Clinical Neuroscience

[Clinical neurophysiological methods in diagnosis and treatment of cerebrovascular diseases]

NAGY Ildikó, FABÓ Dániel

JANUARY 30, 2018

Clinical Neuroscience - 2018;71(01-02)

DOI: https://doi.org/10.18071/isz.71.0007

[Neurophysiological methods are gaining ground in the diagnosis and therapy of cerebrovascular disease. While the role of the EEG (electroencephalography) in the diagnosis of post-stroke epilepsy is constant, quantitative EEG para-meters, as new indicators of early efficiency after thrombolysis or in prognosis of patient’s condition have proved their effectiveness in several clinical studies. In intensive care units, continuous EEG monitoring of critically ill patients became part of neurointenzive care protocols. SSEP (somatosesnsory evoked potencial) and EEG performed during carotid endarterectomy, are early indicative intraoperativ neuromonitoring methods of poor outcome. Neurorehabilitation is a newly discovered area of neurophysiology. Clinical studies have demonstrated the effectiveness of repetitive transcranial magnetic stimulation (rTMS) in the rehabilitation of stroke patients. Brain computer interface mark the onset of modern rehabi-litation, where the function deficit is replaced by robotic tehnology. ]

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Clinical Neuroscience

Insights into the structure and function of the hippocampal formation: Relevance to Parkinson’s disease

GYÖRFI Orsolya, NAGY Helga, BOKOR Magdolna, KÉRI Szabolcs

The link between the hippocampus and declarative memory dysfunctions following the removal of the medial temporal lobe opened unexplored fields in neuroscience. In the first part of our review, we summarized current theoretical frameworks discussing the role of hippocampus in learning and memory. Several theories are highlighted suggesting that the hippocampus is responsible for assembling stimulus elements into a unitary representation that later can be utilized to simulate future events. The hippocampal formation has been implicated in a growing number of disorders, from neurodegenerative diseases to atypical cognitive ageing and depression. Recent neuroimaging studies provided new opportunities to study in detail the hippocampal formation’s role in higher levels of the nervous system. We will present data regarding the regional specialization of the hippocampus in experimental models developed for healthy and neurological conditions with a special focus on Parkinson’s disease. Combined evidence from neuroimaging studies suggested that hippocampal volume is reduced in non-demented, newly diagnosed patients with Parkinson’s disease, which is associated with impaired memory performance. These findings proposed that, beyond the well-known striatal dopamine loss, impaired hippocampal synaptic plasticity may contribute to cognitive and affective impairments in early Parkinson’s disease.

Clinical Neuroscience

Association of cardiovascular risk factors and Parkinson’s disease - case-control study in South East Hungary

MARKÓ-KUCSERA Mária, VÉCSEI László, PAULIK Edit

Aims - Parkinson’s disease (PD) has the second highest incidence among neurodegenerative diseases in the world population. The study aimed to investigate the presence of some cardiovascular risk factors - dyslipidemia, diabetes, and hypertension - in PD patients and to compare their risk with non-PD population in South East Hungary. Methods - A case-control study was conducted at the Department of Neurology, University of Szeged, Hungary. The study included 1299 subjects out of which 620 patients were identified as cases of diagnosed PD and 679 as controls. Logistic regression analyses were conducted to reveal the association of vascular risk factors with PD. Results - In the univariate analysis, diabetes mellitus was positively associated with PD, while dyslipidemia showed negative association to it in the total population, and no significant associations were found between hypertension and PD. The multivariate logistic regression models showed that the odds of diabetes mellitus was higher (OR=2.86), while the odds of dyslipidemia was lower (OR=0.58) among PD patients than in the control group. Hypertension showed a different pattern by gender: the odds of registered hypertension was significantly lower in female PD patients (OR=0.68), whereas the result was not significant in males. Conclusions - This is the first study that provides a comprehensive view of the cardiovascular risk factors in PD patients in Hungary and shows considerable relationship between diabetes mellitus and PD.

