Silva Butković Soldo

The applause sign in Parkinson's disease patients is related to dysexecutive syndrome.

Recent publications report that a positive applause sign is not only present in patients with neurodegenerative diseases where the subcortical structures are affected but also in patients with cortical dementia. The nature of this sign remains unknown. This study aimed to determine the frequency of the applause sign and its correlation with cognitive impairment in patients with idiopathic Parkinsons disease. The study included 30 non-depressed patients diagnosed with idiopathic Parkinsons disease. Study patients underwent the Unified Parkinson Disease Rating Scale part III, Dementia Rating Scale (DRS), Ravens Colored Progressive Matrices, and Mill Hill Vocabulary tests. Statistical analysis was performed by use of the parametric Students t-test, nonparametric Mann-Whitney U test and Fishers exact test, with the level of significance set at p<0.05. Negative applause sign was recorded in 66.7% and positive applause sign in 33.3% of patients. There were no between-group differences according to age, disease duration, or severity of motor symptoms. The positive applause sign group had significantly lower scores on the initiation/perseveration subscale of the DRS and a significantly higher frequency of scores below the cut-off score on the conceptualization and construction subscales of the DRS. The applause sign appears to be part of a broader dysexecutive syndrome in idiopathic Parkinsons disease.

Stroke Caused by Lung Cancer Invading the Left Atrium

We describe a 59-year-old stroke patient presented with sudden onset left side weakness and a speech disorder due to a major acute cerebral infarction in the area of the right middle cerebral artery, right posterior cerebral artery, and small infarctions in the area of the left middle and left posterior cerebral artery. For the previous month, the patient had been feeling weak and had no appetite. The patient had not been previously seriously ill. A chest x-ray showed a large mass in the upper zone of the right lung. Chest computed tomography scan and echocardiography were performed and revealed advanced lung cancer invading the left atrium. Spontaneous tumor embolism is a rare cause of stroke and should be considered in the differential diagnosis of stroke in a cancer patient. Also, sometimes stroke can be the first manifestation of advanced cancer.

25 (OH) D3 levels, incidence and recurrence of different clinical forms of BPPV

INTRODUCTION Benign paroxysmal positional vertigo is the most common cause of dizziness in the general population. It is a condition with potential impact of reduced levels of vitamin D on its recurrent attacks. OBJECTIVES The aim of this study was to measure the serum levels of 25-hydroxyvitamin D3 (25-OH D3) in patients with benign paroxysmal positional vertigo and determine whether there is a difference in the serum levels of vitamin D3 between patients with and without recurrence, as well as between the different clinical forms of benign paroxysmal positional vertigo. METHODS The study included 40 patients who came to the regular medical examination, diagnosed with posterior canal-benign paroxysmal positional vertigo based on the positive Dix-Hallpikes test. All patients underwent Epley manoeuvre after the diagnosis. Patients were classified according to current guidelines for levels of vitamin D3 in the serum in three groups: the deficiency, insufficiency and adequate level. RESULTS The average serum level of 25-OH D3 among respondents was 20.78ng/mL, indicating a lack or insufficiency of the aforementioned 25-OH D3. According to the levels of 25-OH D3, most patients suffer from deficiency (47.5%). 7 (17.5%) respondents had adequate blood level of 25-OH D3, and 14 (35%) respondents suffer from insufficiency. A significant difference was not found in the serum level of 25-OH D3 between patients with and without benign paroxysmal positional vertigo recurrence. There was a significant difference in the serum levels of 25-OH D3 in comparison to the clinical form of the disease. Lower 25-OH D3 values were found in patients with canalithiasis compared to those with cupulolithiasis. CONCLUSIONS There were no significant differences in the vitamin D3 serum level in patients with and without recurrence. The study showed a low level of serum vitamin D3 in most patients, indicating the need for supplemental therapy.

Type I persistent proatlantal artery associated with fusiform subclavian artery aneurysm. Report of one case

We report a 61 years old male presenting with a right cerebral infarction, along with a type I persistent left proatlantal artery (PA), which is a form of primitive carotid-basilar anastomosis. The patient had an absence of the ipsilateral vertebral artery (VA) and hypoplasia of the contralateral VA, while the basilar artery was supplied by the PA. Other vascular anomalies present were a fusiform aneurysm of the right subclavian artery, and an A1 segment aplasia of the hypoplastic anterior right cerebral artery, which originated from the anterior communicating artery. To our knowledge these anomalies were not described previously.

