Muscle mass as a modifier of stress response in acute ischemic stroke patients.

Stroke triggers a systemic inflammatory response over the ensuing days after the cerebral insult. The age and comorbidities of the stroke population make them a vulnerable population for low muscle mass and sarcopenia, the latter being another clinical condition that is closely associated with inflammation, as shown by increased levels of pro-inflammatory biomarkers, including neutrophil-to-lymphocyte ratio (NLR). In this study, we evaluated the relationship between post-stroke NLR changes and muscle mass in a prospective cohort of acute ischemic stroke patients (n = 102) enrolled in the Muscle Assessment in Stroke Study Turkey (MASS-TR). Admission lumbar computed tomography images were used to determine the cross-sectional muscle area of skeletal muscles at L3 vertebra level and calculate the skeletal muscle index (SMI). The median (IQR) SMI was 44.7 (39.1-52.5) cm2/m2, and the NLR at admission and follow-up were 4.2 (3.0-10.5) and 9.4 (5.7-16.2), respectively. While there was no relationship between SMI and admission NLR, a significant inverse correlation was observed between SMI and follow-up NLR (r = - 0.26; P = 0.007). Lower SMI remained significantly associated (P = 0.036) with higher follow-up NLR levels in multivariate analysis. Our findings highlight the importance of muscle mass as a novel factor related to the level of post-stroke stress response.

Discrimination of leptomeningeal carcinomatosis and meningeal inflammation/infection with internal acoustic canal enhancement.

PURPOSE: The purpose of this study is to investigate whether the presence and pattern of enhancement at the internal acoustic canal (IAC) could help in discriminating between leptomeningeal carcinomatosis (LCa) and meningeal inflammation/infection (MMI). METHODS: Magnetic resonance (MR) images of patients with leptomeningeal enhancement were retrospectively evaluated. MR images of the LCa group (n = 33), MMI group (n = 19) and control group (n = 33) were evaluated for the presence, type (moderate/prominent), and localization (unilateral/bilateral) of the IAC enhancement. RESULTS: The presence of IAC enhancement was significantly more common in patients with LCa (p < 0.001). In 73.7 % of patients with MMI, no contrast enhancement was observed in the IAC. In patients with contrast enhancement in the IAC, the risk of LCa in the etiology is 20 times greater than the risk of having MMI. Seventy-five percent of the IAC enhancement seen in LCa patients and 20 % of the IAC enhancements seen in MMI patients was bilateral. This difference was statistically significant (p = 0.029). CONCLUSION: Intense contrast enhancement of the IAC can be a marker for LCa.

Characterizing Camptocormia in Parkinson's Disease Using Muscle Ultrasonography.

BACKGROUND: Camptocormia (CC) is the forward-bending of the spine of more than 30 degrees that can be found in Parkinson's disease (PD) as a disabling complication. Detection of changes in paraspinal lumbar musculature in CC is of value for choosing treatment strategies. OBJECTIVE: To investigate whether these changes can be detected using muscle ultrasonography (mUSG). METHODS: Age and sex-matched groups comprised 17 PD patients with CC (seven acute, PD-aCC; 10 chronic PD-cCC), 19 PD patients with no CC, and 18 healthy controls (HC). Lumbar paravertebral muscles (LPM) on both sides were assessed using mUSG by two different raters blinded to the group assignment. Groups were compared with regard to the linear measurements of the muscle thickness as well as semi-quantitative and quantitative (grayscale) analyses of muscle echogenicity using a univariate general linear model. RESULTS: All assessments showed substantial interrater reliability. The PD-cCC group had significantly thinner LPM compared to groups with no CC (PD and HC). Groups of PD-aCC and PD-cCC differed from the groups of no CC in quantitative and semi-quantitative analyses of LPM echogenicity, respectively. CONCLUSION: Assessment of LPM in PD patients with CC can be reliably performed using mUSG. Also, mUSG may be used as a screening tool to detect CC-related changes in thickness and echogenicity of the LPM in patients with PD.

Nutritional Status in patients with Neuro-Behçet's disease.

