Effectiveness of Surgical Treatment in Traumatic Facial Paralysis.

INTRODUCTION: In the etiology of facial nerve palsy, trauma is the most important. Our aim was to present our experience gained by evaluating the surgical approaches we have used in extratemporal and intratemporal facial nerve injuries and their long-term results, also to contribute to the consensus that will be formed on this subject. MATERIALS AND METHODS: Thirteen patients among 24 patients who underwent surgery with a diagnosis of traumatic facial paralysis were evaluated in this study. The clinical response of these patients to treatment was examined by classifying them according to the House-Brackmann classification in the preoperative and postoperative periods. RESULTS: Of the 13 patients, 9 had fractures due to temporal bone trauma, and 4 had nerve damage in the extratemporal part of the facial nerve. in the treatment, facial nerve decompression was performed using the middle fossa approach in 9 patients with temporal bone fractures. in the 4 patients with extratemporal facial nerve injury, graft repair or primary suturing was performed. in the postoperative period, the stages of the patients were III or below in 12 patients (92%), and only 1 (8%) patient remained in stage IV. DISCUSSION: When the postop conditions of the patients were examined according to House-Brackmann staging, it was observed that surgical treatment caused a significant improvement in the functions of the facial nerve. CONCLUSIONS: Our results showed that surgery was an effective treatment method in patients with indications for traumatic facial paralysis.

The significance of Holter electrocardiography in the etiological evaluation of transient ischemic stroke.

BACKGROUND: Transient ischemic attack (TIA) is a common neurovascular disorder associated with a higher risk of stroke within the first 24 h after the first event. Acute cerebral and arterial neuroimaging combined with long-term electrocardiography (ECG) monitoring have been proven to be useful in determining etiology. Cardio-embolism constitutes 20%-26% etiology of TIAs most of them with atrial fibrillation (AF). Investigation of AF after TIA is very important because oral anticoagulants can reduce the risk of subsequent stroke by two thirds. MATERIALS AND METHODS: The present study included 45 patients suffering from TIA with undetermined source according to the Trial of Org 10172 in Acute Stroke Treatment criteria; the control group (n = 45) was selected from the patients admitted to cardiology outpatient clinic with nonspecific complaints without cerebrovascular and/or cardiovascular disease. All patients underwent echocardiography and 24 h Holter ECG monitoring (HM). RESULTS: There was no significant difference between the patient group and the control group in terms of age and gender. Cholesterol, low-density lipoprotein and urea levels, left atrium diameters and the incidence of hypertension, coronary artery diseases, and AF were significantly higher in TIA group (P < 0.05). In the results of HM, there were six patients with AF in the study group, and in the control group, there was no patients with AF (P = 0.03). DISCUSSION AND CONCLUSION: In acute phase of TIA, 24 h HM is important for determining the etiology and selecting an appropriate treatment that can protect patients from subsequent strokes.

Use of anti-Parkinson medication during pregnancy: a case series.

INTRODUCTION: Experience about the use and safety of anti-Parkinson (anti-PD) medication during pregnancy is scarce. METHODS: We have retrospectively evaluated the course and outcome of pregnancy in PD patients who used anti-PD medication during their pregnancy. RESULTS: 14 PD patients who used anti-PD medication during part or whole of their pregnancy were included. Dopamine agonists were used in 13 patients, levodopa/benserazide in 4, levodopa/carbidopa/entacapone in 1, rasagiline in 7, amantadine in 4, and biperiden in 1 patient. Nine patients were on combination treatment at the time of their pregnancy. During their whole pregnancy, dopamine agonists had been used in six patients, levodopa in four, and rasagiline in one. Four patients experienced adverse outcomes: one had spontaneous abortion while receiving pramipexole, one elderly mother gave birth to a child with Down syndrome, while receiving pramipexole and rasagiline, in one case, there was fetal distress under levodopa/benserazide, piribedil, and rasagiline which resolved spontaneously, in one case, one of the twins did not survive after the birth while the mother was receiving pramipexole and rasagiline. In none of these cases an association with the use of anti-PD medication and adverse outcomes was clearly established. In one patient, motor symptoms worsened despite high dose levodopa, four others experienced transient worsening upon dose reduction. CONCLUSION: Results in our case series suggest that levodopa, rasagiline, pramipexole, and ropinirole alone or in combination with each other may be considered relatively safe during pregnancy. Expected benefits and risks should be considered when prescribing anti-PD medication in pregnant women.

