Ufuk Utku

Factors affecting the outcome of decompressive craniectomy for large hemispheric infarctions: a prospective cohort study

SummaryBackground. Although surgical decompression of large hemispheric infarction is often a life-saving procedure, many patients remain functionally dependent. The aims of this study were to identify specific factors that can be used to predict functional outcome, thus establish predictive criteria to reduce poor surgical results.Method. In this non-randomized prospective study, we performed decompressive craniectomy in 32 patients (age range, 27 to 77 years) with large hemispheric infarctions. Based on their modified Rankin Score (RS), which was calculated 6 months postoperatively, patients were divided into two functional groups: good (RS 0–3, n = 7) and poor (RS 4–6, n = 25). The characteristics of the two groups were compared using statistical analysis.Findings. One-month mortality was 31%. However, most of the surviving patients were severely disabled (RS 4 or 5), and 6-month total mortality reached 50%. Increased age (≥60 years) (P = 0.010), preoperative midline shift greater than 10 mm (P = 0.008), low preoperative Glasgow Coma Score (GCS≤7) (P = 0.002), presence of preoperative anisocoria (P = 0.032), early (within the first three days of the stroke) clinical deterioration (P = 0.032), and an internal carotid artery infarct (P = 0.069) were the positive predictors of a poor outcome.Interpretation. We view decompressive craniectomy for space-occupying large hemispheric infarction as a life-sparing procedure that sometimes yields good functional outcomes. A dominant hemispheric infarction should not be an exclusion criterion when deciding to perform this operation. Early operation and careful patient selection based on the above-mentioned factors may improve the functional outcome of surgical management for large hemispheric infarction.

Migraine Prevalence and Some Related Factors in Turkey

Objectives.—The aim of our study is to determine the prevalence of migraine in Provincial Center of Edirne.

CADASIL syndrome in a large Turkish kindred caused by the R90C mutation in the Notch3 receptor

Mutations in the Notch3 gene are the cause of the autosomal dominant disorder CADASIL (cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy). The CADASIL is an adult‐onset neurologic disorder (average age of onset is 45 years) characterized by recurrent strokes and dementia. Clinical features combined with cerebral magnetic resonance imaging (MRI), showing a diffuse leukoencephalopathy with subcortical infarcts in the basal ganglia and white matter, are highly contributive to the diagnosis. We present a Turkish family with CADASIL, in which 12 individuals in four generations were affected showing the typical clinical features of recurrent strokes. Mutation analysis of the Notch3 receptor gene identified the recently described R90C mutation in the N‐terminal part of the gene in affected individuals. Interestingly, migraine without aura was found as an initial symptom of the disease in two young mutation carriers (22 and 25 years, respectively), who did not show any additional clinical features or any MRI abnormalities. This indicates that migraine without aura in the absence of MRI abnormalities may represent an early initial symptom of CADASIL, which is difficult to diagnose in the absence of molecular diagnosis. Therefore, the used molecular screening method for Notch3 mutations provides a rapid and accurate diagnostic tool in addition to the standard diagnostic procedures.

Deep cerebral vein thrombosis associated with iron deficiency anaemia in adults

Cerebral venous thrombosis (CVT) is rare and has a wide spectrum of symptoms, therefore it is difficult to diagnose. Thrombosis of the deep cerebral veins occurs very rarely: it has been reported that approximately 6% of patients with CVT have deep CVT, and the prognosis for patients with this condition is poor. CVT has been reported in association with dehydration, a hypercoagulable state, mastoiditis, tumour invasion of a venous sinus, use of oral contraceptives, pregnancy, puerperium, head trauma, vasculitis, and intracranial and systemic infections. However, in the literature, there are few reported cases of CVT in association with iron deficiency anaemia, especially in adults. We present here two patients with bilateral thalamic and basal ganglionic lesions due to thrombosis of the deep cerebral veins. Both of our patients had severe hypochromic microcytic anaemia due to iron deficiency, and both had a good prognosis after 2 months.

Reversible postictal MRI change mimicking structural lesion

A reversible change on magnetic resonance imaging (MRI) following generalised seizure mimicking a tumour-like structural lesion is reported in a 15-year-old patient. MRI revealed a left fronto-parietal cortico-subcortical lesion on T2 weighted images. The control MRI after 5 weeks from the onset revealed no pathological finding. The reversible MRI changes may be the result of a local brain swelling, and a defect of cerebral autoregulation during seizure at the site of activity. The transient nature of such neuroradiological findings have to be taken into consideration in the differential diagnosis because of their similar appearance on imaging to intrinsic brain tumours.

Hepatic myelopathy with spastic paraparesis

Progressive myelopathy is a rare neurological complication of chronic liver disease with portal hypertension and there is no special diagnostic tool for hepatic myelopathy. Neuropathological studies of the patients with hepatic myelopathy have demonstrated demyelination of the lateral corticospinal tracts with various degree of axonal loss. Transcranial magnetic stimulation (TMS) is widely utilized as an indicator of changes in excitability and conductivity of the motor pathways. TMS studies are also used for the diagnosis of hereditary spastic paraparesis in the literature. In this study, we described two patients who presented with spastic paraparesis; TMS studies suggested that they had myelopathy and diagnosed as hepatic myelopathy when all the other possible diagnoses were ruled out.

Ischemic stroke in young adults: risk factors, subtypes, and prognosis.

