Dursun Kirbas

Tuberculous meningitis in adults: review of 61 cases.

Abstract.Background:Tuberculosis is still a major cause of serious illness in developing countries. The objective of this study was to assess the clinical, laboratory, radiological and prognostic features of tuberculous meningitis (TBM) in immuncompetent adult patients.Patients and Methods:Sixty-one patients with confirmed or presumed TBM seen over a 12-year period at the Neurology Department of Bakırköy Research and Training Hospital for Psychiatric and Neurological Disease, Istanbul, Turkey, were analyzed retrospectively. Patients were grouped according to the severity of meningitis on admission (stages I, II and III). They were also divided into two groups according to the presence of paradoxical response (progressive increase of lymphocytes or increase of polymorphonuclear cells instead of lymphocytes) in CSF samples. A combination of five antituberculosis drugs was used in the 1st month of treatment. Patients received antituberculosis therapy for at least 12 months. The outcome of the patients was defined on the basis of the 12-month Barthel index (BI) score (BI < 12 poor; BI ≥ 12 good). For statistical analysis death was included in the poor outcome group.Results:Paradoxical response in CSF findings was seen in 20 patients. There was no statistically significant difference between the outcome of the patients with and without CSF paradoxical response; however, new tuberculomas developed more frequently in the first group (p < 0.05). The overall mortality was 27.8%. Stage of disease was found to be independently associated with the 12-month outcome (OR 7.2; 95% CI 1.7–30.3, p = 0.007).Conclusion:In developing countries such as Turkey, tuberculosis is still an important public health issue. Early suspicion and appropriate long-term antituberculosis therapy together with corticosteroids may reduce mortality and morbidity in TBM patients.

Spectrum of medial medullary infarction: clinical and magnetic resonance imaging findings.

Abstract Among 4200 consecutive patients admitted to three hospitals with acute ischemic stroke, we found only 11 patients in whom magnetic resonance imaging (MRI) had proved that they had medial medullary infarction (MMI). In our centers, patients with MMI were less than 1 % of those with vertebrobasilar stroke. The infarcts documented by MRI were unilateral in 10 patients and bilateral in one. On clinico-topographical analysis there were four clinical patterns: (1) Classical Dejerines syndrome was the most frequent, consisting of contralateral hemiparesis, lemniscal sensory loss and ipsilateral lingual palsy in 7 of the eleven patients. (2) Pure hemiparesis was present in 2 patients; (3) Sensorimotor stroke was present in 1 patient with contralateral hemiparesis, hypesthesia and mild decrease in pain sensation without lingual palsy; (4) Bilateral MMI syndrome in 1 patient, accompanied by tetraparesis, bilateral loss of deep sensation, dysphagia, dysphonia and anarthria. Presumed causes of MMI were intrinsic branch penetrator artery disease with concomitant vertebral artery stenosis in 6 of the 11 patients, vertebral artery occlusion in 2, dolichoectatic vertebrobasilar arteries in 2, a source of cardiac embolism in 1. Prognosis at 3 months was favorable in 8 patients, but the patient with bilateral MMI syndrome had persisting motor deficit causing limitation of daily activities, and 2 died from systemic causes. The classical triad of acute MMI facilitates the diagnosis, although the recognition of this syndrome in patients with incomplete manifestations can be difficult and occurs more frequently than commonly thought. Moreover, vertebral artery atherosclerosis and branch atheromatous disease of the penetrating arteries are the main causes of medullary infarction.

Ictal singing due to left mesial temporal sclerosis

Simple ictal or interictal automatisms are commonly seen in epilepsy, whereas complex automatisms are rare. Simple ictal vocalizations or appendicular automatisms have been reported to be due to mesial temporal lobe epilepsy. However, seizure-associated singing and dancing is very rare. We report a seventeen-year-old patient with ictal singing and rhythmic swinging of the arms as a dancing gesture. The video-EEG recording showed ictal left temporal lateralization and neuropathology confirmed left mesial temporal sclerosis.

