Clinical Neuroscience

[Paradigm shift in management of patients with vertigo and imbalance]

MIKE Andrea1, TAMÁS T. László2

JULY 30, 2018

Clinical Neuroscience - 2018;71(07-08)

DOI: https://doi.org/10.18071/isz.71.0221

[Dizziness is one of the most common causes of medical visits. Management of the dizzy patient may be challenging both for the general practitioner, in emergency departments, and special clinics, as behind a seemingly homogeneous clinical presentation several very different etiologies may occur. Research of the last two century enriched our knowledge about physiology and pathophysiology of the vestibular system. Much knowledge is now available about the labyrinth being able to sense head motions and gravity, processing of afferent vestibular stimuli, reflectory oculomotor and postural control, or recovery of the vestibular system. Based on scientific results new beside tests have been introduced including provocation maneuvers for detecting ectopic otoliths in different semicircular canals, head impulse test to examine function of the vestibulo-ocular reflex, and the HINTS+ battery for differentiation of peripheral or central origin of an acute vestibular syndrome. Technical innovations like videooculography and vestibular evoked myogenic potentials enable us to selectively and side-specifically examine the function of all six semicircular canals and two otolith organs. Pathomechanism of disorders with vertigo and dizziness became more clear resulting in the development or amendment of diagnostic criteria of several vestibular disorders including vestibular migraine, Menière’s disease, benign paroxysmal positional vertigo, persistent postural-perceptual dizziness, bilateral vestibulopathy. Broader knowledge about the pathomechanism promoted the development of new therapeutic methods like different repositioning maneuvers in benign paroxysmal positional vertigo, pharmaceutical therapies, vestibular rehabilitation, and psychotherapy. We aimed to summarize the novelties in the field of oto-neurology.]

AFFILIATIONS

  1. Petz Aladár Megyei Oktató Kórház, Neurológiai Osztály, Gyôr
  2. Petz Aladár Megyei Oktató Kórház, Fül-Orr-Gégészeti és Fej-, Nyaksebészeti Osztály, Gyôr

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Clinical Neuroscience

Novel structured MRI reporting system in neonatal hypoxic-ischemic encephalopathy - issues of development and first use experiences

LAKATOS Andrea, KOLOSSVÁRY Márton, SZABÓ Miklós, JERMENDY Ágnes, BAGYURA Zsolt, BARSI Péter, RUDAS Gábor, KOZÁK R. Lajos

Purpose - To develop an evidence-based, standardized structured reporting (SR) method for brain MRI examinations in neonatal hypoxic-ischemic encephalopathy (HIE) suitable both for clinical and research use. Materials and methods - SR template development was based on comprehensive review of the pertinent literature with the basic sections and subdivisions of the template defined according to MRI sequences (both conventional and diffusion-weighted, MR-spectroscopy (MRS), and T2*-weighted imaging), and the items targeted on age-related imaging patterns of HIE. In order to evaluate the usability of the proposed SR template we compared data obtained from the brain MR image analysis of 87 term and 19 preterm neonates with the literature. The enrolled 106 infants were born between 2013 and 2015, went through therapeutic hypothermia according to the TOBY criteria due to moderate to severe asphyxia and had at least one brain MRI examination within the first two weeks of life. Ethical approval was obtained for this retrospective study. Descriptive statistical analysis was also performed on data exported from the structured reporting system as feasibility test. Results - The mean gestational age of the study population was 38.3±2.2 weeks; brain MRI was performed on 5.8±2.9 day of life, hence in 78% of our patients after the conclusion of therapeutic hypothermia. Our main imaging findings were concordant to the pertinent literature. Moreover, we identified a characteristic temporal evolution of diffusion changes. Interestingly 18% (n=19/106) of the clinically asphyxiated infants had isolated axial-extraaxial haemorrhage without any imaging sign of HIE. Conclusion - In this article our approach of reporting HIE cases with our novel SR template is described. The SR template was found suitable for reporting HIE cases, moreover it uncovered time and location dependent evolution of diffusion abnormalities (and pseudonormalization, as well), suggesting its usefulness in clinical research applications. The high number of isolated intracranial haemorrhages, and the changing diffusion pattern emphasizes the importance of early imaging in HIE.

