Factors Associated with Hemorrhagic Transformation in Infarctions Involving the Posterior Circulation System.

BACKGROUNDS AND PURPOSE: Hemorrhagic transformation (HT) following stroke of the posterior circulation is a rare occurrence, and its risk factors remain relatively unknown. This study aimed at examining the rate of HT and its risk factors in patients enduring acute ischemic stroke in the territories of the vertebral, basilar, and posterior-cerebral arteries. MATERIALS AND METHODS: A total of 217 consecutive patients the risk factors for ischemic stroke were recorded and comprehensive biochemical, cardiac assessments, and neuroimaging were performed. National Institutes of Health Stroke Scale (NIHSS) scores were calculated for each patient. Those with HT as documented with neuroimaging based on the European Cooperative Acute Stroke Study criteria and potential risk factors were assessed. RESULTS: There were 217 participants with a mean age of 67.33 ± 12.44 years. Among 17 patients (7.8%) developing HT, 8 (47%) had parenchymal hematoma, and 9(53.5%) had hemorrhagic infarction. Cardioembolism was the most frequent etiological factor both in the overall group (31.0%) as well as in those with HT (41.2%). Factors that emerged as significant predictors of HT included high systolic (odds ratio [OR] 1.14; 95% confidence interval [CI] 1.08-1.20; P< .001) and diastolic blood pressure (P= .001) on the day of admission and the infarction volume of greater than or equal to 3.60 ± 3.29 cm³(OR 1.00, 95% CI 1.00-1.01; P< .001). While NIHSS scores were not significantly different on Day 1, HT patients had higher NIHSS scores at Day 10(OR 1.22; 95% CI 1.09-1.36; P< .001), and this difference was also reflected in mRS at the end of the 3 month period. CONCLUSION: HT is a rare complication of the infarction of the posterior circulation that is associated with increased morbidity and mortality. Identification of predictive factors for HT in patients with the acute infarction of the posterior circulation may facilitate patient selection for thrombolytic treatment.

Effect of hand volume and other anthropometric measurements on carpal tunnel syndrome.

Carpal tunnel syndrome (CTS), majority of cases are considered to be idiopathic, is the most commonly encountered peripheral neuropathy causing disability. We asserted that thick and big hands may more prone to idiopathic CTS (ICTS) than others. The study included 165 subjects admitted to our electrophysiology lab with pre-diagnosis of CTS between May 2014 and April 2015. Eighty-five of the subjects were diagnosed as ICTS. The parameters analyzed were: age, gender, occupation, BMI, hand dominance, grade of ICTS, wrist circumference, proximal/distal width of palm, hand/palm length, hand volume and palm length/proximal palm width. Female gender was significantly higher in both groups. The mean age of study group was 44.02 ± 9.11 years, and control group was 41.25 ± 9.94 years. BMI, wrist circumference and hand volume were significantly higher in the study group (p < 0.05). However, palm length/prox.palm width ratio was higher in the control group (p = 0.00). There were also significant differences among CTS groups in terms of age (p = 0.001). Mean age was higher in severe CTS group. Female gender, older age and high BMI are risk factors for ICTS. Higher hand volume, wrist circumference and lower palm length/prox. palm width ratio can also be anthropometric risk factors. Large hand volumes, big and coarse hands are more prone to ICTS.

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.

Association between the Levels of IL-6, sE-Selectin and Distal Sensory Nerve Conduction Studies in Patients with Prediabetes.