Cognitive dysfunction of right hemisphere-like Todd’s paralysis after status epilepticus: a case report

We describe a case with symptoms of transient diffuse right hemisphere dysfunction (hemispatial neglect, dyscalculia, and disturbance of both spatial construction and visuospatial perception) occurring after status epilepticus. The clinical picture of this case suggested to us that these features could be understood as a variant of Todds paralysis.

Cerebellar syndrome due to hypoparathyroidism

Sirs: Hypoparathyroidism may be idiopathic or acquired. Neurological findings in this condition can include tetany and seizures due to decreased ionized calcium in blood, and some combinations of choreoathethosis, parkinsonism and cerebellar symptoms. Mental and/or motor retardation, dementia, learning disability, cranial nerve dysfunctions, paraesthesias, laryngeal spasm, and muscle cramps are uncommon accompanying findings. Imaging of the brain may reveal calcification in basal ganglia and cerebellum [1, 2]. We report two cases of hypoparathyroidism with a cerebellar syndrome. One of them had calcification in basal ganglia on brain imaging and in the other imaging was normal. Case 1 was a 64-year-old male admitted to hospital with tetanic spasms in the right hand and ataxic gait for a month. He had also experienced two generalized tonic-clonic seizures within the last 2 days. He had a normal medical history. Clinical examination revealed Chvostek and Trousseau signs evoked by hyperventilation, dysarthria, bilateral dysmetria, dysdiadochokinesis and ataxic gait. His blood ionized calcium level was 2.28 mg/dl (normal: 4–4.8), total calcium 4.3 mg/dl (normal: 8–12), inorganic phosphorus 12 mg/dl (normal: 2.7–4.5), parathyroid hormone 38 pmol/l (normal: 40– 100). Thyroid function tests including T3, T4 and TSH were all within normal limits. EEG and brain CT were normal. His condition was diagnosed as idiopathic hypoparathyroidism. He was treated with carbamazepine, calcitonin and calcium. His clinical findings normalized within 10 days of commencing the treatment. He had no seizure during a 2-month follow-up period. Case 2 was a 48-year-old male admitted to hospital with ataxic gait and dysarthria for a year, and generalized tonic-clonic seizures annually for 28 years. He had had subtotal thyroidectomy, which had been performed 28 years before this admission. Clinical examination revealed Chvostek and Trousseau signs, dysarthria, bilateral dysmetria, dysdiadochokinesis and ataxic gait. His blood ionized calcium level was 2.54 mg/dl (normal: 4–4.8), total calcium 5.9 mg/ dl (normal: 8–12), inorganic phosphorus 8 mg/dl (normal: 2.7–4.5), parathyroid hormone 7.1 pmol/l (normal: 40–100). Thyroid function tests (T3, T4 and TSH) were within normal limits. EEG was normal. Brain CT revealed bilateral calcification in the heads of the caudate nuclei, the lentiform nuclei and putamen. On cranial MRI, symmetrical hyperintense areas were observed with T1 sequence in the same anatomical regions as the calcifications shown by CT (Fig. 1). His condition was diagnosed as iatrogenic hypoparathyroidism secondary to subtotal thyroidectomy. He was treated with carbamazepine, calcitonin and calcium. Except for dysarthria, his clinical findings improved within 1.5 months of commencing the treatment. He had no seizure during a 1.5-year follow-up and dysarthria gradually disappeared within this period. Hypoparathyroidism may be idiopathic or due to a variety of conditions such as resection of parathyroid glands during thyroidectomy, intestinal malabsorption, pancreatic failure and vitamin-D deficiency as well as familial autoimmune disorder. Whatever the aetiology, clinical findings of hypoparathyroidism are common. Tetany, paraesthesias, muscle cramps, laryngeal spasm, and convulsions are the consequences of hypocalcaemia. Parkinsonism and choreoathetosis are the most common neurological findings and both cerebellar symptoms and dementia may accompany them. In the cases that we report, the clinical picture consisted of a few generalized tonicclonic seizures and cerebellar signs except for nystagmus. Dysarthria, dysmetria, dysdiadochokinesis and ataxic gait were so prominent that they could not be explained only by muscular hyperexcitability although the neurological examinations of these two cases had revealed findings of neuromuscular hyperexcitability such as Chvostek and Trousseau signs. In a review of the literature, no other case of hyoparathyroidism exhibiting cerebellar without extrapyramidal signs could be found although cerebellar signs accompanied by pyramidal and extrapyramidal signs have been reported [4, 6]. 338

