Faik Budak

Idiopathic Stabbing Headache and Experimental Ice Cream Headache (Short-Lived Headaches)

Idiopathic stabbing headache (ISH) and ice cream headache occur due to paroxysmal firing of trigeminal pathways and a defect in pain control mechanisms. Any defect in pain control mechanisms appears to be localized to the affected areas. Therefore, we compared ISH and experimentally induced ice cream headache localizations in the same group of migraine sufferers to investigate similarities and differences between these headaches. The percentage of ice cream headache localizations restricted to ‘in front of the vertex/on the vertex’ was 94%, while it was 45% for ISH. The percentage of ice cream headache occurrence behind the vertex was 6% and 55% for ISH. Due to the widespread distribution of ISH in the head, there might be irritation of various branches of the trigeminal nerve, while the restricted localizations of ice cream headache suggest irritation of a certain branch or branches of the trigeminal nerve, e.g. in the oropharynx. Either widespread or restricted irritation of trigeminal pathways causes either ISH or ice cream headache, in which intermittent deficits in central pain control mechanisms seem to be playing the key role.

Primary Angiitis of the Central Nervous System: Unusual Clinical Presentation.

Primary angiitis of the central nervous system (PACNS) is a form of vasculitis restricted to the CNS. Most patients with PACNS present with focal neurologic deficits suggesting stroke or with a syndrome of headache and confusion. Less commonly, seizures, dementia, cranial neuropathies, myelopathies and, rarely, radiculopathies are seen. We report a 14-year-old girl who presented with partial motor seizures complicating focal cerebral vasculitis of superior parietal gyrus on the left. Despite extensive evaluation, no etiology was apparent for the vasculitis. Steroid therapy was administered, and 6 months after the therapy, she remains healthy except for a mild weakness of her right leg. Follow-up brain magnetic resonance images were normal. We conclude that partial motor seizures is uncommon as a presenting complaint in PACNS and steroid therapy is successful for this patient.

Tremor in idiopathic distal acquired demyelinating symmetric neuropathy.

Recently, the journal Movement Disorders published a study1 that suggested pathological lesions in essential tremor might be distributed similarly in each cerebellar cortex and two case reports that included important suggestions that the successful treatment strategies in tremor associated with paraproteinemic neuropathy might act to modify the abnormal activation patterns in the cerebellar functional system.2,3 We report on a 71-year-old man with distal acquired demyelinating symmetric (DADS) neuropathy who had complaints of gradually increased weakness and clumsiness in his extremities symmetrically for 5 years. A disabling tremor had been seen in his right hand 4 years ago and in the left hand after 6 months. He had not received any medical treatment for these complaints. No history of a central nervous system (CNS) disorder, familial neuropathy, or essential tremor were present. Neurological examination revealed mild distal muscle weakness, areflexia, severe sensory loss in glove and stocking distribution, imbalance, and sensorial ataxia. Postural and action tremors were observed predominantly in the distal muscle of upper extremities. He had no significant leg tremor or any sign of Parkinson’s disease. Findings in electrophysiological studies were consistent with mixed motor–sensory but predominantly sensory demyelinating axonal polyneuropathy. Slowing in conduction velocity of median (48 m/sec in right), ulnar (40.2 m/sec in right), and posterior tibial (26.4 m/sec in right) motor nerves was detected. Sensory nerve action potentials of sural, superficial peroneal, ulnar, and median nerves, and motor nerve action potential of peroneal nerve were absent. Sural nerve biopsy demonstrated a mild decrease in the number of myelinated nerve fibers and severe axonal involvement. Surface electromyogram recordings revealed a rhythmic and synchronous activity of the wrist extensor and flexor muscles (frequency, 6.5 Hz in right hand) during antigravity posture maintenance. Routine laboratory findings, bone marrow examination, and computed tomography scan of the brain were completely normal. Protein concentration was elevated in the cerebrospinal fluid (46 mg/dl). Serum protein and immunofixation electrophoresis were normal. The level of antibodies reactive to myelin-associated glycoprotein (anti-MAG Ab) examined with thin-layer chromatography, enzyme-linked immunosorbent assay, and Western blot analysis (titer, 1:1,600) was also normal. Prednisone was given at an initial dose of 1 mg/kg per day and gradually tapered to 0.5 mg/kg per day after 4 months. But electrophysiological studies did not show any improvement in neuropathy at 6 months. Primidone was started at an initial dose of 125 mg/day and then gradually increased to 500 mg/day. Tremor assessment was quantified using the Fahn–Tolosa– Marin Rating Scale, administered before initiating primidone therapy, on the 15th day, and at the end of the 6th month. A 5-point scale was used, and the maximum possible score was 156 points. The total score was 58 at baseline, 36 at 15 days, and 16 at 6 months. A relevant decrease in tremor amplitude and frequency (4.5 Hz in right hand), and improved skills in assessed tasks (such as pouring and writing) were noticed. He reported significant improvement in activities of daily living without any side effect. Primidone was discontinued at the end of 6 months to evaluate treatment efficacy. Interruption caused a worsening in tremor (score, 52). Treatment was then restarted and resulted in marked improvement (score, 16). DADS neuropathy is an acquired demyelinating polyneuropathy present with distal, symmetric, predominantly sensory or sensorimotor involvement. Nearly two thirds of the patients have an M-protein, usually immunoglobulin M (IgM) kappa monoclonal protein (DADS-M). The remaining one third does not have it, and the condition is referred to as idiopathic DADS neuropathy (DADS-I).4,5 These patients also were categorized on the basis of antibodies reactive to anti-MAG Ab.6 An action or postural tremor prominent in distal muscles of upper extremities is one of the manifestations of peripheral neuropathies.7,8 It may improve with propranolol hydrochloride in dysgammaglobulinemic polyneuropathy, supporting the hypothesis that tremor is due to enhancement of physiologic tremor.7–9 However, most patients reveal relatively higher amplitude, lower frequency, irregular, and asymmetric tremor that improves as the neuropathy responds to immunosuppressive therapy, which is characteristic of neurogenic tremor.9–11 According to neurogenic theory, dispersed and distorted muscle spindle input due to slow peripheral conduction are central to the generation of tremor in demyelinating neuropathies. These inputs subsequently cause a confusion in the CNS generator that is structurally intact but misled into producing tremor. Activation studies using positron emission tomography have also indicated that cerebellar hemispheres appear to be overactive in patients with tremor associated with IgM paraproteinemic neuropathy.12,13 Even though a few publications about the characteristics and treatment of the tremor seen in dysgammaglobulinemic polyneuropathy are present in the literature, only a very limited amount of data is present about the tremor seen in DADS-I neuropathy. In an early study, patients with demyelinating polyneuropathy without anti-MAG Ab were reported to exhibit tremor having the same characteristics with exaggerated physiologic tremor (EPT).9 Our patient exhibited an asymmetric tremor with relatively higher amplitude and lower frequency (4.5–6.5 Hz) than seen in EPT (8–12 Hz).13 Findings in our case and in a previous report on a patient having tremor associated with nonparaproteinemic demyelinating polyneuropathy support the neurogenic mechanism in generation of Published online 19 August 2005 in Wiley InterScience (www. interscience.wiley.com). DOI: 10.1002/mds.20693 Movement Disorders Vol. 20, No. 11, 2005, pp. 1529–1530

