Clinical Neuroscience

[MIET headache section II. Continuing Education Conference, Abstracts]

JANUARY 20, 1996

Clinical Neuroscience - 1996;49(01-02)

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Clinical Neuroscience

[Differential diagnosis of Parkinson's syndrome]

FERENC Fornádi

[The fundamental improvement of therapy in Parkinson's disease during the last 25 years also led to specific requirements in differential diagnosis of Parkinson-like diseases. It has become rapidly apparent that the idiopathic Parkinson's syndrome can be treated by a substitutional levodopa therapy very well in the beginning. Considering this fact especially in the case of a so-called "primary levodopa failure" a profound differential diagnosis is necessary. On the other hand an initially diagnosed Parkinson's disease can change its character and develops a widening if symptoms secondary to a reduced levodopa responsiveness. This process can be explained bz a spread of affected cerebral systems known as multy system atrophy (MSA). In former times the differentiation of Parkinson-like diseases could only be done by clinical examination and with regard to a missing levodopa responsiveness. In the last decade diagnostic availabilities became more and more. In addition to MRI and SPECT the 18-FDG- and 18-F-levodopa-PET-scan is very helpful in the cases mentioned above. The following presentation of differential diagnosis in Parkinson-like diseases outlines especially the possibilities of PET-screening.]

Clinical Neuroscience

[Sumatriptan autoinjection in the acute treatment of migraine attack]

ERTSEY Csaba, JELENCSIK Ilona, ÁFRA Judit, BOZSIK György

[The authors report the results of the first Hungarian trial of 5-HT1 receptor agonist sumatriptan autoinjector in the acute treatment of migraine. During the treatment of 400 attacks in 67 patients a significant headache relief was reported in 41% after 30 minutes p. i. and 80.5% after 120 minutes p. i., respectively. In the same time frame complete dissolution of the headache was reported in 39.5% and 72%. The majority of the accompanying symptoms disappeared before the headache relief. Migraine recurrence was frequently noted (45.1% of all attacks). Slight side-effects were experienced in 36% of the attacks treated; in one case skin rash and in another one a temporary chest pain was reported. Using the autoinjector device did not pose serious problems to the patients.]

Clinical Neuroscience

[Vasoreactivity changes of healthy volunteers investigated by transcranial doppler]

VALIKOVICS Atilla, OLÁH László, FÜLESDI Béla, MUNKÁCSY Csaba, CSIBA László

[Transcranial Doppler (TCD) was used to measure the effect of 1 g acetazolamide (Diamox, Lederle) on blood flow velocity in the middle cerebral artery of 50 healthy volunteers (aged 20-70 years). Parameters of blood flow, blood pressure, heart rate and blood gas values were determined before and after intravenous administration of Diamox. The reserve capacity was expressed as a percentage change of baseline values. The acetazolamide did not result in significant blood pressure and blood gas changes. The mean velocity of blood flow before Diamox administration was 59.8+14.4 cm/s. The velocity of flow significantly increased after acetazolamide, peaking after 10 minutes. The extent of reserve capacity was the greatest in the age group of 31-40 years and the smallest in the 61-70 years group. The reaction was longer lasting in age groups over 50 years. Significantly higher flow parameters and greater reserve capacity was found in women than in men at each measuring time point. The reserve capacity depended on age and gender.]

Clinical Neuroscience

[Distant neuromuscular effect of locally injected botulinum toxin]

DIÓSZEGHY Péter, GLAUB Teodóra, MECHLER Ferenc

[Distant neuromuscular effect of locally infiltrated botulinum toxin was studied. The extensor digitorum communis muscle far from the place of injection was sampled with single-fiber EMG in patients treated for spasmodic torticollis. In 2 and 8–16 weeks after the infiltration the mean jitter values increased significantly compared to that of the results before the treatment. Extremely increased jitter values and blocks were found, too. The fiber density was also higher after the botulinum toxin infiltration. The electrophysiological changes may be a consequence of presynaptic blockade, the botulinum toxin induced terminal sprouting of motor axons and formation of new neuromuscular junctions. Parallel with the electrophysiological abnormalities no remote clinical effects were found. The single-fiber EMG proved to be a sensitive method to control the remote neuromuscular effect of botulinum toxin.]

