Clinical Neuroscience

[The significance of qualitative CSF lesions in cerebrovascular disease]

PÉTER Ágnes1, SCHMIDT M. Rudolf1

DECEMBER 01, 1963

Clinical Neuroscience - 1963;16(12)

[1 The authors performed qualitative CSF analysis in 30 patients with cerebrovascular disease. They compared the lesions found in patients with soft tissue foci and diffuse cerebral lesions. 2. In apoplectic patients with early post-ictal stage a or a, y globulin accumulation and monocyte rectio along with pathologic cell forms were found. 3. In chronic anapoplegia, qualitative pathologic cell pattern or pherograms were observed in diffuse cerebral blood flow disturbance with nodal symptoms. 4. In vascular encephalopathies without apoplexy, the CSF pherogram was found to be normal, with CSF cell intact usually showing monocyte reactivity. In these cases, only in cases of long-standing disease or periodic cerebral circulatory insufficiency were pathological cell forms or abnormalities in CSF protein fractions detected. 5 Authors have reported that in cerebro-vascular disease, CSF electrophoresis and CSF differential cell pattern varies according to the severity and duration of clinical symptoms, consistent with circulatory failure. ]

AFFILIATIONS

  1. Budapesti Orvostudományi Egyetem Neurológiai Klinikája és a Hallei M. Luther Egyetem Neuro-Psychiatriai Klinikája

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Clinical Neuroscience

[Data for the diagnosis and differential diagnosis of intracranial space-occupying processes in the elderly Part II]

GÁTAI György

[More than 2000 cases (1690 intracranial space-occupying processes and 320 other brain diseases) were studied to determine the diagnostic results, sources of error and characteristics of intracranial space-occupying processes in the elderly. I. The diagnostic results for age-related intracranial space narrowing are unsatisfactory and worse than average. The incidence of misdiagnosis ranges from 34% to 86%, depending on the definition. II. The most common causes of diagnostic errors : 1. Neurological symptoms in elderly individuals, based on advanced age, are attributed ab ovo by the examiner to involutional-vascular lesions, without considering the possibility of a partial constriction process and the need for such studies. 2. Recognition of symptoms of intracranial narrowing processes is complicated by advanced senile involutional lesions. The investigator's attention is not drawn to changes in the nature and progression of the process. 3. Overestimation of the absence of a congestive papilla, failure to recognise that intracranial space-occluding processes are not associated with congestion in the fundus in 1/3 of cases on average, and in 4/5 of cases in older age. 4. The general symptoms of intracranial hypertension, partly due to the absence of a congestive papilla, are not recognised by the investigator and are thought to be the result of a vascular involution process. III. Diagnostic features of intracranial constriction in the elderly : 1. Progression depends on the nature of the constrictive processes. In the majority of cases, the course of malignant tumours is typical (relatively rapid and steady deterioration). The course of the less frequent benign constrictive processes is atypical compared with younger ones: progression is very slow, with late or no progression of pressure-induced symptoms - The coexistence of senile involution and intracranial constrictive processes may be characterised by a biphasic progression: after the initial multisegmental, undulatory symptoms, unilocularity and steady worsening become increasingly dominant. 2. Intracranial constrictive processes also lead to spatial disproportion in older age. The latter is usually affected by senile involution (not only in rare benign spatial constrictive processes). Accordingly, the general symptoms of pressure intensification, with the exception of congested papilla, are only slightly less frequent in older people, and can be assessed diagnostically in a similar way as in younger age. 3. in older age, congestive papillae are typically less frequent, and their presence or absence, or severity, is even less representative of intracranial pressure increase than in younger age groups. The absence of congestion in older age appears to be due partly to localised distribution of constrictive processes and partly to sclerotic vascular wall lesions. 4. Intracranial constrictive processes in old age seem to be characterised by a predominance of focal seizure type and absence of centrencephalic epilepsy on the one hand and a reduced generalisation tendency on the other. 5. The prevalence of psychiatric disorders in terms of spatial constrictive processes in older age cannot be evaluated. Their prevalence is not specific to the constrictive processes but to age. 6. Intracranial constrictive processes in old age are characterised by more frequent and more pronounced protein secretion in CSF. Negative CSF is more valuable against space-occupying processes, with protein levels above 60 mg per cent in space-occupying processes than in younger age. ]

