Attila Oğuzhanoğlu

Ocular pulse amplitude and retina nerve fiber layer thickness in migraine patients without aura

BackgroundTo evaluate the ocular pulse amplitude (OPA), the posterior pole asymmetry analysis (PPAA), the peripapillary retinal nerve fiber layer (RNFL) thickness, the ganglion cell layer (GCL) thickness, macular thickness and visual field testing in migraine patients without aura.MethodsIn this prospective, cross-sectional and comparative study 38 migraine patients and 44 age and sex matched controls were included. OPA was measured by dynamic contour tonometry (DCT), PPAA, RNFL, GCL and macular thickness were measured by Heidelberg Spectral Domain Optical Coherence Tomography (SD-OCT) and standard perimetry was performed using the Humphrey automated field analyzer.ResultsThe difference in OPA was not statistically significant between the two groups (p ≥ 0.05). In the PPAA there was no significant difference between two hemispheres in each eye (p ≥ 0.05). The RNFL thickness was significantly reduced in the temporal and nasal superior sectors in the migraine group (p ≤ 0.05). The GCL and macular thickness measurements were thinner in migraine patients but the difference between groups was not statistically significant (p ≥ 0.05). There was no correlation between RNFL, GCL, macular thickness measurements and OPA values. There was no significant difference in the mean deviation (MD) and pattern standard deviation (PSD) between the two groups (p ≥ 0.05).ConclusionsMigraine patients without aura have normal OPA values, no significant asymmetry of the posterior pole and decreased peripapillary RNFL thickness in the temporal and nasal superior sectors compared with controls. These findings suggest that there is sectorial RNFL thinning in migraine patients without aura and pulsative choroidal blood flow may not be affected during the chronic course of disease.

Deep Brain Stimulation of the Pedunculopontine Nucleus in a Patient with Freezing of Gait

Case Presentation: A 54-year-old male patient presenting probable multiple system atrophy with predominant parkinsonism who underwent bilateral deep brain stimulation (DBS) of the pedunculopontine nucleus (PPN) is presented. The patient had dominant freezing of gait (FOG), levodopa-resistant bradykinesia, and autonomic disturbances, but with a good cognitive condition. Methods: The patient underwent bilateral DBS of the PPN, which ended with modest benefits. Results and Conclusion: Although he had a short postoperative follow-up (6 months), his neurological status remained stable and PPN DBS provided modest improvements in the gait disorder and freezing episodes. This unusual case suggests that the mesencephalic pedunculopontine region may have a role in locomotor symptoms and the potential to provide a limited improvement in FOG.

Conduction in ulnar nerve bundles that innervate the proximal and distal muscles: a clinical trial

BackgroundThis study aims to investigate and compare the conduction parameters of nerve bundles in the ulnar nerve that innervates the forearm muscles and hand muscles; routine electromyography study merely evaluates the nerve segment of distal (hand) muscles.MethodsAn electrophysiological evaluation, consisting of velocities, amplitudes, and durations of ulnar nerve bundles to 2 forearm muscles and the hypothenar muscles was performed on the same humeral segment.ResultsThe velocities and durations of the compound muscle action potential (CMAP) of the ulnar nerve bundle to the proximal muscles were greater than to distal muscles, but the amplitudes were smaller.ConclusionsBundles in the ulnar nerve of proximal muscles have larger neuronal bodies and thicker nerve fibers than those in the same nerve in distal muscles, and their conduction velocities are higher. The CMAPs of proximal muscles also have smaller amplitudes and greater durations. These findings can be attributed to the desynchronization that is caused by a wider range of distribution in nerve fiber diameters.Conduction parameters of nerve fibers with different diameters in the same peripheral nerve can be estimated.

Remarkable effect of benzodiazepine in a patient with anti-NMDA receptor encephalitis.