Clinical Neuroscience

[Schizophrenia-like psychotic episode in Multiple sclerosis]

SIMÓ Magdolna, RÓZSA Csilla, BODROGI László, TAKÁTS Annamária

[A case is presented of a twenty-year-old female with multiple sclerosis. In 1990 the patient had three exacerbations with cerebellar, optic and pyramidal symptoms. After a four-year period of remission she was hospitalized with acute schizophrenia-like psychosis. Acute psychosis is an uncommon manifestation of multiple sclerosis which may cause difficulties in differential diagnosis.]

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Clinical Neuroscience

Life threatening rare lymphomas presenting as longitudinally extensive transverse myelitis: a diagnostic challenge

TOLVAJ Balázs, HAHN Katalin, NAGY Zsuzsanna, VADVÁRI Árpád, CSOMOR Judit, GELPI Ellen, ILLÉS Zsolt, GARZULY Ferenc

Background and aims – Description of two cases of rare intravascular large B-cell lymphoma and secondary T-cell lymphoma diagnosed postmortem, that manifested clinically as longitudinally extensive transverse myelitis (LETM). We discuss causes of diagnostic difficulties, deceptive radiological and histological investigations, and outline diagnostic procedures based on our and previously reported cases. Case reports – Our first case, a 48-year-old female was admitted to the neurological department due to paraparesis. MRI suggested LETM, but the treatments were ineffective. She died after four weeks because of pneumonia and untreatable polyserositis. Pathological examination revealed intravascular large B-cell lymphoma (IVL). Our second case, a 61-year-old man presented with headache and paraparesis. MRI showed small bitemporal lesions and lesions suggesting LETM. Diagnostic investigations were unsuccessful, including tests for possible lymphoma (CSF flow cytometry and muscle biopsy for suspected IVL). Chest CT showed focal inflammation in a small area of the lung, and adrenal adenoma. Brain biopsy sample from the affected temporal area suggested T-cell mediated lymphocytic (paraneoplastic or viral) meningoencephalitis and excluded diffuse large B-cell lymphoma. The symptoms worsened, and the patient died in the sixth week of disease. The pathological examination of the presumed adenoma in the adrenal gland, the pancreatic tail and the lung lesions revealed peripheral T-cell lymphoma, as did the brain and spinal cord lesions. Even at histological examination, the T-cell lymphoma had the misleading appearance of inflammatory condition as did the MRI. Conclusion – Lymphoma can manifest as LETM. In cases of etiologically unclear atypical LETM in patients older than 40 years, a random skin biopsy (with subcutaneous adipose tissue) from the thigh and from the abdomen is strongly recommended as soon as possible. This may detect IVL and provide the possibility of prompt chemotherapy. In case of suspicion of lymphoma, parallel examination of the CSF by flow cytometry is also recommended. If skin biopsy is negative but lymphoma suspicion remains high, biopsy from other sites (bone marrow, lymph nodes or adrenal gland lesion) or from a simultaneously existing cerebral lesion is suggested, to exclude or prove diffuse large B-cell lymphoma, IVL, or a rare T-cell lymphoma.

Clinical Neuroscience

Acute effect of sphenopalatine ganglion block with lidocaine in a patient with SUNCT

KOCATÜRK Mehtap, KOCATÜRK Özcan

Short-lasting unilateral neuralgiform headache with conjunctival injection and tearing/short-lasting unilateral neuralgiform headache with cranial autonomic features (SUNCT/SUNA) is a rare severe headache. At the time of an attack, it can hinder a patient from eating and requires acute intervention. The sphenopalatine ganglion is an extracranial parasympathetic ganglion with both sensory and autonomic fibers. Sphenopalatine ganglion block has long been used in the treatment of headache, particularly when conventional methods have failed. Here, we present a patient who was resistant to intravenous lidocaine, but responded rapidly to sphenopalatine ganglion block during an acute episode of SUNCT/SUNA.