AIM: To determine the association between interleukin-6 (IL-6) and soluble E-selectin (sE-selectin) levels with the electrodiagnostic abnormalities in patients with impaired fasting glucose (IFG) and impaired glucose tolerance (IGT). METHODS: Serum HbA1c, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), fibrinogen, IL-6 and sE-selectin levels were analyzed in 25 IFG patients, 22 IGT patients and 41 controls. Nerve conduction studies (NCS) of sural, dorsal sural (DS), medial dorsal cutaneous and medial plantar sensory nerves were conducted. RESULTS: HbA1c and IL-6 levels were significantly higher in IFG and IGT patients than the controls. IGT patients had higher sE-selectin levels compared to controls and IFG patients. IL-6 levels were significantly correlated with levels of CRP, fibrinogen, ESR and sE-selectin in patients with prediabetes. Both IFG and IGT patients had substantial impairments in very distal sensory NCS. IL-6 levels were positively correlated with HbA1c and negatively correlated with DS NCS in prediabetic patients. CONCLUSIONS: Inflammation and endothelial dysfunction might be important in patients with IFG or IGT. Furthermore, our findings strengthen the idea that inflammation (increased levels of IL-6) might be associated with early electrophysiological impairments in patients with prediabetes. NCS of the most distal sensory nerves significantly enhanced the diagnosis of subclinical neuropathy in patients with prediabetes. Subclinical peripheral sensory neuropathy should be investigated in prediabetes to lower the number of future outcomes they are associated with.

Matrix Metalloproteinase Levels in Cervical and Intracranial Carotid Dolichoarteriopathies.

BACKGROUND: Matrix metalloproteinases (MMPs) are enzymes suggested as a possible candidate for pathogenesis of arterial dolichoarteriopathy (DA). We aimed to investigate the relationship between MMP levels and DA of intra- and extracranial carotid arteries. METHODS: This study included 88 subjects admitted with headache, vertigo, or pulsatile tinnitus and those who underwent computed tomography angiography. The study group (n = 70) consisted of patients with kink-coiling (group I, n = 41) and patients with tortuosity (group II, n = 29). The control group (n = 18) had normal angiography results. The diameter, course, and geometry of the carotid artery were analyzed. Serum MMP-1, -2, -3, and -12 levels were measured in all subjects. Vascular risk factors for DA were also noted. RESULTS: MMP-2 levels were significantly higher in the kink-coiling and tortuous groups than in the control group. In the study group (n = 70), MMP-12 levels were also significantly higher in patients with atheromatous plaques than in those without plaques. Diameters of arteries were meaningfully wider in the kink and tortuous groups than in the control group. Among vascular risk factors, hypertension and diabetes mellitus were more common in the kink group than in the control group, and there were significant differences between them. CONCLUSIONS: MMP-2 plays a role in the etiology of DA, and MMP-12 levels increase in carotid atherosclerotic lesions and may lead to plaque formation. We demonstrated that dilatation and tortuosity occur together.

Central-Variant Posterior Reversible Encephalopathy due to Sulfasalazine: A Case Report.

OBJECTIVE: To report a rare case with central-variant posterior reversible encephalopathy syndrome due to sulfasalazine. CLINICAL PRESENTATION AND INTERVENTION: A 55-year-old female patient presented with seizure and acute-onset hemiparesia. Thirty days earlier, treatment with sulfasalazine was commenced in response to a diagnosis of psoriatic arthritis. Laboratory examinations were normal. Brain magnetic resonance imaging showed symmetric edema within basal ganglia and thalami with sparing of the cerebral cortices. After stopping the treatment of sulfasalazine, clinical and radiological findings regressed dramatically. CONCLUSION: This was a case of central-variant posterior reversible encephalopathy syndrome due to sulfasalazine, and atypical imaging findings should be kept in mind for early diagnosis.

The relationship between scoliosis and upper extremity functions in patients with Duchenne muscular dystrophy.

