Meral E. Kiziltan

Peripheral neuropathy in patients with diabetic foot ulcers: Clinical and nerve conduction study

OBJECTIVES Diabetic foot lesions develop predominantly in male patients and sensory neuropathy is the most frequent type of neuropathy associated with these lesions. The aim of this study was to analyze the clinical and electrophysiological features in a cohort of patients with diabetic foot. RESEARCH DESIGN AND METHODS The recordings of 318 consecutive diabetic patients (127 women and 191 men) with an ongoing or healed foot ulcer who had been referred for electrophysiological consultation were evaluated retrospectively. RESULTS 60.1% of our cohort were male. Loss of deep sensation and deep tendon reflex abnormalities were the most common neurological findings. Negative sensory symptoms (63.7% vs 40.8%, p<0.01) and neuropathic pain (38.5% vs 18.3%, p<0.01) were more frequent in females, whereas atrophy was more frequent in male patients (22.8% vs 46%, p<0.01). Motor nerve conduction abnormalities and ulnar nerve involvement was more frequent and severe in males. Abnormal electrophysiological findings were mild in 70 patients (female 42, 60%). In this group, hemiplegia, peripheral arterial disease, multiple bone fractures, end stage renal failure, recent pulmonary tuberculosis and dementia accompanied mild polyneuropathy. Thirty patients had shown prominent decrease in nerve conduction velocity which indicated severe demyelination. Among these 30 patients, 6 male subjects had clinical features similar to that of chronic inflammatory demyelinating polyneuropathy. CONCLUSIONS Our results indicate that male gender, motor neuropathy and mononeuropathies, especially ulnar neuropathy is associated with the development of DF among our patients with DF. Patients with diabetes mellitus have a predisposition to develop chronic inflammatory demyelinating polyneuropathy and this may also facilitate formation of diabetic foot. History of hemiplegia, dementia and trauma are permissive risk factors for diabetic foot in the presence of mild polyneuropathy.

Traumatic peripheral nerve injuries: demographic and electrophysiologic findings of 802 patients from a developing country.

Objective To study a series of patients with traumatic peripheral nerve injury during the past 10 years in Cerrahpasa Medical Faculty/Istanbul/Turkey. Methods The chart review of 802 patients was evaluated and we explored the type(s) and cause(s) of injury, and electromyographic findings. The study included 171 children and 631 adults and we excluded the patients who suffered from injuries due to the Marmara earthquakes that occurred in 1999. Results Injury was most common in the upper extremities in both children (78.36%) and adults (63.54%). The common causes of nerve injury in children were as follows: obstetric lesions (46.78%), iatrogenic lesions (16.95%), traffic accidents (15.7%), and sharp lacerations (12.8%), whereas the commonest cause of nerve injury in adults was due to sharp lacerations (27.57%), followed by iatrogenic lesions (25.67%), and traffic accidents (23.77%). The most commonly injured nerves were the brachial plexus and ulnar nerve in children and adults, respectively. Electromyography demonstrated that complete nerve injury predominated in both groups. Conclusions If preventive measures are taken into consideration satisfactorily, the incidence of disabling peripheral nerve injury may decrease, as such injuries are often treatable.

Cırcadıan changes ın cortıcal excıtabılıty ın restless legs syndrome

Various investigations have revealed a widespread and somewhat controversial pattern of cerebral, cerebellar and brainstem involvement in the pathophysiology of restless legs syndrome (RLS). However, several studies which investigated functional or structural aspects indicated cortical involvement in RLS. In this study, we aimed to analyze circadian changes of cortical excitability in idiopathic RLS patients by means of transcranial magnetic stimulation (TMS). Eleven idiopathic RLS patients and eight healthy age and sex matched subjects were investigated using single-pulse TMS and motor nerve conduction studies during early afternoon when there were no symptoms and late at night (22:00-23:00) when the symptoms reappeared. Central motor conduction time, latencies and amplitudes of scalp and cervical motor evoked potentials, resting and active motor thresholds, and cortical silent period were measured. Measured parameters were similar between RLS patients and healthy subjects during the daytime. At night, cortical silent periods tended to shorten, and motor thresholds tended to decrease in the RLS group, whereas in controls they tended to increase. At night, active motor-threshold measurements were significantly lower in the RLS group (28.5 ± 6.2% vs 40.4 ± 8.4%, p=0.006). Therefore, we propose that in patients with RLS, conduction along the motor corticospinal axons is normal, with the possible loss of subcortical inhibition at nighttime.

