Fethi Idiman

Comparison of preseptal and pretarsal injections of botulinum toxin in the treatment of blepharospasm and hemifacial spasm

Abstract Although the beneficial effect of subcutaneous injections of botulinum toxin type A (BTX-A) is well known in both blepharospasm and hemifacial spasm, the position of the injection sites around the orbicularis oculi may influence the effectiveness and side effects. Here we report results of preseptal and pretarsal BTX-A injections in 53 patients (25 blepharospasm and 28 hemifacial spasm) in whom we used both injection techniques successively. Pretarsal injections were used in 102 out of 186 treatments in blepharospasm group and in 84 out of 202 treatments in hemifacial spasm group. Pretarsal BTX-A treatment produced significantly higher response rate and longer duration of maximum response in both patient groups. This technique was also associated with a lower frequency of major side effects such as ptosis. We concluded that injections of BTX-A into the pretarsal, rather than the preseptal portion of the orbicularis oculi is more effective for treatment of involuntary eyelid closure due to contractions of this muscle.

Nitric oxide as an activity marker in multiple sclerosis

Abstract. Nitric oxide (NO) molecules have one of the most important roles in the pathogenesis of multiple sclerosis (MS). It has been stated that a continuous and high concentration of NO metabolites in CSF and in the serum of MS patients in relapse may cause toxic damage to myelin and oligodendroglia. The aim of this study was to investigate whether NO is a marker of disease activity and is correlated with other disease activity markers such as active lesions on brain magnetic resonance imaging (MRI) and increased immunoglobulin G (IgG) index.Cerebrospinal fluid (CSF) and peripheral serum (PS) samples were taken from patients with definite MS (n = 24) during relapse and remission and from control subjects (n = 18). The Griess reaction was used to measure the NO metabolites, nitrite and nitrate in CSF and PS. Cranial MRI was carried out with triple dose (0,3 mmol/kg) gadolinium and the IgG index was determined.Nitrite and nitrate concentrations (NNCs) of CSF were 11.16 ± 8.60 μmol/ml in relapse and 6.72 ± 3.50 μmol/ml in remission, whereas in PS they were 12.89 ± 7.62 μmol/ml during relapse and 12.35 ± 6.62 μmol/ml during remission. In control subjects NNCs in CSF and PS were 7.42 ± 2.81 μmol/ml and 4.37 ± 1.63 μmol/ml respectively. NNCs in CSF during relapse period were significantly higher than those of both remission phase and control subjects (p = 0.000). Although serum NNCs did not differ in relapse and remission, they were still higher than normal controls. Validity analysis revealed that NNC measurement in CSF was 71 % specific and 66 % sensitive to disease activity. The most important result was the significant correlation of increased NNCs with the existence of active lesion in cranial MRI and an increase in IgG index (p < 0.05).In conclusion, these results add background data to assist in further outlining the possible role of NO in the pathogenesis of MS. Together with the other markers it may be used as an activity marker in relapses of MS.

Headache in Sleep Apnea Syndrome

Objective.—To find out whether there is a relationship between the headache characteristics and polysomnographic findings in patients with prediagnosis of the sleep apnea syndrome (SAS) and, if there is, to search for its possible cause.

Comparison of cortical excitability in chronic migraine (transformed migraine) and migraine without aura

We studied the excitability of the motor cortex in patients with migraine without aura (MWOA) (n = 20) and with chronic migraine (CM) (n = 20) using transcranial magnetic stimulation (TMS). By using a 90-mm circular coil placed over the vertex and recording of the first dorsal interosseous muscle, we measured thresholds, latencies and amplitudes of motor evoked potentials and duration of cortical silent periods in patient groups and in controls (n = 20). No differences were found between groups for threshold, latency and amplitude values. However, the duration of the cortical silent period was longer in CM patients, being significantly different from both controls and MWOA. We suggest that either this difference in cortical excitability may develop during transformation from MWOA to CM or different pathophysiological mechanisms may play a role in these two headache syndromes.

