Levent Sinan Bir

Migraine patients with or without vertigo: comparison of clinical and electronystagmographic findings.

OBJECTIVE To find the differences between patients with migraine with and without vertigo. STUDY DESIGN A prospective study. SETTING Ambulatory dizziness centre of a tertiary referral hospital. METHODS Eighty-four patients with migraine (31 with headache, 53 with headache and vertigo) according to the diagnostic criteria of migraine published by the International Headache Society in 1988 were included in the study. Patient history, vestibular tests, electronystagmography (ENG), and imaging studies were performed for differential diagnosis. MAIN OUTCOME MEASURES Clinical findings and ENG parameters. RESULTS Fifty-three of 84 patients (63%) had episodic vertigo attacks. Vertigo was independent from headache in 24 patients (45%). Vertigo symptoms always appeared later in the history of migraine headache. Headache started at age 27 +/- 8.3 years and vertigo symptoms began 7.7 +/- 8.7 years later. The beginning age of the migraine and female-to-male ratio were significantly greater in the vertigo group. Fifty-eight of the 84 patients had ENG testing. Fifty-eight percent of the patients with migraine and 55% of the patients with migraine + vertigo had abnormal ENG findings. None of the tests except the Dix-Hallpike manoeuvre had a statistically significant difference between the two groups. CONCLUSION The presence of the same ENG abnormalities in patients with pure headache shows that the vestibular pathways are also affected in these patients, even when there are no vestibular symptoms.

Sympathetic skin response in psoriasis and vitiligo

The sympathetic skin response (SSR) which is considered to be one of the indexes of peripheral autonomic nerve function, especially evaluates sudomotor function of unmyelinated sympathetic fibers. This noninvasive technique has been studied in various neurological disorders particularly in peripheral neuropathies and also in some dermatological disorders associated with nervous system involvement. However, literature lacks sufficient data regarding SSR in immunologically mediated skin disorders. We enrolled patients with vitiligo and psoriasis to determine the possible effects of these disorders on SSR. Examination of SSR was performed in 30 patients with psoriasis and 15 patients with vitiligo as well as in 23 healthy volunteers as controls. Right and left median nerves were stimulated successively and responses were recorded from the palms simultaneously. SSR could be obtained from every subject. The groups were not statistically different for the values of the latency, the amplitude, and the area under the negative component of SSR. Our results indicated that vitiligo and psoriasis did not have any significant effects on SSR.

Deep Brain Stimulation of the Pedunculopontine Nucleus in a Patient with Freezing of Gait

Case Presentation: A 54-year-old male patient presenting probable multiple system atrophy with predominant parkinsonism who underwent bilateral deep brain stimulation (DBS) of the pedunculopontine nucleus (PPN) is presented. The patient had dominant freezing of gait (FOG), levodopa-resistant bradykinesia, and autonomic disturbances, but with a good cognitive condition. Methods: The patient underwent bilateral DBS of the PPN, which ended with modest benefits. Results and Conclusion: Although he had a short postoperative follow-up (6 months), his neurological status remained stable and PPN DBS provided modest improvements in the gait disorder and freezing episodes. This unusual case suggests that the mesencephalic pedunculopontine region may have a role in locomotor symptoms and the potential to provide a limited improvement in FOG.

Acute Transverse Myelitis at the Conus Medullaris Level After Rabies Vaccination in a Patient With Behçet's Disease

Abstract Case report: A 25-year-old man with BehÇets disease was admitted because of weakness of the lower limbs and difficulty in urination. He had received a rabies vaccination 2 months previous because he had been bitten by a dog. Findings: Clinical and laboratory findings supported acute transverse myelitis. A hyperintense lesion and expansion at the level of conus medullaris was detected on spinal magnetic resonance imaging. Conclusion: Although neurologic involvement is one of the main causes of mortality and morbidity in BehÇets disease, the factors that aggravate the involvement of the nervous system are still unclear. Vaccination may have been the factor that had activated autoimmune mechanisms in this case. To our knowledge, involvement of the conus medullaris in BehÇets disease after rabies vaccination has not been reported.

