Husnu Efendi

Evaluation of Normal Appearing White Matter in Multiple Sclerosis

PurposeThe aim of this study was to determine diffusion magnetic resonance imaging (MRI), magnetization transfer (MT) imaging and multivoxel MR spectroscopy findings in plaques, periplaque white matter and normal appearing white matter (NAWM) regions in multiple sclerosis (MS) and to correlate the findings with the expanded disability status scale (EDSS).MethodsA total of 30 patients with MS and 30 healthy control subjects were studied and apparent diffusion coefficient (ADC) values, MT ratio (MTR), N-acetyl-aspartate/creatine (NAA/Cr) and choline/creatine (Cho/Cr) ratios were measured in plaques, periplaques and NAWM regions and compared with the control subjects.ResultsThe MTR and NAA/Cr ratio were decreased more in plaques than periplaques and NAWM, in contrast ADC values and Cho/Cr ratios were highest in plaques and higher in periplaques than in NAWM. Decreased MTR and NAA/Cr in NAWM demonstrated moderate inverse correlations (r = − 0.604, p < 0.001 and r = − 0.494, p < 0.001, respectively) while Cho/Cr ratios and ADC of NAWM demonstrated weak linear correlations (r = 0.370, p = 0.004, r = 0.297, p = 0.021 respectively) with EDSS.ConclusionsThe MS, MTR and MR spectroscopy findings were found to be useful for detecting subtle abnormalities in NAWM. Although ADC values were significantly altered in plaque and periplaque regions a significance difference was not found in NAWM.

Route Learning Impairment Associated with Encephalomalasia Secondary to Traumatic Brain Injury: A Case Report

Topographical disorientation is marked by difficulty finding ones way in familiar or new environments. The present case study reports findings from a 30-year-old male with encephalomalasia of the left parahippocampal region secondary to brain trauma with subsequent difficulty in learning of new routes. His navigation in premorbidly known (familiar) surroundings was intact. Magnetic resonance images revealed left parahippocampal and bilateral occipital encephalomalasia. Neuropsychological screening showed impairment in structuring a representation of the spatial relationships among landmarks with relatively preserved ability to learn visual and verbal information of these landmarks. Decreased visual perception and inappropriate visual inputs due to cervical dystonia and right homonymous hemianopsia also appear to play a role in his disability. The current knowledge about the neuronal systems involved in visual cognition and topographical orientation also are addressed in this report.

A non-traumatic interhemispheric subdural haematoma: presented with headache as the sole complaint

Due to their localisations and symptoms, interhemispheric subdural haematomas (ISH) compose a distinct category. Altered level of consciousness and hemiparesis are the most frequent symptoms. We report a case of ISH who presented with headache as the sole complaint. Left cerebellar haematoma and ISH were found in cranial MRI and cranial computed tomography Cranial MR angiogram was normal. Haemogram and coagulation parameters were within normal limits. ISH should be considered among the diagnostic possibilities in elderly patients who present with headache as the sole symptom without other clinical features such as meningeal irritation signs, focal neurological symptoms and alteration of consciousness. Cranial imaging studies should be done in such cases.

Understanding multiple sclerosis better in 2014 –Environmental factors, remyelination, diagnostic techniques, treatment decisions and the future focus of multiple sclerosis treatment

Epidemiological factors, such as vitamin D, Epstein–Barr virus, smoking and adolescent obesity, are associated with multiple sclerosis (MS) susceptibility and may be involved in MS aetiology. There is also evidence of gene–environment interactions. Both validated predictive biomarkers and gene-expression data will play a crucial role in future diagnosis of MS and prognosis facilitating early treatment and improving management. Understanding the mode of action of disease-modifying therapies (DMTs) should also enhance MS management by identifying the best treatment for different stages of the disease course. Magnetic resonance imaging (MRI) plays a significant role in both diagnosis and monitoring of patients and is likely to become part of the daily MS practice using standardised protocols and software to increase reproducibility. A future goal of MS treatment is to facilitate neuron repair and remyelination. In this respect, animal models of remyelination could be useful in identifying potential therapies. Diagnosis of radiological syndrome is now simpler, but its management is controversial and it does not always convert to MS. In addition, treatment for progressive MS is problematic as current DMTs are indicated only for relapsingremitting MS. Symptomatic treatment is a neglected aspect of MS management, which is often the main concern of both patients and neurologists. Neurologists need to collaborate in trials and consider repurposed drugs that could provide treatment for these symptoms. The second MS Days meeting provided a valuable platform for these critical topics to be discussed and novel solutions to be considered.