Monitoring Physical Activity with Wearable Technologies.

Living a healthy and fulfilling life or at least carrying on the daily activities inevitably depends on some physical activity in different scales. Therefore, measuring the physical activity is necessary to evaluate both healthy people and patients in order to plan their needs for wellbeing. Objective and accurate measurements can be made with wearable sensors and related technologies. Evaluating health and wellness, efficacy of treatment, safety, physical ability and disability are in the scope of monitoring physical activity with wearable technologies.

Long-term disability and progression in spinal onset multiple sclerosis.

The aim of this study is to investigate the long-term effects of the initial spinal cord (SC) involvement in MS patients. In this retrospective, single-center study, 824 patients with definite MS were screened. A total of 348 patients were excluded for ambiguous documentation of the initial relapse, pediatric onset, diagnosis of primary progressive disease, irregular assessments or visits causing doubt on the onset of progression time, and clinical follow-up duration less than 12 months. Eventually, 476 MS patients were included. Data regarding the demographics, initial symptoms, the degree of recovery from the initial relapse, neuroimaging, cerebrospinal fluid analysis, long-term disability, and progression were collected from the medical registry. The mean duration of follow-up was 7.49 ± 5.30 years. The percentage of patients entering the progressive disease course was 23.3 in the whole group. A total of 157 patients (33.0%) had SC involvement during the first clinical relapse. These patients were significantly older at disease onset (31.69 ± 10.18 vs. 29.55 ± 9.49; p = 0.028), had higher rates of progression (32.5 vs. 18.8%; p = 0.001), and had higher disability scores in long-term follow-up (3.41 ± 2.19 vs. 2.62 ± 1.81; p < 0.001). Mean age at the transition of progressive phase was 41.4 ± 11.2 years. The degree of recovery from the initial relapse significantly affected the long-term disability. The poor recovery from the initial relapse was associated with older onset age and higher EDSS scores. Being older than 40 years during MS onset and poor recovery from the initial relapse exerted an increased risk for progression. The initial SC involvement was related to a more severe relapse with less chance of complete recovery and higher risk for progression. Confirmation of risk factors in different MS cohorts would increase our understanding of the complex disease mechanisms.

The Etiological Relationship Between Migraine and Sudden Hearing Loss.

OBJECTIVES: To investigate the relationship between sudden sensorineural hearing loss (SSNHL) and migraine, assess the prevalence of migraine in patients with idiopathic SSNHL, and determine a possible common vascular etiopathogenesis for migraine and SSNHL. STUDY DESIGN: Prospective cohort study. SETTING: Tertiary referral center. PATIENTS: This study initially assessed 178 SSNHL cases obtained from the Head and Neck Surgery Clinic patient database at a tertiary hospital in Turkey between January 2011 and March 2016. Ultimately, a total of 61 idiopathic SSNHL patients participated in the present study. INTERVENTIONS:: Diagnostic. MAIN OUTCOME MEASURES: Cases with inflammation in the middle or inner ear; a retro cochlear tumor; autoimmune, infectious, functional, metabolic, neoplastic, traumatic, toxic, or vascular causes; Meniere's disease; otosclerosis; multiple sclerosis; and/or cerebrovascular diseases were excluded. RESULTS: Of the 61 idiopathic SSHNL patients, 34 were women (55.74%); and 24 (39.34%) had migraine, according to the criteria of the International Headache Society (IHS). The mean age of the migraine patients (Group 1) was 43.83 ±â€Š13.16 years, and that of those without migraine (Group 2) was 51.05 ±â€Š16.49 years. The groups did not significantly differ in terms of age, sex, or SSNHL recovery rates according to the Siegel criteria (p > 0.05). Ten of the migraine patients experienced visual aura, and the recovery rates of this group were higher. Additionally, the rate of total hearing loss was lower in Group 1 (n = 3, 12.5%) than in Group 2 (n = 10, 27%). CONCLUSION: SSNHL patients had a higher prevalence of migraine. Although those with migraine had higher recovery rates, the differences were not statistically significant.

