Can Lamina Cribrosa Indicate Optic Neuritis in Multiple Sclerosis?

Background: In this study, we aimed to evaluate the association of lamina cribrosa thickness (LCT) and lamina cribrosa depth (LCD), as determined by spectral domain optical coherence tomography (SD-OCT), with visual evoked potentials (VEPs) in patients with multiple sclerosis (MS). Materials and Methods: Patients enrolled in this prospective, cross-sectional study were divided into three groups. Group 1 consisted of 25 relapsing-remitting MS patients with VEP pathology in one or both eyes. In patients with VEP pathology in both eyes, one eye was chosen randomly. Group 2 comprised 25 relapsing-remitting MS patients with no VEP pathology or optic neuritis history. A randomly selected single eye of each patient was evaluated. Group 3 consisted of 25 age- and sex-matched healthy volunteers; a randomly selected single eye of these participants was examined. LCT, LCD, and retinal nerve fiber layer (RNFL) thickness measurements were determined in four quadrants (superior, inferior, nasal, and temporal) by SD-OCT. Results: The three groups were similar in terms of age and sex. The mean LCT was lower in Group 1 than in Group 2, but the difference was not statistically significant (268.80 ± 36.69 µm [min-max = 222-394 µm] versus 285.80 ± 12.00 µm [min-max = 249-338 µm]; P = 0.148). The mean LCT was significantly lower in Group 1 than in Group 3 (268.80 ± 36.69 µm [min-max = 222-394 µm] versus 294.80 ± 12.00 µm [min-max = 232-351 µm]; P = 0.012). There was a weak positive correlation between LCT and RNFL-inferior, RNFL-nasal, and RNFL-temporal. Conclusion: We found that the lamina cribrosa was thinner in MS patients with VEP pathology. To the best of our knowledge, this is a novel finding. Our results imply that LCT could be used as an indicator of optic neuritis in MS patients.

Effectiveness of Greater Occipital Nerve Blocks in Migraine Prophylaxis.

INTRODUCTION: Peripheral nerve blocks have been used in primary headache treatment since a long time. In this study, we aimed to examine the efficiency of greater occipital nerve (GON) block in migraine prophylaxis. METHODS: Data from migraine without aura patients who had GON block were collected and divided into two groups: Group PGON (n=25), which included patients who were under medical prophylaxis and had GON block, and Group GON (n=53), which included patients who had only GON blocks. Migraine was diagnosed using International Headache Society (IHS) classification. Data of 78 patients were analyzed. Headache attack frequency, headache duration, and severity were compared between and within groups in a 3-month follow-up period. RESULTS: The decrease in headache parameters after GON block in both groups was significantly similar. Headache attack frequency decreased from 15.73±7.21 (pretreatment) to 4.52±3.61 (3rd month) in Group GON and from 13.76±8.07 to 3.28±2.15 in Group PGON (p<0.05). Headache duration decreased from 18.51±9.43 to 8.02±5.58 at 3rd month in Group GON and from 15.20±9.16 to 7.20±4.16 in Group PGON (p<0.05). Headache severity decreased from 8.26±1.32 to 5.16±2.64 in Group GON and from 8.08±0.90 to 5.96±1.20 in Group PGON (p<0.05). There was no statistically significant difference between the groups in 3rd month after treatment (p>0.05). CONCLUSION: This study showed significant decreases in headache parameters in both groups. As GON blocks were performed in patients unresponsive to medical prophylaxis, a decrease in the headache parameters in Group PGON similar to that in Group GON can be attributed to GON blocks. Consequently, these results show that repeated GON blocks with local anesthetic can be an effective alternative treatment in migraine patients who are unresponsive to medical prophylaxis or who do not prefer to use medical prophylaxis.

Epileptic seizures in Neuro-Behcet disease: why some patients develop seizure and others not?

