Clinical Neuroscience

[Hungarian Society of Neurologists and Mental Physicians SZOTE neurological round table]

SEPTEMBER 20, 1996

Clinical Neuroscience - 1996;49(09-10)

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Clinical Neuroscience

[Hemodynamic adaptation of fetal brain]

JAKOBOVITS Ákos, HENDRIK Jörn

[Doppler color ultrasonography of the middle cerebral and umbilical arteries was performed on 104 fetuses born at term. A total of 254 investigations were carried out. Of the 104 fetuses studied, 52 infants had birth weights appropriate for gestational age (mean 3409.2 g) and 52 infants were small for gestational age (mean 2272.1 g). Cerebral hemodynamic adaptation was observed in growth retarded fetuses due to placenta! insufficiency. ln these cases the elevated umbilical vascular resistance evidenced the placenta! insufficiency. At the same time the decrease of the cerebral vascular velocimetry indexes indicated the improving cerebral blood supply. Only the systolic/diastolic ratio was significantly reduced in growth retarded fetuses when compared with normal controls. ln the umbilical artery the pulsatility index and systolic/diastolic ratio were raised significantly in growth retarded fetuses. The ratio of the cerebral arterial to umbilical cord artery index values proved a better indicator of the difference between growth retarded and normal controls than the index of the cerebral or umbilical artery alone. The ratios of all three index values of the growth retarded fetuses were significantly smaller than those of the normal controls (pulsatility index 1.03 versus 1. 60, resistance index 0.84 versus 1.19 and systolic/diastolic ratio 1.01 versus 2.02). The ratios of the small for date fetuses due to other, nonplacental causes were simi­ lar to the normal controls. The blood circulation disorder evokes hemodynamic adaptation in the feta! brain. The intrauterine growth restriction is a consequence of this disturbed blood supply. The cerebral circulatory adaptation failed in the small for date fetuses non associated with decreased blood supply.]

Clinical Neuroscience

[Distal Ulnar Neuropathies]

KISS Gábor, KÓMÁR József

[Compression of the distal part of the ulnar nerve is an uncommon entrapment neuropathy. Depending on the site of compression it may result in pure motor symptoms. The atrophy of the small hand muscles without sensory deficit may mimic motor neuron disease. Correct clinical examination and electrophysiology including measurement of ulnar distal motor latency to the first dorsal interosseous muscle can reveal the correct diagnosis. 46 surgically treated cases of distal ulnar neuropathy are reported. 12 patients had only muscle weakness without sensory abnormalities. 6 of them showed motor deficit restricted to the first dorsal interosseous and adductor pollicis muscles. 34 patients were followed up 31 of them improved, 3 cases should be reoperated because of recidive lipoma.]

Clinical Neuroscience

[Importance of sociological and psychological factors in pathogenesis of ischaemic stroke]

MENDE Lilla, JÓRI Birkás Adrien, FAZEKAS Gábor, FAZEKAS András

[The authors investigate sociological and psychological factors in the pathogenesis of ischaemic stroke, as a follow up of their earlier study. In the first part of the recent study patients and control subjects are compared in terms of frequency, severity, type and the temporal distribution of life events within the 5 years preceding the stroke. In the second part the importance of coping-style and psychological characteristics are studied. It is shown that the likely factors leading to stroke are: lower life events score in the more distant period, but higher life events score preceding the stroke, poor coping, greater emotional instability, trait-anxiety, hostility, and decreased job involvement. The type of life events, global Type-A behaviour, "speed and impatience", "hard driving and competitiveness” seem indifferent. On the basis of these results a successful stroke-programme should consider the complexity of somatic, sociological and psychological factors.]