OBJECTIVES: The aim of this study was to investigate the relationship between scoliosis and upper extremity functions in patients with Duchenne muscular dystrophy (DMD). PATIENTS AND METHODS: Between January 2018 and July 2018, a total of 55 patients (54 males, 1 female; mean age: 9.9±2.9 years; range, 6 to 15 years) who were diagnosed with DMD based on the clinical, laboratory, muscle biopsy and molecular analysis results were included in this cross-sectional study. Scoliosis was evaluated and Cobb angles were measured. Functional Ambulation Scale and Brooke and Vignos scale scores were recorded. The ABILHAND-Kids questionnaire and Nine-Hole Peg Test (9-HPT) were used to assess the upper extremity functions. Hand grip strengths were also evaluated. RESULTS: The median ABILHAND-Kids scores and the hand grip strength values of the patients without scoliosis were significantly higher compared to those with scoliosis (p=0.002 and p=0.004 for right hand and p=0.012 for left hand, respectively). There was no statistically significant difference in the 9-HPT scores between the patients with and without scoliosis (p>0.05). We found a negative, significant correlation between the Cobb angle and ABILHAND-Kids scores in patients with scoliosis (r=-0.503; p=0.017). CONCLUSION: Our study results show a moderate relationship between scoliosis and upper extremity functions. Scoliosis may adversely affect upper extremity functions in patients with DMD.

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.

Serum Levels of Melatonin and Sleep Evaluation Scales in the Diagnosis of Sleep Disorders in Patients with Idiopathic Parkinson's Disease.

INTRODUCTION: Sleep disturbances, such as difficulty in initiation of sleep, decrease in total sleep duration and efficacy, frequent awakenings, and increased daytime sleepiness are among the most common non-motor symptoms in patients with idiopathic Parkinson's disease (PD). However, patients usually do not consider these symptoms as important as their motor symptoms, and do not complain. We aimed to investigate PD patients for subtle sleep disturbances using sleep evaluation scales, and to evaluate the relationship between these tests and the serum levels of melatonin during night-sleep. METHODS: A total of 40 PD patients (19, female), older than 50 years, registered in our "Movement Disorders Out-patient Clinic", and 40 healthy, age and sex-matched control subjects (20, female) were included in the study. All subjects were assessed using Pittsburg Sleep Quality Index (PSQI) and Epworth Sleepiness Scale (ESS). Serum melatonin levels during night-sleep were measured in blood samples taken at 00:00 and 05:00 hours in every subject. Both groups were compared for demographical data, sleep evaluation scales and serum levels of melatonin. RESULTS: Patients with PD had significantly higher scores in PSQI and ESS than the healthy controls (p<0.001). Although the serum melatonin levels at two different time points during night sleep were lower in PD patients than the controls, these differences did not reach statistical significance (p=0.104 at 00:00 am, p=0.528 at 05:00 am). There was no significant correlation between the PSQI scores and serum melatonin levels in patient group (p>0.05). However, there was a significant but weak correlation (r=-0.353, p=0.025) between ESS scores and the serum melatonin levels measured at 05:00 hours in patients, but not between the melatonin levels measured at 00:00 hours. CONCLUSION: Sleep evaluation questionnaires such as, PSQI and ESS, can provide useful information in PD patients with mild sleep disturbances. However, serum melatonin levels alone were not helpful in diagnosing the sleep disorders.

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.

Predictive Factors for Functional Outcomes After Intravenous Thrombolytic Therapy in Acute Ischemic Stroke.

The objective of our study is to detect the patient group that will most benefit from intravenous (IV) thrombolytic therapy by showing predictive factors of good functional outcomes. The present study covers 88 patients who were admitted to our clinic within the first 4.5 hours from the onset of stroke symptoms, diagnosed with acute ischemic stroke and who received IV thrombolytic therapy between May 2014 and June 2017 as a result of a retrospective analysis of a database prospectively collected. The patients with a score of ≤2 on modified Rankin scale within 3 months were accepted as good functional outcome and those with a score of >2 were accepted as poor functional outcome. As a result, within the period of 3 months posttreatment, good functional outcomes were obtained in 45 (51.1%) patients and poor functional outcomes were obtained in 43 (48.9%) patients. In comparisons, cardioembolic stroke group was statistically significantly higher in the good functional outcome group (P = .03). Pretreatment National Institute of Health Stroke Scale (NIHSS) scores (P < .001), presence of proximal hyperintense middle cerebral artery sign in noncontrast computed brain tomography (P = .03), and being aged ≥80 and older (P = .04) were markedly higher in the group with poor functional outcomes. In conclusion, our study demonstrated that cardioembolic strokes may have an impact on good functional outcomes and being aged 80 and older, presence of proximal HMCAS in computed brain tomography, and pretreatment NIHSS scores may have an impact on poor functional outcomes.