The Effect of Pulse Methylprednisolone Plus Theophylline Treatment on Clinical, Pulmonary and Inflammatory Markers in Relapses of Multiple Sclerosis

OBJECTIVE The aim of this study was to evaluate whether there was a relationship between severity of multiple sclerosis (MS) exacerbation and pulmonary function test (PFT) and to determine the effect of theophylline, which was added to intravenous methylprednisolone, on serum Tumor Necrosis Factor (TNF)-alpha levels and clinical scores in MS relapses. STUDY DESIGN Double blind randomized controlled trial. MATERIAL AND METHODS The baseline Expanded Disability Status Scale (EDSS) score was determined, PFT was performed and blood was taken for analysis of TNF- alpha in patients with MS exacerbation. Patients were randomly divided into two groups; group 1 received intravenous methylprednisolone+IV theophylline and group 2 intravenous methylprednisolone+placebo for 5 days. PFT and EDSS score were repeated and blood was taken for TNF-alpha on the 5(th) and 30(th) days of the treatment. RESULTS Twenty-four patients (14 female, 10 male) were included in the study. Mean age was 32.6±9, duration of disease was 5.4±4.2 years, number of exacerbations was 5±2. There was a significant correlation between the number of exacerbations and EDSS score (p=0.000, r=1). Restrictive PFT findings were detected in 8 and decrease in carbon monoxide diffusing capacity (DLCO) in 3 cases. In within-group analysis, EDSS score was found to be decreased on day 5 and still low on day 30 in the theophylline group (baseline 3±1.3; 5(th) day 2.4±1.6; 30(th) day 2±1.7). There was no statistically significant difference in the EDSS score of the placebo group (3±1.6; 2.8±1.7; 2.4±1.9 respectively). While serum TNF-alpha level was not changed in the placebo group, there was a non-significant decrease on day 5 and increase on day 30 in the theophylline group. There was no correlation between the clinical parameters, PFT and TNF-alpha level. CONCLUSION There was no correlation between severity of MS and PFT findings. It is suggested that theophylline might be effective in MS exacerbations since it caused decreases in clinical scores; studies with longer treatment duration are needed to clarify its possible anti-inflammatory effect.

Subclavian steal syndrome as the presenting feature of hypervascular thyroid nodule

Subclavian steal syndrome (SSS) is a clinical entity characterized by brachial and basilar insufficiency as a result of critical proximal subclavian artery stenosis or occlusion. We report a patient of giant hypervascular thyroid nodule presenting with features of SSS. The left hand ischemia and symptoms of vertebro-basilar artery in our patient were probably related to stealing of blood by the hypervascular thyroid nodule from the subclavian artery. The patient was relieved of the symptoms upon percutaneous subclavian stent placement.

Short-lasting unilateral neuralgiform headache with severe lacrimation and mild conjunctival injection

Short-lasting unilateral neuralgiform headache attacks with conjunctival injection and tearing (SUNCT) were first described by Sjaastad et al. (1). It has been accepted as unilateral orbital, supraorbital or temporal or pulsating pain lasting 5–240 s. Pain is accompanied by ipsilateral conjunctival injection and lacrimation. Attacks occur with a frequency from 3 to 200 per day (2). Some clinical features in SUNCT, such as attack duration, pain profile as well as the precipitating mechanisms, are suggestive of a link with first division (V1) trigeminal neuralgia (TN) (3). From a nosological perspective, attacks changing from TN to SUNCT have been reported (4). Sesso (5) suggested that the autonomic features occur just above a ‘certain pain threshold’ and proposed that many cases diagnosed as SUNCT are TN in reality. Sjaastad et al. (6) emphasized that, V1 trigeminal neuralgia resembles to SUNCT only in later stages of the disease, during severe and long-lasting attacks. Even during these attacks, conjunctival injection and lacrimation, hallmarks of SUNCT, are mostly mild. Neurosurgical literature contains many references to atypical TN (7). Some neurosurgeons believe that current concept of the pathophysiology of TN may have been artificially constrained by clinical classification of the disorder (8). A typical form of TN may, in prolonged cases, develop atypical signs. In contrast, many cases of TN start with pain lacking the typical characteristics of TN, and later develop all the hallmark signs of TN (9). In this article, we presented a case with shortlasting unilateral neuralgiform headache attacks which did not fit into classical descriptions of TN and SUNCT. Our main focus was the accompanying autonomic symptoms of attacks; thus, we analysed laterality, timing and degree of each autonomic symptom. Case report