Background/aim: The aim of this study was to assess the nutritional status and risk factors for malnutrition in Behçet's disease (BD) and neuro-Behçet's disease (NBD) patients. Materials and methods: Medical recordings of 74 patients with BD without neurological involvement (BDWoNI), 72 patients with NBD, and 50 patients with other diseases (carpal tunnel syndrome or lumbar discopathy) were analyzed retrospectively. The serum analyses were performed in the inactive period of disease. Chronic malnutrition was defined as low levels of serum albumin (<3.5 g/dL) with normal sedimentation rate and normal serum CRP levels. Results: Six (8.3%) of the patients in NBD group, 1 (1.4%) of the patients in BDWoNI group, and none of the patients in control group had chronic malnutrition (p = 0.029). Malnutrition rate was higher in NBD than control group (p = 0.036). The mean expanded disability status scale score was 2.92 ± 3.35 (range: 0­8) in patients with malnutrition and 1.44 ± 1.76 (range: 0­9) in patients without malnutrition in NBD group (p = 0.457). The ratio of patients having a progressive disease course was 33.3% and 7.6% in patients with and without malnutrition in NBD group, respectively. The median value of the duration of neurological involvement was 2 years (0­16) in patients with malnutrition and 6.5 years (0­18) in patients without malnutrition in NBD group (p = 0.046). There was no association between malnutrition and medications, disability scores, functional system involvement or findings on brain MRI. Conclusion: Malnutrition was higher in patients with NBD. Higher disability level and progressive disease course may be risk factors for malnutrition in NBD. Malnutrition may be seen more frequently in earlier phases of neurological involvement.

Determinants of preventable stroke-Ankara ACROSS stroke preventability study.

BACKGROUND: Unhealthy lifestyle and inadequate control of vascular risk factors are the major contributors of stroke burden. Failure in achieving the target levels in control of these factors, not only designate missed opportunities contributing to the preventability of an incident stroke, but also set the post-stroke treatment goals in a case wise basis. In this study, we analyzed pre-event clinical features that play a role in stroke preventability, and determined the cumulative burden of risk factors that necessitate optimization following the ischemic insult. METHODS: Information about the pre-stroke optimal control of seven major modifiable risk factors (Life's Simple 7: hypertension, diabetes mellitus, hyperlipidemia, smoking, obesity, diet, and physical activity) was prospectively collected in ischemic stroke patients admitted to three tertiary academic centers in Ankara. Stroke preventability was evaluated by the overall number of factors requiring optimization with patients ≥4 risk factor conditions categorized as those suffering from a preventable stroke. Bivariate and multivariate analyzes were performed to uncover predictors of stroke preventability. RESULTS: Among 787 patients, 386 (49.0%) had ≥4 risk factor conditions requiring optimization. Preventable stroke was more common in younger patients, and patients with small artery occlusion. Multivariate analyses taking into account the pre-stroke antithrombotic treatment regimen, have highlighted age (OR: 0.99, 95%CI 0.98-1.00), female gender (1.59, 95%CI 1.17-2.16), coronary artery disease (1.54, 95%CI 1.10-2.14), small artery occlusion (1.90, 95%CI 1.13-3.18), and cardio-aortic embolism (0.53, 95%CI 0.35-0.82) as significant factors associated with preventability. CONCLUSIONS: Approximately half of the ischemic stroke patients have preventable stroke from the perspective of risk factor control. Extra care should be given to strategies directed to risk factor control and lifestyle interventions in certain high-risk groups for the prevention of future complications.

Prediction of degree of carotid stenosis with the transluminal attenuation difference ratio.

PURPOSE: We aimed to assess the diagnostic performance of transluminal attenuation difference (TAD) in predicting the severity of internal carotid artery (ICA) stenosis. METHODS: The study cohort consisted of 48 patients with <50% stenosis, 50%-69% stenosis, 70%-99% stenosis, and 51 controls without plaque development in ICA. A total of 143 measurements were performed through right and left internal and common carotid arteries. The TAD ratio was calculated as the difference between the mean attenuation values of the common carotid artery (CCA) and ICA, divided by the MAV of the CCA, multiplied by 100. RESULTS: TAD ratio was significantly higher in severe (>70%) stenosis compared with control arteries and low-moderate stenosis. A TAD ratio cutoff of 4.5 predicted 70%-99% stenosis with a sensitivity of 100% and specificity of 93%. The inter- and intraobserver agreements in TAD measurements were almost perfect (ICC, 0.89-0.86). CONCLUSION: Assessment of TAD ratio predicts the degree of stenosis in concordance with NASCET system.