Significance of Multiple Acute Ischemic Lesions on Initial Diffusion-weighted Imaging in Stroke Patients and Relation of Toast Classification.

BACKGROUND: It is important to know whether or not the stroke risk factors and etiologies of patients with multiple acute infarcts are different to those of patients with a single acute infarct. AIM: The frequency of multiple acute infarct was investigated in ischemic stroke patients and a comparison was made of the characteristics of stroke patients with and without multiple acute infarct. PATIENTS AND METHODS: We reviewed the clinical records of 988 ischemic stroke patients who were admitted within 1 week of the onset of stroke and diffusion-weighted imaging (DWI) was performed on first presentation. The clinical characteristics, laboratory, and imaging results were noted from the patient records. According to the DWI findings, the patients were separated into three groups as those with a single acute infarct in a single vascular territory (SI group), those with multiple acute infarcts in a single vascular territory (SMI group) and those with multiple acute infarcts in multiple vascular (MMI group) territories. The frequency of multiple acute infarcts was investigated, and a comparison was made of the characteristics of stroke patients with and without multiple acute infarcts. RESULTS: The SMI group included 119 (12%) patients and the MMI group 126 (12.8%). The most common mechanisms of multiple acute infarcts are large artery atherosclerosis and cardiac origin emboli. Moreover, the risk factors most determined were hypertension, diabetes mellitus, and hyperlipidemia in the MMI group. CONCLUSION: No difference was determined between the groups in respect of stroke etiology and risk factors.

Relapsing-Remitting Multiple Sclerosis diagnosis from cerebrospinal fluids via Fourier transform infrared spectroscopy coupled with multivariate analysis.

Multiple sclerosis (MS) is a chronic, progressive, inflammatory and degenerative disease of central nervous system. Here, we aimed to develop a method for differential diagnosis of Relapsing-Remitting MS (RRMS) and clinically isolated syndrome (CIS) patients, as well as to identify CIS patients who will progress to RRMS, from cerebrospinal fluid (CSF) by infrared (IR) spectroscopy and multivariate analysis. Spectral analyses demonstrated significant differences in the molecular contents, especially in the lipids and Z conformation of DNA of CSF from CIS, CIS to RRMS transformed (TCIS) and RRMS groups. These changes enables the discrimination of diseased groups and controls (individuals with no neurological disease) from each other using hierarchical cluster and principal component analysis. Some CIS samples were consistently clustered in RRMS class, which may indicate that these CIS patients potentially will transform to RRMS over time. Z-DNA band at 795 cm-1 that is existent only in diseased groups and significant increase in carbonyl amount, decrease in amideI/amide II and lipid/protein ratios observed only for RRMS groups can be used as diagnostic biomarkers. The results of the present study shed light on the early diagnosis of RRMS by IR spectroscopy complemented with multivariate analysis tools.

Contribution of Quantitative EEG to the Diagnosis of Early Cognitive Impairment in Patients With Idiopathic Parkinson's Disease.