Clinical Neuroscience

[Transoesophageal echocardiography after stroke]

NAGY Lajos, SÁMOCYI Marianna, TARJÁN Jenő, GARZULY Ferenc

[40 stroke patients were studied by both transoesophageal and transthoracic echocardiography. The diagnosis of stroke was based on medical history, physical examination and computerized tomographic brain scan. 39 patients underwent carotid duplex scan as well. Transoesphageal echocardiography was used to examine 40 patients of whom 19 had cardiac source of embolism. Out of these, 7 patients had definitive, whereas 12 had possible cardiac source of embolism. Transthoracic echocardiography was diagnostic only in 8 cases. Using carotid duplex scan, carotid stenosis was detected in 8 patients and sclerosis without significant stenosis in 8 others. From each of these two groups 4 patients had coexistent cardiac source of embolism as well. In the 8 patients with atrial fibrillation the left atrial thrombus and spontaneous echo contrast were more frequent than in patients with sinus rhythm. The transoesophageal echocardiography altered the management of antico agulation in 3 patients. The authors concluded that transoesophageal echocardiography is necessary in stroke patients.]

Clinical Neuroscience

[Prognosis of neuroepithelial tumours by means of cell proliferation studies]

GYÖMÖRI Éva, MÉSZÁROS István, MÉHES Gábor, DÓCZI Tamás, PAJOR László

[Cell-kinetic analysis of tumours has recently been widely used in clinical oncology for prognosis of patients treated with malignant neoplasms and for controlling the efficiency of treatment protocols. Definition of biological nature of neuroepithelial tumours was based on grading depending on the severity of cellular anaplasia. Neuroepithelial tumours can be characterized not only by the histological features but also by the DNA content and abnormalities of the cell proliferation – though the relationship between histological malignancy, proliferative activity and cellular aneuploidity was found to be rather controversial according to the literature. In this review article the clinical value of cell cycle analysis such as distribution of DNA content, DNA index; S-phase fraction; proliferation-markers [MIB 1 antibody, bromdeoxy uridin labelling index, mitotic index, definition of nucleolar organization region) are discussed on the basis of personal experience and review of the appropriate literature. Flow cytometry and examination of proliferation markers have a significant role in the definition of prognosis of patients suffering from WHO grade II and III neuroepithelial tumours. Gliomas giving rise to recidivism have a rapid cell cycle already at their first occurrence, which is characterized by raised proliferation indices, and occurrence of aneuploid cell clones. An unfavourable outcome can be prognosed in patients suffering from a WHO grade II or III glioma if the DNA index is above or below 1+0.1 if the value of the S phase fraction is above 6%, if more than 1 mitosis is found in 10 large magnification field, and if the number of cells labelled with MIB 1 antibody exceeds 3 in 1 large magnification field. The literature confirms our notion that further studies of proliferation characteristics may help in the production of a malignity score of gliomas that could support the efficiency of traditional histological grading in prognosis and control of complex therapy of these tumours.]

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Clinical Neuroscience

Cases of inborn errors of metabolism diagnosed in children with autism

CAKAR Emel Nafiye, YILMAZBAS Pınar

Autism spectrum disorder is a neurodevelopmental disorder with a heterogeneous presentation, the etiology of which is not clearly elucidated. In recent years, comorbidity has become more evident with the increase in the frequency of autism and diagnostic possibilities of inborn errors of metabolism. One hundred and seventy-nine patients with diagnosis of autism spectrum disorder who presented to the Pediatric Metabolism outpatient clinic between 01/September/2018-29/February/2020 constituted the study population. The personal information, routine and specific metabolic tests of the patients were analyzed retrospectively. Out of the 3261 patients who presented to our outpatient clinic, 179 (5.48%) were diagnosed with autism spectrum disorder and were included in the study. As a result of specific metabolic examinations performed, 6 (3.3%) patients were diagnosed with inborn errors of metabolism. Two of our patients were diagnosed with classical phenylketonuria, two with classical homocystinuria, one with mucopolysaccharidosis type 3D (Sanfilippo syndrome) and one with 3-methylchrotonyl Co-A carboxylase deficiency. Inborn errors of metabolism may rarely present with autism spectrum disorder symptoms. Careful evaluation of the history, physical examination and additional findings in patients diagnosed with autism spectrum disorder will guide the clinician in the decision-making process and chose the appropriate specific metabolic investigation. An underlying inborn errors of metabolism may be a treatable cause of autism.

