Clinical Neuroscience

[Non-contrast brain ct based systemic thrombolysis of two wake up ischemic stroke patients in rural settings]

POZSEGOVITS Krisztián, RENCZ László, CSÚSZ Lajos, SZABÓ Géza

MAY 30, 2017

Clinical Neuroscience - 2017;70(05-06)

DOI: https://doi.org/10.18071/isz.70.0209

[Background and presentation - Conventionally the acute ischemic stroke patients who wake up with symptomes (WUS - wake up stroke) cannot benefit from systemic thrombolysis due to the uncertainty of the exact onset time of the cerebrovascular event. Perfusion brain imaging could be used as patient selection tool but the method is not available in many settings. Simple non-contrast CT scan is easily accessible and reliable as it shows the different stages of the evolving ischemia with high accuracy. Early brain CT scan results of WUS patients have the same characteristics as the ones who are surely within therapeutic window. The intravenous thrombolysis with recombinant tissue plasminogen activator (rTPA) of WUS patients seems to be similarly successful as the ones with known onset time, the treatment does not come with excess complications, higher rate of symptomatic intracranial hemorrhage was not found in previous reports. Purpose - In this report we present two systemic thrombolysis cases of acute ischemic stroke patients who woke up with stroke symptoms. Methods - In 2014 and 2015 we performed systemic thrombolysis for one wake up stroke patients, respectively. Both patients had large vessel occlusion. Indication was based on favourable non-contrast brain CT scan results. Results - Treatment of these two patients with rTPA proved to be safe, no hemorrhage occurred after treatment. Conclusion - We presented two acute ischemic stroke patients with symptomes at early wake up who were treated intravenously with recombinant tissue plasminogen activator based on non-contrast CT alone without complications and some moderate improvement at 90 days in the settings of a rural town hospital in a middle income country.]

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[Multiple sclerosis is an autoimmune demyelinating disorder of the central nervous system. During the last two decades, numerous disease modifying drugs have been introduced for the treatment of the relapsing-remitting form of the disease. Since 2010, natalizumab (NTZ) treatment has been used as a second-line therapy for patients with breakthrough disease. In comparison to conventional immunomodulant drugs, NTZ has a more specific effect in that it prevents the entry of immune cells into the central nervous system without interfering with systemic immune response. The efficacy and the safety of NTZ have been confirmed by several studies. The most severe side-effect of NTZ is progressive multifocal leukoencephalopathy, which has been associated with an increased incidence in patients with anti-JCV antibody positivity, and in those who have been undergoing NTZ treatment for over two years and who have received prior immunosuppressive therapy. In the present study, our experience with natalizumab treatment of 37 patients at the Department of Neurology of Semmelweis University during the last 6 years is presented. We have observed a significant decrease of disease activity in our patients; in many cases the disease has become inactive both clinically (36/37) and radiologically (34/37). The patients’ quality of life has improved significantly during the treatment. In accordance with the literature, we confirm that NTZ is a highly effective treatment in a carefully selected patient group, and can be administered without significant inconvenience to the patient. ]

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The role of the insula in the parieto-frontomedial epileptic network. Clues from successful surgical treatment

BALOGH Attila, AIMEN Anwar, KELEMEN Anna, ERÕSS Loránd, FABÓ Dániel

We present a case of MRI negative SMA seizure with the seizure onset zone in the secondary leg area on the superior bank of the Sylvian fissure, localized with multiscale electro-clinical and neuroradiological examinations. The 34-year-old female patient’s intractable epilepsy started at age 14. She had diffuse pain aura in her left leg followed by tonic posturing with fully preserved consciousness suggesting parieto-fronto-medial seizure propagation. Her daily nocturnal SMA seizures became drug-resistant. Multiple 3T MRI images and neuropsychological evaluations were normal. Interictal PET detected a right parietal and insular FDG hypometabolism. The seizure onset zone and the symptomatogenic zone were localized by invasive electrophysiology. The insular deep electrode showed the propagation of ictal activity with an onset in the secondary sensory leg area through the insula to the fronto-medial surface. Eighteen spontaneous seizures, electrical cortical stimulation and cortical mapping confirmed the designated area of the resection, which was later proved macroscopically abnormal during surgery. The histological and immunohistological workup confirmed focal cortical dysplasia (IIb type). Postoperative postprocessing morphometry of the preoperative MRI study confirmed the lesion in the right inferior parietal lobe. The patient remained seizure free after surgery for more than 4 years, and medication free for the last two years. Our results concluded that the insula has a „relay” or „node” function in the parieto-opercular-fronto-medial epileptic network. The insular functional connectivity predisposed frontal propagation of the epileptic activity in the connectome of her epilepsy. The three-way insular structural connectivity has determining function on the seizure propagation.

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[Aim - Studying the impact of the sunshine on the numbers of suicides. The number of suicides is highest in the late spring and early summer months, while it is lowest in the cold, gloomy winter. Although the exact causes are still un-known, there are some theories about this phenomenon. A number of studies conducted in recent years have conclud-ed that the rise in suicide rate during the warm months might be due to an increased exposure to sunlight, especially in the cases of the violent method. We studied the validity of this hypothesis on a large Hungarian database. Methods and subjects - We analyzed the number of monthly hours of sunshine and the number of suicides by sex and by violent vs. non-violent method over a 360-month period. Our sample consisted of 127 877 committed suicides between 1971 and 2000. The parabolic trend of seasonality had to be removed from the suicide time series, then regression analysis was conducted on the seasonally adjusted data. Results - Our analysis revealed that in Hungary there was no statistically significant direct relationship between the number of hours of sunshine and the number of suicides. Moreover, there was no correlation between the hours of sunshine and the number of violent suicides either. Conclusion - If the above claim were confirmed in subsequent research, it would mean that our current therapeutic regime should be reconsidered during the spring-summer seasons.]

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Clinical Neuroscience

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