Clinical Neuroscience

[The facets of creativity in the light of bipolar mood alterations]

SZAKÁCS Réka

[The link between creativity, as the highest expression form of human achievement, and bipolar disorder came into focus of scientific investigations and research. Accomplished writers, composers and visual artists show a substantially higher rate of affective disorders, prodominantly bipolar mood disorders, comparing to the general population. Then again, patients afflicted with bipolar II subtype (hypomania and depression), as well as persons presenting the mildest form of bipolar mood swings (cyclothymia) possess higher creative skills. It evokes therefore that certain forms and mood states of bipolar disorder, notably hypomania might convey cognitive, emotional/affective, and motivational benefits to creativity. The aim of this paper is to display expression forms of creativity (writing, visual art, scientific work) as well as productivity (literary and scientific work output, number of artworks and exhibitions, awards) in the light of clinically diagnosed mood states at an eminent creative individual, treated for bipolar II disorder. Analysing the affective states, we found a striking relation between hypomanic episodes and visual artistic creativity and achievement, as well as scientific performance, whereas mild-moderate depressed mood promoted literary work. Severe depression and mixed states were not associated with creative activities, and intriguingly, long-term stabilised euthymic mood, exempted from marked affective lability, is disadvantageous regarding creativity. It seems, thereby, that mood functions as a sluice of creativity. Nevertheless, it is likely that there is a complex interaction between bipolar mood disorder spectrum and psychological factors promoting creativity, influenced also by individual variability due to medication, comorbid conditions, and course of disorder.]

Clinical Neuroscience

[Effects of nasal provocation with a single-dose allergen on the explicit and implicit memory of physically active and inactive patients with ragweed allergy]

TOKODI Margaréta, CSÁBI Eszter, KIRICSI Ágnes, SCHULTZ Rebeka, MOLNÁR H Andor, ROVÓ László, BELLA Zsolt

[Background and purpose - Allergy is an endemic disease and has a considerable impact on the quality of life. This study aimed to measure the effect of active allergic rhinitis on memory functions of physically active and inactive patients with ragweed allergy. Methods - Memory functions were assessed before and after allergen exposure. Participants in both groups were provoked nasally with 30 IR/mL ragweed allergen in each nostril. Explicit memory was measured with story-recalling and implicit memory was investigated with reaction time task. Results - In neuropsychological assessments athletes performed significantly better, compared with the control group after allergen provocation in short-term and long-term memory functions. There was no difference between the groups in the implicit tasks. Athletes have achieved better results after provocation, comparing to the baseline test and the tests that measured short-term and long-term memory functions. Conclusion - Short-term disturbing factors, e.g. swollen nasal mucosa, sneezing, and watery eyes after provocation did have not caused deterioration in cognitive functions. A single-shot allergen in high doses have caused an increase of mental concentration, which was more pronounced in athletes.]

Clinical Neuroscience

Electroclinical and prognostic characteristics of epilepsy patients with photosensitivity

YAZAR Olgun Hülya, GUL Gunay, YAZAR Tamer, EREN Fulya, KUSCU Yandım Demet, KIRBAS Dursun

Background - Epilepsy with photosensitivity (PSE) is one of the reflex epilepsy types with pathophysiology still unexplained. In our study we aimed to evaluate the clinical, electroencephalogram (EEG) and prognosis of patients with PSE diagnosis. Method - A total of 44 patients with PSE diagnosis according to international classification were included in this retrospective and cross-sectional study. The age, gender, syndrome, clinical and EEG characteristics of patients, and treatment response were investigated. Results - The mean age was 22.09±6.49 years for 28 females and 16 males included in the study. Of patients, 17 had idiopathic photosensitive occipital lobe epilepsy (IPOLE), 11 had juvenile myoclonic epilepsy (JME), 11 had other PSE and 5 had juvenile absence epilepsy (JAE), with the most common visual trigger factors television and sunlight. In terms of seizure type, the most common was generalized tonic clonic seizure (GTCS), with myoclonus, absence and other seizure types observed. There was family history present in 17 patients and valproic acid was most commonly used for treatment. Conclusion - As noted in the literature, our data show that PSE has defined age group and clinical presentation, good prognosis but requires correct choice of medication for treatment. It is thought that good description of these epilepsy types will reduce misdiagnosis and mistreatment rates.