Recurrent Neural Networks for Diagnosis of Carpal Tunnel Syndrome Using Electrophysiologic Findings

This paper presents the use of recurrent neural networks (RNNs) for diagnosis of carpal tunnel syndrome (CTS) (normal, right CTS, left CTS, bilateral CTS). The RNN is trained with the Levenberg-Marquardt algorithm. The RNN is trained on the features of CTS (right median motor latency, left median motor latency, right median sensory latency, left median sensory latency). The multilayer perceptron neural network (MLPNN) is also implemented for comparison the performance of the classifiers on the same diagnosis problem. The total classification accuracy of the RNN is significantly high (94.80%). The obtained results confirmed the validity of the RNNs to help in clinical decision-making.

A New Application of Recurrent Neural Networks for EMG-based Diagnosis of Carpal Tunnel Syndrome

Konuralp Ilbay1*, Elif Derya Ubeyli2, Gul Ilbay3, Faik Budak4 1Kocaeli University, Faculty of Medicine, Department of Neurosurgery, Kocaeli, 2Osmaniye Korkut Ata University, Faculty of Engineering, Department of Electrical and Electronics Engineering, Osmaniye, 3Kocaeli University, Faculty of Medicine, Department of Physiology, Kocaeli, 4Kocaeli University, Faculty of Medicine, Department of Neurology, Kocaeli, Turkey

Correlations between nonverbal intelligence and nerve conduction velocities in right-handed male and female subjects.

A neurological theory of intelligence suggesting a direct correlation between nerve conduction velocity and psychometric intelligence was tested. Cattells Culture Fair Intelligence Test was used to asses the nonverbal intelligence (IQ) of subjects. The motor median nerve conduction velocity from right hand of males was positively correlated with IQ. In subjects with no familial sinistrality (FS–), the motor ulnar-nerve conduction velocity from the right and left hands of males negatively correlated with IQ; there were inverse correlations between IQ and nerve conduction velocity (motor median nerve from right, sensory median nerve from right and left) in females. In subjects with familial sinistrality (FS+), IQ directly correlated with nerve conduction velocity from motor median (right and left), sensory median (right), and motor ulnar (right) nerves, but only in males. The speed hypothesis and neurological theory of intelligence were not supported by these results, which, in contrast, emphasized the importance of sex and familial sinistrality in any theory of intelligence.

Cerebral Dural Sinus Thrombosis A Case Report

Cerebral dural sinus thrombosis is an uncommon syndrome that a patient presents with severe headache, which may be associated with complex physical and neurologic findings. The authors present a thirty-two-year-old woman with severe headache, focal motor seizures, and subsequent hemiparesis when she was ten weeks pregnant, diagnosed as having a dural sinus thrombosis by magnetic resonance imaging and magnetic resonance angiography. In this report, the application of magnetic resonance techniques, including angiography to diagnose and monitor therapy for dural sinus thrombosis, is presented.

Patients’ postures during migraineattacks.

AbstractThe aim of this study was to determine postures adopted by patients during migraine attack. A total of 199 migraine patients were questioned about their postures during the migraine attack. Of these, 92 patients did not choose a specific lying position, 22 could not lie down during the attack because of the increase in pain, while 6 avoided lying due to scalp tenderness. During the attack, 19 patients preferred holding their heads up (compared to painless period) with a few pillows and 41 applied pressure on the aching side; 15 lay with their necks extended and 15 lay face downward. Various combinations of these postures were also reported. Pain may arise from extracranial muscles as well as vessels during a migraine attack. The posture chosen during attack is a reflection of vascular and muscle pains that provoke symptoms. The postures that patients chose were aimed to lessen the severity of symptoms of their migraine attacks. Patients know the position they adopt and do not need to be told by a doctor, but they come to consultations to be understood, to learn that others behave in the same way, and in some, to obtain reasons for their posture. The existence of a specific lying posture can be an advantage for the physician in terms of approaching the patient and selecting an appropriate therapy.