Ibrahim Bora

Ultrasound therapy effect in carpal tunnel syndrome

OBJECTIVE To investigate the overall effect of repeated ultrasound treatment in carpal tunnel syndrome (CTS). DESIGN Patient-blinded, placebo-controlled, before-after treatment trial. SETTING University hospital PM&R department outpatient clinic and neurology department electromyography laboratory. PATIENTS Eighteen women with diagnosis of CTS in 30 hands. INTERVENTIONS Three groups, each with 10 cases of CTS, were randomly established. Continuous ultrasound therapy, with intensities of 1.5W/cm2 (group A), 0.8W/cm2 (group B), and 0.0W/cm2 (group C), was applied to palmar carpal tunnel area for 5 minutes, 5 days a week, for 2 weeks. OUTCOME MEASURES Patients were evaluated clinically and electrophysiologically before and after the treatment. RESULTS At the end of treatment, statistically significant improvement was obtained in clinical parameters in all groups: pain (p < .05), pain/paresthesia at night/day (p < .05), and frequency of awakening at night (p < .05). Although there was no statistically significant before-after difference in electrophysiologic studies, slightly decreased motor nerve conduction velocity and increased motor distal latency were noted in groups A and B, but not in group C. CONCLUSION Ultrasound therapy in CTS was comparable to placebo ultrasound in providing symptomatic relief, and the probability of a negative effect on motor nerve conduction needs to be considered.

Risk of recurrence after first unprovoked tonic-clonic seizure in adults

The likelihood of seizure recurrence after a first unprovoked seizure has profound social, vocational and emotional implications for the patients. Recurrence rates have varied between 27% and 71% in various studies, and the management of patients with a single unprovoked seizure is a controversial topic. In this prospective study we investigated the influence of age, sex, family history, EEG patterns, and anticonvulsant drug (ACD) therapy on seizure recurrence after a first unprovoked tonic-clonic seizure in adults. For this purpose, between October 1988 and January 1991, we studied adult patients who had experienced their after unprovoked tonic-clonic seizure within last 2 months before neurological consultation, and followed them until June 1993. There were 147 patients who met the criteria for inclusion. Overall cumulative recurrence rates were 31.8% by 6 months, 41.3% by 1 year, 44.1% by 2 years, 42.2% by 3 years, and 45.2% by 4 years. Among the risk factors that were evaluated, the time of the day at which the initial seizure occurred was associated significantly (P < 0.05) with seizure recurrence. In our series, 62 patients received ACD and 85 did not. We did not find a significant difference in recurrence rate with regard to ACID therapy. Our results are comparable with those of studies reported preeviously and suggest that the majority of recurrences after a first unprovoked seizure were seen in the first year (in our series 89% of all recurrences). In our study there was no significant predictor of seizure recurrence, except the time of day at which the initial seizure occurred.

Proton magnetic resonance spectroscopy study of bilateral thalamus in juvenile myoclonic epilepsy

PURPOSE To investigate neuronal dysfunction in the thalami of juvenile myoclonic epilepsy (JME) by using proton magnetic resonance spectroscopy (MRS). METHODS We performed single-voxel proton MRS over the right and the left thalami of 15 consecutive patients (10 women, 5 men) with JME (mean age 20.3 years) and 16 healthy volunteers (10 women, 6 men) (mean age 24.5 years). All patients had seizure onset in late childhood-teenage, normal neurologic examination, typical electroencephalogram (EEG) of JME and normal magnetic resonance imaging (MRI). We determined N-acetylaspartate (NAA) values and NAA over creatine-phosphocreatine (Cr) values. Mann-Whitney U-test was used to evaluate group differences. RESULTS Group analysis showed that echo time (TE) 270 integral value of NAA over left thalamus were significantly decreased in JME patients as compared with controls (34.6033+/-15.8386; 48.0362+/-22.2407, respectively, P=0.019). Also group analysis showed that thalami NAA/Cr ratios were significantly decreased in JME patients (right side, 2.21+/-1.07; left side 2.00+/-0.72) as compared with controls (right side, 3.45+/-1.50; left side, 3.08+/-1.60; P=0.011 and P=0.030, respectively). CONCLUSION In the previous studies, NAA values in patients with JME found that they were not statistically lower in thalami than control group. But, in our study, NAA value was found low as well. It has been known that NAA is a neuronal marker and hence it is a valuable metabolite in the neuron physiopathology. As a result, in the patients with JME we tried to support the theory that the underlying mechanism of the generalized seizures was the abnormal thalamocortical circuity, determining the thalamic neuronal dysfunction in MRS statistically.