Clinical Neuroscience

Isocitrate dehydrogenase mutations in defining the biology of and supporting clinical decision making in glioblastoma

KÁLOVITS Ferenc, TOMPA Márton, NAGY Ádám, BERNADETTE Kalman

Background and purpose - Oncogenesis is related to a sequential accumulation of somatic mutations. Comprehensive characterizations of the genomic landscapes have been completed recently for several tumors, glioblastoma being among the first ones. Our own translational research studies have been focused on defining molecular subtypes of glioblastoma in the clinical setting because of an expected prognostic and therapeutic utility of the information. Somatic mutations in genes of the isocitrate dehydrogenase (IDH) enzyme family appear to be among the best-defined biomarkers that also influence tumor behavior and confer clinical utility. Methods - We have reviewed the literature including our own results to summarize basic science and clinical correlates of IDH mutations. Results - The surveyed data reveal genomic, transcriptomic, epigenomic and biochemical consequences of IDH mutations in the context of glioblastoma biology and phenotype. In addition, a few studies highlight the therapeutic potential of targeting IDH, although thus far all tests have only been conducted in the preclinical setting. Conclusions - Somatic mutations in isoforms of IDH genes represent important biomarkers that correlate with biochemical, biological and phenotypic features of glioblastoma, and may also facilitate the development of new therapeutic strategies complementing the currently available approved protocols.

Clinical Neuroscience

Can high uric acid levels be an independent risk factor for acute ischemic stroke due to large-artery atherosclerosis?

ACAR Türkan, ARAS Guzey Yesim, GÜL Sinem Sidika, ACAR Atılgan Bilgehan

Introduction - Uric acid is a molecule that is known to act as a natural antioxidant in acute oxidative stress conditions such as acute ischemic stroke (AIS). Although there are several studies on the prognostic value of serum uric acid (UA) level, especially the AIS, its importance in ischemic stroke is still controversial. Our aim in this study is to investigate whether the serum UA level is an indicative biomarker in the large-artery atherosclerosis in the AIS etiology. Material and method - Of the patients admitted to Sakarya University Training and Research Hospital Depart-ment of Neurology between January 2017 and November 2017, 91 hospitalized patients, who had AIS diagnosis and had their uric acid levels measured, were analyzed retrospectively. Patients with diabetes mellitus (DM), hypertension (HT), smoking habit, obesity, gout, hyperlipidemia (HL) and renal failure were excluded from the study. Patients were classified as anterior system and posterior system infarct. Then, patients were divided into two groups, one with internal carotid artery (ICA) > 50% stenosis and the other with ICA < 50% stenosis according to carotid-vertebral artery doppler USG examination performed for etiology. Serum UA, total bilirubin, direct bilirubin and indirect bilirubin levels of both groups were statistically compared. Results - In the comparison of serum UA values of ICA>50% stenosis and ICA<50% stenosis group of AIS patients, a statistically significant difference was found between the UA levels (p<0.000), but there was no difference between total bilirubin, direct bilirubin and indirect bilirubin values (p>0.05). Conclusion - High uric acid levels can be considered an independent, indicative risk factor for large-artery disease in AIS.