Clinical characteristics and prognosis of Neuro-Behçet's disease.

OBJECTIVE: Neuro-Behçet's disease (NBD) is a rare manifestation of Behçet's disease (BD) and may cause severe disability. The aim of this study was to evaluate the treatment response in patients with NBD and to investigate the parameters that may influence the prognosis of the disease in patients with severe to mild-moderate disability. METHODS: The files of 60 patients admitted to our outpatient clinic for NBD between January 2007 and June 2014 were retrospectively reviewed. We compared the BD duration, time to NBD, NBD type and course, clinical findings of BD, functional neurological system involvement, localization of lesions on brain MRI, and all the medications between the severe and mild-moderate disability groups. RESULTS: The mean time to the onset of NBD was significantly longer (17.8±4.6 years) and the mean age was significantly higher (50.25±9.1 years) in patients with severe disability than in those with mild-moderate disability (7.5±8.0 years and 37.5±10.9 years; p=0.01 and p=0.03, respectively). Moreover, hemispheric involvement was significantly associated with severe disability (p=0.006). No difference was found with regard toother investigated parameters between the groups. CONCLUSION: We believe that severe neurological disability may be associated with older age at the onset of NBD or longer time to NBD and hemispheric lesions on brain MRI. However, our results should be cautiously evaluated with further research.

Evaluation of the effect of non-ergot dopamine agonists on left ventricular systolic function with speckle tracking echocardiography.

OBJECTIVE: Parkinson's disease (PD) is a neurological disorder, and ergot dopamine agonists (DAs) are no longer usually preferred in the treatment due to the increased risk of valvular heart disease. Some recent studies have shown that commonly used non-ergot DA also increases the risk of heart failure. On the other hand, there are studies showing conflicting data about this relationship. The aim of the present study was to investigate the cardiac effects of non-ergot DAs in patients with PD using echocardiography. METHODS: Conventional echocardiography and two-dimensional (2D) speckle tracking strain echocardiography were performed to determine the possible systolic dysfunction prior to the development of apparent systolic heart failure. Ninety-one (55 male, 64±10 years) patients with PD were included in the study. Furthermore, 25 subjects with newly diagnosed PD and using no drug were enrolled as the control group. All patients were divided into groups according to their medication. Patients using levodopa were classified as Group 1 (36), levodopa+pramipexole as Group 2 (27), and levodopa+ropinirole as Group 3 (28). RESULTS: Left ventricle dysfunction with non-ergot DA use in patients with PD was not established with conventional echocardiographic evaluation. For 2D strain analysis, global longitudinal strain values were obtained as -18.5%, -18.5%, and -18.9% in the groups, respectively. Strain and strain rate values of the left ventricle were not different between the groups (p=0.816 and p=0.881, respectively). CONCLUSION: There was no significant relationship between left ventricular dysfunction and use of non-ergot DA in patients with PD. Similar results were obtained in strain analysis showing left ventricular subclinical dysfunction. Our study appears to confirm the safety of non-ergot DA in the point of heart failure risk. To our knowledge, this is the first study to evaluate the effect of this group of drugs on subclinical left ventricular systolic function.

Prevalence of and risk factors for cognitive impairment in patients with relapsing-remitting multiple sclerosis: Multi-center, controlled trial.

BACKGROUND: Cognitive impairment (CI) is a common problem in multiple sclerosis (MS), may occur either in early or late phase of the disease, and impairs quality of life. OBJECTIVES: This study aimed to determine the prevalence of CI and related risk factors in relapsing-remitting MS (RRMS) patients in Turkey. METHODS: The present cross-sectional, multi-center, and nationally representative study included RRMS patients. Sociodemographic characteristics, cognitive functions and additional outcomes were compared between patients with and without CI. RESULTS: The analyses included 487 RRMS patients. According to the BRB-N battery results, CI prevalence was 53.7%. There was a negative significant correlation of BRB-N subtests with age, disease duration, and EDSS and MSNQ-patient rated scores. On the logistic regression analysis, increased age, living in village/rural area, high income level, and high EDSS score were significant increasing risk factors in the development of CI. CONCLUSIONS: This is the first national cognitive data obtained from MS in Turkey, which is a country between Europe and Asia and thus has characteristics of both continents. The similarity of the results of the present study obtained from Turkey to the Western-based data indicates that CI is universal in MS and the main factors affecting CI have not changed.

