Post-stroke aggressive behavior in patients with first-ever ischemic stroke: underlying clinical and imaging factors.

BACKGROUND: Aggression is defined as a complex behavior consisting of a combination of sensory, emotional, cognitive and motor elements. We aimed to examine the relationships between post-stroke aggressive behavior (PSAB) and neuropsychological and neuroimaging findings. METHODS: 380 patients in the stroke unit were classified as aggressive or non-aggressive based on symptoms elicited by the Neuropsychiatric Inventory (NPI) and aggression screening questionnaire. RESULTS: Aggressive behavior was detected in 42 (11.1%) of 380 patients who had a first ischemic stroke. Patients with PSAB were older than those without (338 patients) (66.98 + 13.68 vs. 62.61 + 13.06, P = 0.043). Hamilton depression and anxiety scales showed significantly higher rates of depression and anxiety in the PSAB group compared to the non-PSAB group (47.6% vs. 16.3% and 57.1% vs. 15.4%, respectively; P = 0.001). Lesion mapping analysis showed that lesions in patients with PSAB mostly included the lower parietal lobe and lateral frontal gyrus. Multiple regression analysis showed that gender (OR, 2.81; CI%, 1.24-6.39), lateral prefrontal infarction (OR, 6.43; CI%, 1.51-27.44), parietal infarction (OR, 2.98; CI%, 1.15-7.76), occipital infarction (OR, 2.84; CI%, 1.00-8.06), multiple infarcts (OR, 5.62; CI%, 2.27-13.93), anxiety (OR, 2.06; CI%, 0.89-4.81) and verbal memory deficit (OR, 4.21; CI%, 1.37-12.93) were significant independent predictors of PSAB. CONCLUSION: The presence of PSAB may be related to neuropsychiatric symptoms such as high anxiety and verbal memory impairment, and neuroanatomical location of the lesions.

Comparison of clinical features in patients with vestibular migraine and migraine.

Vestibular migraine (VM) is accepted as the most common cause of spontaneous episodic vertigo. In most patients, vestibular symptoms follow migraine headaches that begin earlier in life. The aim of this multicenter retrospective study was to find out the differences between migraine patients without any vestibular symptoms (MwoV) and VM patients and to delineate the specific clinical features associated with VM. MwoV and VM patients were compared regarding demographic features, migraine headache years, headache attack frequency, intensity, symptoms associated with headache and vertigo attacks, presence of menopause, history of motion sickness and family history of migraine. Four-hundred and forty patients with MwoV and 408 patients with VM were included in the study. Migraine with aura was more frequent in patients with MwoV (p = 0.035). Migraine headache years was longer (p < 0.001) and headache intensity was higher in patients with VM (p = 0.020). Aural fullness/tinnitus was more common in patients with VM (p < 0.001) when all other associated symptoms were more frequent in patients with MwoV (p < 0.001) as well as attack triggers (p < 0.05). Presence of menopause and motion sickness history was reported more frequently by VM patients (p < 0.001). Logistic regression analysis indicated that longstanding history of migraine with severe headache attacks, aural fullness/tinnitus accompanying attacks, presence of menopause, previous motion sickness history were the differentiating clinical features of patients with VM.

Effects of comorbid diseases on clinical outcomes in patients with myasthenia gravis.