Neuromyelitis optica presenting with horner syndrome: A case report and review of literature.

Neuromyelitis optica (NMO) is a demyelinating disease of the central nervous system that predominantly affects the spinal cord and optic nerves. We describe a 19 years old woman with left Horner syndrome (HS), who was diagnosed as NMO with characteristic longitudinally extensive myelitis and positive serum aquaporin-4 immunoglobulin G antibodies (AQP4-IgG). Our report describes one of the very rare ocular motor symptoms in NMO patients.

Human Leucocyte Antigen B50 Is Associated with Conversion to Generalized Myasthenia Gravis in Patients with Pure Ocular Onset.

OBJECTIVES: The aim of this study was to investigate the associations between major histocompatibility complex (MHC) class I and II alleles and disease characteristics in Turkish patients with myasthenia gravis (MG). SUBJECTS AND METHODS: The MHC class I and II alleles of 108 unrelated MG patients were genotyped. The human leucocyte antigen (HLA) distribution of all MG patients and subgroups of MG patients (grouped according to disease characteristics) was compared to that of 250 healthy controls. RESULTS: Overall distributions of HLA-B*61 and C*05 were more frequent in MG patients (7.4 vs. 2.0% and 14.8 vs. 6.8%, respectively) than in non-MG patients. Subgroup analyses revealed that HLA-DRB1*14 and DQB1*02 alleles were more frequent in early-onset MG [n = 10 (20.8%) vs. n = 25 (10.0%) and n = 21 (43.8%) vs. n = 59 (23.6%)]. In patients seropositive for anti-AchR antibodies, the frequencies of HLA-B*50 and C*05 were higher. HLA-C*05, DRB1*01, and DRB1*11 were higher in patients with ocular MG. In addition, HLA-A*01, A*31, B*08, and DRB1*14 were higher among patients with thymic hyperplasia, whereas DQB1*03 was lower. However, all of these differences lost significance after correction of the p value for multiple comparisons. No allele association was found among patients with thymoma. Strikingly, patients with generalized MG who had pure ocular symptoms at disease onset had significantly increased HLA-B*50 compared to the controls (corrected p < 0.001, OR = 9.92; 95% CI 3.05-32.22). CONCLUSION: The HLA-B*50 allele was associated with conversion to generalized disease in patients with pure ocular symptoms at disease onset. This finding could extend our understanding of the complex interactions between the pathogenesis of MG and genetic heritage.

GNE Myopathy in Turkish Sisters with a Novel Homozygous Mutation.

Background. Hereditary inclusion body myopathy is caused by biallelic defects in the GNE gene located on chromosome 9p13. It generally affects adults older than 20 years of age. Methods and Results. In this study, we present two Turkish sisters with progressive myopathy and describe a novel mutation in the GNE gene. Both sisters had slightly higher levels of creatine kinase (CK) and muscle weakness. The older sister presented at 38 years of age with an inability to climb steps, weakness, and a steppage gait. Her younger sister was 36 years old and had similar symptoms. The first symptoms of the disorder were seen when the sisters were 30 and 34 years old, respectively. The muscle biopsy showed primary myopathic features and presence of rimmed vacuoles. DNA analysis demonstrated the presence of previously unknown homozygous mutations [c.2152 G>A (p.A718T)] in the GNE genes. Conclusion. Based on our literature survey, we believe that ours is the first confirmed case of primary GNE myopathy with a novel missense mutation in Turkey. These patients illustrate that the muscle biopsy is still an important method for the differential diagnosis of vacuolar myopathies in that the detection of inclusions is required for the definitive diagnosis.

Reassessment of Lhermitte's sign in multiple sclerosis.

