Feray Karaali-Savrun

Haemodialysis-related headache

Dialysis may induce severe headache as a result of a large amount of water and electrolyte shifts. It is important to recognize it because it can be a great problem to the patient and changing dialysis parameters or methods can prevent it. In this study we investigated the frequency and clinical characteristics of headaches occurring during haemodialysis (HD). Thirty female and 33 male patients with chronic renal failure on regular dialysis for at least 6 months in the HD unit of the Internal Medicine Department from 1996 to 2000 participated in the study. The dialysis solution contained acetate in 35 patients and bicarbonate in 28 patients. In all patients capillary dialysers and Cuprophan membranes were used and every session of dialysis lasted 4 h. All patients received the same questionnaire and they were visited randomly. Dialysis headache (DH) diagnosis was made according to the criteria of the International Headache Society. Patients with primary headache and under drug treatment during HD, which can cause headache, were excluded from the study. The frequency of DH, its relation to gender, age, dialysis technique and parameters and its features were investigated. DH was detected in 48% (n = 30) of the study group. Compared with dialysis solutions, no difference was found between patients with and without DH. The difference in the pre- and post-dialysis value of urea in patients with DH was statistically significant (P < 0.05). Patients with DH showed significantly higher mean systolic and diastolic blood pressure predialysis values in comparison with patients without DH (systolic, P < 0.001; diastolic, P < 0.01), whereas post-treatment values did not differ between the two groups. Fronto-temporal location, moderate severity, throbbing quality and short duration (<4 h) were the most prevalent features of DH in patients.

Hepatitis B vaccine related‐myelitis?*

We present four incidental cases that developed partial myelitis following the administration of hepatitis B vaccine in 1998. The first two cases, a 33‐year‐old man and a 42‐year‐old woman developed progressive sensory symptoms without motor involvement within 4 weeks following the vaccination. Their magnetic resonance imaging (MRI) disclosed similar lesions consistent with myelitis at their cervical spinal cord. A comparable inflammatory lesion was seen at the T9–T10 levels of the spinal cord in the third case, who was a 40‐year‐old woman presenting with numbness in her legs and urinary retention following the vaccination. The fourth case who was a 42‐year‐old woman, presented with sensory symptoms in her left extremities, which developed 3 months after the vaccination. Her MRI showed a hyperintense lesion at C6. She also had two tiny lesions in her cranial MRI. In all cases, there was no history of preceding infections and no clinical evidence suggestive of any other disorders that may cause myelopathy. All patients recovered completely within 3 months with the exception of the third patient who developed new neurological symptoms after 12 months. Similar clinical and imaging presentation of myelitis following hepatitis B vaccination within a 1 year period with no other demonstrable clinical and laboratory evidence for any other disorder raise the probability of a causal link between these two events.

Hemimasticatory spasm following pontine infarction

age by growth charts. While in Iran, she was noted to have scoliosis and an MRI of the thoracic spine revealed an intramedullary, isointense, hetereogeneous, enhancing mass extending from the second thoracic level to the tenth thoracic level. An attempt at resection of the spinal mass and correction of the scoliosis was not successful but the biopsy specimen revealed a ganglioglioma. Since the surgery, the scoliosis has become worse, requiring a back brace for support and her gait has deteriorated with a right foot drop. Tumor size has been stable since the initial diagnosis. Radiation therapy was recommended but the family refused. The undulating abdominal movements ceaselessly continue. The documented thoracic intramedullary spinal tumor and the localized abdominal movements prompt us to suggest a direct clinical–anatomic correlation for this patient’s unusual movement disorder.

Headache in carotid artery stenting and angiography.

Introduction.— Carotid angioplasty headache and diagnostic criteria are based on scarce data and small series. Here, we aimed to determine presence, frequency, and characteristics of headache after carotid artery stenting and angiography headache and speculate on possible mechanisms of head and neck pain emerging during or after the carotid artery stenting procedure.

