Application of rTMS to the Motor Cortex in a Patient with Startle Reaction: A Case Report.

Startle reaction is a physiological muscle reaction that occurs to protect against an unexpected, sudden stimulus. In this case, we wanted to discuss the response after the rTMS protocol, which we applied to our patient who had startle reactions that severely impair functionality and who did not meet the post traumatic stress disorders (PTSD) criteria or have a major brain lesion after a traffic accident. A 30-year-old single female patient who works as a stewardess in an airline company with no known history of physical or psychological illness but lost consciousness for about three hours after an in-vehicle traffic accident a week ago was admitted to our clinic. The patient had a history of having difficulty in doing her daily work due to the splashing movements that started in her body. No major brain lesion was detected in imaging studies. She did not meet the criteria for PTSD and her EEG results were normal. Medication did not help with the symptoms, so, rTMS was planned. After 6 sessions of rTMS, her movements had stopped completely. Our patient, who did not fully meet the criteria for PTSD and whose imaging and EEG results did not reveal any pathological findings had developed severe onset startle reactions after an in-vehicle traffic accident, fully responded to rTMS treatment and improved her functionality quickly and effectively. Thus, we think that rTMS should be investigated as an effective treatment method in such patients.

Evaluation of serum uric levels in migraine.

OBJECTIVE: In our study, the aim was to identify the serum uric acid levels, a marker of oxidative stress, according to migraine subtypes (aura/without aura and episodic/chronic migraine). METHOD: The study included 300 migraine patients and 150 healthy controls for a total of 450 individuals. Migraine and subtypes were diagnosed according to International Classification of Headache Disorders-2013 criteria. Patients were evaluated during attendance at the neurology clinic. RESULTS: Our patient group was 77.0% female and disease duration was 9.2 ± 7.2 years. Our control group comprised 77.3% females. The age intervals in the patient and control groups were 36.4 ± 10.4 years and 36.0 ± 8.1 years. There was no statistically significant difference between our control and patient groups in terms of age and gender (p = .937 and p = .655). The serum UA, ferritin, and urea levels in our patient group were found to be significantly low compared to the healthy control group (p < .001). The serum UA levels in the migraine and control groups were 3.7 ± 0.7 and 4.6 ± 0.7 mg/dL, respectively (p < .001). There were no statistically significant differences observed between serum uric acid levels and other blood parameters between aura/without aura and episodic/chronic migraine subtypes (p > .05). CONCLUSION: Our study supports the hypothesis that the oxidative stress marker of serum uric acid levels may be associated with migraine diagnosis, concluding that serum uric acid levels were not significant for migraine subtypes.

The Relationship Between Clinico-Pathological Properties and p-Glycoprotein Expression in Hippocampal Sclerosis Among Patients with Mesial Temporal Lobe Epilepsy Who Undergo Selective Amygdalohippocampectomy Operation.

INTRODUCTION: The overproduction of the efflux transporters in the blood-brain barrier is considered to play a role in the development of drug resistance in mesial temporal lobe epilepsy (MTLE) patients. The aim of the present study was to investigate the relationship of clinical features of patients with MTLE accompanied by hippocampal sclerosis (HS) and the p-glycoprotein (p-gp) expression and neuronal loss in the hippocampus. METHODS: This study included a total of 33 patients who underwent selective amygdala-hippocampectomy operation. A detailed medical history of each patient, including age, side of HS, sex, age of habitual seizure onset, duration of habitual seizures, type and age of initial precipitating injury, presence and duration of latent period, presence and duration of silent period, monthly seizure frequency within 1 year prior to operation, mean age at the time of operation was evaluated retrospectively. RESULTS: The p-gp expression was significantly higher in the patient group with a seizure frequency of more than 15 days per month and a disease duration of more than 20 years. There was no significant difference between the p-gp expression and the clinical features of the MTLE-HS patients. CONCLUSION: These results suggest that p-gp expression is affected by disease duration and seizure frequency rather than a patient's clinical and pathological properties. In patients with HS-MTLE, potential use of the p-gp inhibitors as additional therapy and developing novel drugs not carried by multidrug carriers expressed in blood-brain barrier should be regarded as the new treatment targets.