Clinical Neuroscience

Late simultaneous carcinomatous meningitis, temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting with mono-symptomatic vertigo – a clinico-pathological case reporT

JARABIN András János, KLIVÉNYI Péter, TISZLAVICZ László, MOLNÁR Anna Fiona, GION Katalin, FÖLDESI Imre, KISS Geza Jozsef, ROVÓ László, BELLA Zsolt

Although vertigo is one of the most common complaints, intracranial malignant tumors rarely cause sudden asymmetry between the tone of the vestibular peripheries masquerading as a peripheral-like disorder. Here we report a case of simultaneous temporal bone infiltrating macro-metastasis and disseminated multi-organ micro-metastases presenting as acute unilateral vestibular syndrome, due to the reawakening of a primary gastric signet ring cell carcinoma. Purpose – Our objective was to identify those pathophysiological steps that may explain the complex process of tumor reawakening, dissemination. The possible causes of vestibular asymmetry were also traced. A 56-year-old male patient’s interdisciplinary medical data had been retrospectively analyzed. Original clinical and pathological results have been collected and thoroughly reevaluated, then new histological staining and immunohistochemistry methods have been added to the diagnostic pool. During the autopsy the cerebrum and cerebellum was edematous. The apex of the left petrous bone was infiltrated and destructed by a tumor mass of 2x2 cm in size. Histological reexamination of the original gastric resection specimen slides revealed focal submucosal tumorous infiltration with a vascular invasion. By immunohistochemistry mainly single infiltrating tumor cells were observed with Cytokeratin 7 and Vimentin positivity and partial loss of E-cadherin staining. The subsequent histological examination of necropsy tissue specimens confirmed the disseminated, multi-organ microscopic tumorous invasion. Discussion – It has been recently reported that the expression of Vimentin and the loss of E-cadherin is significantly associated with advanced stage, lymph node metastasis, vascular and neural invasion and undifferentiated type with p<0.05 significance. As our patient was middle aged and had no immune-deficiency, the promoting factor of the reawakening of the primary GC malignant disease after a 9-year-long period of dormancy remained undiscovered. The organ-specific tropism explained by the “seed and soil” theory was unexpected, due to rare occurrence of gastric cancer to metastasize in the meninges given that only a minority of these cells would be capable of crossing the blood brain barrier. Patients with past malignancies and new onset of neurological symptoms should alert the physician to central nervous system involvement, and the appropriate, targeted diagnostic and therapeutic work-up should be established immediately. Targeted staining with specific antibodies is recommended. Recent studies on cell lines indicate that metformin strongly inhibits epithelial-mesenchymal transition of gastric cancer cells. Therefore, further studies need to be performed on cases positive for epithelial-mesenchymal transition.

Clinical Neuroscience

Alexithymia is associated with cognitive impairment in patients with Parkinson’s disease

SENGUL Yildizhan, KOCAK Müge, CORAKCI Zeynep, SENGUL Serdar Hakan, USTUN Ismet

Cognitive dysfunction (CD) is a common non-motor symptom of Parkinson’s disease (PD). Alexithy­mia is a still poorly understood neuropsychiatric feature of PD. Cognitive impairment (especially visuospatial dysfunction and executive dysfunction) and alexithymia share com­mon pathology of neuroanatomical structures. We hypo­thesized that there must be a correlation between CD and alexithymia levels considering this relationship of neuroanatomy. Objective – The aim of this study was to evaluate the association between alexithymia and neurocognitive function in patients with PD. Thirty-five patients with PD were included in this study. The Toronto Alexithymia Scale–20 (TAS-20), Geriatric Depression Inventory (GDI) and a detailed neuropsychological evaluation were performed. Higher TAS-20 scores were negatively correlated with Wechsler Adult Intelligence Scale (WAIS) similarities test score (r =-0.71, p value 0.02), clock drawing test (CDT) scores (r=-0.72, p=0.02) and verbal fluency (VF) (r=-0.77, p<0.01). Difficulty identifying feelings subscale score was negatively correlated with CDT scores (r=-0.74, p=0.02), VF scores (r=-0.66, p=0.04), visual memory immediate recall (r=-0.74, p=0.01). VF scores were also correlated with difficulty describing feelings (DDF) scores (r=-0.66, p=0.04). There was a reverse relationship bet­ween WAIS similarities and DDF scores (r=-0.70, p=0.02), and externally oriented-thinking (r=-0.77,p<0.01). Executive function Z score was correlated with the mean TAS-20 score (r=-62, p=0.03) and DDF subscale score (r=-0.70, p=0.01) Alexithymia was found to be associated with poorer performance on visuospatial and executive function test results. We also found that alexithymia was significantly correlated with depressive symptoms. Presence of alexithymia should therefore warn the clinicians for co-existing CD.