Risk Factors, Biomarkers, Etiology, Outcome and Prognosis of Ischemic Stroke in Cancer Patients

Introduction: Cerebrovascular disease is the second most common complication in individuals with tumours. The aim of this study was to investigate risk factors, biomarkers, etiology and prognosis of ischemic stroke in cancer patients (ISCPs). Methods: The medical records of 619 consecutive patients who were admitted with acute ischemic stroke from January 2012 to November 2014 were retrospectively evaluated. The patients were divided into two groups (group 1, patients with an active cancer prior to the onset of ischemic stroke; group 2, patients without an active cancer history). The demographic data, risk factors, NIHSS scores, thrombocyte count, D-dimer, fibrinogen and C reactive protein (CRP) level at admission, modified Rankin Scale (mRS) scores in the follow-up period and location of lesions on DWI were recorded. The Mann-Whitney U test, chi-squared test and logistic regression was used for analyzing data, p<0.05 being considered statistically significant. Results: A total of 46 (7.4%) ISCPs were included. Hyperlipidemia was significantly lower in the ISCP group (p=0.001). Elevated thrombocyte counts, D-dimer, fibrinogen and CRP levels at admission, acute multiple ischemic lesions, other causes, mortality in hospital and worse outcome were significantly related to ISCP (p<0.05). On logistic regression analysis, follow up mRS>3, acute multiple ischemic lesions located in more than one vascular territory (AMIMCT) and other causes were significantly associated with ISCP (p<0.001). Conclusion: In our study, other causes, AMIMCT and mRS>3 were more common in the ISCP group. We consider that CCS could be more suitable for detecting other causes than TOAST. Biomarkers could be important in the ISCP group.

GNE missense mutation in recessive familial amyotrophic lateral sclerosis.

Amyotrophic lateral sclerosis (ALS) is a motor neuron disease eventually leading to death from respiratory failure. Recessive inheritance is very rare. Here, we describe the clinical findings in a consanguineous family with five men afflicted with recessive ALS and the identification of the homozygous mutation responsible for the disorder. The onset of the disease ranged from 12 to 35 years of age, with variable disease progressions. We performed clinical investigations including metabolic and paraneoplastic screening, cranial and cervical imaging, and electrophysiology. We mapped the disease gene to 9p21.1-p12 with a LOD score of 5.2 via linkage mapping using genotype data for single-nucleotide polymorphism markers and performed exome sequence analysis to identify the disease-causing gene variant. We also Sanger sequenced all coding sequences of SIGMAR1, a gene reported as responsible for juvenile ALS in a family. We did not find any mutation in SIGMAR1. Instead, we identified a novel homozygous missense mutation p.(His705Arg) in GNE which was predicted as damaging by online tools. GNE has been associated with inclusion body myopathy and is expressed in many tissues. We propose that the GNE mutation underlies the pathology in the family.

Perioperative and follow-up results in carotid artery stenting with contralateral carotid occlusion.

PURPOSE: Contralateral carotid occlusion (CCO) increases the risk of carotid endarterectomy (CEA). We determined the outcome of carotid angioplasty and stenting (CAS), an alternative to CEA, in the setting of CCO through an independent analysis of imaging and clinical outcome. MATERIALS AND METHODS: Medical records of 26 consecutive patients with CCO who underwent CAS by a single operator using the same procedural protocol (with distal protection and closed-cell stents) were retrospectively evaluated. National Institutes of Health Stroke Scale (NIHSS) and Modified Rankin Scale (mRS) scores before and after CAS, periprocedural complications, and the restenosis rate were analyzed by independent stroke neurologists who were not involved in the care of the patients. RESULTS: The median mRS score for the 26 patients was 1 (range 0-5) before and after CAS. All of the patients underwent clinical and imaging follow-up (mean 19.5 ± 14.3 and 11.6 ± 11.2 months, respectively). Thirty-day mortality/permanent morbidity rates were 0 %. One patient had hyperperfusion syndrome and was managed medically without sequelae; however, he had stent occlusion after 30 days, resulting in a decline in his mRS from 4 (preprocedure) to 5. Otherwise, there was no decline in mRS during the post-discharge follow-up. CONCLUSION: According to an independent analysis of this single-operator series, CAS is safe and effective for the treatment of patients with CCO.

