Ildikó Vastagh

Strategic infarcts of the thalamus in vascular dementia.

Strategic infarcts or focal hemorrhages involving the paramedian nuclei of the thalamus may alter consciousness and produce complex neuropsychological symptoms such as impairment of memory, attention and motivation. Lesions disrupting the thalamo-prefrontal circuits lead to severe subcortical dementia. We analysed here the clinical, neuropsychological and neuroimaging data of 19 patients with cerebrovascular lesions in the thalamus. In six patients with bilateral paramedian infarcts, and in two with anterior thalamic infarcts, vascular dementia and severe personality changes developed. SPECT findings did not correlate with the neuropsychological symptoms. Transcortical sensory and motor aphasia was observed in four patients with thalamic hemorrhages and infarcts. In these patients SPECT detected hypoperfusion in adjacent cortical areas. Clinical symptoms and outcome of four patients are reported in detail. The clinico-morphological correlations of the thalamo-cortical circuits are reviewed and the possible causes of multiple cognitive and behavioural consequences of vascular thalamic lesions are discussed.

Spectral and complexity features of the EEG changed by visual input in a case of subcortical stroke compared to healthy controls

OBJECTIVE To compare spectral and complexity characteristics of the EEG in a unique case of subcortical infarct to those seen in healthy controls. METHODS Absolute and relative frequency spectra, theta/beta ratio, the brain symmetry index (BSI), Omega-complexity and synchronization likelihood were calculated of the EEG recorded in eyes closed and eyes open conditions. RESULTS Increased absolute delta, theta, and Omega-complexity in these frequency bands, higher theta/beta ratios, and decreased relative beta activity were found in the side of the infarct. The BSI localized the excess of slow, and decrease of fast frequency activity to the area of ischemia. Following eyes opening the increase of fast and decrease of slow frequencies, the increase of Omega-complexity in the alpha and beta bands, and the decrease of synchronization likelihood for the fast frequency bands were reduced in the side of the infarct. CONCLUSIONS The subcortical infarct caused ipsilaterally increased slow, and decreased fast frequency activity accompanied by decreased synchronization of slow, increased synchronization of fast frequencies. Reduced reactivity in the ischemic side was particularly apparent for complexity measures. SIGNIFICANCE Complexity indices of the EEG are sensitive complementary measures of electrophysiological changes caused by local lesions such as subcortical stroke.

Embolic strokes of undetermined source: Prevalence and patient features in the ESUS Global Registry:

Background Recent evidence supports that most non-lacunar cryptogenic strokes are embolic. Accordingly, these strokes have been designated as embolic strokes of undetermined source (ESUS). Aims We undertook an international survey to characterize the frequency and clinical features of ESUS patients across global regions. Methods Consecutive patients hospitalized for ischemic stroke were retrospectively surveyed from 19 stroke research centers in 19 different countries to collect patients meeting criteria for ESUS. Results Of 2144 patients with recent ischemic stroke, 351 (16%, 95% CI 15% to 18%) met ESUS criteria, similar across global regions (range 16% to 21%), and an additional 308 (14%) patients had incomplete evaluation required for ESUS diagnosis. The mean age of ESUS patients (62 years; SD = 15) was significantly lower than the 1793 non-ESUS ischemic stroke patients (68 years, p ≤ 0.001). Excluding patients with atrial fibrillation (n = 590, mean age = 75 years), the mean age of the remaining 1203 non-ESUS ischemic stroke patients was 64 years (p = 0.02 vs. ESUS patients). Among ESUS patients, hypertension, diabetes, and prior stroke were present in 64%, 25%, and 17%, respectively. Median NIHSS score was 4 (interquartile range 2–8). At discharge, 90% of ESUS patients received antiplatelet therapy and 7% received anticoagulation. Conclusions This cross-sectional global sample of patients with recent ischemic stroke shows that one-sixth met criteria for ESUS, with additional ESUS patients likely among those with incomplete diagnostic investigation. ESUS patients were relatively young with mild strokes. Antiplatelet therapy was the standard antithrombotic therapy for secondary stroke prevention in all global regions.