PURPOSE: Behcet disease (BD) is a chronic relapsing inflammatory disorder. Neuro BD (NBD) is seen in approximately 5% of all patients. The aim of this study is to investigate the frequency, type and prognosis of epileptic seizures in different forms of NBD. METHODS: All files of 42 patients with NBD were evaluated between 2006 and 2012, retrospectively. The demographic data, the presentation of NBD, clinical findings including seizures, EEG and neuroimaging findings were reviewed. RESULTS: The mean age of patients was 35.02±8.43 years. Thirty (71.4%) patients were male; the remaining 12 of them were female. Twenty-four patients had brainstem lesions; 16 patients had cerebral venous thrombosis. Spinal cord involvement was seen in two patients. Seven patients had epileptic seizures (six partial onset seizures with or without secondary generalization). Six of them had cerebral sinus thrombosis (CVT). Four patients had a seizure as the first symptom of the thrombosis. One patient had late onset seizure due to chronic venous infarct. The other patient with seizure had brainstem involvement. The remaining was diagnosed as epilepsy before the determination of NBD. CONCLUSION: CVT seen in BD seems to be the main risk factor for epileptic seizures in patients with NBD. The prognosis is usually good especially in patients with CVT. Epileptic seizures in patients with brainstem involvement may be an indicator for poor prognosis. Superior sagittal thrombosis or cortical infarct would be predictor of seizures occurrence because of the high ratio in patients with seizures.

Gender differences in older adults with chronic migraine in Turkey.

AIM: Chronic migraine is a growing and disabling subtype of migraine with different risk factors and clinical features, even in older adults. We sought to define and differentiate clinical features of chronic migraine in older adults. We also aimed to compare major clinical features of chronic migraine in older adults with those in younger people of both sexes. METHODS: We used electronic dataset (Turkish Headache Database) from 13 tertiary headache centers in Turkey. Electronic dataset included detailed headache-defining features according to ICHD-II criteria based on face-to-face interviews and examination by a headache specialist. Using statistical methods, clinical variables of chronic migraine in older adults were compared with those of younger adults. We included 915 patients with chronic migraine (mean age 43.80 ± 13.95 years); 83.3% were females. In total, 301 patients (32.9%) with chronic migraine aged >50 years were compared with 614 patients aged <50 years. RESULTS: There was no significant change in men with increasing age. However, duration of headache history, severity of attacks, previous histories of motion sickness and positive family history of headaches were significantly different in women with increasing age. Further sex-related differences have been shown in parameters such as attack duration, quality and associated nausea. CONCLUSION: Chronic migraine is an infrequent type of migraine and shows age-related changes in some phenotypic characteristics, such as severity of attacks, especially in women aged older than 50 years. Furthermore, positive family history of headaches and history of motion sickness increase the likelihood of developing chronic migraine in older women, indicating involvement of some gender-related, but as-yet unknown, genetic factors.

Buccopalpebral reflex in Parkinson disease and blink reflex study.

OBJECTIVE: To define a new primitive reflex named the buccopalpebral reflex (BPR), and to investigate this reflex clinically and neurophysiologically in patients with Parkinson disease. METHODS: This prospectively designed study included 17 patients, 9 BPR positive patients, and 8 BPR negative patients in Ankara Research and Training Hospital, Ankara, Turkey, and was carried out between January and December 2008. All patients had Parkinson disease without any medication. Using the blink reflex technique, 3 branches of the trigeminal nerve were stimulated. Additionally, the Mini Mental State Examination (MMSE), the Unified Parkinson`s Disease Rating Scale (UPDRS), the Hoehn and Yahr Score (HYS), the blink frequency, and the duration of Parkinson disease was also matched between the 2 groups. RESULTS: In patients with positive BPR, 5 had tremor and the remaining 4 had bradykinesia as a dominant symptom, while all other patients with negative BPR had only tremor. When blink reflex findings were compared between the 2 groups, R2 and contralateral R2 latencies that were taken by supraorbital stimulus were significantly shorter in the BPR positive patients. There were no statistically significant differences in terms of MMSE, UPDRS, HYS, and frequency of blinking, and duration of illness between the 2 groups. CONCLUSION: This reflex may be an indicator of sensitivity or decrease of threshold level such as Myerson`s sign, in which there is no inhibition in glabella reflex. The blink reflex findings support this hypothesis.

Efficacy of local lidocaine application on anxiety and depression and its curative effect on patients with chronic tension-type headache.