BACKGROUND: This cross-sectional study was undertaken to evaluate the existence and distribution of comorbid disorders among myasthenia gravis (MG) patients according to subgroups and to identify the effects of the comorbid diseases of MG patients on clinical outcomes. METHODS: The patients were divided into six subgroups according to serum antibodies, age at onset, and thymoma presence. All patients were treated in line with the International Consensus Guidance for Management of Myasthenia Gravis. To assess the clinical outcome after treatment for MG, we used the MGFA Post-intervention Status. In generalized MG patients, the good prognosis group included patients who were classified as having minimal-manifestation status or better. In ocular MG patients, the remission subgroup included patients who were classified as having complete stable remission or pharmacological remission status. RESULTS: Our study included 168 MG patients, 85 were female while 83 were male. Comorbid diseases were present in 124 (73.8%) MG cases. After at least 1 year of follow-up, 106 (86.8%) of the generalized MG patients were in the good prognosis group and 16 (13.2%) generalized MG patients were in the poor prognosis group. 27 (58.6%) ocular MG patients were in the remission group and 19 (41.3%) ocular MG patients were in the non-remission group. Hypertension increased the risk of poor prognosis by 3.55-fold among patients with generalized MG and type 2 DM increased the risk of not achieving remission by 9.32-fold among patients with ocular MG. CONCLUSION: Hypertension and type 2 DM had negative effects on the clinical outcomes of MG.

Nonpainful Trigeminal Neuropathy Associated with a Solitary Pontine Lesion: A Case Series.

A solitary pontine lesion (SPL) is a single brainstem lesion on the trigeminal nerve pathway without any other central nervous system lesion. This research aimed to investigate the demographic and clinical features of nonpainful TNO patients with SPL and identify the most frequently affected anatomical areas using lesion mapping techniques. Demographic and clinical features were retrospectively reviewed from the patients' charts. Brain lesions were mapped using MRIcroGL software. The study included 6 patients (three females and three males) with an SPL. The median age of the patients was 57 (range: 46-68) years. Cranial MRI displayed lesions in the dorsolateral pons and the cerebellar peduncle. The lesion mapping revealed that the lesions were on the trigeminal nerve pathway. SPL is an uncommon cause of TNO. Nonpainful SPL patients have demographic, clinical, and radiological features similar to those of painful SPL patients. The lesion mapping showed that the same brainstem areas are affected in painful and nonpainful SPL patients.

Prognostic predictors of remission in ocular myasthenia gravis.

BACKGROUND: Ocular myasthenia gravis (OMG) constitutes 15% of all myasthenia gravis patients. METHODS: One hundred eight patients with OMG followed-up for over 36 months were retrospectively evaluated regarding factors associated with remission. Demographic features, neuro-ophthalmologic findings at onset, acetylcholine receptor (AChR Ab) and muscle-specifc tyrosine kinase antibodies (MuSK Ab), thymic status, single fiber electromyography (SFEMG) results were the variables considered. RESULTS: Median age of disease onset was 57 years (range 18-82 years). Clinical features at onset was isolated ptosis in 55 (50.9%) and isolated diplopia in 33 (30.6%) patients. Combined ptosis and diplopia were present in 20 (18.5%) patients. Among 75 patients with ptosis, it was unilateral in 65 (86.7%) and bilateral in 10 (13.3%). AChR Abs were found in 66 (61.1%) and MuSK Abs in 2 (1.9%) patients. SFEMG abnormality was detected in 74 (68.5%) patients. Thymoma was present in 16 (14.8%) and thymic hyperplasia in 6 (5.6%) patients. Forty-one patients (37.9%) had been treated with pyridostigmine alone. Sixty-seven (62%) patients were given immunosupressive drugs. In 53 (49.1%) prednisone was used and in 14 (12.9%) patients it was combined with azathioprine. Thymectomy was performed in all 16 patients with thymoma. Complete stable remission (CSR) was achieved in 49 (45.4%) patients. Fifty-nine (54.6%) patients had reached minimal manifestation (MM) status; 32 (29.6%) having a status of MM-1 and 27 (25%) a status of MM-3. CONCLUSIONS: The presence of AchR Abs (p = 0.034) and an abnormal SFEMG (p = 0.006) at onset as increased risk factors for the presence of ongoing signs necessitating medical treatment.

A Neuropsychiatric and Neuroimaging Study of Unilateral and Bilateral Striatal Ischemic Lesions.

