Tulin Tanridag

Autonomic dysfunction in multiple sclerosis: correlation with disease-related parameters.

Cardiovascular autonomic functions were investigated in a prospective, controlled study of 22 consecutive relapsing-remitting multiple sclerosis (MS) patients and 22 healthy subjects using 5 simple noninvasive tests and sympathetic skin response testing. Tests included the heart rate response to deep breathing, valsalva maneuver and standing, blood pressure response to standing and sustained hand grip, and were graded according to the Ewing and Clark classification as early, definite or severe impairment. The relationship between autonomic dysfunction and disease-related parameters such as the expanded disability status scale (EDSS) and disease duration was studied. Ninety percent of the patients had symptoms related with autonomic dysfunction, and 45.5 % had abnormal results in cardiovascular autonomic function testing with 4 patients also having abnormal sympathetic skin responses. Statistical analysis indicated that patients with a long disease duration rather than high EDSS carried a risk of autonomic involvement in MS. Both parasympathetic and sympathetic functions were impaired and this could have been easily overlooked by a standard EDSS follow-up. In this regard, autonomic function testing seems necessary in order to detect subclinical changes in MS patients and should be considered in outcome measures.

Medial plantar and dorsal sural nerve conduction studies increase the sensitivity in the detection of neuropathy in diabetic patients

OBJECTIVE Clinical utility of nerve conduction studies (NCS) of the medial plantar and dorsal sural nerves in the early detection of polyneuropathy have already been shown separately. However, at present, there is no data about the combined assessment of these two nerves in distal sensory neuropathy. In the present study, we aimed to evaluate the medial plantar and dorsal sural NCS in a group of diabetic patients with distal sensory neuropathy (DSN) and in healthy controls. METHODS Thirty healthy and 30 diabetic adult patients were included. In all subjects, peripheral motor and sensory NCS were performed bilaterally with surface electrodes on the lower limbs including medial plantar and dorsal sural nerves. In addition, motor and sensory nerves were studied unilaterally on the upper limb. RESULTS In all patients, nerve action potential (NAP) amplitudes of sural and superficial peroneal nerves were within normal ranges, but in the patient group mean value was significantly lower than in the controls. Among clinically defined 30 DSN patients, medial plantar NAP amplitude was abnormal in 18 (60%) and dorsal sural nerve amplitude was abnormal in 13 (40%) of the patients bilaterally. Additionally, the onset NCV of the dorsal sural nerve was significantly slower in patients than controls (P=0.038). Evaluation of both of these nerves increased the sensitivity up to 70% in the detection of neuropathy. CONCLUSIONS Bilateral NCS assessment of both of the medial plantar and dorsal sural nerves together increases the rate of diagnosis of diabetic distal sensory neuropathy compared to assessment of either of these nerves. SIGNIFICANCE Assessment of medial plantar in addition to dorsal sural NCS together increases the sensitivity in the detection of neuropathy and allows earlier diagnosis, especially when routine NCS are normal.

Evaluation of peripheral and autonomic neuropathy among patients with newly diagnosed impaired glucose tolerance

We have aimed to investigate the presence of peripheral and autonomic neuropathy in individuals who had been diagnosed with impaired glucose tolerance (IGT) on the basis of an oral glucose tolerance test, by comparing with age‐matched healthy subjects with an oral glucose tolerance test (OGTT) in normoglycemic ranges.

Myasthenia gravis with thymoma and autoimmune haemolytic anaemia. A case report

Abstract. Myasthenia gravis is an autoimmune disorder that affects the neuromuscular junction and leads to weakness of the skeletal muscles. Associated autoimmune diseases such as systemic lupus erythematosus, rheumatoid arthritis and pernicious anaemia are present in approximately 5% of the myasthenic patients. This report presents a 64-year-old man with autoimmune haemolytic anemia associated with myasthenia gravis and thymoma. The patient developed a severe Coombs positive autoimmune haemolytic anaemia, which was resistant to treatment with large doses of prednisone. Haemolytic anaemia entered remission one month following thymectomy, and the patient has maintained a normal haemoglobin and a negative Coombs test without the need for steroid or immunosuppressive therapy. In conclusion, thymectomy may induce a striking improvement of therapyresistant autoimmune haemolytic anemia in patients with MG and thymoma, but in terms of remission, a long follow-up is needed as autoimmune diseases can show spontaneous fluctuations.

