Clinical Neuroscience

To treat or not to treat, cheyne-stokes respiration in a young adult with vascular encephalopathy

HUBATSCH Mihaela1,2, ENGLERT Harald1, WAGNER Ulrich1

JANUARY 30, 2016

Clinical Neuroscience - 2016;69(01-02)

DOI: https://doi.org/10.18071/isz.69.0066

Cheyne-Stokes respiration (CSR) is a form of sleep-disordered breathing characterised by recurrent central sleep apnoea alternating with a crescendo-decrescendo pattern of tidal volume, relatively rare observation in sleep labs. It is mainly seen in severe heart failure and stroke. We report the case of a young man with CSR after sudden onset of seizure in the context of hypertensive exacerbation leading to the diagnosis of a leukoencephalopathy, and comment on differential diagnoses, prognostic and therapeutic outcomes. The very uniqueness of this case consists in the extremely young age for developing a vascular encephalopathy in the absence of genetic diseases and without previous diagnose of hypertension. There is no adequate explanation for the origin of vascular encephalopathy; also there is lack of evidence regarding the benefits and modality of treatment for CSR in neurologic diseases. Thus, we were forced to find the best compromise in a nocturnal oxygen therapy and follow-up.

AFFILIATIONS

  1. Sleep Lab Division, Pneumology Department, Klinik Löwenstein, Baden-Württemberg, Germany
  2. University of Medicine and Pharmacy Târgu-Mureș, Romania

COMMENTS

0 comments

Further articles in this publication

Clinical Neuroscience

Internet and stroke awareness in the young hungarian population

BARI Ferenc, TÓTH Anna, PRIBOJSZKI Magda, NYÁRI Tibor, FORCZEK Erzsébet

Background – Although stroke mortality rate in Hungary has tapered off over the last years, it is still twice the European average. This statistic is alarming and a coordinated response is needed to deal with this situation when considering new ways of communication. There are currently more than 300 websites in Hungarian related to stroke prevention, acute stroke treatment, recovery and rehabilitation. Aims and/or hypothesis – We sought to identify base level of stroke knowledge of the Hungarian students and the efficiency with which the knowledge disseminated by internet is actually utilized. Methods – We surveyed 321 high-school and university students to determine their ability to extract specific information regarding stroke from Hungarian websites. The base level of knowledge was established by asking 15 structured, close-ended questions. After completing the questionnaire, students were asked to search individually on stroke in the internet where all the correct answers were available. After a 25-min search session they answered the same questionnaire. We recorded and analyzed all their internet activity during the search period. Results – The students displayed a fair knowledge on the basics of stroke but their results did not change significantly after the 25-min search (53±13% vs. 63±14%). Only correct information given on demographic facts improved significantly. Most of the students used very simple search strategies and engines and only the first 5-10 web-pages were visited. Conclusion – Analysis of the most often visited web-pages revealed that although stroke-related Hungarian web-based resources contain almost all the important and required information the unsuitable structure, lack of simplicity and verbosity hinder their effective public utilization.

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.

Clinical Neuroscience

Facial virus inoculations infect vestibular and auditory neurons in rats

HELFFERICH Frigyes, LOURMET Guillaume, SZABÓ Rebeka Éva, BOLDOGKŐI Zsolt, PALKOVITS Miklós

Background and purpose – There is growing evidence for the viral origin of the Bell’s facial palsy, vestibular neuritis and sudden sensorineural hearing loss, however their exact pathophysiology is still unknown. We investigated the possibility of brainstem infections following peripheral viral inoculations in rats. Methods – Pseudorabies virus, a commonly used neurotropic viral retrograde tracer was injected into the nasolabial region of rats. Five and 6 days after injections, infected brainstem nuclei were demonstrated by immunohistochemical techniques. Results – Infected neurons were found in the motor facial, the medial vestibular, and the sensory trigeminal nuclei, as well as in the medial nucleus of the trapezoid body. Conclusion – Pseudorabies virus infects auditory and vestibular sensory neurons in the brainstem through facial inoculation. The possible routes of infections: 1. trans-synaptic spread constituted by facio-vestibular anastomoses: primarily infected motor facial neuron infects neurons in the medial vestibular nucleus, 2. via trigeminal sensory nerves: the sensory trigeminal complex innervated by GABAergic medial vestibular neurons, and 3. one bisynaptical route: infected facial motoneurons may receive indirect input from the medial vestibular nucleus and the trapezoid body via connecting neurons in the sensory trigeminal complex. We may assume that latent infections of these areas may precede the infections of the peripheral organs and the reactivation of the virus exerts the symptoms.

Clinical Neuroscience

Unanswered questions in the transcranial magnetic stimulation treatment of patients with depression

MORVAI Szabolcs, NAGY Attila, KOVÁCS Attila, MÓRÉ Csaba, BERECZ Roland, FRECSKA Ede

According to the WHO fact sheet depression is a common mental disorder affecting 350 million people of all ages worldwide. Transcranial Magnetic Stimulation (TMS) is a technique which allows the investigator to stimulate and study cortical functions in healthy subjects and patients suffering from various mental and neurological disorders. In the early 1990s, studies revealed that it is possible to evoke long term mood changes in healthy volunteers by rapid rate repetitive, TMS (rTMS) over the frontal cortex. Subsequent studies involving depressed patients found frontal cortical rTMS administered daily to be clinically effective. In the past two decades, numerous trials examined the therapeutic potential of rTMS application in the treatment of mood disorders with constantly evolving treatment protocols. The aim of this paper is to review the literature of the past two decades, focusing on trials addressing the efficacy and safety of rTMS in depressed patients. Our primary goal is to evaluate the results in order to direct future studies which may help investigators in the development of treatment protocols suitable in hospital settings. The time is not far when TMS devices will be used routinely by practitioners primarily for therapeutic purpose rather than clinical research. To our knowledge, a widely accepted “gold standard" that would offer the highest efficacy, with the best tolerability has not been established yet. In order to approach this goal, the most important factors to be addressed by further studies are: localization, frequency, intensity, concurrent medication, maintenance treatments, number of pulses, trains, unilateral, or bilateral mode of application.