Evaluation of simple inflammatory blood parameters in patients with migraine.

AIM: This study aimed to identify the serum neutrophil/lymphocyte ratio (NLR), monocyte/lymphocyte ratio (MLR), platelet/lymphocyte ratio (PLR), and C-reactive protein (CRP)/albumin (CAR) ratios among patients with diagnosis of migraine according to migraine subtypes (attack/attack-free period, migraine with or without aura, episodic/chronic migraine, family history/no family history) and to collect data to investigate the role of inflammation and oxidative stress in etiology. METHOD: The study was completed with 235 patients with migraine diagnosis classified according to the International Classification of Headache Disorders-2013(ICHD) classification and 166 healthy controls. Patients with migraine were assessed during the attack by emergency medicine specialists in the emergency room and in attack-free periods in neurology clinics by neurology specialists. RESULTS: Of patients with migraine, 77.02% were female and 22.98% were male. The neutrophil, NLR, PLR, and MLR levels were higher than the control group (p < 0.05). The serum CRP, neutrophil, NLR, MLR, and CAR levels were higher, and albumin and lymphocyte levels were lower during migraine attack periods (p < 0.05). Migraines with aura were observed to have higher serum NLR levels compared to the aura-free patients (p < 0.05). Migraine patients with positive family history were found to have higher NLR levels compared to patients without a family history (p < 0.05). CONCLUSION: Although non-specific, serum NLR, MLR, PLR, and CAR levels may be potential biomarkers associated with migraine subtypes with different clinical features such as migraine attack period, migraine with aura, and patients with family history of migraine. Elevated inflammatory markers may indicate the severity of disease.

Anterior cerebral artery infarcts; two years follow-up study.

BACKGROUND AND PURPOSE: Anterior cerebral infarct (ACA) infarcts are reported very rare that is due to the compensatory collateral circulation provided by the anterior communicating artery. There are very few studies reporting the long-term follow-up results of ACA infarcts regarding their aetiology, clinical features and prognosis. Most studies reported in the literature vary between several months to one year. METHODS: A total of 27 patients with ACA infarcts were registered (14 women and 13 men). The mean age of the patients was 68.5 (age range: 45-89 years). RESULTS: Bilateral ACA infarcts were reported in four patients (14.8%), right ACA infarct in 11 (40%) patients and left ACA infarct in 12 patients (44%). During the initial examination 15 patients (55.5%) were found to have apathy, 13 patients (48%) had incontinence, nine patients (33.3%) had primitive reflexes, 11 patients (40.7%) had aphasia, while six patients (22.2%) were found to suffer from neglect. At the end of one-year follow-up, five patients (22.7%) were reported to have apathy, 6 patients (27.2%) had incontinence, one patient (4.5%) had primitive reflexes, while one patient (4.5%) was found to have permanent aphasia, and no patients was found to suffer from neglect. CONCLUSION: Here we present our clinical data regarding the aetiology, specific clinical characteristics (including the speech disorders) and prognosis of 27 patients with ACA infarcts during a relatively longer follow-up period (3 months - 30 months) in compared to previous literature. We show that there are differences in the etiological factors of ACA infarcts between the Asian and European communities. Regarding speech disorders which are frequently reported during ACA infarcts, our study results are in agreement with other studies suggesting that this clinical picture is more than a real aphasia and associated with general hypokinesia and reduction in psychomotor activity.

Quality of Life of Patients Under Anticoagulant Therapy Compared to Patients Treated with Antiplatelet Therapy.

