Canan Togay Işıkay

The effects of hematocrit and age on transcranial Doppler measurements in patients with recent ischemic stroke

BACKGROUND The effects of age and hematocrit on transcranial Doppler (TCD) velocities have not been evaluated in a large patient group with recent ischemic stroke. AIM This study assessed the effects of age and hematocrit on TCD measurements in patients with recent ischemic stroke compared to patients with non-vascular diseases. SETTINGS AND DESIGN University Hospital, retrospective study. MATERIALS AND METHODS TCD records and data files of 862 consecutive patients (mean age, 57+/-16 years) with various neurological diagnoses were reviewed retrospectively. The peak systolic, end diastolic and mean flow velocities (FV), systolic/diastolic ratios and pulsatility indices (PI) in the middle cerebral arteries were averaged and the effect of age and hematocrit values on these TCD values was studied. Independent samples t test, Pearsons coefficients of correlation, and linear regression test were used for statistical analysis. RESULTS Among 862 patients, 413 were women (mean age, 53+/-17 years) and 449 were men (mean age, 60+/-13 years). Peak systolic and mean FV were higher and hematocrit concentration was lower in women compared to men (P< 0.001). The relation of TCD velocities with age and hematocrit was more remarkable in the group of patients with non-vascular neurological disorders. PI values demonstrated a significant correlation to age (r=+0.47) (P< 0.001), but did not change significantly with hematocrit level. CONCLUSIONS It should be remembered that blood FV measured by TCD may be significantly affected by age and hematocrit level. However, there seems to be no significant association between TCD velocities and hematocrit in patients with a recent ischemic stroke.

Antioxidant status in cerebrovascular accident

Ischemia is associated with the pathological changes caused by the accumulation of reactive oxygen metabolites (ROM) in cerebrovascular accident (CVA). The aim of this study was to determine red cell copper/zinc-superoxide dismutase (Cu/Zn-SOD) and catalase activities and copper and zinc concentrations both in plasma and in red cells in CVA. Cu/Zn-SOD and catalase activities of 16 patients, with an average age of 64 yr, were measured spectrophotometrically; copper and zinc concentrations were determined by atomic absorption spectrophotometer. The results showed that Cu/Zn-SOD activity was increased markedly in patients compared to the young controls and reached a peak on the d 5 of the disease, whereas the catalase activity of the patients on d 3 and d 5 were in the normal range, but higher on d 10. The enzyme activities of the elderly group were generally increased compared to the young controls. Copper and zinc concentrations showed corresponding alterations. These findings suggested that the effects of oxidative stress in CVA might be reflected in red cell and plasma parameters.

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.

Cerebral Vein Thrombosis as an Exceptional Cause of Transient Ischemic Attack

We present a case of transient ischemic attack (TIA) as an extremely rare presentation of cerebral vein thrombosis. A 41-year-old man presented with a headache and episodes of hypoesthesia on his left side lasting approximately 30 minutes. Several vascular risk factors were remarkable in his medical history. The neurologic examination was normal. TIA of arterial origin was excluded by detailed investigations. Magnetic resonance imaging revealed acute thrombosis of the right superficial middle cerebral vein and the vein of Trolard. TIA-like episodes stopped with anticoagulation. Head trauma a few days earlier was the most likely mechanism of venous thrombosis. We suggest that the patients with TIA and headache should be carefully investigated in terms of cerebral venous thrombosis.

A case of bilateral uveitis and optic disc swelling with Chiari I malformation

We report a case of bilateral uveitis and optic disc swelling with Chiari I malformation. A 16-year-old girl was admitted to our clinic due to conjunctival hyperaemia and blurred vision in her right eye. Ophthalmologic and systemic examinations were performed. Visual acuity was 0.7 (OD) and 1.0 (OS). Bilateral optic disc swelling was observed. Fluorescein angiography demonstrated bilateral retinal vasculitis as well as optic disc hyperflourescence due to leakage. Laboratory examinations were within normal limits. Cranial magnetic resonance venography imaging revealed neither cranial mass nor cerebral venous thrombosis but a Chiari I malformation. The patient was started oral cetazolamid, topical and oral corticosteroids. After six months follow-up, bilateral optic disc swelling was resolved completely and visual acuity was 1.0 in both eyes. Optic disc swelling may be associated with intraocular inflammation; however, patients with bilateral optic disc swelling should be suspected of having an accompanying intracranial pathology.