Clinical Neuroscience

[Strategies of using the new antiepileptic drugs for epilepsy in adults]

NIKL János

[The new antiepileptic drugs have not changed the basic pharmacological treatment principles of epilepsy, but they have given greater choice in focal and in generalized epilepsies as well. The new drugs are not necessarily more effective than traditional drugs, but they have favourable pharmacokinetic characteristics, fewer interactions and better adverse effect profile in the acute and chronic phase of the treatment. They generally show a lower teratogenicity risk than the standard antiepileptics, although carbamazepine, one of the standard drugs can be used and zonisamide, a new one must be avoid in pregnancy. Due to characteristics mentioned above they are not only effective as add-on therapy, but in monotherapy as well. On the basis of the international and national recommendation lamotrigine and levetiracetam belong to the first line antiepileptics. The favourable tolerability of the new antiepileptics may improve the patient’s compliance and adherence to the given treatment. The low teratogenicity makes them especially suitable for the treatment of women of childbearing age. The new antiepileptic drugs can succesfully used for the treatment of special patients’ groups as for the post stroke, poszttraumatic epilepsies, for the epilepsies accompanied with brain tumours as well as for epilepsies in the elderly. The new drugs are advantageous for the treatment of such patients who have psychiatric symptoms or signs of cognitive decline and high risk of these symptoms respectively.]

Clinical Neuroscience

[Early experience with minimal invasive treatment of thirty-one thoracolumbar injury cases]

VARGA Ádám, VERES Róbert, ELEK Péter, MENCSER Zoltán, RIDEG Zoltán, BARZÓ Pál

[A szerzők 31 thoracolumbalis gerincsérült minimálisan invazív műtéti ellátásával szerzett tapasztalataikról számolnak be. A betegek orvosi dokumentációját, radiológiai (preoperatív CT és MRI, valamint posztoperatív CT három és hat hónap után) képanyagát retrospektíven elemzik. A be-avatkozások során minden behelyezett csavar megfelelő pozícióba került, idegrendszeri funkcióromlás és sebfertőzés nem fordult elő. Az utánkövetés során három esetben alakult ki radiológiai korrekcióvesztés, melynek azonban klinikai következménye nem volt. Csavarlazulást, a fémanyag törését nem észleltük. Saját tapasztalataink alapján, a nemzetközi irodalmi adatokkal egybevágóan, a mini-málisan invazív módszer alkalmazását a gerincsérültek ellátása során javasoljuk.]

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Clinical Neuroscience

[What happens to vertiginous population after emission from the Emergency Department?]

MAIHOUB Stefani, MOLNÁR András, CSIKÓS András, KANIZSAI Péter, TAMÁS László, SZIRMAI Ágnes

[Background – Dizziness is one of the most frequent complaints when a patient is searching for medical care and resolution. This can be a problematic presentation in the emergency department, both from a diagnostic and a management standpoint. Purpose – The aim of our study is to clarify what happens to patients after leaving the emergency department. Methods – 879 patients were examined at the Semmel­weis University Emergency Department with vertigo and dizziness. We sent a questionnaire to these patients and we had 308 completed papers back (110 male, 198 female patients, mean age 61.8 ± 12.31 SD), which we further analyzed. Results – Based on the emergency department diagnosis we had the following results: central vestibular lesion (n = 71), dizziness or giddiness (n = 64) and BPPV (n = 51) were among the most frequent diagnosis. Clarification of the final post-examination diagnosis took several days (28.8%), and weeks (24.2%). It was also noticed that 24.02% of this population never received a proper diagnosis. Among the population only 80 patients (25.8%) got proper diagnosis of their complaints, which was supported by qualitative statistical analysis (Cohen Kappa test) result (κ = 0.560). Discussion – The correlation between our emergency department diagnosis and final diagnosis given to patients is low, a phenomenon that is also observable in other countries. Therefore, patient follow-up is an important issue, including the importance of neurotology and possibly neurological examination. Conclusion – Emergency diagnosis of vertigo is a great challenge, but despite of difficulties the targeted and quick case history and exact examination can evaluate the central or peripheral cause of the balance disorder. Therefore, to prevent declination of the quality of life the importance of further investigation is high.]