The reliability and diagnostic value of Lhermitte's sign in multiple sclerosis (MS) has not been fully established. The purpose of this study was to determine the clinical, neurophysiological and neuroradiological correlations of Lhermitte's sign in a cohort of MS patients and reassess the relevance of this phenomenon in the clinical history of the disease. A prospective study of 694 patients with MS and 110 age-matched healthy adults was evaluated by a structured questionnaire that included basic demographic data, age of onset, clinical characteristics of the disease, and the inquiry of Lhermitte's sign. Cranial and spinal magnetic resonance imagings (MRI) and median and tibial somatosensory evoked potentials (SSEP) were performed at the same time. One hundred and twelve (16 %) patients were reported to have Lhermitte's sign; 582 (84 %) patients did not experience Lhermitte's sign during their disease duration (P < 0.026). No correlation was found between Lhermitte's sign and age, gender, EDSS, and disease duration; 88 % of patients with Lhermitte's sign had a demyelinating lesion on the cervical MRI. In negative Lhermitte's sign group, 64 % patients had a positive MRI. SSEP conductions were delayed in 92 % of patients with positive Lhermitte's sign and in 70 % of patients with negative Lhermitte's sign. Regarding the data, a significant correlation was found between MRI lesion and Lhermitte's sign (P < 0.001), and between SSEP abnormality and Lhermitte's sign as well (P < 0.001). This study underlines the relevance of this phenomenon with neuroradiological and neurophysiological abnormalities.

Intracranial hemorrhages related with warfarin use and comparison of warfarin and acetylsalicylic acid.

BACKGROUND: Acetylsalicylic acid (ASA) and warfarin are used to prevent ischemic cerebrovascular events. They have serious complications including intracranial hemorrhages (ICHs). Warfarin-related intracerebral hemorrhage (ich) incidence is .2%-5% in population that accounts for 10%-12% of all ichs. In this article, we investigated the profile of ASA and warfarin-related spontaneous ICHs in comparison with ICHs without any drug use (WADU) with their clinical, radiological, and biochemical properties. METHODS: In all, 486 patients aged 18-101 years with spontaneous ICHs were included. Patients constituted 4 separate groups: users of warfarin, ASA, ASA + warfarin, and WADU. Clinical, neurological, etiological, and radiological data of these patients were compared. RESULTS: There were 32 patients in warfarin, 58 patients in ASA, and 7 in warfarin + ASA group. Most of the patients were in no drug group (389 patients). The most frequent type of hemorrhage was supratentorial intraparenchymal hemorrhage. The most common accompanying disease was hypertension. The number of female patients was statistically significant in the warfarin group. Glasgow Coma Scale (GCS), accompanying diseases, opening of the hematoma to the ventricle, localization of the hemorrhage, age of the patient, and activated partial thromboplastin time level are all related to the outcome of patients. Warfarin users had worst mortality rate. CONCLUSIONS: Use of warfarin, low GCS score, opening to ventricle, older age, accompanying diabetes, and/or hypertension were worse prognostic factors. It is possible that patients with these unfavorable prognostic factors cannot survive.

Diagnostic value of lumbar root stimulation at the early stage of Guillain-Barré syndrome.

OBJECTIVE: The aim of this study is to investigate diagnostic value of electrical lumbar root stimulation (RS) at the laminar level in the early stage of Guillain-Barré syndrome (GBS). METHODS: Fifteen patients (30 sides) and nine controls (17 sides) were included in the study. Conventional nerve conduction studies, needle electromyography, F responses and electrical lumbar RS were obtained from both groups. The needle electrical stimulation was performed at the L2-3 intervertebral level. Vastus lateralis, tibialis anterior and soleus muscles were investigated bilaterally and simultaneously in the first and fourth weeks. RESULTS: In all patients, the amplitudes elicited by lumbar RS were significantly attenuated while the conventional electrophysiological findings were normal and/or not diagnostic in 6 of 15 patients (40%) within the first week. Motor latencies by the lumbar RS were prolonged in the patients, compared to the controls, but the results were not statistically significant. CONCLUSIONS: M-responses elicited by lumbar RS appear to be helpful in disclosing proximal conduction abnormalities of GBS early in the course. SIGNIFICANCE: Lumbar RS seems to be a useful method in making the diagnosis of GBS early and there is no considerable side effect of this particular method.