The cutaneous silent period in diabetes mellitus

The cutaneous silent period (CSP) may be useful as a method for the evaluation of smaller and unmyelinated fiber dysfunctions. CSP refers to the brief interruption in voluntary contraction that follows strong electrical stimulation of a cutaneous nerve. The aim the present study is to establish whether CSP can be instrumental in the determination of diabetic neuropathy. The nerve conduction studies and CSP evaluations were both used in patients with Diabetes Mellitus and control group. All patients were given clinical neurological examinations for the determination of small-fiber neuropathy (SFN). The CSP values for patients with SFN were compared with values of those without SFN. The nerve conduction velocities had changed unfavorably in diabetic patients. No median nerve CSP reponse could be obtained in two of the diabetic patients. CSP latency (84.6+/-14.0) in diabetics was longer than controls (76.2+/-13.1) (p=0.018). The duration of CSP was similar for the two groups (p=0.46). The CSP latency showed a correlation with routine nerve conduction studies. While the CSP latencies (86.7+/-15.8) of patients who were clinically diagnosed with SFN were similar to the latencies (81.3+/-10.4) of patients without SFN (p=0.606), the duration of CSP (44.6+/-13.7) in patients with SFN was shorter than the duration (55.3+/-12.2) in patients without SFN (p=0.012). These results indicate that even though the CSP does not provide any advantage over routine electrodiagnostic studies in determining diabetic neuropathy, still it may be a useful method for the early detection of diabetic SFN.

Auditory startle reflex and startle reflex to somatosensory inputs in generalized dystonia

OBJECTIVE Startle reflex is a generalized defense reaction after unexpected auditory, visual, or tactile stimuli. Auditory startle reflex (ASR) and startle reflex to somatosensory inputs (SSS) have never been studied in generalized dystonia. Here, we aimed to study the characteristics and changes of ASR and SSS in this group. METHODS We have examined ASR and SSS in patients with generalized dystonia (n=11) and healthy subjects (n=25) under the same conditions. ASRs and SSSs were recorded over the orbicularis oculi (O.oc), sternocleidomastoid, biceps brachii (BB), and abductor pollicis brevis (APB) muscles after bilateral auditory stimulation and unilateral median nerve electrical stimulation at the wrist, respectively. RESULTS Both ASR and SSS showed the same sequence of muscle activation in both groups. However, the presence rates over the APB and BB muscles after both modalities of stimuli were significantly higher in the generalized dystonia group. ASR did not habituate in the dystonia group. CONCLUSIONS Both ASR and SSS are disinhibited, and both show a similar sequence of muscle recruitment in generalized dystonia. SIGNIFICANCE Higher probabilities over caudal muscles probably depend on the higher excitability of motor neurons secondary to central modulation.

Electrophysiologic Evaluation of Peripheral Nerve Injuries in Children Following the Marmara Earthquake

The aim of this study was to investigate the clinical, demographic, and electromyographic (EMG) characteristics of 12 earthquake victims in the pediatric age group and to compare the findings with those of the adult group. Following the 1999 Marmara earthquake, 75 subjects with suspected peripheral nerve injury were referred to our EMG laboratory for evaluation. In the pediatric age group, five patients had a history of short-term temporary trauma and seven had a history of being trapped under the debris for 4 to 10 hours and sustaining long-term trauma. Five patients had developed compartment syndrome and one had developed crush syndrome. The EMG examinations revealed peripheral nerve injury findings in all patients. The brachial plexus was damaged in 2 patients, and 19 peripheral nerves were damaged in 10 patients. Peroneal and posterior tibial nerves were predominantly affected. Regeneration was detected in all of the patients with brachial plexus damage at a mean follow-up of 3.5 months and in 62.5% of patients with peripheral nerve damage at a mean follow-up of 7.7 months. Being buried under the debris, compartment syndrome, peripheral nerve injuries in the lower extremities, and total axonal damage in the first EMG examinations were found to be higher in the pediatric age group. Regeneration findings were found at similar rates in both groups, with the brachial plexus being the most favorable. When it is considered that the regeneration process lasts 15 to 18 months and EMG findings mostly show pathologies in the form of neuropraxia and axonotmesis, we think that the prognosis of our patients will be good. (J Child Neurol 2005;20:207—212).