Cerebral Venous Thrombosis in Behçet's Disease Patients Compared to Other Causes of Cerebral Venous Thrombosis: a Retrospective Study.

OBJECTIVES: This study aims to report the outcomes of patients with Behçet's disease (BD) with cerebral venous thrombosis (CVT) due to BD compared to patients with CVT due to other causes and to discuss the treatment options. PATIENTS AND METHODS: Files of 47 patients admitted to our outpatient clinic for CVT between January 2007 and November 2014 were retrospectively reviewed. Patients were divided into two groups; group 1 included 21 CVT patients with BD (9 males, 12 females; mean age 47±12 years; range 27 to 69 years) and group 2 included 26 CVT patients without BD (11 males, 15 females; mean age 45±16 years; range 25 to 79 years). We collected data for diagnosis for BD and CVT, duration of all medications, functional system involvement, baseline Expanded Disability Status Scale scores, modified Rankin Scale scores at follow-up, and localizations of lesions in brain magnetic resonance imaging and magnetic resonance venography. RESULTS: Mean follow-up duration was four years in group 1 and two years in group 2. There was no significant difference between the groups regarding age, sex, neurological symptoms/findings and baseline Expanded Disability Status Scale scores. Localizations of occluded sinus in group 1 and group 2 were similar. For acute CVT, patients were treated with intravenous high dose prednisolone in group 1 and with anticoagulant in group 2. Follow-up modified Rankin Scale score was 0 in both groups. CONCLUSION: Our study revealed similar clinical and radiological findings in CVT patients with or without BD. Although medications used for treatment were different between the groups, treatment responses were good in both groups. Treatment with prednisolone may be sufficient and anticoagulation therapy may not be necessary for acute CVT attacks in BD.

Bilateral optic neuritis in a patient with Behçet's disease who respond to therapeutic plasma exchange.

Bilateral optic neuritis has been reported very rarely as a manifestation of neuro-Behçet's disease. We present a 50 year old woman who had 20-year history of Behçet's disease presented with acutely blurred vision associated with orbital pain in both eyes. Visual acuity was 0.4 in the right eye and light perception in the left eye; afferent pupillary defect was detected in the left eye. Bilateral swelling of the optic disk was found. The cerebrospinal fluid sample tests were within normal limits. Brain magnetic resonance imaging, magnetic resonance venography and fundus fluorescein angiography were normal. She was diagnosed with bilateral optic neuritis and treated with intravenous methyl prednisolone for 10 days. As there was no response to the treatment, therapeutic plasma exchange was started and the patient's visual acuities improved moderately. We suggest that when high dose steroid is failed to treat ON in BD, treatment with TPE may be considered.

Etiologic Subtypes of Watershed Infarcts.

BACKGROUND: Two types of watershed infarcts (WI) are recognized. Internal WI are usually attributed to either severe stenosis in large arteries or acute hypotensive events, whereas external WI are thought to be caused by embolism. The aim of this study was to determine the etiologic background and prognosis of external and internal WI in our patients. METHODS: We reviewed the medical records and diffusion-weighted images of the patients who were admitted to our stroke unit with acute ischemic stroke between January 2012 and November 2014. The demographics, clinical features, radiologic investigations, and other etiologic tests of the patients with internal or external WI were recorded. We determined etiologic stroke subtypes according to the automated Causative Classification System. RESULTS: Fifty-three patients with WI were detected in our registry. Twenty-two (41.5%) of them were women. The mean age was 69 ± 12.8 (33-98) years. Twenty-one (39.6%) patients had external WI: 7 (33.3%) of them had large-artery atherosclerosis (LAA), 8 (38.1%) patients had cardioembolism, 3 (14.3%) patients had stroke due to other causes (vasculitis; n = 3), and etiologic subtype was undetermined in 3 patients (14.3%). Thirty-two (60.4%) patients had internal WI: 21 (65.6.%) of them had LAA, 5 (15.6%) patients had cardioembolism, 3 (9.4%) patients had stroke due to other causes (aneurysm; n = 1, hypercoagulability due to chronic myeloid leukemia; n = 1, vasculitis; n = 1), and etiologic subtype of 3 (9.4%) patients remained cryptogenic. LAA was significantly associated with internal WI (P = .024). Hypertension was more common in patients with internal WI (P = .035). CONCLUSIONS: In this series, cardioembolism was the most common etiologic subtype in the patients with external WI, whereas internal WI were significantly associated with LAA. Uncommon causes should also be investigated in cryptogenic patients.