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Clinical Neuroscience

Comparison of hospitalized acute stroke patients’ characteristics using two large central-eastern european databases

ORBÁN-KIS Károly, SZŐCS Ildikó, FEKETE Klára, MIHÁLKA László, CSIBA László, BERECZKI Dániel, SZATMÁRI Szabolcs

Objectives – Stroke is the third leading cause of death in the European region. In spite of a decreasing trend, stroke related mortality remains higher in Hungary and Romania when compared to the EU average. This might be due to higher incidence, increased severity or even less effective care. Methods – In this study we used two large, hospital based databases from Targu Mures (Romania) and Debrecen (Hungary) to compare not only the demographic characteristics of stroke patients from these countries but also the risk factors, as well as stroke severity and short term outcome. Results – The gender related distribution of patients was similar to those found in the European Survey, whereas the mean age of patients at stroke onset was similar in the two countries but lower by four years. Although the length of hospital stay was significantly different in the two countries it was still much shorter (about half) than in most reports from western European countries. The overall fatality rate in both databases, regardless of gender was comparable to averages from Europe and other countries. In both countries we found a high number of risk factors, frequently overlapping. The prevalence of risk factors (hypertension, smoking, hyperlipidaemia) was higher than those reported in other countries, which can explain the high ratio of recurring stroke. Discussion – In summary, the comparatively analyzed data from the two large databases showed several similarities, especially regarding the high number of modifiable risk factors, and as such further effort is needed regarding primary prevention.

Clinical Neuroscience

Is stroke indeed a “Monday morning disease”?

FOLYOVICH András, BÉRES-MOLNÁR K Anna, GIMESI-ORSZÁGH Judit, KATONA Lajos, BICZÓ Dávid, VÖRÖS Károly, GŐBL Gábor, AJTAY András, BERECZKI Dániel

Introduction - The therapeutic time window of acute stroke is short. Decision on the use of intravenous thrombolysis is based on well-defined criteria. Any delay in the transport to a designated stroke centre decreases the odds of therapeutic success. In Hungary, the admission rate of stroke patients peaks on Monday, the number gradually decreasing by the end of the week. This phenomenon has long been suggested to be due to the lack of emergency care approach. According to the literature, however, returning to work following a holiday is a risk factor for acute stroke. A similar phenomenon is well-known in veterinary medicine, a condition in horses referred to as ‘Monday morning disease’. In our study, we analysed the distribution of admissions due to acute stroke by the day of the week in 4 independent data sources. Patients and methods - The number of patients admitted to the Szent János Hospital, Budapest, Hungary with stroke and that of emergency ambulance transports in the whole city of Budapest due to acute stroke were analysed in the period between January 1 and March 31, 2009. The distribution of thrombolytic interventions reflecting hospitalizations for hyperacute stroke was analysed based on data of the Szent János Hospital in 2009-2012, and on national data from 2006-2012. Descriptive statistics was used to present the data. The variation between daily admission was compared by chi-square test. Results - The proportion of daily admission of stroke patients admitted to the Szent János Hospital was the highest at the beginning of the week (18% on Monday, and 21% on Tuesday) and the lowest on the weekend (9% and 9% on Saturday and Sunday, respectively). The distribution of ambulance transports in Budapest due to acute stroke tended to be similar (15% and 15% on Monday and Tuesday, whereas 13% and 12% on Saturday and Sunday, respectively) on different days of the week. No such Monday peak could be observed in a single centre regarding thrombolytic interventions: 18% and 19% of the total of 80 thrombolytic interventions in the Szent János Hospital were performed on Monday and Sunday, respectively. At the national level the higher Monday rate is obvious: during a 7-year period 16.0%, 12.7%, and 13.5% of all thrombolytic interventions in Hungary were performed on Monday, Saturday and Sunday, respectively. Conclusion - Monday preference of stroke is not exclusively caused by the lack of emergency care approach, and the phenomenon is not consistent at the individual hospital level in cases undergoing thrombolysis.

