigo and disequilibrium), frequency of abnormalities in auditory evoked potentials (AEP) and magnetic resonance imaging (MRI) changes of the brain in multiple sclerosis (MS) patients with balance disorder, relation of patient's disability status to balance disorder and relation of the changes in MRI of the brainstem to AEP abnormalities. It was analyzed 60 patients with relapsing-remitting form of MS. Two groups of patients were made consecutively under Expanded Disability Status Scale score (EDSS): A (EDSS < or =4,5) and B (EDSS > or =5,0). The study was retrospective-prospective. After the neurological exam AEP and MRI of the brain have been done. Balance disorder has been verified as initial symptom in 29 (48,4%) and out of them disequilibrium experienced 24 (83,4%) patients. During the relapses balance disorder experienced 48 (80%) patients and in 37 (77,1%) it was disequilibrium. Among them 33 (68,7%) were with lower EDSS (< or =4,5) and 15 (31,3%) with higher EDSS score (> or =5). There is no correlation between disability status and vertigo which means that vertigo is not more frequent in more disabled patients and vice-versa. The AEP were pathological in 57 (95%) patients. Of all 29 patients with vertigo AEP were pathological in 28 (96,5%) while in 31 patients without vertigo pathological AEP were in 29 (93,5%) but it is not statistical significant. The most frequent characteristic of AEP changes were prolonged inter-peak latency III-V waves (48 patients or 80%). The plaque in brainstem visualized by MRI was found in 41 (71,8%) of patients (38 or 92,6% of them had pathological AEP and in three patients AEP were normal). In group of patients with pathological AEP, 38 (66,6%) of them had plaque in brainstem. In other three patients with normal AEP it was visualized plaque in brainstem. In the group of 29 patients with balance disorder, 20 (68,9%) had plaque in brainstem as well as 21 (67,7%) out of 31 patients without balance disorder had plaque in the brainstem. This difference is not statistical significant. It is concluded that the vertigo (including disequilibrium) is relatively often (48,4%) initial symptom of MS. Vertigo is not more frequent in patients with higher EDSS score and vice-versa. Pathological AEP are frequent neurophysiologic finding in both (95%) patients with (96,5%) and without (93,5%) vertigo. The most often pathological characteristic of AEP are prolonged interpeak latency of III-V waves (78,5%), as well as abnormalities of V and than IV wave. MS plaques in brainstem visualized by MRI technique are frequent in both groups of patients with and without pathological finding of the AEP.

Doppler sonography characteristics of vertebrobasilar circulation in patients with Parkinson's disease.

The objective of the study was to analyze the doppler sonography findings of vertebrobasilar circulation (VB) in patients with Parkinson's disease. 40 patients were analyzed (25 men's and 15 women) with Parkinson's disease, average age was 61.9 years (SD=11.43), treated at the Clinic for Neurology in Tuzla. Device for doppler sonography was Multidop x 4. Doppler sonography findings of VB circulation were analyzed in order to computerized tomography (CT) findings of the brain (with or without ischemic lacunar lesions) and in order to presence of postural disturbances as one of dominant Parkinson's disease symptoms during actual hospitalization. Our results suggest that vertebrobasilar insufficiency is more frequent in patients with Parkinson's disease (no matter of type) and postural disturbances as a dominant symptom comparing to group of Parkinson's disease patients without postural disturbances. These results implicate the importance of doppler sonography findings of vertebrobasilar circulation in patients with Parkinson's disease and possibility of considering role of vertebrobasilar insufficiency in development of postural disturbances.

Epidemiology of multiple sclerosis in western Herzegovina.