Cognitive dysfunction can emerge during the clinical course of Parkinson's disease (PD) even beginning in early stages, which requires extended neuropsychological tests for diagnosis. There is need for rapid, feasible, and practical tests in clinical practice to diagnose and monitor the patients without causing any discomfort. We investigated the utility of quantitative analysis of digital EEG (qEEG) for diagnosing subtle cognitive impairment in PD patients without evident cognitive deficits (ie, "normal cognition"). We enrolled 45 patients with PD and age- matched 39 healthy controls in the study. All participants had Mini-Mental State Examination (MMSE) score greater than 25. qEEG analysis and extensive neuropsychological assessment battery were applied to all participants. Test scores for frontal executive functions, verbal memory processes, attention span, and visuospatial functions were significantly lower than healthy controls ( P < .01). qEEG analysis revealed a significant increase in delta, theta, and beta frequencies, and decrease in alpha frequency band in cerebral bioelectrical activity in patient group. In addition, power spectral ratios ([alpha + beta] / [delta + theta]) in frontal, central, temporal, parietal, and occipital regions were significantly decreased in patients compared with the controls. The slowing in EEG was moderately correlated with MMSE scores ( r = 0.411-0.593; P < .01). However, qEEG analysis and extensive neuropsychological assessment battery were only in weak correlation ( r = 0.230-0.486; P < .05). In conclusion, qEEG analysis could increase the diagnostic power in detecting subtle cognitive impairment in PD patients without evident cognitive deficit, perhaps years before the clinical onset of dementia.

Efficacy of Different Durations of Intravenous Methylprednisolone Treatment in Relapses of Multiple Sclerosis.

INTRODUCTION: Relapses of multiple sclerosis (MS) are usually treated with high-dose intravenous methylprednisolone (IVMP), given over 3-10 days. There is no consensus on the optimal duration of treatment. In this study, we aimed to investigate whether longer treatment provides additional short-term clinical benefits assessed by the change in plasma cytokine levels and EDSS scores in patients with relapsing-remitting MS (RRMS). METHODS: Forty RRMS patients during relapse were grouped into 3 and treated with 1 g/day of IVMP for either 5, 7, or 10 consecutive days. RESULTS: Levels of IL-10 and IL-12 were analyzed, and EDSS scores were noted before treatment, after treatment (on days 6, 8, or 11) and at the 4th week. IVMP treatment significantly induced anti-inflammatory IL-10 levels but had no effect on IL-12 levels. IVMP treatment for 7 or 10 consecutive days was not significantly different than that for 5 days in terms of the change in IL-12, IL-10 levels or clinical outcome. CONCLUSION: In conclusion, pulse high-dose IVMP treatment enhances functional recovery in patients with acute relapses of RRMS. In addition, IVMP treatment significantly increases the levels of IL-10 but has no effect on the levels of IL-12 in the short term.

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.

Effects of common anti-epileptic drug monotherapy on serum levels of homocysteine, vitamin B12, folic acid and vitamin B6.

There is emerging evidence to support the unfavorable effects of some anti-epileptic drugs on the plasma homocysteine concentrations. Elevated homocysteine levels induced by anti-epileptic drug administration can theoretically increase not only the risk of vascular occlusive diseases, but also the risk of resistance to anti-epileptics and development of refractory epilepsy. To investigate the effect of common anti-epileptic drugs on the homocysteine metabolism, a total of 75 epileptic patients receiving phenytoin (n=16), carbamazepine (n=19), or valproic acid (n=22) and no anti-epileptic drug (n=18) were enrolled. Eleven age- and sex-matched healthy subjects served as the control group. Blood concentrations of homocysteine, folic acid, Vitamin B12 and pyridoxal 5'-phosphate (active circulating form of Vitamin B6) were measured. Compared to the control group, epileptic patients on anti-epileptic drug had higher blood levels of homocysteine. No difference in homocysteine concentrations was observed among epileptic patients in terms of the anti-epileptic drug used. Patients receiving phenytoin had significantly lower folic acid levels and those receiving carbamazepine had marginally lower pyridoxal 5'-phosphate levels in comparison with those using other anti-epileptic drugs. A negative correlation between homocysteine and folic acid concentrations was detected in epileptic patients on anti-epileptic drug. The duration of anti-epileptic drug use was correlated to the decrease of folic acid levels, but not with changes observed in homocysteine, Vitamin B12 and pyridoxal 5'-phosphate levels. No relationship between seizure frequency and homocysteine levels was observed in epileptic patients. Our results confirm that common anti-epileptic drugs has disadvantageous effects on homocysteine status. Because there was no significant change in homocysteine concentrations in epileptic patients who were not receiving an anti-epileptic drug, and no positive correlation between seizure frequency and homocysteine levels, we suggest that increase of homocysteine levels may be due to anti-epileptic drug use, rather than being epileptic in origin. Additionally, the underlying mechanism for homocysteine increase seems to be a decrease of cofactor molecules in patients using carbamazepine and phenytoin (pyridoxal 5'-phosphate and folic acid, respectively). However, changes observed are not related to the alteration in the levels of cofactors and remain unclear in the patients using valproic acid.

