Isolated abducens nerve palsy: Comparison of microvascular and other causes.

OBJECTIVE: Abducens nerve paralysis is the most common ocular motor neuropathy. In this article, we aimed to compare the causes of isolated abducens nerve palsy in terms of demographic, clinical features, and prognosis. METHODS: Thirty-six isolated abducens nerve palsy patients were prospectively enrolled in the study. The demographic, clinical features, and prognosis compared in two etiological groups as microvascular and other causes. RESULTS: The most common etiology was microvascular, which was seen in 16/36 (44.4%) patients. Mean clinical recovery time was 2.5±1.3 months (range, 10 days-6 months). When etiological groups were compared as microvascular and other causes, the mean age of the microvascular group was significantly higher (62.8±13.3 vs. 44.5±16.4, p=0.001). Diabetes mellitus was seen significantly higher in the microvascular group than other causes group (p=0.001), but no significant difference was observed in terms of other atherosclerotic risk factors (p>0.05). The fasting blood glucose and hemoglobin A1c value were significantly higher in the microvascular group (p=0.02 and p=0.02, respectively). There was no significant difference in terms of clinical improvement and clinical recovery times between groups (p>0.05). CONCLUSION: There is no difference between microvascular group and other causes in terms of clinical outcome, while the mean age and presence of diabetes were higher in the microvascular group. The presence of diabetes should be questioned in cases with isolated abducens nerve palsy.

Autonomic dysfunction in patients with COVID­19.

PURPOSE: Autonomic dysfunction in patients with viral infections has been described before. In this study, we aimed to evaluate autonomic functions in patients with the coronavirus infectious disease 2019 (COVID-19). METHODS: In this cross-sectional study, we compared 112 patients who had recovered from COVID-19 and 106 healthy controls. Symptoms of autonomic dysfunction were assessed with the SCOPA-AUT scale. RESULTS: Pupillomotor, urinary and sudomotor subscores of SCOPA-AUT scale were significantly higher in the COVID-19 patient group (p = 0.03, p = 0,006, p = 0.0001, respectively). There were no significant difference in terms of gastrointestinal, cardiovascular, sexual subscores and total SCOPA-AUT scores between the patient and control groups. The presence of fatigue symptom in the acute phase of COVID-19 increased the total SCOPA-AUT score by 2.2 points (p = 0.04) whereas the presence of smell loss (OR = 5.82, p = 0.01) and dyspnea (OR = 5.8, p = 0.03) were significant risk factors for pupillomotor dysfunction. The urinary, cardiovascular, sexual subscores and the total score of SCOPA-AUT scale were positively correlated with the age of the patient group. CONCLUSION: Our study suggests that many patients might have prolonged symptoms of autonomic dysfunction after the acute phase of COVID-19 that might worsen the clinical recovery.

An Unusual Cause of Internal Carotid Artery Dissection: Mobile Phone Misuse.

The use of mobile phones has become an indispensable part of our lives, especially due to widespread use of the internet. We report the case of a 38-year-old male patient who developed internal carotid artery dissection after talking on the phone between her left shoulder and ear by laterally flexing the neck for 20 minutes. In addition to many positive effects of technology that facilitate the daily life, the development of neurological deficits may be observed with widespread use of mobile phones. Misuse of mobile phone should be considered in patients with carotid artery dissection.

Restless Legs Syndrome in Multiple Sclerosis.

INTRODUCTION: The co-existence of Restless Legs Syndrome/Willis-Ekbom Disease (RLS/WED/WED) and multiple sclerosis (MS) is a common condition. For this reason, we aimed to evaluate the effects of RLS/WED and its relationship with MS. METHODS: We evaluated the clinical features of 102 patients diagnosed with MS who were in follow-up between 2010 and 2015 in outpatient clinic. All the patients were evaluated for RLS/WED according to the revised International Restless Legs Syndrome Study Group (IRLSSG) diagnostic criteria. The Expanded Disability Status Scale (EDSS), Beck Depression Inventory, Beck Anxiety Inventory and Fatigue Severity Scale scores of all the patients were recorded. The IRLSSG 2003 severity scale was used to determine the degree of RLS/WED. RESULTS: RLS/WED was detected in 30.4% (n=31) of the patients (MS-RLS/WED+), but not in 69.6% (n=71) (MS-RLS/WED-). The mean EDSS score of the MS-RLS/WED+ patients were 3.2±2.1 while the MS-RLS/WED-patients were 2.0±1.6. The incidences of depression, moderate or severe anxiety, fatigue and intestinal and bladder dysfunction in the MS-RLS/WED+ patients were significantly higher. Regarding to RLS/WED complaints, 32.2% were mild, 35.4% were moderate, 19.3% were severe and 12.9% were very severe. When the MS subgroups were evaluated the highest RLS/WED severity score was found in the secondary progressive MS group. In the patients with pyramidal symptoms and intestinal and bladder dysfunction, the mean RLS/WED severity was significantly higher. The mean RLS/WED severity score was also significantly higher in those with depression and anxiety. The RLS/WED severity was significantly correlated with the number of pyramidal attacks and the EDSS score. CONCLUSION: Restless legs syndrome is a cause of depression, anxiety and fatigue and has negative effects on MS patients. Therefore, after the diagnosis of MS, the RLS/WED symptoms and signs should be determined, as soon as possible, in addition to the other MS symptoms. The treatment of this condition should be started early.

