Mehmet Saraçoğlu

A Sledgehammer on the Brachial Plexus: Thoracic Outlet Syndrome, Subclavius Posticus Muscle, and Traction in Aggregate

Reported here is a 30-year-old man who was seen because of pain and weakness in the upper extremities after a tractional injury. Physical examination revealed significant atrophy in the left deltoid and right intrinsic hand muscles, generalized hypoesthesia, decreased deep tendon reflexes bilaterally, and decreased strength in various muscle groups. Roos (right) and hyperabduction (bilateral) tests were positive. Electrodiagnostic studies were consistent with bilateral brachial plexopathy. Cervical radiographs showed long transverse process of C7 on the right side and a small rudimentary rib articulating with C7 on the left side. Brachial plexus magnetic resonance imaging demonstrated an aberrant muscle and compressive brachial plexus injury on the left side. Surgery via transaxillary approach was performed on the left side. The occurrence of traumatic brachial plexopathy in the presence of underlying thoracic outlet syndrome and subclavius posticus muscle is discussed for the first time in the literature.

Incidence of ischemic brain lesions in hyperbaric chamber inside attendants

Concern is growing about the negative long-term effects of hyperbaric exposure on the central nervous system of divers. This study was conducted with magnetic resonance imaging (MRI) to evaluate attendants that work inside hyperbaric chambers (known as inside attendants) for hyperintense brain lesions. Ten inside attendants and 10 healthy nondiving subjects were included in the study. A questionnaire was used to obtain information about subjects’ medical history, hyperbaric exposure history, alcohol intake, and smoking habits. T1-weighted, T2-weighted, and fluid-attenuated inversion recovery images were acquired with a 1.5-T MRI device. A lesion was included in the count if it was hyperintense on both T2-weighted and fluid-attenuated inversion recovery images. Although MRI revealed 3 hyperintense brain lesions in 2 of 10 inside attendants and in none of the controls, the differences between groups were not statistically significant (P=.147). The number of brain lesions counted did not correlate with the age of the inside attendants (r=0.007;P=.978), the number of hyperbaric exposures (r=-0.203;P=.574), or the duration of work as an inside attendant (r=0.051; P=.890). Investigators found a correlation, however, between the number of cigarettes smoked in a day and the number of brain lesions identified (r=0.779;P < .01). An increased incidence of hyperintense brain lesions was not observed in inside attendants who had never experienced decompression sickness compared with nondiving controls. Additional multicenter epidemiologic studies are needed if the occupational safety of inside attendants is to be enhanced.

Serum asymmetric dimethylarginine levels in diabetic patients with neuropathy

OBJECTIVE The goal of our study was to evaluate the role of asymmetric dimethylarginine (ADMA) in patients with diabetic neuropathy. MATERIALS AND METHODS In this study, 58 diabetic patients and 26 healthy volunteers were included. In both groups ADMA measurements were performed together with other biochemical examinations. Nerve conduction studies and Neuropathy Symptom Score (NSS) were administered to the diabetic patients. RESULTS ADMA levels were found significantly higher in diabetic patients compared to the control group (p = 0.0001). However, ADMA levels were not statistically significant between diabetic patients with neuropathy and without neuropathy (p = 0.86 and p = 0.47). CONCLUSION These results demonstrate that there is not any significant relationship between ADMA and diabetic neuropathy.

Role of anti-GQ1B antibody in differential diagnosis of acute ophthalmoparesis

Miller Fisher syndrome (MFS) is a triad of total external ophthalmoplegia, ataxia, and areflexia, while botulism has the usual clinical presentation of involvement of cranial muscles and palsies with blurred vision, diplopia, ptosis, dilated pupils, and facial paralysis, caused by a bacterial neurotoxin which attacks proteins involved in presynaptic vesicle release. In this report, we needed to make the differential diagnosis between MFS and botulism in a patient who presented with acute ophthalmoparesis and a history of diarrhea three days before, which started two days after consuming tinned food. Routine laboratory, neurophysiologic, and imaging investigations were normal. A clinical diagnosis of Miller Fisher syndrome was reached by anti-ganglioside GQ1B and GM1 Ig G and M antibody investigations which proved positive. The patient was treated with intravenous immunoglobulin two weeks after (in the late period) the symptoms started and he has recovered completely. Systemic autoimmune diseases should be considered in patients with bilateral ophthalmoparesis. As in the present patient, the evaluation of specific antibodies helps in the diagnosis and thus early effective treatment is possible.