Clinical Neuroscience

[The role of sleep in the relational memory processes ]

CSÁBI Eszter, ZÁMBÓ Ágnes, PROKECZ Lídia

[A growing body of evidence suggests that sleep plays an essential role in the consolidation of different memory systems, but less is known about the beneficial effect of sleep on relational memory processes and the recognition of emotional facial expressions, however, it is a fundamental cognitive skill in human everyday life. Thus, the study aims to investigate the effect of timing of learning and the role of sleep in relational memory processes. 84 young adults (average age: 22.36 (SD: 3.22), 21 male/63 female) participated in our study, divided into two groups: evening group and morning group indicating the time of learning. We used the face-name task to measure relational memory and facial expression recognition. There were two sessions for both groups: the immediate testing phase and the delayed retesting phase, separated by 24 hours. 84 young adults (average age: 22.36 (SD: 3.22), 21 male/63 female) participated in our study, divided into two groups: evening group and morning group indicating the time of learning. We used the face-name task to measure relational memory and facial expression recognition. There were two sessions for both groups: the immediate testing phase and the delayed retesting phase, separated by 24 hours. Our results suggest that the timing of learning and sleep plays an important role in the stabilizing process of memory representation to resist against forgetting.]

Clinical Neuroscience

Evaluation of the effectiveness of transforaminal epidural steroid injection in far lateral lumbar disc herniations

EVRAN Sevket, KATAR Salim

Far lateral lumbar disc herniations (FLDH) consist approximately 0.7-12% of all lumbar disc herniations. Compared to the more common central and paramedian lumbar disc herniations, they cause more severe and persistent radicular pain due to direct compression of the nerve root and dorsal root ganglion. In patients who do not respond to conservative treatments such as medical treatment and physical therapy, and have not developed neurological deficits, it is difficult to decide on surgical treatment because of the nerve root damage and spinal instability risk due to disruption of facet joint integrity. In this study, we aimed to evaluate the effect of transforaminal epidural steroid injection (TFESI) on the improvement of both pain control and functional capacity in patients with FLDH. A total of 37 patients who had radicular pain caused by far lateral disc herniation which is visible in their lumbar magnetic resonance imaging (MRI) scan, had no neurological deficit and did not respond to conservative treatment, were included the study. TFESI was applied to patients by preganglionic approach. Pre-treatment Visual Analogue Scale (VAS) and Oswestry Disability Index (ODI) scores of the patients were compared with the 3rd week, 3rd month and 6th month scores after the procedure. The mean initial VAS score was 8.63 ± 0.55, while it was 3.84 ± 1.66, 5.09 ± 0.85, 4.56 ± 1.66 at the 3rd week, 3rd month and 6th month controls, respectively. This decrease in the VAS score was found statistically significant (p = 0.001). ODI score with baseline mean value of 52.38 ± 6.84 was found to be 18.56 ± 4.95 at the 3rd week, 37.41 ± 14.1 at the 3rd month and 34.88 ± 14.33 at the 6th month. This downtrend of pa­tient’s ODI scores was found statistically significant (p = 0.001). This study has demonstrated that TFESI is an effective method for gaining increased functional capacity and pain control in the treatment of patients who are not suitable for surgical treatment with radicular complaints due to far lateral lumbar disc hernia.