BACKGROUND: Tension-type headache (TTH) is a primary headache disorder. In this study, the efficacy of local lidocaine application on anxiety and depression and its curative effect in patients with chronic TTH was investigated. METHODS: Forty-eight patients (24 local lidocaine injection, 24 local saline injection group) with chronic TTH were enrolled in our study. Injections were applied to the trigger points of the muscles that are innervated by C1-C3 and the trigeminal nerve, exit points of the fifth cranial nerve, and around the superior cervical ganglion. Each patient underwent one session every 3 days. Patients were evaluated before and 3 months after the treatment. RESULTS: In both groups, the number of painful days in a month, visual analogue scale values, amount of analgesic use in a month, Hamilton depression score, and Hamilton anxiety score decreased after the treatment. As a result, all of the parameters were found to have improved in both groups (p < 0.05), the results were statistically significant, and the lidocaine group's response to the treatment was better than the placebo group (p < 0.001). CONCLUSION: Our findings suggest that local lidocaine administration can be an effective method in the treatment of chronic TTH.

Lidocaine injection of pericranial myofascial trigger points in the treatment of frequent episodic tension-type headache.

BACKGROUND: The present study aimed to evaluate the efficacy of local lidocaine injections into the myofascial trigger points (TPs) located at the pericranial muscles in patients with episodic tension-type headache (ETTH). METHODS: The study included 108 patients with frequent ETTH that were randomized into 4 groups. One injection of saline (NaCl 0.9%) was administered to group 1 (n = 27), 1 injection of lidocaine (0.5%) was administered to group 2 (n = 27), group 3 (n = 27) received 5 injections of saline (NaCl 0.9%), and group 4 (n = 27) received 5 injections of lidocaine (0.5%); on alternate days 2 mL for each muscle was injected into the frontal, temporal, masseter, sternocleidomastoid, semispinalis capitis, trapezius and splenius capitis muscles bilaterally. The frequency of painful days per month (FPD) and the patients' visual analogue scales (VAS) were evaluated before treatment, and 2, 4 and 6 months after treatment. RESULTS: Mean age of the patients was 36.28 ± 9.41 years (range: 18-54 years). FPD scores improved significantly in group 2, 3 and 4 at 2 months posttreatment compared to pre- treatment (all P < 0.05), and also VAS scores improved significantly in group 2 and 4 at 2 months posttreatment (P < 0.05) but this improvement insisted at the 6 month only in group 4. Group 2 had better VAS and FPD than group 1 only at 2. and 4. months after treatment (for VAS P < 0.0121, P = 0.0232; for FPD P = 0.0003, P = 0.0004, respectively). Group 4 had better scores than group 3 at the 2., 4. and 6. months after treatment in both parameters (all P < 0.05). Group 2 had better scores than group 1 in FPD at the 2. and 4. months posttreatment (P = 0.0003, P = 0.0004, respectively), but not at the 6. month. CONCLUSION: Local lidocaine injections into the myofascial TPs located in the pericranial muscles could be considered as an effective alternative treatment for ETTH.

Peripheral neuropathy and visual evoked potential changes in workers exposed to n-hexane.

The aim of this study was to evaluate patients who had peripheral neuropathy and changes to their visual evoked responses resulting from exposure to n-hexane. Eighteen patients with acute or subacute neuropathy, who were working in a shoe factory, were investigated clinically and electrophysiologically. These evaluations were then repeated 9 months to 12 months after cessation of exposure to n-hexane. Results of the nerve conduction studies predominantly showed a decrease in motor and sensory conduction velocities. Between 9 and 12 months after cessation of exposure to n-hexane, 83.3% of patients had a complete clinical recovery. The electrophysiological studies also revealed improvement to the majority of motor and sensory nerve conduction velocities. The results of the visual evoked potential (VEP) studies were considered normal at admission, however, the P100 latencies at the 9-month to 12-month retest had improved (p < 0.05). As the abnormalities identified with clinical examination and nerve conduction studies, and the subclinical abnormalities revealed through VEP assessment, could be reversed after exposure to n-hexane had ceased, the clinical prognosis was usually good.

Reversible encephalopathy due to sulfasalazine.