OBJECTIVE: Neuropsychiatric disorders after striatal territory stroke have not been studied systematically. The investigators aimed to study the spectrum of cognitive and behavioral disorders following striatal infarcts. METHODS: Different aspects of cognitive functions, including executive, frontal lobe, memory, visuospatial, language, and semantic processing, were assessed among patients with striatal infarct. Structural MRI data sets were obtained 3 months after stroke to delineate affected territories of the striatum. MRIcroGL software was used to acquire multiple layers of images, generate volume renderings, and draw volumes of interest. To determine the brain locus most frequently affected in patients with distinct cognitive disorders, ischemic area distributions in patients with cognitive dysfunction versus those without cognitive impairment were contrasted. RESULTS: Among 60 patients in this study, six different striatal infarction types were significantly associated with seven different cognitive categories (p<0.001). Unilateral caudate lesion was characterized by attention, planning, and executive disorders (38%), and unilateral lentiform infarct was characterized by executive (36%) and frontal (36%) dysfunctions. Bilateral caudate infarcts caused impairments in frontal and executive functions (75%), as well as in autobiographical (50%) and episodic (50%) memory. In those with bilateral caudate plus lentiform infarcts, all components of frontal and executive functions were dramatically impaired. The anteromedial striatum was affected more frequently in patients with language impairment compared with patients with other types of cognitive dysfunction (p<0.001). CONCLUSIONS: Following striatal stroke, a wide range of frontal-like cognitive impairments occurred, along with impaired working memory, declarative memory, executive function, speech fluency, and motor function.

Cognitive and Behavioral Disorders in Patients with Superior Parietal Lobule Infarcts.

BACKGROUND/OBJECTIVE: The superior parietal lobule (SPL) plays a strategic role in somatosensory and visuomotor integration. This study aims to evaluate the clinical, neurocognitive, and behavioral characteristics of isolated SPL stroke. METHODS: We assessed neuropsychological and behavioral findings in 14 patients with isolated SPL stroke among 4200 patients with ischemic stroke. All patients underwent neuroimaging, clinical and neuropsychological assessment after stroke. RESULTS: Of the 14 patients enrolled, the first complaints were tactile and visuospatial disorders at stroke onset. Except for 6 patients with only 1 cognitive impairment, the majority of patients (57%) experienced more than 1 cognitive impairment category. Functional hemispheric asymmetries have been found in different cognitive processes, such as between visuospatial and body image functions and language process. Among visuospatial abilities disorders, spatial disorientation, visuospatial neglect, and visual extinction were found in two-thirds (63%) of patients with right SPL lesion. Body schema and image disorders were observed in all patients with right-sided lesions, such as alien hand, autotopagnosia for body parts (36%), autotopagnosia for sensory sensations (36%), and fading limb (21%). Two-thirds (57%) of patients with left SPL had impairment in language abilities. CONCLUSION: Our findings after stroke suggest that SPL plays a pivotal role in the regulation of visuospatial abilities, body schema and body image processing, and language skills through bilateral frontoparietal networks and interhemispheric parietal networks.

Quality of Life in Patients with Idiopathic Intracranial Hypertension and the Impact of the COVID-19 Pandemic.

The COVID-19 pandemic became a challenge to maintain care for patients with idiopathic intracranial hypertension (IIH). We aimed to find out how they were affected during lockdown. Thirty IIH patients admitted to hospital during the COVID-19 pandemic were studied. Their demographic and neuro-ophthalmological findings were evaluated. The World Health Organization - Five Well-Being Index (WHO-5), the EUROHIS Quality of Life (QOL) 8-item index, National Eye Institute Visual Functioning Questionnaire (NEI-VFQ-25), Headache Impact Test (HIT-6), and COVID-19 Fear Scale were used to assess QOL and pandemic-associated fear. Thirty age, sex, and body mass index matched volunteers constituted the control group. Apart from the COVID-19 Fear Scale and colour vision subscale of the NEI-VFQ-25, all scale scores were worse in IIH patients than in healthy control subjects. Patients with severe visual field defects had higher HIT-6 scores (p = .036). Both vision-specific and overall QOL was reduced in patients with IIH. Headache severity and disability were more prominent in patients with severe visual loss. Fear caused by the COVID pandemic was not different in IIH patients than in healthy control subjects.