Reversible nerve conduction slowing in hyponatremia

Sirs: The best known neurological complications of systemic hyponatremia are disorders of central nervous system function, such as encephalopathy and central pontine myelinolysis [1, 4, 5]. Its effect on peripheral nerve function is less well known. We present a patient who underwent nerve conduction studies before and after the correction of severe hyponatremia. The female patient of 71 years of age had a history of hypertension and trigeminal neuralgia, and was receiving diuretic and carbamazepine treatment. About a year before admission she began to complain of paresthesia and involuntary jerking in her legs, unstable gait, dizziness and headache. These complaints together with the findings of neurological examination (brisk tendon reflexes, pyramidal signs, distal sensory disturbance and spinal ataxia) were suggestive of an encephalo-myelopathy. MRI of the spine and brain was uninformative, CSF and vitamin B12 levels were likewise normal. The sodium level on admission was slightly reduced (131 mmol/l; norm. range 135–148 mmol/l); previous laboratory tests also showed consistently lower sodium levels. Chronic hyponatremic encephalo-myelopathy, brought on by the combined effect of diuretic and carbamazepine treatment, was therefore proposed as an explanation for the clinical picture. Meanwhile, during the course of her stay in the hospital she acquired a gastrointestinal infection causing vomiting for several days. During this time the patient became somnolent, confused and EEG showed diffuse slowing. Laboratory testing revealed severe hyponatremia (105 mmol/l), with normal potassium and calcium levels. This confirmed the diagnosis of acute hyponatremic encephalopathy, as a result of further gastrointestinal loss of sodium. The gradual correction of sodium levels resulted in almost full recovery, even the neurological signs seen at initial presentation showed improvement. During the stage of severe hyponatremia nerve conduction studies were performed by one of the authors (Zs. A.); the results are summarized in Table 1. Moderate conduction slowing was observed in all the nerves examined, without temporal dispersion or conduction blocks. F wave persistence was normal. One week later, after sodium levels reached 135 mmol/l and the patient had improved substantially, nerve conduction studies were repeated. This time all conduction velocities and F wave minimum latencies were within normal limits (Fig. 1). The difference in conduction velocities and F wave minimum latencies between the two examinations was about 12–30 % or 10–15 m/s, being more conspicuous in longer nerve segments. Our case study demonstrates that severe systemic hyponatremia in addition to central nervous system dysfunction may cause moderate uniform slowing of peripheral nerve conduction velocity as well, which is promptly restored to normal upon correction of the hyponatremia. There have been so far LETTER TO THE EDITORS

Global Survey of the Frequency of Atrial Fibrillation-Associated Stroke: Embolic Stroke of Undetermined Source Global Registry.

Background and Purpose— Atrial fibrillation (AF) is increasingly recognized as the single most important cause of disabling ischemic stroke in the elderly. We undertook an international survey to characterize the frequency of AF-associated stroke, methods of AF detection, and patient features. Methods— Consecutive patients hospitalized for ischemic stroke in 2013 to 2014 were surveyed from 19 stroke research centers in 19 different countries. Data were analyzed by global regions and World Bank income levels. Results— Of 2144 patients with ischemic stroke, 590 (28%; 95% confidence interval, 25.6–29.5) had AF-associated stroke, with highest frequencies in North America (35%) and Europe (33%) and lowest in Latin America (17%). Most had a history of AF before stroke (15%) or newly detected AF on electrocardiography (10%); only 2% of patients with ischemic stroke had unsuspected AF detected by poststroke cardiac rhythm monitoring. The mean age and 30-day mortality rate of patients with AF-associated stroke (75 years; SD, 11.5 years; 10%; 95% confidence interval, 7.6–12.6, respectively) were substantially higher than those of patients without AF (64 years; SD, 15.58 years; 4%; 95% confidence interval, 3.3–5.4; P<0.001 for both comparisons). There was a strong positive correlation between the mean age and the frequency of AF (r=0.76; P=0.0002). Conclusions— This cross-sectional global sample of patients with recent ischemic stroke shows a substantial frequency of AF-associated stroke throughout the world in proportion to the mean age of the stroke population. Most AF is identified by history or electrocardiography; the yield of conventional short-duration cardiac rhythm monitoring is relatively low. Patients with AF-associated stroke were typically elderly (>75 years old) and more often women.

Cervical juxtafacet cyst combined with spinal dysraphism

Juxtafacet cysts of the cervical and thoracic spine are rare and often cause radiculopathy or myelopathy. We present a case of a patient with radicular pain and early onset myelopathy. A juxtafacet cyst at the cervico-thoracic junction combined with discal herniation and spina bifida occulta was diagnosed with computed tomography (CT) and magnetic resonance imaging (MRI). Laminectomy with removal of the cyst was the treatment and the patient recovered rapidly.

Evolution and predictors of morphological and functional arterial changes in the course of type 1 diabetes mellitus

Diabetes mellitus results in accelerated atherosclerosis. We evaluated preclinical, morphological and functional vascular changes in type 1 diabetes mellitus.