Clinical Neuroscience

[Covid-19 associated neurological disorders]

SZÔTS Mónika, PÉTERFI Anna, GERÖLY Júlia, NAGY Ferenc

[The clinical signs of SARS-CoV-2 infection has become more recognisable in recent times. In addition to common symptoms such as fever, cough, dyspnea, pneumonia and ageusia, less common complications can be identified, including many neurological manifestations. In this paper, we discuss three Covid-19 associated neurological disorders (Case 1: Covid-19 encephalitis, Case 2: Covid-19 organic headache, Case 3: SARS-CoV-2-infection and ischaemic stroke). We emphasize in our multiple case study that during the present pandemic, it is especially important for neurologists to be aware of the nervous system complications of the virus infection, thus saving unnecessary examinations and reducing the frequency of patients’ contact with health care personnel. ]

Clinical Neuroscience

[Tension type headache and its treatment possibilities]

ERTSEY Csaba, MAGYAR Máté, GYÜRE Tamás, BALOGH Eszter, BOZSIK György

[Tension type headache, the most common type of primary headaches, affects approximately 80% of the population. Mainly because of its high prevalence, the socio-economic consequences of tension type headache are significant. The pain in tension type headache is usually bilateral, mild to moderate, is of a pressing or tightening quality, and is not accompanied by other symptoms. Patients with frequent or daily occurrence of tension type headache may experience significant distress because of the condition. The two main therapeutic avenues of tension type headache are acute and prophylactic treatment. Simple or combined analgesics are the mainstay of acute treatment. Prophylactic treatment is needed in case of attacks that are frequent and/or difficult to treat. The first drugs of choice as preventatives of tension type headache are tricyclic antidepressants, with a special focus on amitriptyline, the efficacy of which having been documented in multiple double-blind, placebo-controlled studies. Among other antidepressants, the efficacy of mirtazapine and venlafaxine has been documented. There is weaker evidence about the efficacy of gabapentine, topiramate, and tizanidin. Non-pharmacological prophylactic methods of tension type headache with a documented efficacy include certain types of psychotherapy and acupuncture. ]

Clinical Neuroscience

A new method to determine the optimal orientation of Slim Modiolar cochlear implant electrode array insertion

HORVÁTH Bence, PERÉNYI Ádám, MOLNÁR Fiona Anna, CSANÁDY Miklós, KISS József Géza, ROVÓ László

Our goal was to determine the optimal orientation of insertion of the Slim Modiolar electrode and develop an easy-to-use method to aid implantation surgery. In some instances, the electrode arrays cannot be inserted in their full length. This can lead to buckling, interscalar dislocation or tip fold-over. In our opinion, one of the possible reasons of tip fold-over is unfavourable orientation of the electrode array. Our goal was to determine the optimal orientation of the Slim Modiolar electrode array relative to clear surgical landmarks and present our method in one specified case. For the measurement, we used the preoperative CT scan of one of our cochlear implant patients. These images were processed by an open source and free image visualization software: 3D Slicer. In the first step we marked the tip of the incus short process and then created the cochlear view. On this view we drew two straight lines: the first line represented the insertion guide of the cochlear implant and the second line was the orientation marker (winglet). We determined the angle enclosed by winglet and the line between the tip of the incus short process and the cross-section of previously created two lines. For the calculation we used a self-made python code. The result of our algorithm for the angle was 46.6055°. To validate this result, we segmented, from the CT scan, the auditory ossicles and the membranaceous labyrinth. From this segmentation we generated a 3D reconstruction. On the 3D view, we can see the position of the previous lines relative to the anatomical structures. After this we rotated the 3D model together with the lines so that the insertion guide forms a dot. In this view, the angle was measured with ImageJ and the result was 46.599°. We found that our method is easy, fast, and time-efficient. The surgery can be planned individually for each patient, based on their routine preoperative CT scan of the temporal bone, and the implantation procedure can be made safer. In the future we plan to use this method for all cochlear implantation surgeries, where the Slim Modiolar electrode is used.