Vestibular migraine and persistent postural perceptual dizziness: Handicap, emotional comorbidities, quality of life and personality traits.

OBJECTIVE: To compare vestibular migraine (VM) and persistent postural-perceptual dizziness (PPPD) regarding dizziness associated handicap, emotional and somatic disorders, health-related quality of life (QoL) and personality traits. METHODS: Thirty patients for each group [VM, PPPD and healthy volunteers (HC)] were studied. Dizziness Handicap Inventory (DHI), Beck depression and anxiety scales, Somatic Symptom Scale-8 (SSS-8), Short Form (36) Health Survey (SF 36) and the Big Five Inventory (BFI) were used. RESULTS: DHI sub-scores were significantly high in both patient groups in comparison with the HC (p < 0.001 for all). Emotional (p = 0.001) and functional (p = 0.022) sub-scores of the PPPD patients were worse. Anxiety and somatic symptom scores of VM (p = 0.026 and p < 0.001 respectively) and PPPD (p < 0.001 for both) and depression scores of the PPPD (p = 0.003) were higher than the HC. Both anxiety (p = 0.009) and somatization (p = 0.005) scores of the PPPD patients were higher than the VM. SF-36subscales were affected in both groups (p < 0.05). Vitality (p = 0.002), mental health (p = 0.045) and social role functioning (p = 0.006) of the PPPD group were worse than the VM. Higher scores for neuroticism (p < 0.001) was present for both groups. Scores for extraversion was low in PPPD patients (p = 0.010) in comparison with the HC. CONCLUSION: Dizziness associated handicap, anxiety and somatic symptom burden is high in both groups, even higher in PPPD with additional depression. Severe impairment in QoL is present with more severe impairment in emotional aspects in patients with PPPD. Neuroticism is a common personality trait for both groups with additional introversion in PPPD.

Factors determining the response to treatment in patients with vestibular migraine.

PURPOSE: To find out clinical features associated with poor response to treatment in vestibular migraine (VM). METHODS: VM patients treated with drugs recommended in migraine prophylaxis were included in this multicenter study. Migraine features including type, age of onset of headache and vertigo attacks, attack frequency, intensity, associated symptoms, triggering factors, presence of interictal dizziness/imbalance, anxiety, depression, history of motion sickness, and family history of migraine were noted. Amitriptyline, flunarizine, propranolol, topiramate and venlafaxine were chosen depending on patients' individual requirements. Maximum dose of each drug was tried for 2 months to decide its efficacy. In the case of inefficacy, it was changed with another preventive drug of different class. If there was still no improvement, two drugs of different classes were combined. ≥ 50% reduction in attack frequency and severity in patients using one drug and a combination of two drugs was compared, with patients showing <50% reduction despite combination therapy, regarding their clinical features. RESULTS: The results of 430 VM patients, 65 men and 365 women with a mean age of 42.2 ± 12.2 years (range: 17-74 years), were analyzed. CONCLUSION: Cutaneous allodynia frequently associated with female sex, comorbid anxiety and depression and interictal dizziness/imbalance enhanced with comorbid anxiety were risk factors for reduced treatment response. Aural fullness might be the clue of impending concomitant Meniere's disease not responding to migraine preventives.

Vestibular migraine, demographic and clinical features of 415 patients: A multicenter study.