INTRODUCTION: Health-related quality of life (HRQoL) includes the physical, functional, social, and emotional well-being of an individual. The most important and frequently used generic HRQoL assessment is Short Form- 36 (SF-36). The objective of this study was to analyze the HRQoL of patients under chronic use of oral anticoagulants in a specialized stroke unit. METHODS: One hundred and twenty-six stroke patients from our stroke clinic between April 1, 2014 and June 1, 2014 were included in this cross-sectional study. The inclusion criteria included only patients whose Rankin score was "0" and were on oral anticoagulant or antiplatelet treatment for ≥1 year. Questionnaire SF-36 was used for the study. The patients' age, sex, comorbidities, medical treatments, modified Rankin Scores, bleeding complications, emergency polyclinic admissions, and hospitalization were also noted. RESULTS: Seventy-five of them were men. The median age was 55.67± 14.23 years. Seventy-seven of the patients were on anticoagulant therapy. Being on anticoagulation therapy did not influence the domains of HRQoL. All of the domains presented the lowest scores in female group. The domains of general health, physical function, and vitality had the lowest scores among hypertensive patients. The domains of physical function, role function, vitality, and mental health had significantly lower scores in the diabetic group. Bodily pain scores were lowest in patients having recurrent stroke attacks. Stroke patients taking more than 3 drugs were found to have worse QoL scores. CONCLUSION: Patients under chronic treatment with oral anticoagulants had no negative perception of QoL when attending an anticoagulation specialized outpatient clinic.

Electroclinical and prognostic characteristics of epilepsy patients with photosensitivity.

BACKGROUND AND PURPOSE: Epilepsy with photosensitivity (PSE) is one of the reflex epilepsy types with pathophysiology still unexplained. In our study we aimed to evaluate the clinical, electroencephalogram (EEG) and prognosis of patients with PSE diagnosis. METHODS: A total of 44 patients with PSE diagnosis according to international classification were included in this retrospective and cross-sectional study. The age, gender, syndrome, clinical and EEG characteristics of patients, and treatment response were investigated. RESULTS: The mean age was 22.09±6.49 years for 28 females and 16 males included in the study. Of patients, 17 had idiopathic photosensitive occipital lobe epilepsy (IPOLE), 11 had juvenile myoclonic epilepsy (JME), 11 had other PSE and 5 had juvenile absence epilepsy (JAE), with the most common visual trigger factors television and sunlight. In terms of seizure type, the most common was generalized tonic clonic seizure (GTCS), with myoclonus, absence and other seizure types observed. There was family history present in 17 patients and valproic acid was most commonly used for treatment. CONCLUSION: As noted in the literature, our data show that PSE has defined age group and clinical presentation, good prognosis but requires correct choice of medication for treatment. It is thought that good description of these epilepsy types will reduce misdiagnosis and mistreatment rates.

Cognitive Outcome after Surgery in Patients with Mesial Temporal Lobe Epilepsy.

INTRODUCTION: The aim of the present study was to evaluate the neuropsychological outcomes of patients with medically intractable unilateral mesial temporal lobe epilepsy (MTLE) due to hippocampal sclerosis (HS) treated either by anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SAH). METHODS: This was a retrospective study where 67 patients who had undergone surgery for MTLE were evaluated. Thirty-two patients underwent ATL and 35 underwent SAH. All patients underwent a detailed neuropsychological evaluation before and 1 year after surgery. RESULTS: The verbal memory outcome was unchanged after left-sided surgery, whereas learning capacity increased after right-sided surgery (p=0.038). The visual memory outcome improved after right-sided surgery. Improvement of executive functions, particularly in the resistance of interference pattern in the Stroop Test, shortened 5th card time (p=0.000), and decreased corrections (p=0.003), after right-sided surgery and increased attention (p=0.027) after left-sided surgery were observed. After both surgery types, although statistically insignificant, there was a marked decrease in incorrect answers in the Stroop Test, which also showed an improvement in the resistance of interference pattern. Moreover, there was a significant decrease in switching errors with word pairs in the Verbal Fluency Test (p=0.008) after right-sided surgery. When the two sides were compared, we observed that the recall phase of the verbal memory worsened (p=0.018); however, the recognition phase improved (p=0.015) after left-sided surgery. Additionally, the short-term visual memory was better for both sides (p=0.035). CONCLUSION: Our results showed that patients with left MTLE were not worsened in verbal memory, but despite improved recognition, they have some problems in recalling information and only a minor improvement in attention. Patients with right MTLE improved in their verbal learning capacity, visual memory, and resistance of interference pattern 1 year after surgery. It was thus shown that while epilepsy surgery is associated with some negative cognitive changes, it may also improve some cognitive functions.