Cognitive Outcome after Surgery in Patients with Mesial Temporal Lobe Epilepsy

INTRODUCTION The aim of the present study was to evaluate the neuropsychological outcomes of patients with medically intractable unilateral mesial temporal lobe epilepsy (MTLE) due to hippocampal sclerosis (HS) treated either by anterior temporal lobectomy (ATL) or selective amygdalohippocampectomy (SAH). METHODS This was a retrospective study where 67 patients who had undergone surgery for MTLE were evaluated. Thirty-two patients underwent ATL and 35 underwent SAH. All patients underwent a detailed neuropsychological evaluation before and 1 year after surgery. RESULTS The verbal memory outcome was unchanged after left-sided surgery, whereas learning capacity increased after right-sided surgery (p=0.038). The visual memory outcome improved after right-sided surgery. Improvement of executive functions, particularly in the resistance of interference pattern in the Stroop Test, shortened 5th card time (p=0.000), and decreased corrections (p=0.003), after right-sided surgery and increased attention (p=0.027) after left-sided surgery were observed. After both surgery types, although statistically insignificant, there was a marked decrease in incorrect answers in the Stroop Test, which also showed an improvement in the resistance of interference pattern. Moreover, there was a significant decrease in switching errors with word pairs in the Verbal Fluency Test (p=0.008) after right-sided surgery. When the two sides were compared, we observed that the recall phase of the verbal memory worsened (p=0.018); however, the recognition phase improved (p=0.015) after left-sided surgery. Additionally, the short-term visual memory was better for both sides (p=0.035). CONCLUSION Our results showed that patients with left MTLE were not worsened in verbal memory, but despite improved recognition, they have some problems in recalling information and only a minor improvement in attention. Patients with right MTLE improved in their verbal learning capacity, visual memory, and resistance of interference pattern 1 year after surgery. It was thus shown that while epilepsy surgery is associated with some negative cognitive changes, it may also improve some cognitive functions.

The Effects of Cognitive Rehabilitation on Relapsing Remitting Multiple Sclerosis Patients

INTRODUCTION The aims of this study were to determine the severity of cognitive impairment with Brief Repeatable Battery Neuropsychology (BRB-N) and to show the benefits of cognitive rehabilitation programs to develop coping strategies for the retardation of cognitive losses in relapsing remitting multiple sclerosis (RRMS) patients. METHODS The cognitive screening with BRB-N was performed in RRMS patients who had applied to the MS outpatient clinic of Bakırköy Psychiatric and Neurological Diseases Hospital, had an Expanded Disability Status Scale (EDSS) score between 1.0 and 5.5, and had no other cognitive disease or used drugs that effected the cognitive status. Thirty two patients with cognitive impairment underwent consecutive computer-assisted cognitive rehabilitation program once a week for 8 weeks conducted by psychologists. The effects of the program were evaluated with the tests repeated every 4 weeks. RESULTS The mean age of the patients was 36.09±7.19 years. Their initial and control test scores were found to be paced auditory serial addition test (PASAT) 29.21±17.97; 42.43±15.43, Selective Reminding Test-Total Learning (SRT-TL) 8.03±2.36; 10.09±1.77, Selective Reminding Test-Long-term Memory (SRT-DR) 6.72±2.74; 9±2.29, Spatial Recall Test-Total Learning (SPART-TL) 4.72±2.02; 4.22±1.74, Spatial Recall Test-Long-term Memory (SPART-DR) 5.94±2.54; 5.16±2.23, Symbol Digit Modalities Test (SDMT) 40.44±17.04; 46.47±17.94, Word Fluency Test (WLG) 32.88±9.87; 40.44±9.95 respectively. There was no significant statistical difference between Multiple Sclerosis Neuropsychological Screening Questionnaire (MSNQ) and SPART values of preface, 1st control and 2nd control (p>0.05). There was significant statistical difference between PASAT, WLG, SDMT, SRT-TL, SRT-DR values of Preface, 1st control, and 2nd control (p=0.0001). CONCLUSION It was determined that on distinctive improvement on sustaining attention, working memory and information processing speed, and verbal fluency and verbal learning with cognitive rehabilitation, no changes were observed on visuospatial learning. This approach is hopeful and further comprehensive studies are needed.