Clinically Isolated Syndromes: Clinical Characteristics, Differential Diagnosis, and Management

Clinically isolated syndrome (CIS) is a term that describes the first clinical onset of potential multiple sclerosis (MS). The term CIS is typically applied to young adults with episodes of acute or subacute onset, which reaches a peak quite rapidly within 2-3 weeks. In 85% of young adults who develop MS, onset occurs with an acute, CIS of the optic nerves, brainstem, or spinal cord. When clinically silent brain lesions are seen on MRI, the likelihood of developing MS is high. Because no single clinical feature or diagnostic test is sufficient for the diagnosis of CIS, diagnostic criteria have included a combination of both clinical and paraclinical studies. Diagnostic criteria from the International Panel of McDonald and colleagues incorporate MRI evidence of dissemination in time and space to allow a diagnosis of definite MS in patients with CIS. As CIS is typically the earliest clinical expression of MS, research on patients with CIS may provide new insights into early pathological changes and pathogenetic mechanisms that might affect the course of the disorder. With recent improvements in diagnosis and the advent of disease-modifying treatments for MS, there has been growing interest and research in patients with CIS.

P194 Median-to-ulnar nerve comperative tests in diagnosis carpal tunnel syndrome (CTS)

Purpose: Although production of emotional prosody is a cognitive function of high clinical and social importance, its underlying neural principles are not yet fully understood. The goal of this study was to get an insight into these mechanisms using repetitive transcranial stimulation (rTMS). Method: rTMS was applied over the left and right dorsolateral prefrontal cortex (DLPFC) during two separated sessions using 10 Hz frequency at 100% of resting motor threshold. Three series of stimulation were delivered with ten minutes breaks between first and second series. Each of three 2.5 min series of stimulation consisted of 15 1-s trains with a 10-s between train interval resulting in a total of 450 stimuli delivered. Additionally, sham stimulation was performed by positioning figure 8-shaped coil at the angle of 45° to the skull. After rTMS 16 healthy subjects (8 female) pronounced semantically neutral word “ANNA” in happy, neutral or sad emotional intonation. The fundamental frequency F0 (its mean and modulation) was analyzed and compared between different stimulation conditions. The study was approved by the ethics committee of the Hanover Medical School. Results: Analysis of volitional speech showed statistically significant difference (p<0.05) and reduced mean F0from values of 156.1±48.4 Hz to 146.8±48.1 Hz in producing neutral and 201.7±66.6 Hz to 186.5±64.7 Hz in happy prosody after the left-sided stimulation. Increased F0modulation from 201.7±66.6 Hz to 206.±78.7 Hz was found only in happy prosody after the right-sided stimulation. No significant changes were observed after sham stimulation. Conclusion: The DLPFC and its connections to the anterior cingulate cortex (ACC) play important role in production of emotional prosody. The left part of DLPFC refers to more motor components of emotional speech like initiation of mean F0. The right part is assumed to refine articulation by more emotional intonation realized through modulation of F0.

Acute Encephalopathy Due to Plasticizer Intoxication: MRI Findings of Two Cases and Review of the Literature

Polyvinyl chloride and plasticizer intoxication have a degenerative effect on the cerebral white matter characterized by bilateral, confluent lesions that reflect diffuse demyelination. We report similar clinical and neuroimaging manifestations in two patients with inhalation of these substances. MRI findings described here may be helpful in the diagnosis of future cases of suspected chloroparaffin poisoning.