Efficacy and Safety of Warfarin Experience in a Stroke Polyclinic in Stroke Patients.

INTRODUCTION: Cardioembolic stroke is associated with high morbidity and mortality, with an increased risk of recurrent stroke. Oral anticoagulation is highly effective in reducing the risk of stroke and mortality compared with placebo. Our study aimed to highlight the safety and efficacy of warfarin by analyzing the 20-year follow-up of patients on warfarin therapy. METHODS: A retrospective observational study was performed with ischemic stroke patients receiving warfarin at our stroke polyclinic between 1992 and 2012. The CHADS2 scoring system was used to assess the annual risk of stroke, and a bleeding risk score termed the HAS-BLED scoring system was calculated to estimate the risk of bleeding. RESULTS: In our study, 394 patients who were receiving warfarin therapy were included. The patients' median age was 66.35±13.602 years. The median follow-up period of the patients was 4.85±3.572 years. During follow-up, 79.9% of the patients revealed no complication on warfarin therapy. Thirty-seven patients had hemorrhagic complications; among these, 33 had systemic complications (including nose bleeding, hematuria, hematochezia) and 4 patients had intracerebral bleeding. The INR value related to hemorrhagic complications was >2.5 in 75.8% of 33 patients having systemic bleeding and in 75% of 4 patients having intracerebral bleeding. The HAS-BLED risk score was >3 in 72.7% of the patients experiencing systemic bleeding complications. Forty-one patients had a recurrent ischemic stroke/TIA during the follow-up. Of this patient group, the INR value at the time of recurrent ischemic stroke was <2 in 41 patients (92.7%), while the CHADS2 risk score was low in this group. Sixty-eight patients were receiving antiplatelet therapy with warfarin. In these groups, 16 patients experienced a complication during the follow-up (bleeding/ischemic), while 10 patients had bleeding complications (systemic and intracerebral). CONCLUSION: The results suggest that the effectiveness and safety of warfarin depend on maintaining its dose at sufficient levels to keep the patient's INR within the therapeutic range.

The Effects of Cognitive Rehabilitation on Relapsing Remitting Multiple Sclerosis Patients.

INTRODUCTION: The aims of this study were to determine the severity of cognitive impairment with Brief Repeatable Battery Neuropsychology (BRB-N) and to show the benefits of cognitive rehabilitation programs to develop coping strategies for the retardation of cognitive losses in relapsing remitting multiple sclerosis (RRMS) patients. METHODS: The cognitive screening with BRB-N was performed in RRMS patients who had applied to the MS outpatient clinic of Bakirköy Psychiatric and Neurological Diseases Hospital, had an Expanded Disability Status Scale (EDSS) score between 1.0 and 5.5, and had no other cognitive disease or used drugs that effected the cognitive status. Thirty two patients with cognitive impairment underwent consecutive computer-assisted cognitive rehabilitation program once a week for 8 weeks conducted by psychologists. The effects of the program were evaluated with the tests repeated every 4 weeks. RESULTS: The mean age of the patients was 36.09±7.19 years. Their initial and control test scores were found to be paced auditory serial addition test (PASAT) 29.21±17.97; 42.43±15.43, Selective Reminding Test-Total Learning (SRT-TL) 8.03±2.36; 10.09±1.77, Selective Reminding Test-Long-term Memory (SRT-DR) 6.72±2.74; 9±2.29, Spatial Recall Test-Total Learning (SPART-TL) 4.72±2.02; 4.22±1.74, Spatial Recall Test-Long-term Memory (SPART-DR) 5.94±2.54; 5.16±2.23, Symbol Digit Modalities Test (SDMT) 40.44±17.04; 46.47±17.94, Word Fluency Test (WLG) 32.88±9.87; 40.44±9.95 respectively. There was no significant statistical difference between Multiple Sclerosis Neuropsychological Screening Questionnaire (MSNQ) and SPART values of preface, 1st control and 2nd control (p>0.05). There was significant statistical difference between PASAT, WLG, SDMT, SRT-TL, SRT-DR values of Preface, 1st control, and 2nd control (p=0.0001). CONCLUSION: It was determined that on distinctive improvement on sustaining attention, working memory and information processing speed, and verbal fluency and verbal learning with cognitive rehabilitation, no changes were observed on visuospatial learning. This approach is hopeful and further comprehensive studies are needed.