Here, we report a case of anti-NMDA receptor encephalitis with a history of vaccination in which peroral low dosages of benzodiazepines caused reversible episodes of wakefulness. A 42-year-old male patient presented with a reversible attack of blurred vision, paresthesia in his right hand followed by psychiatric symptoms, visual hallucinations, and episodes of disorientation. In the end of the first month, he experienced seizures. He had a history of vaccination just 3 weeks before the symptoms started. Cranial imaging was within normal limits. EEG demonstrated persistent, repeated sharp waves localized to left parietal cortex. Cerebrospinal fluid (CSF) examination revealed an elevated protein level without any cells or microorganism. All infectious markers were negative. Antinuclear antibody profile, lupus anticoagulants were also negative. Whole body 18F-fluorodeoxyglycose positron emission tomograpghy (FDG-PET) demonstrated hyperactivity in bilateral temporoparietal cortex. Treatment with acyclovir and meropenem was initiated. Seizures were under control with levetiracetam treatment (2,000 mg daily). The sharp waves previously observed in the left hemisphere were no longer present after treatment. In his follow-up, the patient progressively became unresponsive and the clinical picture deteriorated to a catatonic state. With the suspicious of nonconvulsive status epilepticus, he received intravenous benzodiazepine (Bz) which caused a period of wakefulness lasting for 15 min. Phenytoin was added to the treatment, but despite an adequate free phenytoin serum level of 22 mg/ml, no beneficial clinical effect was seen, and the patient was still unresponsive. Twenty-four hour EEG monitoring demonstrated mild diffuse slowing (6–7 Hz) without any epileptic discharges. This remarkable clinical effect was observed after diazepam injection but not with other antiepileptic drugs, and the absence of obvious EEG findings suggested a pathology rather than nonconvulsant status epilepticus. Low dosage of peroral lorazepam (1 mg) also caused a 2-h period of wakefulness which also supported another diagnosis rather than status epilepticus. Then, the dosage was increased to 4 9 1 mg daily which provided a day time wakefulness. On the other hand, he returned to his unresponsive status when the drug was delayed. Further investigation demonstrated antibodies to NMDA receptors in CSF. No tumor was found by whole body FDG-PET, testicular ultrasound, or chest tomography. At the end of the second month from symptom onset, all anti-infectious agents were stopped step by step and the patient was put on high dosage (1,000 mg) IV pulse corticosteroid treatment for 5 days followed by a 1-mg/kg oral dose regimen. After 2 weeks of treatment, he was awake but still experienced hallucinations and episodes of disorientation so he received seven cycles of plasma exchange (Pex) on alternate days. After Pex, oral benzodiazepine was gradually stopped, and the patient was still awake and was able to perform daily tasks. Ç. Erdoğan (&) E. Değirmenci A. Oğuzhanoğlu Department of Neurology, Pamukkale University, Kinikli, Denizli, Turkey e-mail: drcagdaserdogan@gmail.com

Nasopharyngeal carcinoma presenting with horner syndrome and carotid-sinus syncope.

Introduction:Nasopharyngeal carcinoma can present with different neurological signs and findings. In this paper, we report a patient presenting with Horner syndrome and syncopal episodes who was finally diagnosed with nasopharyngeal carcinoma. Case Report:A 56-year-old man presented with a history of slowly progressive right upper-eyelid droop for the last 1.5 months and episodes of loss of consciousness. After detailed clinical and laboratory examinations, the patient had the final diagnosis of metastatic nasopharyngeal carcinoma. Conclusions:This is the first case with nasopharyngeal carcinoma presenting with both Horner syndrome and carotid-sinus syncope. The mechanism of Horner syndrome and the syncopal episodes and their relation with the lesion location are discussed.

Comparison of the Nerve Conduction Parameters in Proximally and Distally Located Muscles Innervated by the Bundles of Median and Ulnar Nerves

Objective: The aim of this study was to investigate and compare the conduction parameters of nerve bundles of median and ulnar nerves that innervate proximal and distal muscles. Subjects and Methods: Thirty male and 30 female healthy volunteers between 18 and 70 years of age were enrolled in the study. The conduction parameters were recorded from the proximally located flexor carpi ulnaris, pronator teres and the flexor carpi radialis muscles to the distally located abductor digiti minimi and abductor pollicis brevis muscles for the ulnar and median nerves. Each nerve was stimulated at the region above the elbow and at the axillary region separately. The Student t test was used for statistical analysis, and Levenes test was used to assess whether or not the group variances exhibited a uniform distribution. Results: The conduction velocities were faster (78.27 ± 6.55 vs. 67.83 ± 6.76 m/s, and 74.57 ± 5.66 and 74.23 ± 5.88 vs. 66.38 ± 6.85 m/s) and the durations of compound muscle action potential (CMAP) response were longer (15.65 ± 2.43 vs. 13.55 ± 1.78 ms, and 16.38 ± 2.39 and 16.04 ± 2.34 vs. 13.40 ± 1.79 ms) in proximally located muscles than in distally located muscles that are innervated either by ulnar or median nerves (p < 0.001). However, the CMAP amplitudes were smaller (2.52 ± 1.16 vs. 5.81 ± 3.13 mV, and 2.90 ± 1.20 and 3.59 ± 1.66 vs. 6.88 ± 2.77 mV) in proximal muscles than in distal muscles (p < 0.001). There was no significant difference (p > 0.05) between males and females regarding conduction velocities and CMAP amplitudes recorded from proximal and distal muscles. Conclusion: Proximal muscles innervated by median or ulnar nerves had lower CMAP amplitude values, longer CMAP durations and higher conduction velocities than distal muscles. These findings could reveal a temporal dispersion and phase cancellation due to desynchronized conduction during nerve stimulation.