Electrophysiological findings of acute peripheral facial palsy in diabetic and non-diabetic patients

The aim of this study is to investigate the role of diabetes mellitus on the clinical and electrophysiological findings of peripheral facial palsy (PFP), the effect of the diabetes duration and polyneuropathy on the electrophysiological parameters. A total of 32 diabetic and 40 non-diabetic patients with peripheral facial palsy were included. All patients were divided into two subgroups based on the time of electrophysiological examinations: within the first 15 days versus within 16-30 days. Neuropathy symptoms and the results of neurological examinations and electrophysiological findings were recorded. The findings of electroneurography (EnoG), blink reflex (BR) evaluation, and needle electromyography (EMG) indicated statistically significant blink reflex abnormalities in diabetic patients compared to non-diabetics. Delay in the latency was more remarkable in the R2 component than in the R1 (p<0.001). The delay in the R1 latency was also observed in the non-affected side for diabetic patients. The longer duration of the diabetes caused significant delay on the blink reflex latency on both the affected and non-affected sides for R1 component (p=0.019, p=0.041, respectively). In contrary, neither the diabetes duration nor the age of the patients correlated with the clinical severity of facial palsy, fiber loss, fibular nerve compound muscle action potential amplitudes, and the nerve conduction velocities.

Peripheral neuropathy in patients with diabetes mellitus presenting as Bell's palsy

The aim of this study is to evaluate the peripheral nerves in diabetes mellitus with or without peripheral facial paralysis (PFP). A total of 49 diabetic patients with PFP within the last year (23 females, mean age 60.3 +/- 9.3), and 83 diabetic patients without PFP (41 females, mean age 59.5 +/- 9.9) were enrolled. The neurological examination, eye-blinking response, needle EMG and electrophysiological parameters of peripheral nerves were evaluated. The neuropathic pain, other positive and negative sensory symptoms were statistically more frequent in controls than the PFP group, while no difference was noted in total neuropathy score. Sural sensorial nerve action potential amplitudes were same in both groups, but median nerve amplitudes were significantly lower in the PFP group. It is suggested that PFP is not a part of multifocal neuropathy in diabetes mellitus. However, at least some parts of the nerve conduction studies were involved, focal neuropathies were more frequent while sensory neuropathies with small nerve fiber involvement were less frequent in diabetes patients with PFP.

Is diabetic dermopathy a sign for severe neuropathy in patients with diabetes mellitus? Nerve conduction studies and symptom analysis

OBJECTIVE To assess if diabetic dermopathy (DD) is a sign for severe polyneuropathy (PNP). METHODS We investigated the clinical and electrophysiological characteristics of 166 diabetic men (59.5+11.1 years) with different degrees of peripheral nerve involvement. RESULTS All of the clinical variables were more common in patients with diabetic foot ulcers (DF) than in patients with sole PNP (P<0.001). Only the loss of superficial and vibration sense was more common in the DF patients than the DD patients (P<0.02). Nerve conduction studies showed the mean compound muscle action potentials (CMAP) were smaller in the DD and DF patients than the PNP patients for peroneal, median and ulnar nerves (P<0.01). The mean nerve conduction velocities (NCV) of all nerves were slower in the DD and DF patients in compared to sole PNP patients (P<0.01). The mean distal latencies (DL) of the DD/DF patients were longer than the PNP group. CONCLUSIONS The DD and DF patients did not significantly differ in CMAP, NCV, and DL. SIGNIFICANCE Both clinical and electrophysiological features of DD and DF are similar, and significant different than PNP alone. These results suggest that DD is an important clinical sign for more severe neuropathic impairment.

Simultaneous multiple cranial nerve neuropathies and intravenous immunoglobulin treatment in diabetes mellitus

Asymmetrical, simultaneous multiple cranial nerve palsies and mild signs of peripheral neuropathy in diabetic patients may cause difficulties in diagnosis as they are relatively rare. A case of a 55-year-old diabetic woman who developed simultaneous right VII and left III, IV, VI cranial nerve palsies with spared pupils is presented here. We also discuss the role of intravenous immunoglobulin (IVIG) in the management of this condition and suggest that simultaneous multiple cranial palsies may have a good response to IVIG treatment.