Clinical Neuroscience

[Meningioma patients with some electrographic characteristics]

TOMKA Imre, BAUMANN Piroska

[Authors present EEG data from 122 meningioma patients. Of these, all but 6 were diagnosed by surgery or dissection. Locally, significant nodal activity was mainly provided by tumours with frontal location, followed by those with olfactory, occipital and temporal localisations. In contrast, the EEG abnormalities of centro-parietal, parasagittal meningiomas are mild but often diffuse and bilateral. No correlation was found between the background activity of electrical activity and the increase in brain pressure expressed by congestion in the orbital floor. Nor can the degree of relaxation of cerebral electrical activitas be used to infer surgical prognosis. Localisation diagnosis based on EEG was completely or approximately accurate in 75% of cases. However, in 14 cases the EEG opinion was insufficient or negative. The majority of these cases were centro-parietal parasagittal, posterior scalar or deep tumours. In 74% of patients with nodal activity before surgery, a significant reduction of nodal lesions was observed on the catamnestic curve, but complete negativity was observed in only a few cases. In contrast, excitatory or epileptiform activitas after surgery became appreciably more pronounced with a significant reduction of the slow foci in the majority of cases. ]

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Fluoxetine use is associated with improved survival of patients with COVID-19 pneumonia: A retrospective case-control study

NÉMETH Klára Zsófia, SZÛCS Anna , VITRAI József , JUHÁSZ Dóra , NÉMETH Pál János , HOLLÓ András

We aimed to investigate the association between fluoxetine use and the survival of hospitalised coronavirus disease (COVID-19) pneumonia patients. This retrospective case-control study used data extracted from the medical records of adult patients hospitalised with moderate or severe COVID-19 pneumonia at the Uzsoki Teaching Hospital of the Semmelweis University in Budapest, Hungary between 17 March and 22 April 2021. As a part of standard medical treatment, patients received anti-COVID-19 therapies as favipiravir, remdesivir, baricitinib or a combination of these drugs; and 110 of them received 20 mg fluoxetine capsules once daily as an adjuvant medication. Multivariable logistic regression was used to evaluate the association between fluoxetine use and mortality. For excluding a fluoxetine-selection bias potentially influencing our results, we compared baseline prognostic markers in the two groups treated versus not treated with fluoxetine. Out of the 269 participants, 205 (76.2%) survived and 64 (23.8%) died between days 2 and 28 after hospitalisation. Greater age (OR [95% CI] 1.08 [1.05–1.11], p<0.001), radiographic severity based on chest X-ray (OR [95% CI] 2.03 [1.27–3.25], p=0.003) and higher score of shortened National Early Warning Score (sNEWS) (OR [95% CI] 1.20 [1.01-1.43], p=0.04) were associated with higher mortality. Fluoxetine use was associated with an important (70%) decrease of mortality (OR [95% CI] 0.33 [0.16–0.68], p=0.002) compared to the non-fluoxetine group. Age, gender, LDH, CRP, and D-dimer levels, sNEWS, Chest X-ray score did not show statistical difference between the fluoxetine and non-fluoxetine groups supporting the reliability of our finding. Provisional to confirmation in randomised controlled studies, fluoxetine may be a potent treatment increasing the survival for COVID-19 pneumonia.

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

[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.]

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[Diagnosis and treatment of microvascular coronary heart disease. Specialities of conditions in Hungary]

SZAUDER Ipoly

[Invasive investigations show that in two-thirds of patients the myocardial ischaemia persists without obstructive coronary disease and any other heart conditions (INOCA). The underlying cause may be microvascular dysfunction (CMD) with consecutive microvascular coronary disease (MVD) and microvascular or epicardial vasospastic angina (MVA). The modern practice of clinical cardiology while using the developed non-invasive cardiac imaging permits exact measuring of the coronary flow with its characteristic indices. All of these improve the diagnosing of CMD-induced myocardial ischemia and provide opportunity to determine primary MVD cases. Since the recognition and treatment of MVD is significantly underrep­resented in the Hungarian medical care, the primary stable microvascular angina (MVA) is described in detail below with its modern invasive and non-invasive differential diagnosis and treatment, concerning especially its frequency provoked by high blood pressure and female coronary heart diseases. There are highlighted all recommended diagnostic procedures available under domestic conditions.]