Rezzan Tuncay

Etiology of first‐ever ischaemic stroke in European young adults: the 15 cities young stroke study

Risk factors for IS in young adults differ between genders and evolve with age, but data on the age‐ and gender‐specific differences by stroke etiology are scare. These features were compared based on individual patient data from 15 European stroke centers.

Demographic and geographic vascular risk factor differences in european young adults with ischemic stroke: The 15 cities young stroke study

Background and Purpose— We compared among young patients with ischemic stroke the distribution of vascular risk factors among sex, age groups, and 3 distinct geographic regions in Europe. Methods— We included patients with first-ever ischemic stroke aged 15 to 49 years from existing hospital- or population-based prospective or consecutive young stroke registries involving 15 cities in 12 countries. Geographic regions were defined as northern (Finland, Norway), central (Austria, Belgium, France, Germany, Hungary, The Netherlands, Switzerland), and southern (Greece, Italy, Turkey) Europe. Hierarchical regression models were used for comparisons. Results— In the study cohort (n=3944), the 3 most frequent risk factors were current smoking (48.7%), dyslipidemia (45.8%), and hypertension (35.9%). Compared with central (n=1868; median age, 43 years) and northern (n=1330; median age, 44 years) European patients, southern Europeans (n=746; median age, 41 years) were younger. No sex difference emerged between the regions, male:female ratio being 0.7 in those aged <34 years and reaching 1.7 in those aged 45 to 49 years. After accounting for confounders, no risk-factor differences emerged at the region level. Compared with females, males were older and they more frequently had dyslipidemia or coronary heart disease, or were smokers, irrespective of region. In both sexes, prevalence of family history of stroke, dyslipidemia, smoking, hypertension, diabetes mellitus, coronary heart disease, peripheral arterial disease, and atrial fibrillation positively correlated with age across all regions. Conclusions— Primary preventive strategies for ischemic stroke in young adults—having high rate of modifiable risk factors—should be targeted according to sex and age at continental level.

Cerebral vasculitis and ischaemic stroke in Behçet's disease: report of one case and review of the literature.

Introduction. Behçet’s disease (BD) is a multisystemic, recurrent, inflammatory disorder. Neurological involvement is well‐known but cerebral vasculitis and ischaemic stroke are unusual.

Stroke unit versus neurology ward--a before and after study.

Few studies have tested the hypothesis of whether the beneficial effect of Stroke Units (SUs) can be reproduced in routine clinical practice and whether SU are also superior to neurological wards [NWs]. We aimed to compare the outcomes of patients of a newly implemented SU to the outcomes of patients hospitalized in a NW. We made a before-after comparison of 352 SUs and 352 NWs patients after adjusting for case-mixes by the multivariate method. Subgroup analyses were also performed to evaluate which patient groups benefit the most. In-hospital case-fatality, proportion of independent patients at discharge, length of hospital stay (LOHS), medical complication rate were the main outcome measures. Adjusted in-hospital case fatality was significantly reduced in the SUs (OR: 0.44, 95 % CI: 0.26–0.76; p = 0.003). The proportion of independent patients at discharge and patients having medical complications was not different. Length of hospital stay was shorter in SU patients (13.76 days vs. 16.72 days, p = 0.003). Treatment in the SUs decreased case fatality in many subgroups [men, elderly, early admitted, severe stroke, co-morbidity present and ischemic stroke groups]. The results of randomized trials in favor of SUs can be reproduced in routine clinical practice. The benefit of SU care seems to be more apparent with advancing age and increasing stroke severity. Stroke Unit seems to be a better alternative to an experienced NW.

Vertebral artery dissection presenting with isolated neck pain.

Unilateral pain in the cervical region and limitation of neck movements are nonspecific symptoms frequently encountered in daily medical practice. Vertebral artery dissection is rarely considered as a diagnostic possibility unless brainstem or cerebellar ischemia follows the acute pain. Three cases of vertebral artery dissection (VAD) having the sole complaint of pain of acute onset in the posterior neck region are presented. None of the patients had ever reported a similar pain, and the neurological examination was unremarkable in all of them. Doppler ultrasonography suggested VAD in 2 cases, and the diagnosis was confirmed with T1 fat‐suppressed magnetic resonance imaging technique in all patients. Severe neck pain and/or occipital headache frequently accompanies ischemic symptoms in cases with VAD. The cases in this report emphasize that spontaneous and often unilateral posterior cervical pain of acute onset can be the only manifestation of a VAD. A high degree of suspicion especially in young patients with no past history of a similar pain can help to establish the diagnosis, thereby preventing erroneous and potentially hazardous therapeutic interventions such as physiotherapy or neck manipulation.

Gender differences in acute stroke: Istanbul medical school stroke registry.