Clinical Neuroscience

[Thrombolysis in case of ischemic stroke caused by aortic dissection]

LANTOS Judit, NAGY Albert, HEGEDŰS Zoltán, BIHARI Katalin

[Seldom, an acute aortic dissection can be the etiology of an acute ischemic stroke. The aortic dissection typically presents with severe chest pain, but in pain-free dissection, which ranges between 5-15% of the case, the neurological symptoms can obscure the sypmtos of the dissection. By the statistical data, there are 15-20 similar cases in Hungary in a year. In this study we present the case history of an acute ischemic stroke caused by aortic dissection, which is the first hungarian publication in this topic. A 59-year-old man was addmitted with right-gaze-deviation, acute left-sided weakness, left central facial palsy and dysarthric speech. An acute right side ischemic stroke was diagnosed by physical examination without syptoms of acute aortic dissection. Because, according to the protocol it was not contraindicated, a systemic intravenous thrombolysis was performed. The neurological sypmtoms disappeared and there were no complication or hypodensity on the brain computed tomography (CT). 36 hours after the thrombolysis, the patient become restlessness and hypoxic with back pain, without neurological abnormality. A chest CT was performed because of the suspition of the aortic dissection, and a Stanford-A type dissection was verified. After the acute aortic arch reconstruction the patient died, but there was no bleeding complication at the dissection site caused by the thrombolysis. This case report draws attention to the fact that aortic dissection can cause acute ischemic stroke. Although it is difficult to prove it retrospectively, we think the aortic dissection, without causing any symptoms or complain, had already been present before the stroke. In our opinion both the history of our patient and literature reviews confirms that in acute stroke the thrombolysis had no complication effect on the aortic dissection but ceased the neurological symptoms. If the dissection had been diagnosed before the thrombolysis, the aortic arch reconstruction would have been the first step of the treatment, without thrombolysis. ]

Clinical Neuroscience

[Dizziness - vertigo Warning symptoms in vertebrobasilar ischemia - Part I. ]

FAZEKAS András

[Dizziness and vertigo - like headache - are the most common complaints which leads patients to visit the doctor. In spite of the headache - which may be primary (e.g. migraine) or symptomatic - dizziness and vertigo do not appear to be a separate nosologic entity but rather the symptoms of several neurological disorders. For differential diagnosis, interdisciplinary thinking and activity is needed because the vestibular, neurological and psychiatric disorders might have a common role in the development of symptoms and further overlapping can also occur. The vascular disorders of the vertebrobasilar system are discussed in detail in this review. The importance, occurrence and causes of vertigo as a warning symptom is in the focus. The author draws attention to life-threatening conditions with acute onset in cases of the posterior scale ischemia and emphasizes the importance of the correct and early diagnosis. The author tries to clear up the nihilistic aspect in treating of stroke and stresses the necessity of thrombolysis and interventional radiological procedures which may be the only chance for the recovery of the patients. The pharmacological prevention of recurrent vascular events is also important and obligatory for the clinicians.]

Clinical Neuroscience

[Angioneuritic edema in ischaemic stroke patients treated with rt-PA]

LOVÁSZ Rita, SAS Attila, KOLLÁR Tibor, PETERCSÁK Edina, FEKETE István, BILINSZKI Erika, VALIKOVICS Attila

[Data of our 254 patients who were treated with rt-PA between 1st of Jan, 2011 and 31st of Dec, 2014 were processed. We focused on angioneurotic oedema as allergic complication of thrombolysis which caused life threatening respiratory obstruction in two cases. We describe these two patients’ history. Out of 254 patients six (2.3%) suffered angioneurotic edema caused respiratory obstruction in two (0.90%) cases. This occurrence is approximately 1.3-5.1% in literature. Five, out of six patients who suffered from angioneurotic oedema, had been treated with ACE inhibitors or ARB before. The role of ACE inhibitors is known in metabolism of bradykinin cascade. Plasmin which present during thrombolysis, precipitates biochemical mechanisms of this potential life threatening complication. Therefore rt-PA alone can be the cause of angioedema, but it can be more frequent together with ACE inhibitors therapy.]