Hereditary multiple exostoses: an unusual cause of spinal cord compression

We report on a 19-year-old boy with hereditary multiple exostoses (HME) who presented several months history of progressive weakness of his left hand and left lower limb. He walked unsteadily and with difficulty. A detailed neurological examination revealed the power of 2/5 in the left hand, 3/5 in the left lower extremity, and 4/5 in the right limbs. There was significant hypoesthesia over left hand and left lower extremity, as well as a loss of position and vibration senses on sensory examination. Deep tendon reflexes were hyperactive in both lower extremities. There were clonus, Hoffman, and Babinski signs bilaterally. Magnetic resonance imaging (MRI) is recommended. MRI demonstrates an exophytic, lobulated bone mass extending from the left aspect of the C6 vertebral body, including left pedicle and left facet joint C6–C7 measuring 3 9 5.0 9 2.7 cm. The lesion has a heterogeneous signal and demonstrates an extensive displacement of the surrounding paravertebral soft tissues and nerve root and entering and occupying the spinal canal, thus causing a significant contra lateral displacement of the medulla (Fig. 1). Computed tomography (CT) of cervical spine through the area demonstrates a large solitary osteochondroma arising from the left side low-cervical spine area with bulging into the vertebral canal (Fig. 2). The patient was surgically treated for intraspinal exostoses and showed cessation of neurological deficits (Fig. 3). HME is an autosomal dominant inherited musculoskeletal disorder with a wide spectrum of clinical manifestations. It is characterized by the development of benign tumors, multiple osteochondromas (exostoses), growing outward from the metaphyses of long bones. Multiple osteochondromatosis is the most common of the bone dysplasia, but neurological complications are rare [1]. The number of osteochondromas, and the number and location of involved bones vary. Spinal cord compression, however, is a very rare entity in patients with HME. Between 1 and 4 % of solitary osteochondromas arise in the spine, and 7–9 % of patients with HME develop a spinal lesion. The cervical, thoracic, and lumbar regions can be affected. Lesions mostly originate from posterior vertebral elements, less often lesions causing neural compression originate from the vertebral bodies. Spinal osteochondromas usually cause a variety of signs and symptoms, including those of spinal cord or root compression. These are the result of progressive encroachment of the slowly expanding mass on neural structures [2, 3]. Cervical spinal cord compression resulting from osteochondroma is an extremely serious complication of HME. The incidence of malignant transformation into chondrosarcoma is reported to be between 5 and 11 % [4]. & Antonija Krstačić akrstacic@gmail.com

Epileptic seizure as initial and only manifestation of neuroborreliosis: case report

Lyme borreliosis is a multisystem disease caused by the spirochete Borrelia burgdorferi [1]. Neuroborreliosis may be manifested as Bannwarth’s syndrome (symptom triad: facial palsy, lymphocytic meningitis, and radicular pain), progressive encephalomyelitis, encephalopathy, cerebral vasculitis, transverse myelitis, amyotrophic lateral sclerosis syndrome, internal hydrocephalus, dementia, depression, axonal motor polyneuropathy, acrodermatitis chronica atrophicans, radicular lesions, and sensory neuropathies [1]. We present a patient who developed epileptic seizure as initial and only manifestation of neuroborreliosis.

Jugular phlebectasia in adult—an overlooked cause of cervical pain

We present a case of a 50-year-old woman with history of neck pain during the 12-month period. It was unilateral pain, with heaviness and unusual discomfort deep in the affected left side of the neck. General and neurological examination was normal. Initially, by using the magnetic resonance imaging (MRI)of the cervical spine, we found no identifiable mass. Repeated MRI scan demonstrated massive dilation of the left internal jugular vein, with a well-defined mass isointense to hypointense on T1 weighted and hyperintense on T2 weighted images. Considering the abovementioned clinical examination and performed radiological MRI evaluation results, the diagnosis of left internal jugular phlebectasia without complications (thrombosis or Horner’s syndrome) was made. We recommended conservative treatment with analgesics for pain and control MRI for 6 months if there is no worsening of symptoms.

Role of Vestibular Evoked Myogenic Potentials as an Indicator of Recovery in Patients with Benign Paroxysmal Positional Vertigo

Ocular vestibular evoked myogenic potentials (oVEMP) and cervical VEMP (cVEMP) are newer diagnostic methods, which allow an insight into the otolith senses. Our aim was to determine changes in certain parameters of the VEMP wave complex after successfully performed repositioning procedure, as an indicator of the state of recovery in patients with benign paroxysmal positional vertigo (BPPV). This may confirm the theory of otolith returning into the area of otolithic senses. The study included 48 patients with unilateral posterior semicircular canal BPPV. On their first arrival, otoneurological examinations, oVEMP and cVEMP tests were performed. The same were included in follow up check-ups scheduled at seven days and six months after successful implementation of Epley maneuvers. The initial measurement revealed a significantly reduced amplitude of oVEMP on the affected side. On the 7-day measurement, the amplitude increase was observed on the affected side, with significant reduction in the amplitude ratio (p=0.693), which reached statistical significance on the last measurement at 6 months (p=0.006). These findings confirmed the hypothesis of the return of otoconia into the utricular area.

Atypical cause of radiculopathy - Intradural spinal arachnoid cyst.

Intradural spinal arachnoid cysts are a relatively uncommon lesion that may be either intra, or extradural, and intradural spinal arachnoid cysts are even less common. Arachnoid cysts are cerebrospinal fluid collections in the spine that can present with neurological symptoms. The objective of this paper is to describe a rare case of radicular pain due to a spinal arachnoid cyst.