An alternative nerve conduction study method to evaluate early diabetic neuropathy: Ratio of different diameter nerve fibers in peroneal nerve

Different nerve fibers may have disparate conduction parameters even though they are in the same peripheral nerve. Hyperglycemia can have differential effects on nerve fibers, depending on diameter. In diabetes, conventional nerve conduction studies have allowed us to classify a peripheral nerve as normal or not. But, there may be differential involvement in disparate nerve fibers of the same peripheral nerve. This study evaluated the effects of hyperglycemia on nerve fibers of peroneal nerve by diameter. Thirty-five diabetic patients with normal nerve conduction studies and thirty-two healthy controls were included to the study. The peroneal nerve was stimulated from two points (upper and below the fibula head) and recorded from the tibialis anterior (TA) and extensor digitorum brevis (EDB) muscles. Then the ratios of conduction velocity parameters recorded in these sides were compared between the diabetic and control groups. The conduction velocity recorded from EDB seemed to be faster in both groups. But there were no significant differences among the ratios between the groups. Our study has demonstrated the conduction parameters of two nerve fibers with different diameters in the peroneal nerve. The ratios of conduction parameters were similar in both groups, suggesting that fibers in the peroneal nerve are similarly affected by hyperglycemia.

Effect of hyperglycemia on conduction parameters of tibial nerve's fibers to different muscles: A rat model

Introduction: Routine conduction studies reflect the summation of all nerve fibers in a peripheral nerve. Nerve fiber groups to distal, small muscles have smaller diameters than the ones to large proximal muscles. There may be minimal differences between the diameters of nerve fiber groups innervating different muscles; even they are all same type of fibers. So, in neuropathic processes some nerve fiber groups may be more seriously affected. Materials and Methods: 14 rats ( 7 diabetic, 7 control) were studied. Tibial nerve was stimulated from two points and while recorded from a distal (foot intrinsic muscles) and a proximal (gastrocnemius) muscle. Results: There was a significant difference between the proximal and distal recorded conduction velocities. Both proximal and distal recorded conduction velocities decreased during the hyperglycemic process. Discussion: Our method successfully demonstrated different nerve fiber groups; but, the neuropathic process seemed to be homogeneous in both fiber groups.

Winging scapula due to demyelinating polyneuropathy

A 47-year-old male was admitted to our hospital with numbness and clumsiness in both hands. These symptoms developed 4 months ago and exacerbated progressively. A neurological examination revealed mild distal symmetrical sensory loss. He had no apparent muscle weakness in his shoulder muscles, but the medial section of the scapula was winging, especially after 120 of elevation and when he was asked to push the wall with both hands. The patient did not complain of pain. Nerve conduction studies (Table 1) demonstrated conduction blocks, slowed nerve conduction velocities, and prolonged distal latencies and F latencies in more than 2 peripheral nerves, meeting the electrophsyiological diagnostic criteria for CIDP [1]. By needle electromyography, we observed spontaneous denervation potentials in the serratus anterior muscle. There were no abnormalities in the other neck and shoulder muscles. His spinal magnetic resonance images were within normal limits. Examination of cerebrospinal fluid (CSF) revealed nothing except elevated protein levels (80 mg/dL). The patient was negative for anti-GM1, and no elevation of monoclonal antibodies was noted by blood or urine electrophoresis. There was nothing in his medical or family history that helped us exclude underlying hereditary polyneuropathy. Due to symmetrical diffuse demyelinating involvement in the nerve conduction studies, duration of the complaints, and elevated CSF protein levels, the patient was diagnosed with CIDP after excluding paraneoplastic conditions, diabetes mellitus, vasculitis, and rheumatological and hematological diseases. The patient was treated daily with 1 mgr/kg cts. His clinical symptoms, including the winging scapula, improved by the end of Week 8. In addition, the results of the nerve conduction studies improved slightly, and the conduction block abated (Table 2). Further, there were no abnormalities by repeated needle electromyography.

Bilateral Intracavernous Internal Carotid Artery Aneurysms Simulating Myasthenia Gravis: Case Report

Bilateral intracavernous carotid artery aneurysms are rare and can present with various clinical findings. The authors report on a case presenting with symptoms mimicking myasthenia gravis due to bilateral internal carotid artery aneurysms. This case illustrates a rare clinical condition, and the importance of detailed neuroimaging in neurological practice is emphasized in the paper.