An unusual case of vascular loop syndrome

Coexistence of hemifacial spasm (HFS) and trigeminal neuralgia (TN) is a rare entity known as painful tic convulsif (PTC). Here, we present a case of right-sided HFS after which left TN developed, which is an unusual form of PTC. Both disorders were caused by bilateral vascular compression of the cranial nerves and successfully treated with botulinum toxin and carbamazepine. As PTC is benign in nature and can be treated with botulinum toxin, neuroradiological investigations should be performed for an accurate aetiological diagnosis, particularly in young patients with atypical disease manifestations.

Efficacy of Nebivolol and Amitriptyline in the Prophylaxis of Cyclic Vomiting Syndrome: A Case Report

Background:Cyclic vomiting syndrome (CVS) is an episodic disorder with recurrent attacks of nausea and vomiting. The exact cause of the disorder is still unclear. It was first described in children but may affect patients of any age. The syndrome is frequently misdiagnosed, and patients receive redundant investigations and treatments. Patients are referred finally to a neurologist because of the differential diagnosis of abdominal migraine or abdominal epilepsy. Case Report:We present a 18-year-old girl with episodic nausea and vomiting attacks who was diagnosed as CVS. The attacks regressed with combination treatment with amitriptyline and nebivolol. Conclusion:CVS has no specific diagnostic test and the diagnosis is based on history, clinical presentation and exclusion of other possible causes with similar presentation. The syndrome has a strong association with migraine; treatment options may also overlap. Treatment is still based on case series and reports. Here, we aim to present the clinical features as well as treatment response of a patient with CVS.

EEG Correlates of Startle Reflex with Reactivity to Eye Opening in Psychiatric Disorders: Preliminary Results

Previous studies have shown alterations of eyeblink reflex in patients with various psychiatric disorders. It has previously been demonstrated by our group that EEG measures of the reactivity to eye opening could effectively predict patient-reported startle response in patients with acute stress reaction. In our present study, EEG spectral power analysis and eyeblink electrical startle responses were acquired from a total of 39 patients diagnosed with various psychiatric disorders: 7 patients with schizophrenia, 10 patients with major depressive disorder (MDD), 10 patients with panic disorder, 5 patients with posttraumatic stress disorder (PTSD) and 7 patients with generalized anxiety disorder (GAD). EEG percent power data of each frequency band (delta, theta, alpha, beta) obtained from the 19 leads under open or closed eyelid conditions were used to calculate the arithmetical difference between eyes-open and eyes-closed states as representative of “EEG reactivity to eye opening.” Data was analyzed separately for each diagnostic group. For all of the disorders, right-sided R2c (contralateral secondary component) latency was the single eyeblink startle measure that was found to be significantly correlated with EEG reactivity to eye opening. The correlation was most significant for right temporal theta frequency in schizophrenia, right temporal theta frequency in MDD, left central beta frequency in panic disorder, left parietotemporal delta frequency in PTSD and right occipital alpha frequency in GAD. Findings showed a newly identified pattern that has potential scientific and clinical value with respect to psychiatric medicine.

Deficient prepulse inhibition of blink reflex in migraine and its relation to allodynia

OBJECTIVE Prepulse inhibition (PPI) of the blink reflex (BR) is a reduction in BR excitability due to a conditioning stimulus, reflecting sensory gating by brainstem structures. We aimed to analyze PPI changes during a painful episode in chronic or episodic migraine and its relation to allodynia, since abnormal brainstem filtering has been hypothesized in migraine pathophysiology. METHODS We included 20 patients with migraine during headache episode, and age- and gender-matched 22 healthy subjects. We recorded BR after unconditioned and conditioned supraorbital stimuli. For conditioned stimuli, we applied preceding subthreshold stimulus to the median nerve at wrist. The presence of PPI was compared between the two groups, as well as the specific BR parameters (latency, amplitude or area of R1 and R2 components) in unconditioned (test) and conditioned (PPI) paradigms. RESULTS In the patient group, seven (35%) patients did not have R2-PPI whereas all healthy subjects had R2-PPI (P=0.003). Healthy subjects displayed significantly increased R1 amplitude and reduced R2 amplitude and area after conditioned stimuli. In migraine patients, we observed significant reduction only in R2 amplitude. Logistic regression demonstrated that allodynia was independently related with the presence of PPI (beta: -0.535, P=0.021). CONCLUSIONS Our study provides evidence for sensory gating impairment at brainstem level in migraine headache, related to the presence of allodynia.