What Is the Efficacy of Nasal Surgery in Patients With Obstructive Sleep Apnea Syndrome

Purpose: Obstructive sleep apnea syndrome (OSAS) is characterized by repetitive episodes of partial or complete obstruction of the upper airway during sleep and is associated with increasing respiratory efforts, with a consequent oxyhemoglobin desaturation, sleep fragmentation, and daytime symptoms, most commonly excessive sleepiness. The effectiveness of continuous positive airway pressure (CPAP) is undoubtedly high in treating those patients who use it regularly, but for those who refuse it, the success rate is 0. It is for this subset of patients that surgical therapy can be useful. The purpose of this study was to evaluate the effects of nasal surgery on nasal resistance, sleep apnea, sleep quality, and nasal volumetric measurement in adult male patients with OSAS. Methods: Twenty male patients with complaints of hypersomnia and snoring were included in the study. Polysomnography of patients with the prediagnosis of OSAS was planned. All patients underwent CPAP treatment before and after surgery. Patients, who had anatomic structural defects causing nasal valve shrinkage, were operated on at the Plastic Reconstructive and Aesthetic Department. Volumetric measurements of the nose were obtained before and after the operation. Results: In our study, it was observed that respiratory tract space of patients increased subsequent to the surgery, and thereby OSAS level decreased, and tolerating CPAP device was easier. Measurements of internal nasal valve vertex and fields and external nasal valve fields before and after operation were significant. Conclusions: Surgical relief of this nasal obstruction may improve quality of life in patients with OSAS.

Delayed diagnosis of a neuroBehçet patient with only brainstem and cerebellar atrophy: Literature review

We report a 34-year-old male neuroBehçets Disease (NBD) patient with atypical magnetic resonance imaging (MRI) findings, whose behavioral problems were followed by progressive neurological symptoms. The patient was hospitalized due to forgetfulness, irritability, behavioral dyscontrol and a choking sensation. T2-weighted MRI showed prominent atrophy of cerebellar hemispheres, the cerebellar peduncle, the midbrain and the pons. He was diagnosed with NBD after an evaluation of his medical history together with neuropsychiatric and laboratory findings. There are few reports of NBD with only brainstem and cerebellar atrophy. We discuss our patient in the context of the four previously reported cases. In NBD without evident mucocutaneo-ocular symptoms, neurologists should always consider the medical and family history. Early diagnosis of NBD helps to initiate appropriate treatment, thereby modulating the course of the disease and preventing complications.

Vulnerability of an epileptic case to psychosis: Sodium valproate with lamotrigine, forced normalization, postictal psychosis or all?

Patients with epilepsy can be considered to be at high risk for developing psychotic disorders. Furthermore, there is association between seizure freedom or the disappearance of the interictal epileptiform events from the EEG record and the occurrence of psychotic symptoms. Also, several newer antiepileptic drugs have been reported to induce psychotic symptoms. We present a patient with epilepsy who developed psychotic symptoms under the treatment of valproic acid (VPA) and lamotrigine (LTG) combination. The mechanism underlying the association between LTG, seizure control and development of psychosis are discussed in the light of the literature.

Nonconvulsive status epilepticus cases arising in connection with cephalosporins

Cephalosporins, particularly cefepime, exert neurotoxic side effects that can lead to status epilepticus. These neurotoxic side effects include myoclonus, dystonic movements, tremor, asterixis, seizure, status epilepticus, encephalopathy, and sometimes coma. Status epilepticus, particularly nonconvulsive status epilepticus (NCSE), is a well-known but unusual complication in patients with altered renal function who were receiving treatment with intravenous cephalosporins, especially cefepime. We reviewed the clinical and electroencephalographic (EEG) characteristics of 7 patients with renal failure who developed consciousness alterations with changes in EEG activity while being treated with cephalosporins. All patients developed renal failure: six patients had chronic renal failure, one patient had acute renal failure, and two patients were administered hemodialysis. Nonconvulsive status epilepticus was observed between 2 and 8 days (average of 5.6 days) after initiation of cephalosporins. Cephalosporins are epileptogenic drugs, especially when used in excessive doses or when renal function is impaired. Critically ill patients with chronic kidney disease are particularly susceptible to cefepime neurotoxicity. Clinical and electrophysiological results of patients guide the diagnosis of NCSE by healthcare providers.