Chronic inflammatory demyelinating polyradiculoneuropathy associated intracranial hypertension

Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) is an acquired immune-mediated demyelinating neuropathy. In this report, we detail the course of a 58-year-old male patient who had headache and double vision followed by progressive paresthesia and difficulty in walking. The patient had bilateral papilledema and mild leg weakness, absent ankle jerks and loss of sensation in distal parts of his lower and upper extremities. His electromyography (EMG) was concordant with CIDP and lumbar puncture revealed high opening pressure. The polyradiculoneuropathy as well as the papilledema and elevated cerebrospinal fluid (CSF) pressure improved under steroids. The improvement in intracranial hypertension (IHT) and papilledema under steroid treatment suggests that the IHT in this patient might be associated with CIDP.

Electroclinical and prognostic characteristics of epilepsy patients with photosensitivity

Background and purpose Epilepsy with photosensitivity (PSE) is one of the reflex epilepsy types with pathophysiology still unexplained. In our study we aimed to evaluate the clinical, electroencephalogram (EEG) and prognosis of patients with PSE diagnosis. Methods A total of 44 patients with PSE diagnosis according to international classification were included in this retrospective and cross-sectional study. The age, gender, syndrome, clinical and EEG characteristics of patients, and treatment response were investigated. Results The mean age was 22.09±6.49 years for 28 females and 16 males included in the study. Of patients, 17 had idiopathic photosensitive occipital lobe epilepsy (IPOLE), 11 had juvenile myoclonic epilepsy (JME), 11 had other PSE and 5 had juvenile absence epilepsy (JAE), with the most common visual trigger factors television and sunlight. In terms of seizure type, the most common was generalized tonic clonic seizure (GTCS), with myoclonus, absence and other seizure types observed. There was family history present in 17 patients and valproic acid was most commonly used for treatment. Conclusion As noted in the literature, our data show that PSE has defined age group and clinical presentation, good prognosis but requires correct choice of medication for treatment. It is thought that good description of these epilepsy types will reduce misdiagnosis and mistreatment rates.

Az arteria cerebri anterior infarktusai; kétéves utánkövetéses vizsgálat

Background and purpose Anterior cerebral infarct (ACA) infarcts are reported very rare that is due to the compensatory collateral circulation provided by the anterior communicating artery. There are very few studies reporting the long-term follow-up results of ACA infarcts regarding their aetiology, clinical features and prognosis. Most studies reported in the literature vary between several months to one year. Methods A total of 27 patients with ACA infarcts were registered (14 women and 13 men). The mean age of the patients was 68.5 (age range: 45-89 years). Results Bilateral ACA infarcts were reported in four patients (14.8%), right ACA infarct in 11 (40%) patients and left ACA infarct in 12 patients (44%). During the initial examination 15 patients (55.5%) were found to have apathy, 13 patients (48%) had incontinence, nine patients (33.3%) had primitive reflexes, 11 patients (40.7%) had aphasia, while six patients (22.2%) were found to suffer from neglect. At the end of one-year follow-up, five patients (22.7%) were reported to have apathy, 6 patients (27.2%) had incontinence, one patient (4.5%) had primitive reflexes, while one patient (4.5%) was found to have permanent aphasia, and no patients was found to suffer from neglect. Conclusion Here we present our clinical data regarding the aetiology, specific clinical characteristics (including the speech disorders) and prognosis of 27 patients with ACA infarcts during a relatively longer follow-up period (3 months - 30 months) in compared to previous literature. We show that there are differences in the etiological factors of ACA infarcts between the Asian and European communities. Regarding speech disorders which are frequently reported during ACA infarcts, our study results are in agreement with other studies suggesting that this clinical picture is more than a real aphasia and associated with general hypokinesia and reduction in psychomotor activity.