Botulinum toxin injections for the treatment of hemifacial spasm over 16 years.

The aim of this study was to investigate the efficacy and side effects of botulinum toxin (BTX) in the treatment of hemifacial spasm (HFS). We also focused on the divergence between different injection techniques and commercial forms. We retrospectively evaluated 470 sessions of BTX injections administered to 68 patients with HFS. The initial time of improvement, duration and degree of improvement, and frequency and duration of adverse effects were analysed. Pretarsal and preseptal injections and Botox (Allergan, Irvine, CA, USA) and Dysport (Ipsen Biopharmaceuticals, Paris, France) brands were compared in terms of efficacy and side effects, accompanied by a review of papers which reported BTX treatment of HFS. An average of 34.5 units was used per patient. The first improvement was felt after 8 days and lasted for 14.8 weeks. Patients experienced a 73.7% improvement. In 79.7% of injections, no adverse effect was reported, in 4.9% erythema, ecchymosis, and swelling in the injection area, in 3.6% facial asymmetry, in 3.4% ptosis, in 3.2% diplopia, and in 2.3% difficulty of eye closure was detected. Patients reported 75% improvement on average after 314 sessions of pretarsal injections and 72.7% improvement after 156 sessions of preseptal injections (p=0.001). The efficacy and side effects of Botox and Dysport were similar. BTX is an effective and safe treatment option for HFS. No difference was determined between Botox and Dysport, and pretarsal injection is better than preseptal injection regarding the reported degree of improvement.

Restless legs syndrome in multiple sclerosis.

BACKGROUND/AIM: There have been conflicting results in the literature regarding the relationship between functional system involvement, the expanded disability status scale (EDSS), and the presence of restless legs syndrome (RLS) in patients with multiple sclerosis (MS). MATERIALS AND METHODS: Ninety-one patients with MS and 40 patients in a control group (headache, essential tremor, and benign positional paroxysmal vertigo) were studied. The patients underwent a complete neurological examination and Kurtzke functional system scores were calculated. In order to assess the temporal relation between the onset of RLS and MS, a semistructured interview guided by a questionnaire about RLS was applied to all of the patients. RESULTS: Sixteen (17.6%) of the patients with MS and 1 (2.5%) patient in the control group had RLS. The prevalence of RLS was higher in patients with MS, compared to the control group (P = 0.018). Among the patients with MS, none of them suffered from RLS before the onset of MS, whereas sixteen patients (16%) suffered RLS after the onset of MS. There was no significant relationship between functional system involvement and the presence of RLS. CONCLUSION: The prevalence of RLS was higher in MS patients than it was in the control group. No association was found between RLS and functional system involvement in MS patients.

Is malnutrition a problem for multiple sclerosis patients?

Nutritional problems associated with multiple sclerosis (MS) have been observed in a number of studies and case reports. However, the prevalence of malnutrition in MS patients is currently unknown. The primary aim of this study was to assess the prevalence of malnutrition in MS patients and to compare the frequency of malnutrition in MS to that of other diseases. The second aim of the study was to determine whether malnutrition was associated with MS type, disease duration or disability status in MS patients. One hundred two MS patients were included in the current study. The control group consisted of 50 patients with other chronic neurological diseases. Neurological examination scores, Kurtzke Functional System Scale scores, serum albumin levels, sedimentation rate and C reactive protein (CRP) were recorded for all patients. Chronic malnutrition was defined as serum albumin levels below 3.5 g/dl with normal sedimentation rate and CRP levels. Twelve MS patients and one control patient were diagnosed with chronic malnutrition, but the difference was not statistically significant (p=0.062). In the MS group, MS type, disease duration, number of attacks, Expanded Disability State Score and Functional System Scale scores were not significantly different regardless of patients' serum albumin levels. We found malnutrition was more prevalent in MS patients than in other chronic diseases. Malnutrition in MS patients was independent of disease course, disease duration, number of attacks, disability status and functional system involvement. These results should be confirmed with further prospective studies in larger MS populations from several facilities.