A comparison of sural nerve conduction studies in patients with impaired oral glucose tolerance test

Objective –  Monitoring of the sural nerve is a sensitive method for detection of neuropathies. We examined different methods of studying sural nerve conduction in a group of patients with impaired glucose tolerance (IGT) in the same study.

Assessment of symptomatic diabetic patients with normal nerve conduction studies: utility of cutaneous silent periods and autonomic tests.

Established electrophysiological methods have limited clinical utility in the diagnosis of small‐fiber neuropathy (SFN). In this study, diabetic patients with clinically diagnosed SFN were evaluated with autonomic tests and cutaneous silent periods (CSPs). Thirty‐one diabetic patients with clinically suspected SFN and normal nerve conduction studies were compared with 30 controls. In the upper extremities (UE), the CSP parameters did not differ statistically between the patient and control groups, whereas, in the lower extremities (LE), patients had prolonged CSP latencies (P = 0.018) and shortened CSP durations (P < 0.001). The sensitivity of the CSP duration was 32.6%, and the specificity was 96.7%. The expiration‐to‐inspiration ratios and amplitudes of the sympathetic skin responses in the lower extremities were also reduced. Our findings indicate that the diagnostic utility of CSPs was higher than that of the autonomic tests to support the clinically suspected diagnosis of SFN. Muscle Nerve, 2011

The Relationship between Quiescent Inflammatory Bowel Disease and Peripheral Polyneuropathy

BACKGROUND/AIMS Inflammatory bowel disease is a chronic, recurrent disorder that involves multiple organ systems. Polyneuropathy is the most common neurological manifestation. The aim of the present study was to investigate the relationship between polyneuropathy and inflammatory bowel disease. METHODS The study included 40 patients with infl ammatory bowel disease (20 with ulcerative colitis and 20 with Crohns disease) and 24 healthy controls. The patients had no clinical signs or symptoms of polyneuropathy. Nerve conduction studies were performed using an electroneuromyography apparatus. RESULTS Mean distal motor latencies, conduction velocities, and F wave minimum latencies of the right median nerve were signifi cantly abnormal in the patient group, compared to the healthy controls (p<0.05). CONCLUSIONS Some electrophysiological alterations were observed in chronic inflammatory bowel disease patients who showed no clinical signs. While investigating extra-intestinal manifestations in inflammatory bowel disease patients, nerve conduction studies must be performed to identify electrophysiological changes and subclinical peripheral polyneuropathy, which can subsequently develop.

A neurophysiological approach to the complex organisation of the spine: F-wave duration and the cutaneous silent period in restless legs syndrome

OBJECTIVE It is generally accepted that F-wave duration (FWD) and the cutaneous silent period (CSP) are influenced by diminished central inhibition. The aim of this study was to diagnose patients of restless legs syndrome (RLS) with the help of FWD and/or CSP parameters. METHODS In all, 24 patients with primary RLS were compared with 31 age- and sex-matched controls. The participants were evaluated based on nerve conduction study (NCS), F-wave parameters (minimum, maximum and mean latency; chronodispersion, persistence and duration; and the ratio of the mean FWD to compound muscle action potential (CMAP) duration), CSP (latency, duration and the ratio of lower-extremity (LE) to upper-extremity (UE) duration that is, silent period ratio (SPR)), the expiration to inspiration ratio (E/I) and sympathetic skin response (SSR). RESULTS There were not any significant differences in NCS, E/I or SSR between the patients and controls. However, FWD was prolonged (P<0.0001 for UE and LE) and FWD/CMAP duration was increased in upper and lower extremities (P<0.001 for UE and P<0.0001 for LE). Further, CSP latencies in UE (P=0.030) and LE (P<0.001) were prolonged, and CSP duration and SPR were significantly reduced in the patient group (P<0.0001). CONCLUSIONS As both NCS and autonomic test results were in the normal range, abnormalities in FWD and CSP parameters were attributed to the dysfunction of different interneuron groups in the spine. SIGNIFICANCE The use of FWD and CSP could aid in the diagnosis of RLS patients in whom conventional electrophysiological procedures are ineffective.