Acute multiple cranial neuropathy in a patient with neurosarcoidosis

Sarcoidosis is an idiopathic granulomatous multisystem disease of unknown etiology. The central nervous system (CNS) is affected only about 5–15% of cases, called neurosarcoidosis [1]. Cranial neuropathy is a common manifestation of neurosarcoidosis, occurring in as many as 75% of patients [2, 3]. The most often involved cranial nerve is the facial nevre and it is involved in up to 50% of neurosarcoidosis patients [3, 4]. Multiple cranial nerve involvement, especially involving the V, VII, IX and X cranial nerves is rare [3, 5, 6]. We present a patient with neurosarcoidosis who had multiple cranial neuropathies involving III, VII, IX and X cranial nerves. A 36-year-old famale was admitted to our hospital with acute onset of right peripheral facial palsy, difficulty in swallowing and diplopia. On neurological examination she had pitosis on the left side, paralysis in internal gaze, left partial III, VII cranial nerve paresis on the right side and evidence of IX and X cranial nerve palsies. Lumbar puncture showed elevated protein level in the cerebrospinal fluid. An magnetic resonance imaging (MRI) of the brain was normal. Serologic studies for syphilis, brucellosis, toxoplasmosis were unrevealing. The tuberculin skin test result was negative. Chest radiography revealed diffuse mediastinal enlargment. A computed tomography (CT) scan of the chest revealed multiple paraaortic, subcarinal, pretracheal and hilar lymph nodes in both lung fields. Noncaseating granulomas with giant cell formation was showed using mediastinoscopy with biopsy. Serum angiotensin-converting enzyme (ACE) level was elevated to 146 U/L (normal range 12–68 U/L). Abdomen ultrasonography was normal. After the patient treated with oral prednisolone in the dose of 1.5 mg/kg/day for 1 week, she revealed markedly improvement in facial paralyses and bulbar symptoms. In the follow-up period, streoid dose was tapered gradually. Subsequently, the patient totally recovered after 4 weeks from the onset of the symptoms. Sarcoidosis is commonly affecting lungs, lymph nodes, liver, skin, eyes, and musculoskeletal system [7]. As any part of the nervous system could be affected from sarcoidosis, patients could present with a wide variety of symptoms. Clinical and neuroradiological manifestations include cranial neuropathy, aseptic meningitis, encephalopathy, vasculopathy, seizures, hydrocephalus, intracranial mass, chiasmal, hypothalamic and pituitary lesions, cognitive or psychiatric manifestations, myelopathy, peripheral neuropathy and myopathy [3, 7]. Neurosarcoidosis occurs in 5–10% of patients with systemic sarcoidosis, typically within 2 years of initial diagnosis [2, 6, 8]. However, neurological involvement is rarely seen particularly in the absence of systemic signs of sarcoidosis. Its differential diagnosis should be made with other conditions such as infectious, demyelinating, granulomatous, neoplastic, and connective tissue disorders affecting the nervous system [9]. Similarly, we defined a patient with neurosarcoidosis as an acute onset multiple cranial neuropathy without a prior sarcoidosis diagnosis, consequently our case was challenged for differantial diagnosis. To our knowledge, acute onset lower (IX, X) cranial nerve palsies without previously diagnosis of saecoidosis is very rarely seen in the literature [3, 4]. In addition, we S. Erer-Ozbek (&) I. Bora S. Yurtogullar Department of Neurology, Uludag University School of Medicine, 16059 Bursa, Turkey e-mail: sevdaerer@uludag.edu.tr; sevdaerer@gmail.com

Progressive cerebroretinal microangiopathy with calcifications and cysts syndrome: an unusual cause of complex partial seizure.