BACKGROUND: Sulfasalazine was devised by Swedish physician in the late 1930s in an attempt to treat "rheumatic polyarthritis." It is still a widely used anti-inflammatory agent especially in the treatment of rheumatologic disorders and inflammatory bowel diseases. Most of its side effects are benign, tolerable, and dose dependent, but less common severe systemic reactions have also been revealed. CASE PRESENTATION: A 42-year-old woman diagnosed with rheumatoid arthritis was admitted to emergency service because of status epilepticus. Hepatitis and myelotoxicity were also present after laboratory investigations. The patient was on sulfasalazine treatment for 3 weeks with a daily dose of 2g. Cranial magnetic resonance imaging (MRI) revealed bilateral periventricular and subcortical lesions in the white matter of especially temporal and occipital regions. Cerebrospinal fluid (CSF) examination showed very high protein level (564 mg/L). After discontinuation of treatment, the clinical, CSF, and MRI findings regressed rapidly. CONCLUSIONS: Side effects of sulfasalazine include neurotoxicity such as status epilepticus, cranial MRI lesions, and CSF abnormalities that were diagnosed in our patient after excluding other etiologic factors causing encephalitis.

Levetiracetam monotherapy for late poststroke seizures in the elderly.

Stroke is the most common cause of seizures in the elderly. Antiepileptic drugs are used to treat most patients with late poststroke seizures. The aim of this study was to evaluate the efficacy and tolerability of levetiracetam (LEV) in patients aged 60 or older with late-onset poststroke seizures. This prospective study evaluated patients 60 years of age or older, who had at least two late-onset poststroke seizures and were given LEV monotherapy. Demographic data and seizure and stroke characteristics were recorded. Outpatient visits were made after 2, 4, 6, 9, and 12 months and every 3 months thereafter, and the effectiveness and tolerability of LEV were investigated. Thirty-four patients with a mean age of 69.76+/-6.41 were included in this study. Average seizure frequency before treatment was 3.61+/-3.02/month. Mean follow-up time was 17.68+/-3.24 months. At daily doses of 1000-2000 mg, 82.4% of the patients were seizure free, and 7 patients (20.6%) had side effects. LEV was discontinued in one patient because of severe somnolence. Two patients were switched to another antiepileptic drug because of uncontrolled seizures despite an increase in dose up to 3000 mg/day. LEV monotherapy can be effective and well tolerated in elderly patients with late-onset poststroke seizures.

Does the seizure frequency increase in Ramadan?

During Ramadan, the ninth month of the Islamic lunar calendar, adult Muslims are required to refrain from taking any food, beverages, or oral drugs, as well as from sexual intercourse between dawn and sunset. In this study, we aimed at discovering alterations in drug regimens and the seizure frequency of epileptic patients during Ramadan (15 October 2004-13 November 2004). In the 3 months following Ramadan in the year 2004, 114 patients with epilepsy who were fasting during Ramadan were examined at our Epilepsy Department. Of the 114 patients who were included in the study, 38 patients had seizures and one of these patients developed status epilepticus during Ramadan. When the seizure frequency of these patients during Ramadan was compared to that in the last 1 year and last 3 months period just prior to Ramadan, a statistically significant increase was observed (p<0.001). Moreover, there was an important increase in the risk of having seizures in the patients who changed their drug regimens compared with those who did not (p<0.05). In the patients who received monotherapy or polytherapy, no difference in the frequency of seizures during Ramadan was seen (p>0.05). During Ramadan, an increase in the seizure frequency of patients with epilepsy was observed. The most important reason for this situation was the alteration in the pharmacokinetics and pharmacodynamics of drugs, and consequently, in their efficacy. We believe that in the patients who received monotherapy and who did not change their drug regimes, the increase in seizure frequency may have been related to the changes in their daily rhythms, emotional stress, tiredness and their day-long fasting.

Parapharyngeal tumor mimicking cervicogenic headache.