Headache During Air Travel: An Unusual Cause of Reversible Cerebral Vasoconstriction Syndrome

Reversible cerebral vasoconstriction syndrome (RCVS) is a rare condition characterized by segmental and reversible narrowing of the cerebral arteries. High altitude has been reported as an extremely rare cause for this distinctive syndrome. Here, we report a case of RCVS and propose air travel as the triggering factor. A 51-year-old female patient experienced an intense thunderclap headache during air travel, which persisted through her entire trip. On the second day after landing back home, she presented with right hemiparesis accompanying the headache at a facility different from where the authors are located. Diffusion weighted magnetic resonance imaging (DWI) and cranial magnetic resonance angiography (MRA) had revealed a pattern of restriction on the left frontoparietal cortical region and segmental vasoconstrictions that were more predominant on the posterior circulation consecutively. A diagnosis of RCVS was considered. When the patient was discharged with verapamil therapy, she had normal neurological status. Two days later, she was hospitalized at our hospital with an attack of weakness of the left leg, which lasted for 10 min. The DWI showed no infarctions. However, segmental vasoconstrictions on bilateral posterior cerebral arteries, anterior cerebral arteries (ACAs), and middle cerebral arteries were observed on cranial MRA. Her therapy regimen was changed to nimodipine and dexamethasone. On the follow-up, her left-sided weakness and thunderclap headache attacks had recurred until the last attack, which persisted. No significant blood pressure changes were observed at that time. The DWI revealed acute infarctions on ACA territory and bilateral head of the caudate nuclei. MRA showed that the vasoconstrictions were more prominent on the mentioned arteries. Her therapy was switched to intravenous nimodipine and the dose was gradually increased up to 1.5 mg/hour and dexamethasone was stopped. Under this treatment, she developed no further symptoms or infarctions. When she was discharged 1 month after her first symptom on oral From the Department of Neurology, Marmara University Faculty of Medicine, Istanbul, Turkey (H. Alibas, S. Ceferova, P. Kahraman Koytak, K. Uluc, I. Midi, N. Tuncer Elmaci, S. Aktan, and T. Tanridag).

Where Is the Core of the Volcano? The Undetermined Origin of Primary Restless Legs Syndrome

ABSTRACT An association between small fiber neuropathy and primary Restless Legs Syndrome (RLS) is suggested since both of them share common characteristics. Our aim was to investigate the existence of autonomic neuropathy on the basis of autonomic tests. The patients and the age-matched controls were evaluated with Neuropathy Symptom Profile and Autonomic Symptom Profile, nerve conduction studies (NCS), and autonomic tests. Patients suffered from neuropathic and autonomic complaints obviously. There was no significant difference for NCS, heart rate variability tests, and sympathetic skin responses (SSRs) among patients and controls. Since both the NCSs and the autonomic tests were within normal, the complaints were considered to be the consequences of the problem in sensory integration due to the dysfunction of the caudal diencephalic A11 group, rather than a neuropathic process. The cardiac autonomic imbalance possibly emerges as a consequence of arousal periods prior to or during the Periodic Leg Movements (PLM) episodes during sleep, but not due to autonomic neuropathy.