Diagnostic value of cauda equina motor conduction time in lumbar spinal stenosis.

OBJECTIVE: Lumbar spinal stenosis (LSS) is a chronic degenerative disease with pain in the back, buttocks and legs aggrevated by walking and relieved after rest without associated vascular disease of lower extremities observed in patients between 50 and 60 years. Several studies, using different methods indicated an association between slowing or blocking of root-nerve conduction and LSS. None of the previous research had applied the more conceivable methods such as recording the cauda equina potentials from the lumbar level or stimulating the spinal roots within the canal using either leg nerves or muscles. In this study, electrical lumbar laminar stimulation was used to demonstrate prolongation of cauda equina motor conduction time in lumbar spinal stenosis. METHODS: Twenty-one LSS patients and age matched 15 normal control subjects were included in the study. Lumbar laminar electrical stimulation from L1 and L5 vertebra levels were applied by needle electrodes. Compound muscle action potential (CMAP) from gastrocnemius muscles were recorded bilaterally. Latency difference of CMAPs obtained from L1 and L5 spine levels were accepted as the cauda equina motor conduction time (CEMCT). RESULTS: CEMCT was significantly longer in patient group when compared to normal controls. Mean latency difference was 3.59 ± 1.07 msec on the right side, 3.49 ± 1.07 msec on the left side in LSS group, it was 1.45 ± 0.65 msec on the right side, 1.35 ± 0.68 msec on the left side on normal control group (p<0.0001). CONCLUSIONS: The prolongation of CEMCT was statistically and individually significant in patient group. This may indicate that lower lumbosacral motor roots were locally and chronically compressed due to lumbar spinal stenosis. Lumbar spinal stenosis may have induced local demyelination at the cauda equina level. SIGNIFICANCE: Since the prolongation of CEMCT was found only in patients with LSS, the method of laminar stimulation can be chosen for patients with uncertain diagnosis of LSS.

The effects of botulinum toxin A on ephaptic transmission in idiopathic hemifacial spasm.

OBJECTIVE: Lateral spreading and synkinetic responses of blink reflex are a sign of ephaptic transmission in idiopathic hemifacial spasm (HFS). The aim of this study was to evaluate the effect of botulinum toxin A (Btx A) on ephaptic transmission in idiopathic HFS. METHODS: Thirty-three patients with idiopathic HFS were investigated. Btx A was injected only into the affected orbicularis oculi (OC) muscle. Electrophysiological studies were performed before and three weeks after the Btx A injection. RESULTS: After Btx A, the latencies of motor response and blink reflexes elicited from the OC muscle were significantly increased. The lateral spreading was not obtained in the OC muscle, while the orbicularis oris muscle response was not changed. There were no significant differences in the synkinetic responses of blink reflex. During needle EMG examination, positive sharp waves and fibrilation potentials were observed due to chemodenervation only in the OC muscle. CONCLUSION: Btx A affects only the neuromuscular junctions of the injected muscle and has no effect upon ephaptic transmission.

Hemifacial spasm in correlation with electrophysiological and radiological findings.

OBJECTIVE: To investigate the correlation between the electrophysiological and radiological findings of primary hemifacial spasm patients. SUBJECTS: Patients with primary hemifacial spasm who had had no botulinum toxin treatment previously were included in the study. DESIGN: In this prospective study patients underwent cerebral magnetic resonance imaging,a magnetic resonance angiography investigation and an electrophysiological examination after informed consent had be given by the patients. The facial nerve distal latency, amplitude and blink reflex responses were recorded as well as clinical and demographic data. RESULTS: Twenty five patients completed radiological and electrophysiological investigations. The radiological investigations disclosed neurovascular compromise which can cause hemifacial spasm in twelve patients (48%) while the findings of two patients were not considered as a certain cause of hemifacial spasm. All patients except two had at least one electrophysiological abnormality (92%). The most frequent finding was an increased R1/D ratio which suggested an increased central conduction time. CONCLUSION: In this study, an increased R1/D ratio suggests that there is a functional impairment in the brain stem even if it is not possible to disclose structural abnormalities in some hemifacial spasm patients. Combining magnetic stimulation may be a useful tool for further investigations. An inadequate radiological investigation might be the cause of relatively low radiological abnormalities in comparison with the electrophysiological ones.