OBJECTIVE: To evaluate demographic and clinical features of vestibular migraine (VM) patients METHODS: Four hundred fifteen patients with VM were evaluated by using a structured questionnaire in addition to clinical examination. RESULTS: The mean age of headache and vertigo onset was 25 years and 39 years, respectively. In 12.3%, benign paroxysmal positional vertigo (BPPV) was detected during the interictal period. Ten percent had hearing loss on audiometry, in 8.7% it was one-sided low-frequency sensory-neural hearing loss below 2000 Hz and the history was typical for Meniere's disease (MD) in addition to VM. Tinnitus was present in 94.4%, aural fullness in 83.4%, nausea in 72.2% and vomiting in 30.5% of patients with VM/MD. The prevalence of these symptoms was higher in patients with VM/MD than in pure VM. Median attack severity determined by visual analog scale measured in centimeters from 0 to 10 was 8 for headache and 7 for vertigo for the whole group. Severe headache was significantly correlated with age of ≤ 43 years (OR: 6.831, 95% CI: [4.10-11.63]; p < 0.001) and severe vertigo was significantly correlated with age ≥ 41 years (OR: 7.073, 95% CI: [4.55-10.98]; p < 0.001). Motion sickness was revealed from past medical history in 51.8%. Family history of migraine was present in 72.5% and the age of onset of both migraine headaches (p = 0.008) and vertigo attacks (p = 0.004) was lower in these patients. CONCLUSION: Younger patients suffered more severe headache attacks whereas vertigo attack severity was higher in the elderly. BPPV and MD were commonly associated with VM and VM/MD was accompanied by aural and autonomic features more frequently than pure VM. Previous history of motion sickness was detected in more than half of the whole group. Family history of migraine was associated with younger onset of migraine headaches and vertigo attacks.

Are COVID-19 vaccines safe for people with epilepsy? A cross-sectional study.

BACKGROUND: COVID-19 disease was first seen in December 2019 and was declared a pandemic soon after. To fight the pandemic, there is an immense need for effective vaccines. The purposes of our study were to investigate the effect of coronavirus vaccines on seizures in people with epilepsy (PWE) and assess the adverse events of COVID-19 vaccine in PWE. METHODS: This was a cross-sectional study. We included epilepsy patients who got vaccinated with two or three doses at least 1 month earlier. We gathered the data using a standardized form. The form contained questions about patients' demographic features, clinical features, and information about the vaccination and its adverse events. The questionnaire included questions about epilepsy-related adverse events. RESULTS: We included 178 people with epilepsy in our study. The frequency of adverse events was lower than clinical studies of the vaccines. The mean number of seizures in the month before the vaccination was 1.62, between the doses was 1.61, and after vaccination was 1.64. There was no significant difference in the number of monthly seizures before the vaccination, the month between the doses, or the month after the vaccination (p = 0.46). CONCLUSIONS: The vaccines under consideration in our study were tolerated well by the epilepsy patients. The vaccines did not affect the monthly number of seizures of the PWE. A small number of patients had more seizures than normal after vaccination. We think that benefits of the vaccines outweigh the slightly increased possibility of having a seizure after vaccination.

Exploring Cognitive Impairment in Patients With Bilateral Capsular Genu Lesions.

OBJECTIVE: The authors investigated for presence of cognitive impairment after occurrence of bilateral lesions of the genu of the internal capsule (GIC). Clinical and neuropsychological features of unilateral GIC lesions have previously been studied, but the cognitive profile of bilateral lesions of the GIC has not been fully explored. METHODS: An investigation was conducted of neurocognitive deficits and computerized tomography MRI findings among 4,200 stroke patients with bilateral GIC involvement who were admitted to the hospital between January 2010 and October 2018. RESULTS: Eight patients with bilateral lesions of the capsular genu were identified and their data analyzed. Overall, behavioral and cognitive dysfunction were characterized by impairment of frontal, memory, and executive functions. Attention and abstraction were present among all eight patients (100%); apathy, abulia, and executive dysfunctions, among seven (87.5%); global mental dysfunction and planning deficits, among six (75.0%); short-term verbal memory deficits and language dysfunctions, among five (62.5%); long-term verbal memory deficits, among four (50.0%); and spatial memory deficits, reading, writing, counting dysfunctions, and anarthria, among two (25.0%). Four of the patients (50.0%) without a history of cognitive disorder showed severe mental deterioration compatible with the clinical picture of dementia. A clinical picture of dementia was still present in these patients 6 months after stroke. CONCLUSIONS: Bilateral lesions of the capsular genu appearing either simultaneously or at different times were significantly associated with executive dysfunctions.