Pronation Test: Eyes Closed or Open?

Background: The pronation test reveals slight paresis in the upper limbs. Patients hold their arms outstretched in front of them with the hands supinated while they keep their eyes closed. Position changes such as pronation, abduction, or drift indicate a positive pronation test. However, proprioceptive disorders also result in position changes when the eyes are closed. Aim: To evaluate the effects of vision on the pronation test and the relation of test results to electrophysiological findings. Methods: Sixteen patients with slight unilateral paresis due to recent stroke were included in the study. Two pronation tests, one while the patients’ eyes were open and the other while the eyes were closed (in randomized order), were performed in all patients and recorded with a video camera. Two neurologists double-blinded to the position of the patients’ eyes then assessed the position changes in each recording. Electrophysiological examination included median sensory and motor evoked potentials in both upper limbs. Sensory and motor central conduction times (CCTs) were determined for all patients. Results: Assessments of position changes by two physicians were concordant. Ten patients had position changes more evident in the pronation test with the eyes closed (group 1), while 6 patients had similar position changes in both tests (group 2). Motor CCT difference between two sides was similar in the two groups. However, sensory CCT difference longer than 1.0 ms was significantly more frequent in group 1 (p < 0.01). Conclusion: All patients who developed more obvious position changes during the pronation test with eyes closed had sensory CCT abnormalities. Therefore, we suggest that patients should keep their eyes open and then close them during the pronation test in order to distinguish motor or proprioceptive involvement.

Nutritional Approach and Treatment in Patients with Stroke, An Expert Opinion for Turkey

1Hacettepe University Faculty of Medicine, Department of Neurology, Ankara, Turkey 2Ege University Faculty of Medicine, Department of Neurology, İzmir, Turkey 3Ondokuz Mayıs University Faculty of Medicine, Department of Neurology, Samsun, Turkey 4Ankara University Faculty of Medicine, Department of Neurology, Ankara, Turkey 5Dokuz Eylül University Faculty of Medicine, Department of Neurology, İzmir, Turkey

The Significance and Reliability of Imaging Findings in Pseudotumor Cerebri

ABSTRACT The objective of our study was to provide a comparative assessment of previously reported magnetic resonance imaging (MRI) parameters in primary and secondary pseudotumor cerebri (PTC) patients, to examine their diagnostic contribution, and to evaluate their association with symptoms, neuro-ophthalmological findings, laboratory results, and cerebrospinal fluid characteristics. Twenty-eight consecutive patients with PTC were included in the study. Age- and sex-matched 20 individuals with normal neurologic examination served as the control group. Modified Dandy Criteria were used for the diagnosis of PTC. Orbital and cranial MRI and MR venography of all patients and controls were assessed by three radiologists. According to our study, posterior flattening of the globe (64% sensitive, 100% specific), optic nerve sheath distention (46% sensitive, 100% specific), vertical tortuosity of the optic nerve (30% sensitive, 95% specific), and partial empty sella (43% sensitive, 100% specific) emerged as particularly valuable markers for a diagnosis of PTC.

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.

Oculomotor Nerve Palsy Presented with Isolated Unilateral Ptosis and Minimal Upgaze Palsy

ABSTRACT This case with unilateral complete blepharoptosis and slight limitation of upgaze as ocular findings due to midbrain infarction represents an unusual form of intra-axial oculomotor nerve involvement. A 65-year-old man was admitted with acute unilateral ptosis of the left eyelid and gait ataxia. He had chronic hypertension in the medical history. The neurologic examination revealed that he had a complete ptosis of the left eyelid, slight limitation of elevation in the left eye, bilateral dysmetria, and gait ataxia. Magnetic resonance imaging showed acute infarction in the central part of midbrain tegmentum. Previous models for arrangement of oculomotor fascicle in the midbrain suggest that a lesion involving the most caudal fibres for levator palpebrae and superior rectus without affecting other extraocular muscles and pupillomotor fibres is the most likely aetiology.