Nasopharyngeal cancer can occur in any age group and is often misdiagnosed. Cervicogenic headache (CEH) is a clinical condition, putatively originating from nociceptive structures in the neck. A patient with CEH-like symptoms occurring as a result of nasopharyngeal cancer invasion is reported. A 77-year-old man was admitted to the anesthesiology department (pain unit) with a 3-month history of severe unilateral headache. The headache began in the right part of the neck and spread to the right frontoorbital region and was always unilateral. There was no history of neck trauma, and the headache did not increase with neck movement. Analgesics were ineffective. The visual analog scale score for pain was 6. Neurological examination demonstrated tenderness over the right greater occipital nerve and reduced range of motion in the cervical spine. Cervical computerized tomography revealed a solid tumor in the right parapharyngeal region, adjacent to the C2-C3 vertebrae. To the authors' knowledge, this is the first case in the literature of tumoral invasion of nasopharyngeal cancer presenting as CEH. Cervical neuroimaging is obligatory in patients with late-onset, severe CEH.

Differences in improvement between patients with idiopathic versus neurovascular hemifacial spasm after botulinum toxin treatment.

This study was performed to investigate the differences in response to botulinum toxin treatment between patients with idiopathic versus neurovascular hemifacial spasm. A total of 69 patients with hemifacial spasm were investigated prospectively with cranial magnetic resonance imaging and magnetic resonance angiography. Neurovascular contact was found in 23 patients. All patients were assessed with a severity scale and a disease awareness scale. After treatment, the patients with idiopathic hemifacial spasm improved significantly in terms of both severity and awareness scores, but the patients with neurovascular hemifacial spasm improved only in the awareness scores. In conclusion, patients with idiopathic hemifacial spasm experienced a greater improvement after treatment with botulinum toxin than did patients with neurovascular hemifacial spasm.

Visual evoked potentials in neurobrucellosis.

OBJECTIVE: To investigate whether visual evoked potentials (VEPs) are valuable for distinguishing between brucellosis with or without neurological involvement. METHODS: A total of 23 patients who were admitted to the Department of Infectious Diseases and Microbiology, and Neurology, Ministry of Health Ankara Education and Research Hospital, Ankara, Turkey between December 2004 and August 2005 with a diagnosis of brucellosis were included in this study. After a detailed neurological and ophthalmological examination, VEPs were recorded. The P100 latencies and amplitudes were compared between the group of brucellosis (n=17) and neurobrucellosis (n=6) patients. RESULTS: Although there was no difference in the mean P100 latencies between the groups (n=17 for brucellosis, and n=6 for neurobrucellosis) (p=0.38), the mean P100 amplitude in patients with neurobrucellosis was significantly lower (p=0.012). CONCLUSION: It could be emphasized that VEPs might reflect an underlying axonal pathology as a distinctive feature in neurobrucellosis.

Is there a role for nitric oxide activity in cervicogenic headache?

Cervicogenic headache (CEH) is a unilateral headache that can be provoked by neck movement, awkward head positions or pressure on tender points in the neck. The mechanisms underlying the stimulation of pain in CEH are not clearly known. In this study, we measured serum nitrate and nitrite levels as an index of nitric oxide (NO) activity in 15 patients with CEH during headache and headache-free periods and in 15 healthy controls. Total nitrate+nitrite levels were found to be higher in CEH patients during headache periods than in healthy controls (20.7+/-3.8 micromol/l vs 14.4+/-3.6 micromol/l, p<0.001), but not in CEH patients during headache-free periods (16.1+/-2.2 micromol/l) compared with the controls (p>0.05). In the patients with CEH, serum total nitrate+nitrite levels were found to be higher during headache periods than during headache-free periods (p=0.001). It can thus be hypothesized that the changes observed are a cause of the attack rather than a consequence of the disease process.

Peripheral nervous system involvement in patients with Behçet disease.