Intrarater and Interrater Reliability of Heckmatt Scoring System in Amyotrophic Lateral Sclerosis.

PURPOSE: This study aims to determine the intrarater and interrater reliability of the Heckmatt score in the upper extremity muscles in patients with amyotrophic lateral sclerosis and to investigate its relationship with the clinical features and quantitative echo intensity measurements. METHODS: The Heckmatt scores of multiple upper extremity muscles were calculated in 28 patients with amyotrophic lateral sclerosis and examined the relationships of these values with quantitative ultrasound (QUS) measurements and the Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised. RESULTS: The Heckmatt scores showed strong intrarater and interrater correlations with Cohen's Kappa scores ranging from 0.7 to 0.91. In all investigated muscles, the Heckmatt scores showed moderate correlations with quantitative echo intensity measurements and Amyotrophic Lateral Sclerosis Functional Rating Scale-Revised dressing subscale. CONCLUSIONS: The Heckmatt score is a reliable method in evaluating muscles of the upper extremities in patients with amyotrophic lateral sclerosis. It moderately correlates with quantitative values and functional status.

Use of CMAP, MScan fit-MUNE, and MUNIX in understanding neurodegeneration pattern of ALS and detection of early motor neuron loss in daily practice.

BACKGROUND: The pattern of lower motor neuron (LMN) degeneration in amyotrophic lateral sclerosis (ALS), i.e., dying-back (from the nerve ending to cell body) or dying-forward (from the cell body to nerve ending), has been widely discussed. In this study, we aimed to evaluate LMN loss using compound muscle action potential (CMAP), motor unit number index (MUNIX), and MScan-fit-based motor unit number estimation (MUNE) to understand the pattern of neurodegeneration in ALS. METHODS: Twenty-five patients were compared with 25 controls using CMAP amplitude and area, MUNIX, and MScan-fit MUNE in three proximal and distal muscles innervated by the ulnar nerve. RESULTS: Unlike the controls, the CMAP area, MScan-fit MUNE, and MUNIX recorded in ALS patients showed more neurodegeneration in distal muscles than proximal muscles. In ALS patients with unaffected CMAP amplitudes (n = 13), the CMAP area, MScan-fit MUNE, and MUNIX showed subtle motor unit loss of 30.7 %, 53.8 %, and 38.4 %, respectively. CONCLUSION: The CMAP area, MScan-fit MUNE, and MUNIX showed neurodegeneration earlier than the reduction in CMAP amplitude. These tests confirmed dying-back neurodegeneration, while only MUSIX showed re-innervation in ALS.

Assessment of Patients with Intracerebral Hemorrhage or Hemorrhagic Transformation in the VENOST Study.

INTRODUCTION: Cerebral venous and sinus thrombosis (CVST) may lead to cerebral edema and increased intracranial pressure; besides, ischemic or hemorrhagic lesions may develop. Intracerebral hemorrhages occur in approximately one-third of CVST patients. We assessed and compared the findings of the cerebral hemorrhage (CH) group and the CVST group. MATERIALS AND METHODS: In the VENOST study, medical records of 1,193 patients with CVST, aged over 18 years, were obtained from 35 national stroke centers. Demographic characteristics, clinical symptoms, signs at the admission, radiological findings, etiologic factors, acute and maintenance treatment, and outcome results were reported. The number of involved sinuses or veins, localizations of thrombus, and lesions on CT and MRI scans were recorded. RESULTS: CH was detected in the brain imaging of 241 (21.1%) patients, as hemorrhagic infarction in 198 patients and intracerebral hemorrhage in 43 patients. Gynecologic causes comprised the largest percentage (41.7%) of etiology and risk factors in the CVST group. In the CH group, headache associated with other neurological symptoms was more frequent. These neurological symptoms were epileptic seizures (46.9%), nausea and/or vomiting (36.5%), altered consciousness (36.5%), and focal neurological deficits (33.6%). mRS was ≥3 in 23.1% of the patients in the CH group. DISCUSSION AND CONCLUSION: CVST, an important cause of stroke in the young, should be monitored closely if the patients have additional symptoms of headache, multiple sinus involvement, and CH. Older age and parenchymal lesion, either hemorrhagic infarction or intracerebral hemorrhage, imply poor outcome.