Effects of valproate on vestibular symptoms and electronystagmographic findings in migraine patients.

Objectives: To investigate the effects of valproic acid on vestibular symptoms and electronystagmography (ENG) findings in patients with migraine-related vestibulopathy. Methods: Thirty-seven patients with migraine (13 with vertigo, 13 with dizziness, and 11 without vestibular symptoms) were included in the study. Slow-released valproic acid (500 mg/d) was given for 3 months. Frequency of headache and vestibular symptoms in the first, second, and third months of the therapy were recorded and compared with the pretreatment values. The ENG findings were also evaluated before and 2 months after the therapy. Results: We determined that prophylactic low-dose valproic acid decreased the frequency of headache and vestibular symptoms, although it does not cause any statistically meaningful change in ENG findings. Conclusions: Valproate can be used satisfactorily for patients with migraine who have vestibular complaints. Ineffectiveness of valproic acid on ENG findings can be clarified by the permanent effect of migraine on the vestibular system.

Correlation between blink reflex abnormalities and magnetic resonance imaging findings in patients with multiple sclerosis

This study investigates the correlation between brain magnetic resonance imaging findings and blink reflex abnormalities in patients with relapsing remitting multiple sclerosis. Twenty-six patients and 17 healthy subjects were included in this study. Blink reflex test (BRT) results were obtained using right and left stimulations; thus, 52 BRT results were recorded for the patient group, and 34 BRT results were recorded for the control group. The magnetic resonance imaging (MRI) findings were classified based on the existence of brainstem lesions (hyperintense lesion on T2 weighted (W) and fast fluid-attenuated inversion recovery MRI or contrast-enhancing lesion on T1W MRI). Correlation analysis was performed for the BRT and MRI findings. The percentage of individuals with abnormal BRT results (including R1 latency, ipsilateral R2 latency, and contralateral R2 latency) was significantly higher in the patient group as compared to the control group (p values: 0.015, 0.001, and 0.002, respectively). Correlation analysis revealed significant correlations between contralateral R2 latency abnormalities and brainstem lesions (p value: 0.011). Our results showed significant correlation correlations between contralateral R2 latency abnormalities and brainstem lesions and these results may be explained the effects of multiple demyelinating lesions of the brain stem of patients with relapsing remitting multiple sclerosis.

Clinical and electronystagmographical evaluation of vestibular symptoms in relapsing remitting multiple sclerosis

Abstract Objective: Multiple sclerosis (MS) may give rise to a variety of clinical signs and symptoms including vertigo and/or other problems related with equilibrium. In this study, we aimed to evaluate clinical and electronystagmographical (ENG) characteristics of relapsing remitting MS (RRMS) patients. Design: This is a prospective controlled study consisting of 30 patients who were diagnosed as definite RRMS according to McDonalds diagnostic criteria and 30 healthy individuals. Setting: Entire population of patients were examined and followed up at the same tertiary centre during the period of September 2003 and March 2005. Clinical examination and detailed electronystagmographic investigations were performed in each group. Methods: Vestibular laboratory testing was carried out by a computerized ENG system. All ENG subtests including tracking, saccade, optokinetic, gaze, positional and Dix-Hallpike tests were performed in each group but caloric, which is relatively an invasive test, was performed only in the patient group. Main outcome measures: We aimed to find the ratio of abnormal tests indicating, central and/or peripheral pathology in ENG. We also analyzed the correlation of total number of abnormal tests in ENG with clinical parameters. Results: Differences of ENG abnormality indicating central and/or peripheral pathology and ENG abnormality indicating only central pathology between the two groups were statistically significant. Correlation of total number of abnormal tests in ENG with EDSS score was statistically significant. Conclusion: ENG is sensitive in detecting the vestibular system involvement in RRMS patients if all subtests are performed and evaluated in detail with clinical symptoms and signs.

