Hadiye Sirin

Generalized tonic-clonic status epilepticus: causes, treatment, complications and predictors of case fatality.

Abstract We retrospectively reviewed the clinical course of 66 patients treated for generalized tonic-clonic status epilepticus at the Ege University neurological intensive care unit from 1988 to 1997. Seventy-two per cent of the study group had a pre-existing seizure disorder, and antiepileptic drug withdrawal was the most prominent cause of status epilepticus. The other causes included drug toxicity, central nervous system infection, cerebrovascular disease, tumour and trauma. Seventy-three per cent of all patients responded to the first-line therapy (diazepam and/or phenytoin), and the remainder were considered to have refractory status epilepticus and required pentobarbital anaesthesia. Overall case fatality was 21%, but death could be attributed directly to status epilepticus and/or treatment complication in 10% of the study group. Major determinants of fatal outcomes were: increasing age, longer duration of status epilepticus before initiation of therapy and central nervous system infection as a causal factor.

Mesencephalic and Associated Posterior Circulation Infarcts

Background and Purpose— The purposes of this study were to evaluate and review the risk factors and clinical features of patients with posterior circulation stroke involving mesencephalon and neighboring structures and to describe the clinical syndromes according to the mesencephalic arterial territory involved. Methods— We studied all patients with acute posterior circulation stroke involving mesencephalon who were admitted consecutively to our stroke unit over a 6-year period. We selected these patients (3%) from 1296 patients with posterior circulation infarct. Neurological and radiological investigations, including MRI and angiography, were performed in all cases. We classified patients into 4 groups on the basis of MRI findings: (1) isolated mesencephalic infarcts (9 patients); (2) distal territory infarcts (19 patients), including mesencephalon, thalamus, medial temporal and occipital lobes, and cerebellum; (3) middle territory infarcts (12 patients), including the pons and anterior inferior cerebellar artery territory; and (4) proximal territory infarcts (1 patient), including the medulla and posterior inferior cerebellar artery territory. Results— Middle mesencephalon involvement was the most common in all groups, and the anteromedial territory was frequently affected, depending on the direct perforators of basilar artery. In patients with isolated mesencephalic infarct, the clinical picture was dominated by nuclear or fascicular third-nerve palsy and contralateral motor deficits. The distal territory involvement was the most common and associated with consciousness disturbances, gait ataxia, ocular motor disturbances, and visual field deficits. The neurological picture of middle territory infarcts was dominated by consciousness disturbances with dysarthria, horizontal ocular motor disorders, and hemiparesis. Proximal territory involvement was rare and associated with acute unsteadiness, vertigo, dysphagia, dysphonia, tetra-ataxia, and motor weakness. The most common cause of stroke was large-artery disease in 16 patients (39%), cardioembolism in 8 (20%), and small-artery disease with lacunar mesencephalic infarct in 10 (24%). Bilateral mesencephalic infarcts were not uncommon (27%), mainly in patients with multiple and extended infarcts in the posterior circulation, and were associated with poor outcome compared with unilateral infarct. Conclusions— Our study highlights the topographic and clinical heterogeneity of the acute posterior circulation infarcts involving mesencephalon. The variety of the underlying potential causes of stroke requires detailed investigations of the extra and intracranial arteries and the heart.

Cerebral cortical and deep venous thrombosis without sinus thrombosis: clinical MRI correlates

Background –  Cortical and/or deep vein thrombosis (CDVT) without dural sinus involvement is uncommon and presents diagnostic difficulty for many reasons. Our aim is to determine the relationship between magnetic resonance imaging (MRI) findings and clinical findings in patients with CDVT.

Clinical assessment of topiramate therapy in patients with migrainous vertigo.

(Headache 2010;50:77‐84)

Ophthalmoplegic migraine : two patients, one at middle age with abducens palsy

Ophthalmoplegic migraine (OM) had been classified as a form of migraine by the Headache Classification Committee of the International Headache Society in the 1988 classification (1). The classification was revised by the same committee in 2004 and OM was classified under the heading of ‘Cranial neuralgias and central causes of facial pain’ and was defined as consisting of at least two episodes of headache accompanied or followed within 4 days of its onset by paresis of one or more cranial nerves: third, fourth and/or sixth with appropriate investigations having excluded paracellar, orbital fissure and posterior fossa lesions (2). Hansen et al. (3) estimated an annual incidence of 0.7 per million. Although it may have onset at any age, it occurs most frequently in infants and children under 12 years of age. The headache is unilateral and invariably ipsilateral to the side of ophthalmoplegia. It is typically severe and may precede the ophthalmoplegia by several days. In OM there is a predilection for males whereas the preponderance of persons with common migraine is female (4). We report two unusual cases: two women with probable OM, one having an onset at age 16 years and the other at 50, both with abducens palsy.