OBJECTIVES: To determine epidemiological rates of multiple sclerosis (MS) in western Herzegovina. PATIENTS AND METHODS: We analysed data from 81 MS patients (49 females, 32 males) on the prevalence day, 31 December 2003. Patient information was obtained from a search of all available medical records from the period 1994-2003 in the investigated area. RESULTS: Crude prevalence of MS was 27/100,000 (95% confidence interval (CI) 20-34). Prevalence was highest in the mountainous municipality of Posusje (56/100,000) and lowest in the coastal municipality of Neum (0 incidence). The annual incidence of MS was 1.6/100,000 (95% CI 0-3.3). The female/male ratio of MS was 1.5. The mean age of the patients on prevalence day was 40.0+/-11.6 years, and the mean age at disease onset was 31.0+/-7.1 years. Eight (10%) of the patients had a first-degree relative with MS. The primary progressive (PP) disease course was observed only in females. Visual symptoms were the initial symptom of MS in 6 (7%) of the patients. CONCLUSIONS: Western Herzegovina is an area of moderate risk for MS, and the distribution of MS in western Herzegovina is heterogeneous. PP-MS occurred only in females, and involvement of the visual pathways as the initial symptom of MS was low.

Plasmapheresis in neurological disorders: six years experience from University Clinical center Tuzla.

BACKGROUND: Therapeutic plasma exchange (TPE) is an extracorporeal blood purification technique that is designed to remove substances with a large molecular weight. The TPE procedure includes removal of antibodies, alloantibodies, immune complexes, monoclonal protein, toxins or cytokines, and involves the replenishment of a specific plasma factor. The aim of the study was to describe the clinical response to TPE in various neurological patients, and to assess the clinical response to this therapy. METHODS: The study was retrospective. We analyzed the medical records of 77 patients who were treated at the Department of Neurology, University Clinical Center (UCC) Tuzla from 2011 to 2016.   Results: 83 therapeutic plasma exchanges were performed in the 77 patients. There was a slight predominance of male patients (54.5%), with an average age of 51±15.9 years. The most common underlying neurological diseases were Guillain-Barré syndrome (GBS) (37.7%), then chronic inflammatory demyelinating polyneuropathy (CIDP) (23.4%), multiple sclerosis (MS) (11.7%) and myasthenia gravis (10.4%). Less frequent neurological diseases that were encountered were paraneoplastic polyneuropathies (5.2%), neuromyelitis optica (also known as Devic's disease) (3.9%), motor neuron disease (3.9%), polymyositis (2.6%) and multifocal motor neuropathy (1.2%). CONCLUSIONS: Six years experience of therapeutic plasma exchange in neurological patients in our department have shown that, following evidence-based guidelines for plasmapheresis, the procedure was most effective in patients with GBS, CIDP and myasthenia gravis.

Risk factors impact on the long-term survival after hemorrhagic stroke.

AIM: To analyze the impact of risk factors on the survival rate within a period of five years after hemorrhagic stroke (HS). PATIENTS AND METHODS: In this study 303 patients were analyzed with a first ever hemorrhagic stroke admitted at the Department of Neurology Tuzla, from January 1st 1997 to December 31st 1998. Data were collected from patient's medical records, whereas the final examination of all patients, who survived HS, took place five years after stroke. Medical history was obtained and presence of risk factors was evaluated on the day of admission. Computed tomography (CT) of the brain was performed in all patients during hospitalization. The average age of patients was 62 +/- 11 (from 31 to 90) years, 180 (59%) were women. The most frequent risk factor was hypertension, registered in 252 (83%) patients, followed by history of heart diseases in 182 patients (60%), smoking in 72 (23.8%), diabetes mellitus in 26 (8.5%), history of transient ischemic attack in 24 (8%) and alcohol intake in 13 (4.3%) patients. The risk factors were not registered in 22 (7.3%) patients. RESULTS: Five years after HS 82 (26.7%) patients survived. No statistical significance was found in survival between men and women (p = 0.2). The lowest number of patient that survived were over 70 years old (9%), while the highest number of survived was between 41-50 years (60.5%). The average number of risk factors was 2.5 +/- 1.0 and significantly higher in men compared to women (2.7 +/- 1 : 2.3 +/- 1) (p < 0.001). Significant difference was found in patients with hypertension (n = 252) (p < 0.0001), alcohol intake (n = 13) (p = 0.0170), as well as in patients with diabetes mellitus (n = 26) (p = 0.005). Regarding other risk factors such as heart diseases, cigarette smoking and transient ischemic attack there were no significant difference in survival in patients with hemorrhagic stroke (p = 0.2; p = 0.7; p = 0.8; retrospectively). CONCLUSION: We found that hemorrhagic stroke is associated with a very high risk for death in the acute and subacute phase. The survival rate after hemorrhagic stroke was 26.7% within a period of five years. Long-term survival rate prognosis is significantly better among the younger patients, without hypertension, alcohol intake and diabetes mellitus.