Lower motor neuron disease associated with myelofibrosis

We present a patient who has signs pointing to the involvement of lower motor neurons and myelofibrosis. To our knowledge, unlike lymphoproliferative disorders, co-occurrence of myelofibrosis and lower motor neuron disease (MND) has not been reported so far. A 64-year-old male patient was admitted to our hospital with the complaint of painful cramps in his neck and forearms. On physical examination marked hepatomegaly and splenomegaly were found. On neurologic examination nasal quality of the voice and slight palatal weakness were detected. There were generalised slight weakness and atrophy in both proximal and distal muscle groups. Fasciculations were observed especially in forearm muscles and it was observed that he had been avoiding head movements because of painful muscle cramps. Deep tendon reflexes were hypoactive. Nerve conduction studies were normal. By needle electromyography, giant motor unit action potentials (amplitudes up to 8 mV), fibrillation potentials, positive sharp waves and fasciculation potentials were detected in all muscles which were investigated. A hypercellular bone marrow (100%) was determined by bone marrow biopsy. In addition to increased production of the myeloid and megakaryocytic lines, abnormal aggregation and grouping of megakaryocytes were seen. Reticular fibers were increased. He had some benefit of dyphenilhydantoin treatment given for the painful cramps in his neck and forearm muscles. Hydroxyurea treatment was started for myelofibrosis. Six months later, his general condition was better, and the painful cramps were completely resolved. No marked deterioration has been detected in neurologic examination and electromyography for 1 year.

Optic Disc and Retinal Nerve Fibre Layer Changes in Parkinson’s Disease

Abstract This study was conducted to assess optic nerve and peripapillary retinal nerve fibre layer (RNFL) changes in patients with idiopathic Parkinson’s disease (PD) and its correlation with disease duration and severity. Optic nerve parameters and RNFL thickness were measured in 24 PD patients and 25 age–gender-matched controls by Heidelberg Retinal Tomography II (Heidelberg Engineering, Dossenheim, Germany). Patients with visual acuity below 20/25 were excluded. The mean RNFL in the temporal sector was significantly thinner in the study group than the control group (p = 0.020). Additionally, disease severity and duration negatively correlated with optic disc parameters in some sectors.

Sudden sensorineural hearing loss in a patient with primary antiphospholipid syndrome

An autoimmune basis for sudden sensorineural hearing loss (SSNHL) has long been suspected. Immunoserological assays of patients with SSNHL have revealed the presence of different antibodies. Recently a number of case reports have highlighted the association of anticardiolipin antibodies (aCA) and SSNHL in systemic lupus erythematosus (SLE) [1]. Here we report a case with primary antiphospholipid syndrome (APS) who had SSNHL. A twenty eight years old male patient was applied to our hospital with the complaint of bilateral, sudden onset deafness. Past medical history revealed that he had Wernicke aphasia lasted one hour one year ago. Systemic and neurologic examinations were normal except bilateral sensorineural hearing loss. Complete blood count, PT, aPPT, sedimentation, biochemistry, protein C, S antithrombin III and complement levels were in normal limits. ECG and echocardiogram were normal. We confirmed bilateral sensorineural hearing loss with audiogram. Cranial and temporal bone MRI were normal. Anti HIV and VDRL were negative. Anticardiolipin antibody Ig G was positive (28 IU/mL). In repeated tests, ANA, anti-DNA and aCA IgM were found negative, but aCA Ig G was positive. Prednisone 80 mg/day was started and continued with decreasing doses for 3 months. He has completely recovered in one month. Then he was anticoagulated. No other ischemic attack, any systemic finding or audiovestibular complaint have been seen for two years. APS occurs in isolation (primary APS) or in association with connective tissue diseases (secondary APS), particularly with SLE [2]. The most common clinical manifestation of APS is thrombosis, which affects the vessels of any organ. Arterial thrombosis involves the brain in up to 50% of cases, causing transient ischemic attack or stroke [3]. Other neurological mani-