Reorganization of sensorimotor gating after peripheral facial palsy starts at brainstem

ABSTRACT Background and objective We aimed to analyze the alterations in sensorimotor gating at brainstem after peripheral facial palsy (PFP). To examine sensorimotor gating, we used prepulse modulation (PPM) of blink reflex (BR). We also recorded BR recovery to identify excitability changes in the facial nucleus. Patients and method We included 33 patients and 39 recordings. Control group was composed of 16 healthy subjects. Simultaneous bilateral baseline BR, BR recovery at ISI of 300-ms and BR-PPM at ISI of 100-ms recordings were performed after stimulation of trigeminal nerve on right sides of healthy subjects and on both sides of patients. Severity of PFP and time lapse from the onset was noted. Results Mean R1 amplitude was increased, whereas mean R2 and R2c magnitude were reduced in all groups after prepulse stimulation. However, multivariate ANOVA showed significance at group level (patients and healthy subjects), at prepulse level (no prepulse and 100-ms prepulse) and group and prepulse level. Suppression of R2 or R2c was lower on both sides of patients compared to healthy subjects and the deficit first started on the symptomatic side. Conclusion Suppression of R2 and R2c after prepulse stimulation is reduced in PFP suggesting decreased filtering of facial sensory input at brainstem level. Trigeminal sensitization at brainstem develops early after PFP.

F27. Myoclonus in demyelinating polyneuropathies: Preliminary results

Introduction The reports on tremor and different types of polyneuropathies have been increasing and it was suggested to be associated with cerebellar involvement in chronic inflammatory demyelinating polyneuropathy (CIDP). Apart from specific syndromes, the co-existence of polyneuropathy and myoclonus is exceptional. We previously observed cortical myoclonus in cases with inflammatory polyneuropathy who were referred for tremor analysis and aimed to analyze presence of myoclonus and its relation with clinical features in demyelinating polyneuropathies. Methods We prospectively included all patients with inflammatory polyneuropathy who were admitted between January 2017 and June 2017 and had tremor-like, regular or irregular involuntary movements on clinical examination. All patients underwent neurological examination and multichannel surface electromyography which included upper extremity muscles as well as lower extremity and facial or neck muscles in selected cases. We also recorded long latency reflexes and somatosensory evoked potentials (SEPs) to categorize myoclonus. Results We identified eight patients with demyelinating polyneuropathy who matched the inclusion criteria: four patients with CIDP, three patients with Guillain–Barre syndrome and one patient with Charcot-Marie-Tooth disease. The mean age was 50.5 ± 19.6 years (range: 26–81 years) and there were seven male patients. Seven out of eight patients had myoclonus, two of which were in the form of polyminimyoclonus. Others had myoclonus on both proximal and distal parts of upper extremities. Negative myoclonus was observed in four of them. Duration of myoclonus was between 30 and 100 ms. only one had duration of 200 ms. Most patients (five out of seven) had cortical myoclonus (with high-amplitude C reflex or SEPs). Conclusion Myoclonus in the patients with polyneuropathy was irregular tremor-like, however, the electrophysiological characteristics was similar to a cortical subtype. Therefore, it would be interesting to investigate a bigger cohort of inflammatory polyneuropathies for the presence and subtypes of myoclonus and to determine associated clinical features.