Isolated hand palsy due to cortical infarction: localization of the motor hand area.

OBJECTIVE: To evaluate the cortical presentation of the hand area according to MRI images of the infarcted area in patients who have predominantly hand weakness. BACKGROUND: "Pseudoperipheral palsy" is an old term employed to describe a rare clinical picture consisting of predominant weakness of the hand in association with cerebral infarction. Because the organization of the cortical efferent area of the hand has not been fully defined, this phenomenon merits attention. Recent advances in functional imaging have stimulated renewed interest in the cortical mapping of various body parts, particularly that of the hand. METHODS: The patients who had isolated hand palsy due to cerebral infarction underwent clinical examination and cerebral MRI investigation to locate the exact lesion site. RESULTS: Eight patients (6 men, 2 women) aged 55 to 80 years (mean 69 years) were included in this study. All had at least one risk factor for cerebrovascular disease. All our 8 patients presented with hand palsy and lesions were detected in the contralateral precentral gyrus in all cases. The lesions were located in the middle to lower portion of the anterior wall of the central sulcus just posterior to the intersection of the superior frontal and precentral sulci. CONCLUSION: Our findings indicate that the hand area in the cerebral motor cortex is located in the middle to lower portion of the anterior wall of the central sulcus, that is, in Brodmann area 4. We present our 8 patients showing isolated hand palsy due to a discrete cortical infarction on MRI to expand the knowledge about cortical localization of the hand area.

Sexual dysfunction and sympathetic skin response recorded from the genital region in women with multiple sclerosis.

Multiple Sclerosis is known to cause autonomic and sexual dysfunction. However, genitourinary and sexual problems in female multiple sclerosis patients are difficult to analyse. Therefore, it is an understudied field. As an attempt to fill this gap, we evaluated genital region autonomic dysfunction of female multiple sclerosis patients by using genital sympathetic skin response. Forty female patients with definite multiple sclerosis and twenty healthy female controls were included in the study. We examined hand, foot and genital sympathetic skin responses. Some genitourinary parameters were questioned by and results were compared with genital sympathetic skin response results. Among multiple sclerosis patients 42.5% of them had genitourinary and 75% had sexual problems clinically. Sympathetic skin response pathologies were distributed as following: 22.5% in hand, 20% in the foot, and 50% in genital region in the patient group. A statistically significant correlation between sexual dysfunction and genital sympathetic skin response could not been found. It is found that patients with multiple sclerosis have higher genital sympathetic skin response abnormalities than foot and hand sympathetic skin response abnormalities. This might be the early sign of autonomic dysfuntion in multiple sclerosis patients. Genital sympathetic skin response may be an easy and objective method to apply and helpful to evaluate genitourinary dysfunction in women in conjunction with female sexual dysfuntion index.

Isolated dysarthria-facial paresis syndrome: a rare clinical entity which is usually overlooked.

BACKGROUND AND AIMS: The aim of the study is to search the lesion localization of the pure isolated facial paresis-dysarthria syndrome in patients who were admitted to our neurology clinic in a prospective study. METHODS: Over a period of six years, the patients who had no prominent sensorimotor dysfunction were examined by neurologists and underwent computerized tomography (CT) and/or magnetic resonance imaging (MRI). RESULTS: Eleven patients out of more than 2000 had the aforementioned clinical picture. Lacunar infarctions were identified at the corona radiata in nine patients, and at the internal capsule in two patients. As reported previously, facial paresis was usually mild and temporary. Six of our eleven patients were seen at the outpatient clinic one month later. Four of them had completely recovered and the other two had mild dsyarthria without any facial paresis. The other five could not be reached after leaving the hospital. CONCLUSIONS: Dysarthria-facial paresis is a rare clinical entity and possibly a variation of dysarthria-clumsy hand syndrome, and we suggest that pure facial paresis (FP) and pure dysarthria should be considered as very extreme examples of this syndrome.