Preserved structural and functional characteristics of common carotid artery in properly treated normoglycemic women with gestational diabetes mellitus

Women with gestational diabetes mellitus (GDM) are at high risk of subsequently developing type 2 diabetes mellitus which is an important cardiovascular risk factor. We have evaluated whether preclinical morphological and functional arterial changes are present in GDM. Diameter, intima-media thickness (IMT), intima-media cross-section area (IMCSA) and elasticity features (compliance, distensibility coefficient, circumferential strain, stiffness index (SI) α and β, incremental elastic modulus) of the common carotid arteries (CCA) were studied in the 3rd trimester in 25 women with GDM, and 17 normal pregnant women matched for age and body mass index using an ultrasonographic vessel wall-movement tracking system and applanation tonometry. Mean IMT, IMCSA and SI α tended to be larger, whereas compliance was smaller in women with GDM but none of these differences were significant. Serum glucose (4.99 ± 0.51 vs. 4.79 ± 0.61 mmol/L, p=0.37) and HbA1c (5.33 ± 0.27 vs. 5.36 ± 0.47 mmol/L, p=0.85) proved normoglycemia in both groups. In conclusion, by the combination of methods we applied in this case control study, neither morphological nor functional characteristics of large elastic arteries differ significantly between well-treated normoglycemic women with GDM and non-diabetic pregnant women in the 3rd trimester.

Extranodal marginal zone lymphoma of the CNS arising after a long-standing history of atypical white matter disease

In February 2009 a 39 year old female patient with a long standng history of atypical white matter lesions mimicking multiple clerosis was admitted to the Department of Neurology, Budapest, ue to disease progression. The onset of disease was at the age of 16 with retrobulbar neuitis on the right side. Two years later the neuritis also involved the eft side. Optometric examination showed temporal decoloration f the papilla and optic nerve atrophy on both sides. Brain MR mages were abnormal with confluent high signal intensities in the hite matter of the trigonum on both sides. Although CSF examnation did not detect oligoclonal bands, multiple sclerosis was iagnosed. Control-MRI examination at the age of 28 showed diffuse hyperntensive signals on T2, proton and FLAIR images in the white atter of the right frontal lobe and in both parieto-occipital egions. In addition to atypical multiple sclerosis, leukodystrohy was also considered. Within several years, her visual acuity radually worsened and she became amblyopic. Subsequent MRI erformed at the age of 33, 35 and 37 revealed a slow increase n the intensity of the white matter lesions. At the age of 37 he suffered from a generalized convulsion. From that time she eceived carbamazepin as monotherapy, later combined with valroate and levetiracetam. Due to the slowly progressive diffuse hite matter lesions, retrobulbar neuritis, depression, repeated ertigo and numbness, mitochondrial disease was also discussed. owever, muscle biopsy did not confirm any pathological lesions, urthermore serum ammonia and creatinin kinase levels were ormal. In February 2009 she presented with a visual acuity of 0.15 n the right side and 0.5 on the left side. She exhibited horzontal rotary nystagmus in every position of the bulbs, brisk endon reflexes and dysthymia. Laboratory examinations includng serum lactate, hormones and quantitative immunoglobulines ere normal. Serum immuno-electrophoresis did not detect oligolonal bands. EEG detected rarely theta waves in the temporal egion on the right side. CSF examination showed elevated proein (157 mg/dL) and IgG-levels (8.55 mg/dL) but no increase in hite blood cells. Flow cytometry of CSF, however, detected a Bell population with lambda light chain restriction (kappa:lambda atio 1:4). Brain MRI showed further mild progression of the white mater lesion with inhomogeneous contrast enhancement and marked nhancement along the sulci of the right frontal lobe in T2 weighted mages (Fig. 1A). MR spectroscopy revealed moderately elevated holin levels in the right frontal lobe. A brain biopsy from the ight frontal lobe was performed to clarify these striking radioogic findings. Histology revealed a dense, perivascular accentuated nfiltration of the brain parenchyma by small B-lymphocytes with

Cortical Hand Knob Stroke: Report of 25 Cases

BACKGROUND Although uncommon, cortical hand knob territory stroke is a well-defined stroke entity that mimics peripheral nerve damage. Atherosclerosis and hypertension are the most prevalent risk factors for the disease. Embolic origin, either artery-to-artery or cardioembolic, has been suggested as the most probable underlying mechanism. MATERIALS AND METHODS Twenty-five patients with isolated hand palsy due to central origin were admitted to our department between 2006 and 2016. Cortical lesions were proven by either computed tomography or magnetic resonance imaging. RESULTS The average age was 67 ± 12 years. Most of the cases were first-ever strokes (n = 23, 92%). Isolated infarct in the hand knob region was found in 18 of the 25 cases, whereas 7 had multiple acute infarctions. Supra-aortic atherosclerosis was found in 21 patients, 8 of them had 50% or greater ipsilateral stenosis of the internal carotid artery. Hypertension was the second most prevalent risk factor (n = 20, 80%). Quick improvement of symptoms was seen in almost every case (mean follow-up 17.5 months), 9 patients showed complete recovery, whereas 2 remained disabled and 1 died due to a malignant disease. Three patients suffered a recurrent stroke on follow-up. CONCLUSIONS We conclude that distal arm paresis is a rare presentation of acute stroke with usually benign course.