The simple and fast swallowing function assessment in acute stroke patients.

OBJECTIVE: The dysphagia associated pulmonary aspiration is one of the important reasons for mortality and morbidity in stroke. In this study, we evaluated the early swallowing functions of the acute ischemic stroke patients, and tried to choose the right way to start feeding with simple tests. METHODS: Seventy-three inpatients with acute stroke were included in this study. Age, gender, type of stroke, NIHSS and RANKIN scores, risk of aspiration and feeding route were recorded for all the subjects. Dysphagia was evaluated with the bedside clinical evaluation of swallowing function score (BDS) tests. These BDS tests are the assessment of dysphagia with neurological examination score (DSNE) and the bedside water drinking test (BWT) and the Swallowing score (SS) ratio (combining BWT and DSNE scores). All tests to evaluate swallowing were planned to be carried out 24 hours after the last known time of the patient's healthy and 48 hours after hospitalized. The tests were performed in awake patients who were able to manage to cooperate at the scheduled time. In addition, stroke patients were evaluated quantitatively using the Gugging Swallowing Screen (GUSS) test for dysphagia and compared with BDS tests. All patients were evaluated for aspiration pneumonia seven days after admission. If the patients had drowsiness or were unable to cooperate, they were not included in this study. RESULTS: Seventy-three (26F/47M) patients were included in this study if they were conscious and the Glasgow coma scale was above 10 points. When only BDS tests were performed, we decided that 74% (n=54) of the patients could be fed by the oral route, 13.7% of the patients could be fed only by NG route (n=10) and the patients who had the worst BWT and DSNE scores preferred to be feed with PEG route (11% of all the patients, n=8). In 41.1% of the patient (n=30) established the risk of aspiration on referral clinic and 23.3% of the patients (n=17) developed aspiration pneumonia in the clinical follow-up. When 30.1% (22) of the patients had dysphagia with GUSS test, 23.3% (n=17) of the patients were dysphagic with DSNE and 30.1% of the patients (n=22) were dysphagic with BWT and 22% (n=16) of the patients were moderate-severe, 11% (n=8) of the patients were mild dysphagic with the SS ratio. CONCLUSION: These BDS tests concluded are fast and reliable methods for evaluating the dysphagia and risk of aspiration pneumonia without laborious and very few clinically applicable methods, such as endoscopic or video fluoroscopy, in patients who are hospitalized with stroke.

Cerebral Venous Sinus Thrombosis as a Rare Complication of Systemic Lupus Erythematosus: Subgroup Analysis of the VENOST Study.

AIM: Systemic lupus erythematosus (SLE) is an unusual risk factor for cerebral venous sinus thrombosis (CVST). As few CVST patients with SLE have been reported, little is known regarding its frequency as an underlying etiology, clinical characteristics, or long-term outcome. We evaluated a large cohort of CVST patients with SLE in a multicenter study of cerebral venous thrombosis, the VENOST study, and their clinical characteristics. MATERIAL AND METHOD: Among the 1144 CVST patients in the VENOST cohort, patients diagnosed with SLE were studied. Their demographic and clinical characteristics, etiological risk factors, venous involvement status, and outcomes were recorded. RESULTS: In total, 15 (1.31%) of 1144 CVST patients had SLE. The mean age of these patients was 39.9 ± 12.1 years and 13 (86.7%) were female. Presenting symptoms included headache (73.3%), visual field defects (40.0%), and altered consciousness (26.7%). The main sinuses involved were the transverse (60.0%), sagittal (40.0%), and sigmoid (20.0%) sinuses. Parenchymal involvement was not seen in 73.3% of the patients. On the modified Rankin scale, 92.9% of the patients scored 0-1 at the 1-month follow-up and 90.9% scored 0-1 at the 1-year follow-up. CONCLUSIONS: SLE was found in 1.31% of the CVST patients, most frequently in young women. Headache was the most common symptom and the CVST onset was chronic in the majority of cases. The patient outcomes were favorable. CVST should be suspected in SLE patients, even in those with isolated chronic headache symptoms with or without other neurological findings.