Risk for generalization in ocular onset myasthenia gravis: experience from a neuro-ophthalmology clinic.

Conversion to generalized myasthenia gravis (GMG) within the first 2 years has been reported in 18-85% of patients with ocular myasthenia gravis (OMG). The aim of the study was to investigate the risk factors for generalization in patients with OMG admitted to a neuro-ophthalmology clinic and to determine if there were differences between patients with GMG with predominant bulbar (GMG-B) or extremity muscle (GMG-E) involvement according to the 6th and 24th-month Myasthenia Gravis Foundation of America classification ranks. Patients with OMG who were followed-up for at least 24 months were retrospectively analyzed. Demographic, clinical, laboratory features and treatment strategies that can be associated with generalization and time to generalization were evaluated. Of the 139 patients with OMG, 54 (39%) showed generalization with a mean time of 10.3 (range 2-24) months. GMG-B and GMG-E were diagnosed in 31 (22.3%) and 23 patients (16.5%), respectively. Seropositivity for acetylcholine receptor and muscle-specific tyrosine kinase antibodies, abnormal single-fiber electromyography (SFEMG), and the presence of thymic abnormalities (thymoma and hyperplasia) were factors associated with generalization on multivariate analysis without a significant difference between the GMG-B and GMG-E groups. In addition, an abnormal repetitive nerve stimulation test was related to a shortened time to generalization. Bilateral ptosis at onset was found as a risk factor for generalization. In a neuro-ophthalmology clinic, bilateral ptosis as an initial feature of OMG must be approached cautiously because it may be the first sign of impending GMG.

Cognitive and Behavioral Disorders in Patients with Precuneal Infarcts.

OBJECTIVE: Ischemic stroke of the precuneal cortex (PC) alone is extremely rare. This study aimed to evaluate the clinical, neurocognitive, and behavioral characteristics of isolated PC infarcts. METHODS: We assessed neuropsychological and behavioral findings in 12 patients with isolated PC infarct among 3,800 patients with ischemic stroke. To determine the most frequently affected brain locus in patients, we first overlapped the ischemic area of patients with specific cognitive disorders and patients without specific cognitive disorders. Second, we compared both overlap maps using the "subtraction plot" function of MRIcroGL. RESULTS: Patients showed various types of cognitive disorders. All patients experienced more than 1 category of cognitive disorder, except for 2 patients with only 1 cognitive disorder. Lesion topographical analysis showed that damage within the anterior precuneal region might lead to consciousness disorders (25%), self-processing impairment (42%), visuospatial disorders (58%), and lesions in the posterior precuneal region caused episodic and semantic memory impairment (33%). The whole precuneus is involved in at least one body awareness disorder. The cause of stroke was cardioembolism in 5 patients (42%), large artery disease in 3 (25%), and unknown in 4 (33%). CONCLUSIONS: This study showed a wide variety of neuropsychological and behavioral disorders in patients with precuneal infarct. Future studies are needed to achieve a proper definition of the function of the precuneus in relation to the extended cortical areas. PC region infarcts have been found to predict a source of embolism from the large arteries or heart.

Oculogyric Crisis with Downward Deviation - A Photo Essay.

Oculogyric crisis (OGC) describes the clinical phenomenon of sustained dystonic, conjugate and typically upward deviation of the eyes. A few cases with downward or lateral deviations have been described.1,2.