BACKGROUND: Central nervous system involvement in Behçet disease (BD) has been well documented, but studies evaluating peripheral nervous system involvement are relatively uncommon. OBJECTIVE: The aim of this study is to evaluate the frequency and characteristics of peripheral nervous system involvement in BD. METHODS: Sixty-nine BD patients (36 women, 33 men) followed by neurology and dermatology outpatient clinics between October 1999 and October 2004 were enrolled into study. A careful history was taken and physical and neurologic examinations were done. All other medical causes that may be related to peripheral nervous system involvement were studied. All patients underwent nerve conduction studies using standard electrophysiologic procedures. RESULTS: Peripheral nervous system involvement was detected in 13 patients. There was no sign and symptom related to peripheral nervous system involvement in these patients. Causes other than BD were found in 5 patients with polyneuropathy. Asymptomatic delay in conduction velocities of the median nerves was detected in 3 patients. In 5 patients with clinically evident peripheral nerve involvement due to BD, 3 had sensorimotor and 2 had sensory axonal neuropathies. CONCLUSION: Axonal type polyneuropathy may be seen in BD patients. Peripheral involvement may be detected by electrophysiological examinations in asymptomatic BD patients.

Predisposing factors of restless legs syndrome in pregnancy.

The occurrence of restless legs syndrome in pregnancy is well known. However, the mechanism of this association is unclear. In this study, we aimed to identify the factors that predispose women to have restless legs syndrome during pregnancy. A total of 146 pregnant women were included in the study. Patients were asked questions regarding demographic characteristics, complications of pregnancy, medical therapy (vitamin and iron intake), sleep disorders, muscle cramps, and excessive daytime sleepiness. Electroneurography, routine blood biochemistry tests, complete blood count, and thyroid function tests were performed and vitamin B12, folic acid, serum iron, iron-binding capacity, ferritin, iron saturation, prolactin, estradiol, and progesterone were measured. Of the participants, 38 were diagnosed as having restless legs syndrome. In women with restless legs syndrome, additional medical problems, night cramps, and excessive daytime sleepiness were more frequent. In women without restless legs syndrome, serum hemoglobin levels were significantly higher and the use of supplemental iron or vitamins was greater. Among the women with restless legs syndrome, progesterone levels were slightly higher but this difference was not statistically significant. In summary, in this study, lower hemoglobin levels and supplementation deficits of iron and vitamins were found be the risk factors for restless legs syndrome in pregnancy.

Increased nitrosative and oxidative stress in platelets of migraine patients.

The molecular mechanisms of migraine have not been fully clarified yet. Increased nitrosative and oxidative stress may be associated with migraine attacks. Platelets may play an important role in migraine patients and they can reflect the lability of tissues to nitrosative/oxidative stress. In the present study, we aimed to determine the levels of nitrosative and oxidative stress markers in platelets of migraine patients during headache-free and attack periods. A total of 56 subjects (22 migraine without aura, 14 migraine with aura, and 20 age- and sex-matched healthy controls) were included in the study and nitric oxide (NO) metabolites, malondialdehyde (MDA), and thiol (SH) groups were measured in platelets. During migraine attacks, platelet levels of nitrate, nitrite and MDA were significantly higher in migraineurs than these in control subjects (p = 0.042, p = 0.005 and p = 0.042, respectively). By contrast, during headache-free period, no statistically significant differences were found in the platelet levels of nitrate, nitrite and MDA between migraineurs and controls (p > 0.05), although the marginal increases were detected in migraineurs. These results suggest that increased biomarkers of nitrosative and oxidative stress in platelets may be important in migraine patients, especially during attacks; increase of NO metabolites in platelets during attacks supports the opinion that NO may play a modulatory role in biological processes particularly by vasodilatation in migraine attacks. Therefore, MDA and NO metabolites may serve as useful markers to show the increased vulnerability to nitrosative and oxidative stress in migraine patients.

Effect of valproic acid on withdrawal therapy in patients with overuse of chronic daily headache medications.

Discontinuation of medication is the treatment of choice for patients with chronic daily headache (CDH) who overuse their medications. This treatment may be difficult due to increased headache severity observed in patients immediately after withdrawal. We retrospectively evaluated the efficacy of valproic acid therapy in 66 patients with overuse of CDH medication during withdrawal therapy. Patients were all withdrawn from medications and valproic acid started at 250 mg or 500 mg daily. Forty-two (63.6%) patients had decreased headache severity, including 27.3% objective responses in the first week. At the last visit in the 12th week, 50 patients were headache-free and only one patient had persistent headache. Fifteen patients withdrew from therapy due to side effects and lost to follow-up within this timeframe. Thus, low dose valproic acid appears to be safe and effective in the management of withdrawal therapy.