Sanela Zukić

gErSTmANN'S SyNdrOmE iN ACuTE STrOkE PATiENTS

Objective: Gerstmann in 1924. observed in a few patients a concomitant impairment in discriminating their own fingers, writing by hand, distinguishing left from right and performing calculations. He claimed that this tetrad of symptoms constituted a syndromal entity, assigned it to a lesion of the dominant parietal lobe. Since than, Gerstmann`s syndrome (GS) was enigma for neuropsychologists. The aim of this study was to analyze frequency and clinical features of GS among acute stroke patients. Patients and methods: We prospectively analyzed 194 acute stroke patients (average age 65±11.06 years, male 113 (58.2%), female 81 (41.8%) hospitalized at department of Neurology, University Clinical Center tuzla, during the six mounths in 2010. For clinical assessment of agraphia, alexia and acalculia we used Minessota test for differential diagnosis of aphasia’s. Results: Among these acute stroke patients, 59 (30.40%) had alexia, agraphia and acalculia or different combinations of these disorders. two patients (3.4%) had agraphia and acalculia associated with other part of tetrad of GS: fi nger agnosia and left-right disorientation. they both where men, right handed, and cranial computed tomography scan showed ischemic lesion in the left parietal and left temporoparietal lobe. Conclusion: Gerstmann`s syndrome is rare clinical entity, and has the high value in localization and the lesion is mainly localized to angular gyrus of the dominant hemisphere.

Tamoxifen associated bilateral optic neuropathy.

Tamoxifen is a selective estrogen receptor modulator and its use in estrogen receptor positive breast cancer patients can significantly reduce breast cancer mortality [1]. The use of tamoxifen is associated with several ocular toxicities: keratopathy, cataract, optic neuritis, retinopathy and maculopathy [1]. These conditions are reported to be dosedependent and are reversible if the symptoms are recognized on time and tamoxifen treatment is stopped [1–4]. We report a case of severe unrecognized tamoxifen associated optic neuropathy resulting with optic atrophy.

Anton's Syndrome due to Bilateral Ischemic Occipital Lobe Strokes.

We present a case of a patient with Antons syndrome (i.e., visual anosognosia with confabulations), who developed bilateral occipital lobe infarct. Bilateral occipital brain damage results in blindness, and patients start to confabulate to fill in the missing sensory input. In addition, the patient occasionally becomes agitated and talks to himself, which indicates that, besides Antons syndrome, he might have had Charles Bonnet syndrome, characterized by both visual loss and hallucinations. Anton syndrome, is not so frequent condition and is most commonly caused by ischemic stroke. In this particular case, the patient had successive bilateral occipital ischemia as a result of massive stenoses of head and neck arteries.

Carnitine Palmitoyl Transferase Deficiency – Unrecognized Cause of Recurrent Acute Kidney Injury

Metabolic myopathies represent a small percentage of rhabdomyolysis causes that could lead to acute kidney injury (AKI). This could be prevented if this condition is suspected and timely treated. Carnitine palmityl transferase (CPT) deficiency is the most frequent metabolic myopathy and should be considered whenever recurrent myoglobinuria is suspected, and distinguished from the second frequent one, McArdle disease. We present a case of a patient with two medically misinterpreted episodes of AKI in whom the subsequent diagnosis of CPT deficiency was established based on high index of clinical suspicion and correlation of clinical manifestations to specific metabolic defects. Application of simple measures and lifestyle changes improved our patient’s life quality and prevented potential new life-threatening complications.

Two year outcomes of poststroke writing and reading disorders

ABSTRACT Poststroke language disorders are frequent and include aphasia, alexia, agraphia, and acalculia. These disorders refer to an acquired inability to read, write and calculate. In this study, we evaluated the two year outcomes of writing and reading disorders in poststroke patients, the natural course, recovery and mortality. We evaluated all the patients with stroke who were admitted to the Department of Neurology, University Clinical Centre Tuzla in period of six months, who developed poststroke alexia, agraphia, acalculia, or different combinations of these language disorders. Outcome of these patients was evaluated again after 24 months. For clinical assessment of alexia, agraphia, and acalculia we used Minnesota Test for Differential Diagnosis of Aphasia. We investigated 59 (30.5%) of 193 stroke patients with alexia, agraphia, acalculia, and combinations. Outcome of these patients after 24 months was: 37 (62.7%) died, 13 (22%) fully recovered, and 9 (15.3%) of them retained the same disorder or developed dementia or blindness. Binary logistic regression analysis showed that patients with combined language disorders had significantly higher mortality. The main factors influencing language disorders recovery in this study are initial severity of reading, writing and calculation impairment, age, neglect, and level of education.

Plasmapheresis in neurological disorders: six years experience from University Clinical center Tuzla

Background: Therapeutic plasma exchange (TPE) is an extracorporeal blood purification technique that is designed to remove substances with a large molecular weight. The TPE procedure includes removal of antibodies, alloantibodies, immune complexes, monoclonal protein, toxins or cytokines, and involves the replenishment of a specific plasma factor. The aim of the study was to describe the clinical response to TPE in various neurological patients, and to assess the clinical response to this therapy. Methods: The study was retrospective. We analyzed the medical records of 77 patients who were treated at the Department of Neurology, University Clinical Center (UCC) Tuzla from 2011 to 2016. Results: 83 therapeutic plasma exchanges were performed in the 77 patients. There was a slight predominance of male patients (54.5%), with an average age of 51±15.9 years. The most common underlying neurological diseases were Guillain–Barré syndrome (GBS) (37.7%), then chronic inflammatory demyelinating polyneuropathy (CIDP) (23.4%), multiple sclerosis (MS) (11.7%) and myasthenia gravis (10.4%). Less frequent neurological diseases that were encountered were paraneoplastic polyneuropathies (5.2%), neuromyelitis optica (also known as Devic’s disease) (3.9%), motor neuron disease (3.9%), polymyositis (2.6%) and multifocal motor neuropathy (1.2%). Conclusions: Six years experience of therapeutic plasma exchange in neurological patients in our department have shown that, following evidence-based guidelines for plasmapheresis, the procedure was most effective in patients with GBS, CIDP and myasthenia gravis.

Atypical carpal tunnel syndrome due to the presence of Martin- Gruber anastomosis

Introduction: Carpal tunnel syndrome (CTS) is compressive neuropathy of median nerve at the point where the nerve passes through the carpal tunnel, and it is the most common compressive neuropathy. Classic symptoms include pain, paresthesia, numbness, swelling, weakness and clumsiness of fingers (typically in the first three fingers). CTS can occur in one or both hands. Case presentation: We report a patient with carpal tunnel syndrome in the presence of Martin-Gruber anastomosis (median to ulnar anastomosis in the forearm) with atypical clinical presentation of CTS in terms of numbness of the first three fingers of the right hand and unexpected electromyoneurography examination (absurdly high speed motor velocity through the median nerve). Conclusion: The presence of anomalous communications between median and ulnar nerves (MGA anastomosis) is not so rare condition and we have to keep in mind this fact in routine clinical and neuropysiological examination to avoid some diagnostic mistakes.

Megalencephalic leukoencephalopathy with subcortical cysts.

The classic phenotype of megalencephalic leukoencephalopathy with subcortical cysts (MLC) is characterized by early-onset macrocephaly, combined with mildly gross motor developmental delay and seizures, gradual onset of ataxia, spasticity, sometimes extrapyramidal findings, and usually late onset of mild mental deterioration. The disease was recognised independently in India and the Netherlands, and also know as van der Knaap– Singhal disease [1, 2].