PROGRESSIVE CEREBRORETINAL MICROANGIOPATHY syndrome is characterized by cerebral calcification and cyst formation (CRMCC), as defined in recent years, and is described in the published reports as Coats plus syndrome, Labrune syndrome and leukoencephalopathy calcification and cysts (LCC) syndrome. Cerebral, ophthalmic, skeletal, intestinal involvement can be seen. CRMCC determined in late adolescence is limited. Autosomal recessive inheritance is reported. In the majority of patients, neurological findings showing progression have been reported, such as spasticity, dystonia, ataxia and loss of cognitive abilities. Imaging findings with laboratory data should support the diagnosis. The case presented here is of a 20-year-old male patient whose indications began in late adolescence and were defined as CRMCC characterized by central nervous system involvement. The patient had a history of febrile convulsions at the age of 2, and until 20 years old had suffered no seizures. He started to have complex partial seizure (CPS) with an aura of loss of speech and extremity numbness followed by extremity spasms accompanied by spasm of the head and neck area, versive rotation movements and manual automatisms after 20 years of age. Familial inheritance was not shown. The neurological and ophthalmological examination was normal. There were no psychiatric, psychological or behavioral problems besides CPS. Memory disturbance due to left temporal lobe dysfunction was determined by the Wechsler Memory Scale (WMS) psychometric tests. Under observation in the video electroencephalography monitorization unit, CPS were seen three times. Seizures lasting up to 1 min were observed, before the seizure, showing a defining aura of loss of speech and numbness on the right side of the body, while during the seizure he had a behavioral arrest, his head was versive turned to the right and there were oral-alimentary and bilateral manual automatisms. Spike, sharp and slow wave activities were observed starting from the left frontal region and emitting to the temporal region during the seizure. For this reason, the seizure from the left frontal region and spread to the left temporal region was concluded. Computed tomography showed multiple calcified foci in the cyst wall, basal ganglia, thalami and cerebral white matter. Magnetic resonance (MR) imaging revealed signal abnormalities in the cerebral white matter, and a right thalamo-caudate cyst and a smaller pontine cyst. There was no restriction of diffusion-weighted MR images. MR spectroscopy demonstrated minimal increase in the choline peak, mild decrease in the N-acetylaspartate peak, and a lactate peak. Serology positive data were not determined. CRMCC cases generally show indications at an early age and the number of cases determined in late adolescence and older is relatively limited. Cases may present with different clinical tables related to the system involvement. To the best of our knowledge, cases of CRMCC-related complex partial seizures have not been reported. In the radiological imaging data of CRMCC syndrome as leukoencephalopathy (demyelinization and white matter edema), calcification and cyst formation were found. It is a syndrome which may accompany retinal microangiopathy. A differential diagnosis of CRMCC should be considered for cases presenting with CPS and radiological imaging findings. The patient gave the authors written informed consent to publish this report. We would like to thank Patricia E. Miller, University of Rochester Medical Center, NY, USA.

Functional MRI in Patients with Intracranial Lesions near Language Areas.

We aimed to depict Brocas area and Wernickes area by word generation and sentence formation paradigms in patients with various intracranial lesions adjacent to language areas using functional MRI technique and to evaluate the ability of functional MRI to lateralize the hemispheric dominance for language. Twenty-three right-handed patients were included in this study. Lesions were classified as low-grade glioma (n=8), high-grade glioma (n=9), metastasis (n=1), meningioma (n=1), arteriovenous malformation (n?2) and mesial temporal sclerosis (n=2). We performed blood-oxygenated-level-dependant functional MRI using a 1.5-T unit. Word generation and sentence formation tasks were used to activate language areas. Language areas were defined as Brodmann 44, 45 (Brocas area) and Brodmann 22 area (Wernickes area). Laterality index was used to show the dominant hemisphere. Two poorly cooperative patients showed no activation and were excluded from the study. Brocas area was localized in 21 patients (100 %). Wernickes area, on the other hand, could only be localized in eight of the 21 patients (38 %). The left hemisphere was dominant in 86% of patients while atypical language lateralization (right or bilateral) was demonstrated in 14% of the patients. Bilateral activation areas were shown in 10% of those patients while right cerebral hemisphere was dominant in 4% of the patients. Word generation and sentence formation tasks are especially helpful in localizing Brocas area. Wernickes area could also be demonstrated in some of the cases. Functional MRI can be used as an important and useful means of demonstrating language areas in patients with lesions adjacent to those areas and depicting the hemispheric dominance.