Intrathecal sICAM-1 production in multiple sclerosis Correlation with triple dose Gd-DTPA MRI enhancement and IgG index

In this study the aim was to evaluate the intrathecal sICAM-1 production in multiple sclerosis (MS) patients during relapse and remission. In addition to this, we assessed whether there is a correlation between intrathecal sICAM-1 production and other disease activity markers such as IgG index and gadolinium enhancement in magnetic resonance imaging (MRI). Twenty four relapsing- remitting MS patients were included in the study. Serum and cerebrospinal fluid (CSF) samples were obtained both during relapse and remission. The soluble form of ICAM (sICAM) was measured by the ELISA method in serum and CSF. Cranial MRI with triple dose gadolinium injection was performed for each patient both during relapse and remission. Serum levels of sICAM-1 (245.23±92.88 ng/ml) were higher during relapse than those in remission (219.90±110.94 ng/ml), but the difference was not statistically significant. In relapse periods CSF levels of sICAM-1 (1.304±0.92 ng/ml) were higher than those in remission (1.06±0.86 ng/ml), but this was not significant. However, during relapse periods patients had significantly higher sICAM-1 index values (1.76±0.60) than those found during remission periods (1.01±0.44) (p<0.05). The IgG index values were higher in relapse periods than in remission (0.88±0.37 vs. 0.67±0.28) (p<0.005). On T1 weighted images following triple dose Gd injection, at least two or more enhancing lesions were present in 22/24 of the patients (91 %) in relapse and 4/24 of the patients (19 %) in remission. There was strong correlation both between the sICAM-1 index and Gd enhancement (r=0.72 p<0.05) and sICAM-1 index and IgG index in relapse (r=0.69 p<0.05). In conclusion, there is association between high sICAM-1 and IgG indices, as well as between high sICAM-1 index and Gd enhancing MRI lesions in relapsing MS patients.

Dermatomal and mixed nerve somatosensory evoked potentials in the diagnosis of neurogenic thoracic outlet syndrome

To evaluate the diagnostic utility of dermatomal and mixed nerve somatosensory evoked potentials (SEPs) in patients with thoracic outlet syndrome (TOS) and to compare their value with routine electrodiagnostic methods, we studied a group of 44 patients with neurogenic TOS and 30 healthy controls. In addition to bilateral median and ulnar SEPs, evoked potentials were recorded after stimulation of C6 and C8 dermatomes from the first and fifth digits, respectively. The patients were classified into 3 groups according to the nature of their clinical condition. The abnormality rate for both ulnar and C8 dermatomal SEPs was 100% in a small group of patients with severe neurological signs like atrophy. In groups of patients with lesser degrees of neurogenic damage, abnormality rates for ulnar and C8 dermatomal SEPs on affected limb(s) were 67 and 50%, respectively. Same abnormality rates were 25 and 18% in patients with only subjective symptoms. In patients with objective neurological signs, the major increase in sensitivity was with electromyography (EMG). Abnormalities of routine nerve conduction studies and F-wave latency were observed in patients with severe neurogenic damage. We concluded that the most useful tests in the diagnosis of neurogenic TOS are needle EMG and ulnar SEPs.

VISUAL EVOKED POTENTIAL IS SUPERIOR TO TRIPLE DOSE MAGNETIC RESONANCE IMAGING IN THE DIAGNOSIS OF OPTIC NERVE INVOLVEMENT

The aim of this study was to evaluate whether VEP is sensitive to optic neuritis (ON) when compared with triple dose orbital MRI. Twenty-four relapsing-remitting MS (RRMS) patients were included in the study. Group I (n = 10) patients with acute ON, Group II (n = 8): patients presenting with a current relapse who had the history of ON in the previous relapses. Group III (n = 6): patients presenting with a current relapse but with no history of ON. Neuro-ophtalmological evaluation. VEP investigation and orbital MRI with triple dose (0.3 mmol/kg) gadolinium (Gd) were carried out for all. VEP was found to be 70% sensitive and 12.5% specific to the acute ON, whereas orbital MRI with triple dose Gd was 70% sensitive and 100% specific. In chronic ON, the sensitivity of orbital MRI is 0%, whereas the VEP is still 75% sensitive to chronic optic nerve involvement and can distinguish the pathology 100% specifically. In conclusion, orbital MRI with triple dose Gd is not more sensitive than VEP in determining the acute optic nerve pathologies but it is a 100% specific method. The results suggest that VEP is superior to the orbital MRI in determining the chronic optic nerve involvement.