Wallenberg's lateral medullary syndrome: Diffusion-weighted imaging findings

Purpose: To investigate the efficacy of diffusion‐weighted imaging in patients with Wallenbergs lateral medullary syndrome. Material and Methods: Thirteen patients with Wallenbergs lateral medullary syndrome were examined with conventional and echoplanar diffusion‐weighted magnetic resonance (MR) imaging in a 1.5 T magnetic resonance unit. MR examinations were obtained in the acute or subacute stage of clinical syndrome, and diffusion‐weighted imaging (DWI) was considered to be positive for infarction when an increase in signal was seen on b=1000 s/mm2 images in the posterolateral medullary localization. Results: DWIs were positive in 12 patients in the acute or subacute stages of this clinical syndrome. A false‐negative result was obtained in only one patient examined within the first day, 10 h after onset of the symptoms. In the visual evaluation of the DWI, the contrast between normal and infarcted brainstem area was better in the high b‐value images than in the apparent diffusion coefficient map images. Conclusion: DWI is a valuable technique for examining patients presenting with the signs and symptoms of Wallenbergs syndrome and high b‐value images can provide complementary data to T2‐weighted images. However, because most of our case group were in either the acute or subacute stage, true sensitivity of the method in the hyperacute stage of the syndrome remains unclear.

A non-alcoholic Wernicke’s encephalopathy case with atypical MRI findings: Clinic versus radiology

Wernickes Encephalopathy is an acute neuropsychiatric syndrome that can be seen in both alcohol abusers and non-alcoholic population as a result of thiamine deficiency. We herein report a non-alcoholic patient with typical clinical presentations but atypical MRI findings. Early clinical suspicion of WE is especially important in non-alcoholic patients with atypical MRI findings. The diagnosis of this group is more difficult to make and the prognosis of the syndrome mostly depends on early initiation of thiamine supplementation.

Magnetic Resonance Imaging Characteristics of Persistent Vegetative State Due to Prolonged Hypoglycemia

Hypoglycemia is the sudden decrease in serum glucose level <50mg/dL. Neurological manifestations complicating profound and prolonged hypoglycemia range from reversible focal deficits and transient encephalopathy to irreversible coma. Here, we report magnetic resonance imaging characteristics of a patient with prolonged hypoglylicemia. A 47-year-old woman with a history of insulin dependent diabetes mellitus has been brought to the emergency room by her relatives. She used mistakenly overdose insulin injection and probably stayed 11 hours with low level blood glucose. The initial blood sugar level was 39.6 mg/dL at the emergency department visit, which was recovered urgently by 50% dextrose. MR imaging revealed high intensities at the bilateral posterior parietal cortices, corona radiata and hippocampus, but not in the basal ganglia. Seventy-two hour after admission, confluent lesions in the posterior parietal, temporal, frontal cortices and splenium of corpus callosum were more prominent on DWI and FLAIR, and did not match typical arterial territories. None of the lesions were enhanced on contrast-enhanced T1-weighted images. The prognosis or neurologic sequelae of hypoglycemic encephalopathy may depend on the severity and duration of hypoglycemia and persistent, diffuse involvement of the cerebral cortex, basal ganglia, or hippocampus on the following MR imaging. MR imaging findings in hypoglycemic vegetative state can be helpful in the differential diagnosis distinguishing from other neurologic conditions.

A rare cause of ischemic stroke: Intravasculer B cell lymphoma

Intravascular B cell lymphoma is rare and an agressive form of large B cell lymphoma which can affect central nervous system. Because of its varied clinical symptoms and the absence of lymphadenopathy, it is generally diagnosed postmortem. Cerebral infarction due to occlusion of arteries can be seen as a rare clinical form of central nervous system involvement. Large artery atherosclerosis, cardiyoembolism and small artery occlusion are the important causes of ischemic stroke but no any cause is detected in %15-40 of all cases. In this report, with the discussion of a case with ischemia like encephalopathy and multiple cerebral ischemic lesions at different stages in cranial MRI which was diagnosed by the help of brain biopsy as a intravascular B cell lymphoma, it is aimed to take attention intravascular lymphoma as a rare cause of ischemic stroke.