Plasma apelin levels in diabetic patients with and without neuropathy

The aim of this study was to investigate the plasma apelin levels in diabetic patients with and without neuropathy. All consecutive diabetic patients who presented for routine follow-up at our outpatient clinic were invited to participate in this clinical study. Forty diabetic patients (20 female and 20 male) and twenty-two non-diabetic control subjects (9 female and 13 male) were included in the study. Neurological evaluations in diabetic subjects were done by nerve conduction studies and evaluated with the Neuropathy Symptom Score. Fasting plasma glucose, HbA1c, lipid and apelin levels were measured in each subject. The mean plasma apelin level was significantly higher in the diabetic patients than in the control subjects (p = 0.026). Apelin levels were statistically similar between diabetic patients with and without neuropathy (p = 0.43). Further, plasma apelin levels were found to be higher in diabetic patients with neuropathy when compared with those of healthy control subjects (p = 0.02). In diabetic patients with neuropathy, plasma apelin levels correlated significantly with diabetes duration (r = 0.5, p = 0.02). We propose that apelin levels in diabetic patients are higher in the presence of neuropathy and longer disease duration, although this might not solely suffice as an indicator for the presence of neuropathy in diabetic patients. Drawing attention to the possible association between the apelinergic system and diabetes mellitus, we believe that further studies with larger samples should be carried out also to investigate the presence of retinopathy and nephropathy.

Migren hastalarında atak olmayan dönemde koku tanımlama testi ile koku fonksiyonunun değerlendirilmesi

Objective: Despite the fact that there are many studies about the osmo- phobia and migraine, we have very little knowledge about the olfactory abilities of migraineurs during the period between the attacks. So, the aim of this study was to evaluate the olfactory function of migraineurs during the period without headaches with odor identification test. Methods: Two hundred and ninety healthy people aged 16 to 65 years (152 female, 138 male) and 84 migraine patients aged 18 to 55 years (47 female, 37 male) were studied. The participants with migraine were selected from the patients who applied to headache outpatient clinic for assessment. Participants, appropriate to the study, were physically and neurologically examined in detail and then they were taken to the test room in order to be screened with Short Smell Test Battery of GATA Haydarpafla (GULTEST). Results: The mean GULTEST score of the migraine group was less than the healthy group and the difference was significant. The effect of gender, cigarette smoking and disease status (migraine) on GULTEST scores was evaluated by linear regression model. It was found that females had higher odor identification scores than males in both migraineurs and controls. On the other hand, cigarette smoking had a significant negative effect on GULTEST scores. Furthermore, migraine had a significant negative effect on GULTEST scores. Conclusion: Our study showed that even during the headache-free peri- od, migraineurs might have reduced olfactory abilities.

Simultaneous posterior and middle cerebral artery infarct

On the follow-up, the patient developed painful, erythematous skin lesion of 15 cm in diameter, located on the lateral malleolus and dorsum of the foot [Figure 2]. MEFV gene investigation revealed homozygote mutation for M694V gene. Five pyrin gene mutations (E148Q, M680I, M694V, M694I and V726A) were detected by using the PRONTOTM FMF Basic Kit according to the manufacturer’s instructions. Biopsy specimens from the duedonum and rectum were negative for amyloidosis. A diagnosis of FMF with CNS demyelination was considered and colchicine therapy was started. With colchicine therapy, her symptoms regressed and no further progression of the disease was observed during two years follow-up.

How long does denervation take in poliomyelitis? Or is it a lifetime?”