Clinical Neuroscience

The applications of transcranial Doppler in ischemic stroke

FINNSDÓTTIR Herdis, SZEGEDI István, OLÁH László, CSIBA László

Background: This overview provides a summary of the applications of transcranial Doppler (TCD) in ischemic stroke. Results: A fast-track neurovascular ultrasound protocol has been developed for detecting occlusion or stenosis. The technique is more reliable in the carotid area than in the posterior circulation. By monitoring the pulsatility index the in­crea­sed intracranial pressure can be diagnosed. TIBI score was developed for grading residual flow. TCD has been shown to accurately predict complete or any recanalization. Regarding recanalization, TCD has a sensitivity of 92%, a specificity of 88%, a positive predictive value of 96%, a negative predictive value of 78% and an overall accuracy of 91%, respectively. Sonothrombolysis seemed to be a promising application but randomized controlled trials have shown that it does not improve clinical outcome. TCD examination can detect microembolic signals (MES) which are associated with an increased risk of stroke. Micro­em­boli were detected in symptomatic and asymptomatic carotid artery stenosis and during carotid endarterectomy. The number of microemboli can be decreased by antithrombotic therapy. Contrast en­chan­ced examination and Valsalva maneuver with continuous TCD monitoring can accurately screen for right-to-left shunt.

Clinical Neuroscience

[Systemic thrombolysis and endovascular intervention in postpartum stroke]

BERECZKI Dániel Jr., NÉMETH Beatrix, MAY Zsolt, SZAKÁCS ZOLTÁN, GUBUCZ István, SZIKORA István, SZILÁGYI Géza

[Introduction - There are no previously published cases about intravenously applied recombinant tissue plasminogen activator in acute ischemic stroke during puerperium. Case presentation - We report a 40-year-old woman with postpartum acute ischemic stroke caused by multiple cervical artery dissections treated by systemic thrombolysis and endovascular intervention. Discussion - There are only limited data regarding thrombolytic treatment in acute stroke during pregnancy and puerperium. Current acute stroke treatment guidelines - while considering pregnancy as a relative exclusion criterion - do not deal with the postpartum state. Conclusion - As the condition is rare, randomized controlled trials are not feasible, therefore further reports on similar cases could eventually help us suggest guidelines or at least propose recommendations for the acute thrombolytic treatment of strokes occurring in pregnancy and puerperium.]

Clinical Neuroscience

[Relationships between COVID-19 disease, nutritional status, and dysphagia, particularly in stroke patients ]

KOVÁCS Andrea, SZABÓ Pál Tamás, FOLYOVICH András

[The new coronavirus, SARS-CoV-2, which causes the COVID-19 disease can lead to severe acute respiratory distress syndrome (ARDS). It poses a serious challenge to the health care system, especially intensive care. Neurological patients, usually of advanced age and with a myriad of comorbidities, are at particular risk through the impact of the new coronavirus on their condition and nutritional capacity. Stroke is a leader in morbidity and mortality data, with a focus on dysphagia and its complications due to COVID-19 disease and acute cerebrovascular accident. In the acute phase of stroke, 30-50% of patients suffer from dysphagia, which still shows a prevalence of 10% six months later. Dysphagia results in decreased or insufficient fluid and nutrient uptake, supp­lemented by inactivity, leading to malnutrition and sarcopenia, which worsens overall condition, outcome, and rehabilitation efficiency. Screening and early detection of swallowing disorders is a fundamental issue in order to develop a personalized and timely-initiated nutritional therapy strategy. Nutritional therapy plays a key role in frequent intensive care due to COVID-19 disease, where it increases the chances of recovery and reduces the length of stay in the intensive care unit and mortality. This is especially true in critically ill patients requiring prolonged ventilation. In COVID-19 diagnosed patients, screening for dysphagia, bedside assessment, and instrumental examination, followed by swallowing rehabilitation, are of paramount importance. Stroke can also be a complication of the COVID-19 infection. Care for cerebrovascular patients has also adapted to the pandemic, “triazination” has become systemic, and dysphagia screening for stroke patients and nutritional therapy adapted to it have also shed new light. ]

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.