Cortical silent period and motor evoked potentials in patients with multiple sclerosis

In order to determine the importance of central motor conduction time (CMCT) and silent period (SP) in patients with multiple sclerosis (MS), we enrolled this clinical and electrophysiological study. Additionally, we planned to compare the correlation between electrophysiological findings and clinical status. We examined 58 patients with definite MS and 31 controls. Patients were classified as relapsing-remitting (N: 37), secondary progressive (N: 21) groups. Eleven out of 58 patients with MS had no neurological findings (subclinical patients). We evaluated CMCT and the duration of SP. Prolonged CMCT latency was shown in 75.2% of patients. We observed SP abnormalities in 69% of patients. In subclinical patients, SP abnormalities (six of 11) were observed more common than CMCT (two of 11). The duration of SP was extremely prolonged in MS patients with cerebellar dysfunction. When the both electrophysiological parameters are taken into account, the abnormality ratio was determined as 89.7%. Our results indicate that CMCT and SP analysis are complementary tests in evaluating motor pathways of patients with MS. We observed a relationship between cerebellar dysfunction and SP prolongation. It is suggested that, SP can be applied in patients with pure cerebellar dysfunction and it can be a valuable test in subclinical cases with MS.

Contingent negative variation is associated with cognitive dysfunction and secondary progressive disease course in multiple sclerosis.

Background and Purpose The relationship between contingent negative variation (CNV), which is an event-related potential, and cognition in multiple sclerosis (MS) has not been examined previously. The primary objective of the present study was thus to determine the association between CNV and cognition in a sample of MS patients. Methods The subjects of this study comprised 66 MS patients [50 with relapsing-remitting MS (RRMS) and 16 with secondary progressive MS (SPMS)] and 40 matched healthy volunteers. A neuropsychological battery was administered to all of the subjects; CNV recordings were made from the Cz, Fz, and Pz electrodes, and the amplitude and area under the curve (AUC) were measured at each electrode. Results RRMS patients exhibited CNVs with lower amplitudes and smaller AUCs than the controls at Pz. SPMS patients exhibited CNVs with lower amplitudes and smaller AUCs than the controls, and CNVs with a smaller amplitude than the RRMS patients at both Cz and Pz. After correcting for multiple comparisons, a lower CNV amplitude at Pz was significantly associated with worse performance on measures of speed of information processing, verbal fluency, verbal learning, and verbal recall. Conclusions CNV may serve as a marker for disease progression and cognitive dysfunction in MS. Further studies with larger samples and wider electrode coverage are required to fully assess the value of CNV in these areas.

The cooling effect on proinflammatory cytokines interferon-gamma, tumor necrosis factor-alpha, and nitric oxide in patients with multiple sclerosis.

Multiple sclerosis (MS) is the most common inflammatory demyelinating disease of the central nervous system (CNS) in young adults. The proinflammatory cytokines such as interferon-gamma (IFN-γ), tumor necrosis factor-alpha (TNF-α), and nitric oxide (NO) which are known to be produced by inflammatory cells play a key role in the pathogenesis of MS. Some metabolic changes may have an effect on axonal transmission, and white blood cells NO and other inflammatory mediators such as cytokines may be affected from cooling process. In this study, we evaluated the effects of body cooling procedure on proinflammatory cytokines such as TNF-α, IFN-γ, and NO levels. Twenty patients with MS were evaluated. Thirteen of the patients were women, 7 were men (mean age: 33.6 ± 7.5 yrs.). Body temperature was reduced by an average of 1°C approximately in 1 hour with using the “Medivance Arctic Sun Temperature Management System” device. In our study, the decrease in TNF-α, IFN-γ levels after the cooling procedure has no statistical significance, whereas the decrease in the mean level of NO level after the cooling procedure is 4.63 ± 7.4 μmol/L which has statistical significance (P = 0.002). These results suggested that the decrease in NO level improves conduction block in demyelinated axonal segments after cooling procedure in multiple sclerosis.