Background and Objective: This study aims to determine the period of reinnervation in patients with poliomyelitis. This research was conducted to identify the appearance of denervation potentials in patients with poliomyelitis as indicators for reinnervation. Materials and Methods: A total of 246 male patients with poliomyelitis were assessed electrophysiologically between 1988 and 2007. The mean age was 22.8 (18–42). It has been an average of 19.9 ± 4.9 years since the beginning of complaints from the patients. Results: The patients had no complaints of newly developing muscle weakness, fatigue, muscle and joint pain, and difficulties in breathing and swallowing. Neurological examinations revealed the absence of myotomal pain and sensory loss. Upon assessment of the patients’ limbs, the following findings were revealed: two patients had left upper and lower limb involvement, two patients had left upper and right lower limb involvement, 6 patients had left upper limb involvement, 12 patients had both lower limb involvement, 105 patients had left lower limb involvement, 1 patient had both upper limb involvement, 2 patients had right lower and upper limb involvement, 12 patients had right upper limb involvement, 6 patients had both lower limb involvement, 95 patients had right lower limb involvement, and 3 had all the three extremities affected. The needle electromyography revealed the presence of denervation potentials in 25.2% (62) of the patients. Conclusion: When poliovirus attacks the motor neuron, this neuron may be completely destroyed, damaged, or unaffected. Reinnervation occurs when nearby functioning motor units send out terminal axon sprouts to reinnervate the damaged muscle fibers. As a consequence of poliomyelitis, several muscle fibers become atrophic and fibrotic, but others continue to survive. This study showed that patients with a history of poliomyelitis experienced denervation with subsequent reinnervation for many years.

Is Further Examination Necessary in Patients with Behçet's Disease Without Any Neurological Signs or Symptoms? -

Background and Purpose: A mean percentage of 5% was reported for neurological involvement in researches related to Behcets disease. The neurological involvement may be characterized by headache, neuropsychiatric symptoms, brain stem involvement, cerebral venous thrombosis or peripheral nervous system involvement. Sometimes neurological involvement may be seen without any neurological sign or symptom. In our study, we aimed to evaluate the cognitive, psychiatric and neurophysiological responses in Behcets disease without neurological sign and symptom. Methods: The study was performed on patients with Behcets disease without neurological signs and symptoms and healthy volunteers that would make the control group. The patients were assessed with Mini Mental State Examination, Hamilton Rating Scale for Depression, nerve conduction study and visually evoked potential. Results: A total of 27 male patients (age: 24.88±5.45 years) were enrolled in the study. Neurological examinations of all the patients were normal. Mean Mini Mental State Examination score of the patients was 29.62±0.79 (2 patients had loss of focus, 2 patients had disturbance in the copying function) and 2 patients had mild depression in Hamilton Rating Scale for Depression. In the nerve conduction study, 2 patients had right sensory-motor carpal tunnel syndrome, 1 patient had right sensory-motor carpal tunnel syndrome - bilateral ulnar nerve entrapment. In the visually evoked potential examination, 8 patients had prolonged P100 latency, decreased amplitude and disturbance of wave morphology. Conclusion: Visually evoked potential examination may be used as a conductive method to detect the subclinical neurological pathologies in Behcets disease. The possible silent neurological involvement should be evaluated with further neuro-screening methods.

P187 Comparison of the effects of the antiepileptic drugs on peripheral nerve conduction

Purpose: There are mostly difficulties in the study of femoral sensory nerve transmission due to muscle artefacts. Moreover, as of today no orthodromic study related to anterior femoral cutaneous nerve (ACFN femoral intermediate cutaneous branch) has been made. In our study, saphenous nerve (SN) which was defined before, infrapatellar nerve (IPBSN) and the newly-defined orthodromic ACFN nerve transmissions have been examined. Method: The present study was undertaken in 50 normal, healthy control subjects. The IPBSN was stimulated medially with a surface electrode 1-2 cm below the patella. SN was stimulated in the side of index medial after saphenous vein. ACFN was conformed from almost 6 cm above the patella. The response was recorded with a needle electrode located close to the nerve 1cm lateral to the femoral artery in the inguinal region. Results: Sensory nerve action potentials were obtained. IPBSN: Mean latency of the first positive peak was found to be 8.1±0.9 ms and; conduction velocity was 54.1±4.4 m/s and response amplitude was 1.3±1.1 μV. SN: Mean latency of the first positive peak was found to be 7.1±0.8 ms and; conduction velocity was 59.2±4.8 m/s and response amplitude was 2.8±1.5 μV.ACFN: Mean latency of the first positive peak was found to be 4.1±1.0 ms and; conduction velocity was 57.4±5.2 m/s and response amplitude was 3.7±2.3 μV. Conclusion: The mostly-common case in the femoral and around the knee is the post traumatic injury. So,femoral sensory nerve transmissions become more important. In our study, the method used is both invasive anc usable in the selected cases.