Betaferon in the treatment of multiple sclerosis.

The aim of the study was to analyze the usefulness and side effects of treatment with interferon beta 1B (Betaferon) in patients with the relapsing-remitting form of multiple sclerosis (RRMS). The study included 32 RRMS patients that had completed two-year therapy with interferon beta 1B or were still receiving this therapy. Every six months, patients were clinically evaluated and scored by the Expanded Disability Status Scale (EDSS). Two-year therapy was completed by 11 (34.3%) of 32 RRMS patients. Relapse was verified in 4 (36.36%) patients. The mean EDSS score was 2.45 +/- 1.03 at the beginning of therapy and 2.54 +/- 0.98 after two-year therapy; the difference was not statistically significant. In 2 (6.25%) patients on therapy for 18 months there was no relapse, and the mean EDSS was 1.75 +/- 0.35 (both at therapy introduction and at 18 months). Five (15.62%) patients were on therapy for one year. The mean EDSS was 1.6 +/- 1.08 at the beginning of therapy and 1.5 +/- 0.70 at one year. One patient experienced relapse. Two patients were on therapy for six months. They had no relapses with the same EDSS at six months as at therapy introduction (2.0). At the beginning of 2008, another 12 patients started therapy with interferon beta 1B. In conclusion, our experience with two-year interferon beta-1B therapy for RRMS is favorable, with a relatively low rate of relapses (36.36%) and without significant worsening on EDSS. The medication side effects were mild and transient.

Bilateral oculomotor nerve palsy in Guillain-Barre syndrome.

Guillain-Barre syndrome (GBS) is an acquired immune-mediated inflammatory disorder of the peripheral nervous system. GBS is also called acute idiopathic polyradiculoneuritis. Cranial nerves are affected in over 50% of all cases, with the facial nerves being affected the most. Otherwise, oculomotor nerves affection is rare and might occur in about 10% of cases. In this case report we present 61 years old female with GBS (acute motor and sensory axonal neuropathy subtype) associated with bilateral oculomotor nerve palsy. At the admittance in the neurological status were flaccid paraplegia, tendon reflexes absent at legs and reduced at arms, sensory disturbances in a distal (stocking-glove) distribution and bilateral ptosis. The disease was diagnosed on clinical features, nerve conduction velocity test (NCV), electromyogram (EMG) and cerebrospinal fluid (CSF) tests. After treatment with intravenous immunoglobulins and physical treatment the patient improved. She was able to walk by her own, mild semiptosis remained and she had no paresthesia.

[Bladder, bowel and sexual dysfunction in patient with mulitple sclerosis]. / Poremecaj uriniranja, defeciranja i seksualnosti pacijenata sa multiplom sklerozom.