BACKGROUND We aimed to investigate gender differences in Turkish stroke patients. MATERIAL AND METHODS Demographics, risk factors, clinical and etiologic subtypes, laboratory findings, clinical course, and in-hospital prognosis of 1 522 patients with ischemic stroke (IS) and 320 patients with intracerebral hemorrhage prospectively registered in the Istanbul Medical School Stroke Registry (1994-2004) were analyzed separately. RESULTS The mean age of IS patients was higher in females (n : 751) (P<0.0001). In males, smoking, ischemic heart disease, peripheral arterial disease, posterior circulation syndromes, and strokes due to large-artery atherosclerosis were more common (P<0.0001 for each). Prestroke disability, atrial fibrillation (P<0.0001), hypertension (P=0.041), modified Rankin Scale (mRS) 3-5 at admission (P<0.0001), total anterior circulation syndrome (P<0.0001), and cardioembolic stroke (P<0.0001) were more frequent in females. Female gender was an independent predictor of poor outcome (mRS 3-6). CONCLUSION Gender differences were observed exclusively in patients with IS. Although our patients were younger than those reported, gender differences were similar.

Internuclear Ophthalmoplegia and Cerebellar Ataxia: Report of One Case

Deep hemispheric or brainstem small infarcts can lead to atypical lacunar syndromes. Unilateral internuclear ophthalmoplegia (INO) and cerebellar ataxia has not been reported previously. A 57-year-old hypertensive female presented with bilateral appendicular and left truncal cerebellar ataxia and right INO. Cranial MRI showed a right paramedian infarct of lacunar size located in the tegmentum of caudal mesencephalon. At this level the involvement of medial longitudinal fascicle (MLF) led to right INO and the lesion of brachium conjunctivum caused the bilateral cerebellar ataxia. Ipsilateral involvement of both cerebellofugal fibers, before and after decussation, was responsible for bilateral cerebellar ataxia.

Venous infarction of brainstem and cerebellum.

The authors describe 2 cases of posterior fossa venous infarction. A 56‐year‐old woman with essential thrombocytemia presented with fluctuating complaints of headache, nausea, vomiting, left‐sided numbness‐weakness, and dizziness and became progressively stuporous. Cranial magnetic resonance imaging (MRI) showed bilateral parasagittal frontoparietal and left cerebellar contrast‐enhancing hemorrhagic lesions. On magnetic resonance venography, the left transverse and sigmoid sinuses were occluded. The second patient, a 39‐year‐old woman, presented with acute onset of diplopia, numbness of the tongue, vertigo, and right‐sided weakness following a gestational age stillbirth. MRI revealed lesions in the right half of midbrain and pons and in the superior part of the right cerebellar hemisphere. Digital subtraction angiography showed right transverse and sigmoid sinus occlusion. The authors suggest that one should investigate the possibility of venous infarction in the presence of posterior fossa lesions that are often hemorrhagic and are not within any arterial territory distribution but respect a known venous drainage pattern. Recognition of the observed clinical and neuroimaging features can lead to earlier diagnosis and, potentially, more effective management.

Intracerebral hemorrhage associated with sildenafil use : a case report

Sirs: Intracerebral hemorrhage (ICH) accounts for approximately 10 % of all strokes and carries high morbidity and mortality. Causes of nonhypertensive intracerebral hemorrhage are arteriovenous malformations, aneurysms, amyloid angiopathy, coagulopathies and drugs. Drug-induced ICH occurs mostly due to anticoagulants, thrombolytics, sympathomimetics, metamphetamine and cocaine. To our knowledge, there are two previous reported cases about the relationship between sildenafil use and ICH [1, 2]. Here we report a case of ICH after a single dose of sildenafil use. A 62-year-old, right-handed male was admitted with left-sided weakness and numbness. He reported that he had taken 50 mg of sildenafil two hours previously and had noticed numbness and weakness in his left arm and leg an hour after taking the drug. This was the first time he used the drug which was prescribed by a urologist. He indicated that the symptoms develLETTER TO THE EDITORS

A Case Report of Cerebral Venous Thrombosis in Polycythemia Vera Presenting with Intracranial and Spinal Subdural Hematoma.

Spinal subdural hematoma (SDH) is a rare condition and can be caused by several factors. Concomitant cranial and spinal SDH is even much less common. We present a 77-year-old male patient with lower back pain, paraparesis, and urinary retention following a sudden onset headache. Imaging revealed concomitant cranial and spinal SDH related to cerebral venous thrombosis (CVT) associated with hemorrhagic venous infarct. Laboratory examinations were consistent with polycythemia vera. There was no history of trauma and previous cranial surgery. Brain angiography did not reveal any evidence of arteriovenous fistula or vascular malformation. Since lower back pain occurred shortly after the headache and there was no other reasonable explanation for spinal hemorrhage, we suppose that the mechanism of spinal SDH is the migration of blood from the intracranial compartment. Therefore, this is the first report of concomitant spinal SDH and cerebral hemorrhage associated with CVT in a patient with myeloproliferative disease.