Novel SNARE Complex Polymorphisms Associated with Multiple Sclerosis: Signs of Synaptopathy in Multiple Sclerosis

Background: It is well known that axonal degeneration plays a role in disability in patients with multiple sclerosis, and synaptopathy has recently become an important issue. Aims: To investigate the possible roles of selected synaptic and presynaptic membrane protein genetic polymorphisms (VAMP2, SNAP-25, synaptotagmin, and syntaxin 1A) in patients with multiple sclerosis. Study Design: Case-control study. Methods: A total of 123 patients with multiple sclerosis and 192 healthy controls were included. The functional polymorphisms of specific SNARE complex proteins (VAMP2, synaptotagmin XI, syntaxin 1A, and SNAP-25) were analyzed by polymerase chain reaction. Results: Significant differences were detected in the genotype and allele distribution of 26-bp Ins/Del polymorphisms of VAMP2 between patients with multiple sclerosis and control subjects; Del/Del genotype and Del allele of VAMP2 were more frequent in patients with multiple sclerosis (p=0.011 and p=0.004, respectively). Similarly, Ddel polymorphism of SNAP-25 gene C/C genotype (p=0.059), syntaxin 1A T/C and C/C genotypes (p=0.005), and synaptotagmin XI gene C allele (p=0.001) were observed more frequently in patients with multiple sclerosis. CC, syntaxin rs1569061 1A gene for 33-bp promoter region TC haplotypes, and synaptotagmin XI gene were found to be associated with an increased risk for multiple sclerosis (p=0.012). Similarly, GC haplotype for rs3746544 of SNAP-25 gene and rs1051312 of SNAP-25 gene were associated with an increased risk for multiple sclerosis (p=0.022). Conclusion: Genetic polymorphisms of SNARE complex proteins, which have critical roles in synaptic structure and communication, may play a role in the development of multiple sclerosis.

Evaluation of ischemic stroke patients with systemic cancer.

BACKGROUND AND PURPOSE: In cancer patients, an ischemic stroke can be seen as both a direct effect of cancer and a complication of treatment. This condition can negatively affect the follow-up and treatment of these patients. For this research, we aimed to evaluate the clinical features, stroke types and etiological features of ischemic stroke patients with histories of cancer or found to have cancer during the aetiological investigation. METHODS: We retrospectively evaluated 100 patients (57 males, 43 females) who were hospitalized with acute stroke and determined to have the presence of cancer or a cancer history during the aetiological investigation between 2011 and 2016. All the demographic features, stroke types and localizations, National Institutes of Health Stroke Scale (NIHSS) scores, Rankin Scale scores, durations of cancer and cancer treatments were recorded. RESULTS: The mean age of the patients was 67.07 ± 10.9 years old, the median NIHSS score was 5, and the median Rankin Scale score was 4. While 79% of patients had ischemic stroke risk factors, 21% did not. Atherosclerotic stroke was the most common stroke type (49%, n=49) and cryptogenic strokes were detected in 21% (n=21). In addition, 63% of the patients had chronic cancer (later than 6 months), 31% of the patients had recent cancer histories (less than 6 months), and 29% of the patients had metastases. Among all the malignancies, lung cancer (n=23), gastrointestinal cancer (n=20) and gynaecological-breast cancer (n=16) were the three most common. Moreover, 37% of the patients underwent chemotherapy, 29% underwent radiotherapy, and 88% of the patients had Carotid/Vertebral Doppler USG abnormalities. CONCLUSION: Similar to what is stated in the literature, an atherosclerotic stroke was the most common type of stroke in the cancer patients. Stroke risk factors were not detected in 21% of the patients, and in the majority of the patients, atherosclerotic changes in the carotid artery were observed in the Doppler examinations. In the aetiology and prognosis of ischemic stroke, it is important to keep in mind the existence of cancer in addition to the classical stroke risk factors.

Alien hand syndrome and migraine with aura: A case report.

BACKGROUND: Alien Hand Syndrome (AHS) is an uncontrollable, involuntary, but in appearance, purposeful motor control disorder of the upper extremity. CASE REPORT: A 42-year-old male patient was admitted to our clinic complaining of involuntary motor activity in his right hand. He had a previous history of migraine with visual aura. The uncontrollable motor control disorder was compatible with Alien Hand Syndrome, which was appearing immediately after the visual aura and before the beginning of headache. CONCLUSION: Alien Hand Syndrome is usually observed with anterior cerebral artery infarction, midline tumors, trauma and several neurodegenerative diseases, but is rarely seen in paroxysmal conditions such as migraine with aura.