Epileptic nystagmus.

Epileptic nystagmus is a rare, ictal phenomenon characterized by rapid, repetitive eye movements caused by epileptic activity. We report on a patient with cryptogenic focal epilepsy who presented a long-lasting (>30mn) episode of left head and eyes deviation and left-beating nystagmus not crossing the midline. Interictal EEG showed right temporal abnormalities.[Published with video sequences].

Autonomic Neuropathy and Endothelial Dysfunction in Patients With Impaired Glucose Tolerance or Type 2 Diabetes Mellitus.

Autonomic neuropathy is one of the most common complications of diabetes mellitus (DM). The etiology of autonomic impairment is not well-understood, yet. There is need for studies to investigate the cause-effect relationships of inflammation and/or endothelial dysfunction and diabetic autonomic neuropathy. Only a few reports have mentioned autonomic neuropathy in individuals with impaired glucose tolerance (IGT), previously. Furthermore, the association between the plasma markers of endothelial dysfunction (von Willebrand factor (vWF), soluble E-selectin) and autonomic neuropathy in patients with IGT or DM has not been studied before. In this study, we aimed to investigate the correlation between plasma markers of endothelial dysfunction and autonomic neuropathy in patients with IGT or type 2 DM (T2DM).In this case-control study, 25 IGT patients, 25 T2DM patients with autonomic symptoms, and 30 controls were included. Demographical data, HbA1c, vWF, and soluble E-selectin (sE-selectin) levels were analyzed. Sympathetic skin response (SSR) and heart rate variability (HRV) were used as the indicator of autonomic activity.Plasma levels of HbA1c, vWF, and sE-selectin were higher in patients with IGT than the controls; patients with T2DM had higher levels than both the controls and the patients with IGT. SSR measures were similar among the groups. However, higher number of T2DM patients had absent plantar SSR than controls. HRV analysis at rest revealed lower standard deviation of R-R interval, coefficient of variation of R-R interval, low-frequency (LF) power and total power in patients with IGT and T2DM than the controls. In addition, HRV analysis at deep breathing showed lower high-frequency (HF) power in IGT group. LF:HF ratio was lower in both patient groups at rest. No strong correlation was found between the levels of HbA1c, vWF, sE-selectin, HRV, and SSR measures.Our results support that endothelial dysfunction is evident in individuals with IGT or T2DM and HRV is impaired in early stages in the course of T2DM. However, increased levels of biomarkers of endothelial damage do not correlate with HRV or SSR. More studies are needed to clarify the disease pathogenesis and its clinical correlates. Impaired HRV in T2DM could be due to mechanisms other than endothelial dysfunction.

Tongue myokymia presenting twelve years after radiation therapy.

OBJECTIVE: This case is a patient with tongue myokymia following radiation therapy 12 years earlier, documented using video and EMG. CASE REPORT: A 68-year-old woman with a history of nasopharyngeal carcinoma presented with subacute onset of difficulty in speaking and involuntary movements of her tongue approximately 12 years after radiation therapy to head and neck. Electromyography displayed myokymic discharges. There was no evidence of recurrent malignancy. SIGNIFICANCE: Delayed effects of radiation therapy might be seen decades later. Myokymic discharges may reveal radiation-induced neuropathy.