Bladder, bowel and sexual dysfunction are not rare in multiple sclerosis (MS). The most frequent bladder disorders are in urgency, frequency as well as retention. In this study we analyzed bladder dysfunction (urgency, frequency and retention), defecation (constipation and incontinence) as well as sexual problems (libido, erection and vaginal lubrication) in patients with relapsing-remitting form of multiple sclerosis (MS) depending on disability status. Concerning Expanded Diasability Status Score (EDSS), patients have been divided in two groups: EDSS 0-4.5. (Group A), and EDSS 5.0-10.0 (group B). We analyzed 60 patients: 35 (58.3%) women, and 25 (41.7%) men. In both group A and B, with no bladder disorder was 18 patients (30%). In group A: 15 (25%); in group B: 3 (5%). With urgent incontinence were 36 (60%) patients - group A: 19 (31%); group B: 17 (28%). With retention were 6 (10%) patients - group A: 4 (6.6%); group B: 2 (3.3%). There is no statistical significant difference in number of patients with and with no urinary problems in both groups (p>0.05). Of all analyzed patients in group A and B with no urinary disorders were 9 men (15%) and 9 women (15%). With urinary problems were 16 men (26.7%) and 26 women (43.3%). Statistically it is significant higher number of women than men (p<0.05). With no defecation problems were 54 (90%) patients - in group A: 36 (60%); in group B: 18 (30%). With constipation were 5 (8.3%) - in group A: 2 (3.3%); in group B 3 (5%). In group B one patient (1.6%) had incontinence. There is no statistical significant difference in number of patients with and with no bowel elimination dysfunction in both groups p>0.05). 12 (20%) men had no bowel elimination problems and 24 women (40%), but 10 (16.6%) men and 8 (13.3%) women had the bowel elimination dysfunction. There is no statistical significance (p>0.05). No libido disturbance had 44 (73.3%) patients. In the group A: 35 (58.3%); in group B: 9 (15%). 16 (26.7%) patients had the libido disturbances. In group A: 3 (5%); in group B 13 (21.6%). Statistically there is significant lower number of patients with libido problems in group A (p<0.05). No vaginal lubrication had 21 (35%) women. In group A: 18 (30%); in group B 3 (5%). Vaginal lubrication disturbance had 14 (23.3%). In group A: 7 (11.6%); in group B 7 (11.6%). Statistically it is significant lower number of women with no lubrication in group B (p<0.05). No erection problems had 11 (18.3%) men. In group A: 9 (15%); in group B 2 (3.3%). Erection disturbance had 14 (23.3%). In group A: 4 (6.6%); in group B: 10 (16.6%). There is statistical significant lower number of men with erection problems in group A. (p<0.05). Of all analyzed patients in both groups A and B 18 men (30%) and 26 (43%) women had no problems with libido and 7 (11.6%) men and 9 (15%) women had the problems. There is no statistical significance in sex distribution (p>0.05). 11 (18.3%) men had no erection problems, 14 (23.3%) had the problems. 21 (35%) women had no vaginal lubrication problems, 14 (23.3%) women had the problems. Erection disturbances are not statistically significant to vaginal lubrication problems (p>0.05).

Stroke in patients with diabetes mellitus: a hospital based study.

INTRODUCTION: Diabetes mellitus is a risk factor for stroke, but it is unclear whether stroke is different in diabetic and nondiabetic individuals. The aim of the study was to compare characteristics of stroke in patients with and without diabetes mellitus. METHODS: This study included 833 acute stroke patients (697 [84%] had ischemic stroke, and 52% were females) admitted at the Department of Neurology Tuzla, Bosnia and Herzegovina, from January 1st 2003 to December 31st 2003. Risk factors, stroke severity (Scandinavian Stroke Scale, SSS)), stroke type, etiology, lesion topography and the outcome at 1 month (mortality and handicap) were assessed in all patients. RESULTS: Overall, diabetes mellitus was present in 194 patients (23.5%). Females were overrepresented in the diabetic group of stroke patients (66% vs 48%, p = 0.0001). Initial stroke severity and lesion topography were comparable between the two groups. The diabetic patients reported a significantly lower current smoking (21% vs 29%) and alcohol intake (4.5% vs 9%) (p < 0.05). Patients with diabetes mellitus compared with patients without diabetes had more frequently atherothrombotic stroke (62% vs 33%, p < 0.0001), but less frequently embolic stroke (10% vs 17.5%, p = 0.02) and intracerebral hemorrhage (10% vs 18.5%, p = 0.005). Mortality at 1 month was higher in patients with diabetes mellitus (38% vs 26%, p = 0.001), and diabetes increased the relative death risk by 1.53 (95% confidence interval, 1.19 to 1.96). At the other hand, handicap (Rankin Scale) in surviving patients was insignificantly higher in diabetic group (2.7 vs 2.4, p = 0.07). Older age (70 vs 66 years, p = 0.008), atherothrombotic stroke (76% vs 53%, p = 0.002), and severe strokes (SSS 20.5 vs 39, p < 0.0001) were more associated in died stroke patients with diabetes mellitus compared with surviving diabetic stroke patients. CONCLUSION: Diabetes mellitus is present in one fourth of acute stroke patients. Stroke patients with diabetes mellitus are associated with specific patterns of stroke type, etiology and mortality but not with stroke severity and handicap.