BackgroundIschemic strokes occurring in patients younger than 47 years is a relatively rare event and accounts for less than 5% of all ischemic strokes in western countries. ObjectiveThe etiologic spectrum in younger patients and older patients differs considerably. MethodsIn this hospital case series study, we enrolled 192 patients with ischemic stroke, aged 18 to 47 years, all of whom were submitted to a diagnostic protocol. The risk factors for stroke and the distribution of stroke subtype and prognosis were studied. Modified diagnostic criteria adopted from the Trial of ORG 10172 in Acute Stroke Treatment and the Baltimore-Washington Cooperative Young Stroke Study, were used for etiologic classification. ResultsHypertension was found to be the main risk factor (45%) followed by cigarette smoking (37%), hyperlipidemia (35.4%), diabetes mellitus (17%), and family history of stroke (18%). Hypertension, diabetes mellitus, hypercholesterolemia, and smoking were present either alone or in combination in the majority of our patients. Oral contraceptives were being taken by 25% of the women. The etiology of stroke was as follows: atherothrombosis 26.5%, cardioembolism 20%, nonatherosclerotic vasculopathies 13%, other determined causes 10%, lacunar stroke 6%, migraine 3.6%, and undetermined causes 21%. ConclusionsHypertension, diabetes mellitus, hypercholesterolemia, and smoking were the most common risk factors in our ischemic stroke patients between 18-47 years of age. Health care programs targeting the prevention and treatment of these factors will reduce the associated morbidity and mortality of stroke among this socioeconomically active age group.

Clinical and neuroradiological predictors of mortality in patients with primary pontine hemorrhage

BACKGROUND AND PURPOSE Primary pontine hemorrhage (PPH) accounts approximately for about 5-10% of intracranial hemorrhages, and PPHs are known to have a much less uniform prognosis. We aimed to evaluate the clinical and radiological predictors affecting the mortality in 32 patients with PPH. MATERIAL AND METHODS We retrospectively evaluated the data of 32 patients with PPH admitted to our clinic between 1994 and 2004. We divided the patients into two groups: (1) patients who survived (14 patients), and (2) patients who died (18 patients). The two groups were compared for age, gender, diabetes mellitus, hypertension, initial clinical status, initial GCS, pupillary abnormalities, ophthalmoparesis, volume and localisation of hemorrhage, intraventricular and extrapontine extension, necessity of mechanical ventilation and hydrocephalus. The hematoma volumes were measured with the formulation described by Broderick. RESULTS Eighteen patients (56%) died and 14 patients (44%) survived. The patients who died (61.3 +/- 8.8) were older than the survivors (56.4 +/- 11.0), but the difference was not statistically significant. The mean GCS was 4.4 +/- 0.2, the mean hematoma volume was 9.9 +/- 3.3 ml for patients who died and the mean GCS was 10.1 +/- 3.3, the mean hematoma volume was 3.3 +/- 1.2 ml for survivors (p < 0.001). Coma on admission (p = 0.001), extrapontine extension (p = 0.001), intraventricular extension (p = 0.019), necessity of mechanical ventilation (p = 0.007), hydrocephalus (p = 0.024), massive and bilateral tegmental localisation (p = 0.006) were found statistically significant predictors for mortality with univariate comparison, and coma on admission (p = 0.038) was the only significant predictor with multivariate regression analysis. CONCLUSION In patients with PPH, it is important to know the prognostic factors for mortality for planning the treatment protocol, and coma and bad clinical status on admission was found the only significant prognostic predictor for mortality with multivariate regression analysis.

Hypercoagulopathy in Stroke Patients with Nonvalvular Atrial Fibrillation: Hematologic and Cardiologic Investigations

The coagulation system is activated and coagulation activation markers are elevated in acute ischemic stroke with nonvalvular atrial fibrillation (NVAF). The etiology, severity, and prognosis of the ischemic stroke might be estimated with the level of the activation of the coagulation system. In this study, prothrombin F1+2 (F1+2), D-dimer, and fibrinogen levels were measured in patients with acute ischemic stroke with and without NVAF, and stroke severity was compared with these hemostatic parameters. Of 55 patients, 29 had sinus rhythm (group I), 26 had NVAF (group II); 20 healthy subjects (group III) were included in the study. Subtypes of cerebral infarction were classified. The patients underwent stroke severity, electrocardiography, echocardiography, cranial computed tomography, cervical duplex ultrasonography, and hemostatic parameter studies. In group II, F1+2 level (2.83±0.89) was significantly higher than in group I (2.33±0.80) and III (1.94±0.64) (p values: group I-II, 0.036; groups II-III, 0.001; groups I-III, 0.104). In group III, fibrinogen level (251.64±60.96) was significantly lower than that in groups I (347.97±111.49) and II (364.04±86.20) (p=0.001). D-dimer was not significantly different between groups. In group I, lacunar syndrome (LACS), and in group II, partial and total anterior circulation syndrome (PACS+TACS) were more common (p=0.013, p=0.001, respectively). In group II, Scandinavian Stroke Scale scores were lower than those in group I (group I=45.2±14, group II=35.4±18.9, p=0.02). In conclusion, activation of coagulation, demonstrated by increment F1+2, is more abundant in the stroke patients with NVAF than in the stroke patients with sinus rhythm. Our results also showed that activation of the hemostatic system might be related to stroke subtype and stroke severity. It is suggested that the oral anticoagulation treatment as prophylaxis is important in the prevention of stroke in patients with NVAF.

Risk factors of status epilepticus in children.

Abstract Background : Although there is abundant literature about the morbidity and mortality rates of status epilepticus (SE), little is known about the risk factors of this medical emergency. The aim of the present study is to assess the risk factors of SE in children.