[ARMENIAN DOCTORS DURING IST WORLD WAR].

In this article, we mainly discussed about Armenian doctors who took part in WWI.As Mazhar Osman stated in his speech in La Paix Hospital, dedicated to the victims of the war: "The number of doctor died in WWI was 215, 75 of which being non-Muslim and 32 out of this 75 being Armenian." Similarly, we can see another list of Armenian doctors on a tablet created in 1920, to the memory of Beirut American College graduates who died during WWI.bBesides, we mentioned about the experiences of Armenian doctors during the war based on the information we gathered from various memoirs.

Chronic inflammatory demyelinating polyradiculoneuropathy associated intracranial hypertension.

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an acquired immune-mediated demyelinating neuropathy. In this report, we detail the course of a 58-year-old male patient who had headache and double vision followed by progressive paresthesia and difficulty in walking. The patient had bilateral papilledema and mild leg weakness, absent ankle jerks and loss of sensation in distal parts of his lower and upper extremities. His electromyography (EMG) was concordant with CIDP and lumbar puncture revealed high opening pressure. The polyradiculoneuropathy as well as the papilledema and elevated cerebrospinal fluid (CSF) pressure improved under steroids. The improvement in intracranial hypertension (IHT) and papilledema under steroid treatment suggests that the IHT in this patient might be associated with CIDP.

Ictal singing due to left mesial temporal sclerosis.

Simple ictal or interictal automatisms are commonly seen in epilepsy, whereas complex automatisms are rare. Simple ictal vocalizations or appendicular automatisms have been reported to be due to mesial temporal lobe epilepsy. However, seizure-associated singing and dancing is very rare. We report a seventeen-year-old patient with ictal singing and rhythmic swinging of the arms as a dancing gesture. The video-EEG recording showed ictal left temporal lateralization and neuropathology confirmed left mesial temporal sclerosis.

Spectrum of medial medullary infarction: clinical and magnetic resonance imaging findings.

Among 4200 consecutive patients admitted to three hospitals with acute ischemic stroke, we found only 11 patients in whom magnetic resonance imaging (MRI) had proved that they had medial medullary infarction (MMI). In our centers, patients with MMI were less than 1% of those with vertebrobasilar stroke. The infarcts documented by MRI were unilateral in 10 patients and bilateral in one. On clinico-topographical analysis there were four clinical patterns: (1) Classical Dejerine's syndrome was the most frequent, consisting of contralateral hemiparesis, lemniscal sensory loss and ipsilateral lingual palsy in 7 of the eleven patients. (2) Pure hemiparesis was present in 2 patients; (3) Sensorimotor stroke was present in 1 patient with contralateral hemiparesis, hypesthesia and mild decrease in pain sensation without lingual palsy; (4) Bilateral MMI syndrome in 1 patient, accompanied by tetraparesis, bilateral loss of deep sensation, dysphagia, dysphonia and anarthria. Presumed causes of MMI were intrinsic branch penetrator artery disease with concomitant vertebral artery stenosis in 6 of the 11 patients, vertebral artery occlusion in 2, dolichoectatic vertebrobasilar arteries in 2, a source of cardiac embolism in 1. Prognosis at 3 months was favorable in 8 patients, but the patient with bilateral MMI syndrome had persisting motor deficit causing limitation of daily activities, and 2 died from systemic causes. The classical triad of acute MMI facilitates the diagnosis, although the recognition of this syndrome in patients with incomplete manifestations can be difficult and occurs more frequently than commonly thought. Moreover, vertebral artery atherosclerosis and branch atheromatous disease of the penetrating arteries are the main causes of medullary infarction.