Clinical Neuroscience

Long term follow-up of lesional and non-lesional patients with electrical status epilepticus in slow wave sleep

HEGYI Márta, SIEGLER Zsuzsa, FOGARASI András, BARSI Péter, HALÁSZ Péter

Objectives – A retrospective study has been done at the Bethesda Children’s Hospital Epilepsy Center with those patients whose EEG records fulfilled in one or more records the criteria of electrical status epilepticus in slow wave sleep (ESES) pattern, occupying at least 75% of NREM sleep with bilateral discharges, and had detailed disease history and long term follow-up data, between 2000 and 2012. Patients and methods – Thirty-three patients (mean 11.1±4.2 years of age) were studied by 171 sleep EEG records. Sleep was recorded after sleep deprivation or during spontaneous sleep at least for one hour length of NREM. From the 492 EEGs, 171 sleep records were performed (average five/patient). Average follow-up time was 7.5 years. Eighty-two ESES records have been analyzed in 15 non-lesional and 18 lesional (11 with dysgenetic and seven with perinatal - asphyxic or vascular origin) patients. Variability of seizure types, seizure frequency and frequency of status epilepticus was higher in the lesional group. Impairment of the cognitive functions was moderate and partial in the non-lesional, while severely damaged in the lesional group. Results – EEG records of 29 patients showed unihemispherial spike fields with a perpendicular axis (in anterior, medial and posterior variants) to the Sylvian fissure, regardless their lesional or non-lesional origin. Only three (1one non-lesional and two lesional) patients had bilateral synchronous spike-wave discharges with bilateral symmetric frontocentral spike fields. The individual discharges of the sleep EEG pattern were very similar to the awake interictal records except their extension in time and field, their increased number, amplitude, and continuity of them and furthermore in the increased trans-hemispheral propagation and their synchronity. Conclusions – Assumed circuits involved in the pathomechanism of discharges during NREM sleep in ESES are discussed based on our findings.

All articles in the issue

Related contents

Clinical Neuroscience

[Measurement of mental fatigability by task related spectral EEG. A pilot study (in English language)]

RAJNA Péter, HIDASI Zoltán, PÁL Iván, CSIBRI Éva, VERES Judit, SZUROMI Bálint

[Background - Task related EEG spectra are promising markers of mental activity. But the cooperation of the patients necessary for the registration limits its application in the neuro-psychiatry. Methods - EEG difference spectra on counting (EDSC) - was developed to detect the effect of a short calculation task on the spectral EEG. The originality of the task situation is a continuous mental work in a very short period of time, while the level of task difficulty is adapted to the patient’s actual mental capacity. While the rest pre-task and the post task EEG sections were compared, the results show the mental “EEG fatigability” caused by the short intensive cognitive activity. The first preliminary results have been demonstrated by a comparative study of two healthy and three patient (probable Alzheimer disease, post-stroke state without mental deficit and mixed type of dementia) groups. Results - Similarly to the findings of other authors, in addition to the differences of the alpha band seen on the temporo-parieto-occipital regions, the frontal localization and the beta band seem to be prominent, too. Demented patients had stronger EEG reactions than post-stroke patients without mental deficits and healthy elder persons had more extensive changes than the younger ones. Conclusions - The test can be considered as indirect marker showing the different mental fatigability in diverse pathological conditions and during the aging process. Effect of therapeutic processes can also be followed based on “key-lock principle”. Standardization of the test is essential for the introduction of EDSC to the every-day routine of clinical neuropsychiatry.]

Clinical Neuroscience

[Depression in neuropsychiatric diseases]

HIDASI Zoltán, SALACZ Pál, CSIBRI Éva

[Depression is frequently observed together with neurological disorders. Moreover this connection is bidirectional in the case of several neurological disorders, as depression can be either a comorbide syndrome or also a risk factor of them. Neurobiological background of depression involves neuroanatomical structures, their interconnected networks, disturbances of neurotransmitters, neurohormonal, neuroimmunological and neurotrophic changes, genetic background. Disfunction of these systems also plays a role in the pathogenesis of comorbid depression of neurological disorders. Interactions and clinical aspects of biological factors involved in the pathogenesis of depression in dementias, Parkinson’s disease, cerebrovascular disorders and epilepsy are discussed further. Depression as a result of neurobiological factors responsible for both neurological and psychiatric consequencies of these disorders, are often atypical as a clinical manifestation, however chracteristic for the particular neurological disorder. Evaluation of the biological backgound and clinical features of depression in neurological disorders makes the complex neuropsychiatric approach of these disorders possible.]

Lege Artis Medicinae

[“Yesterday no longer exists either…” - End-of-life ethical issues in the care of dementia patients]

HEGEDÛS Katalin

[The number of dementia patiens is rising. Most of them die in various institutions, often after many years of care. The long process of nursing and care entails particular ethical requirements that are built primarily on vulnerability, dignity, and dia-logue. The dialogue, however, is often absent from the care of dementia patients. Do we find - as physicians, patients, relatives - that specific time when the patients can still make decisions about end-of-life treatments in a good mental state? Most patients would like to participate in these decisions. Talking about these issues in the early stage of dementia may help in the great emotional burden of family members and caregivers. Therefore the ethical aim is the ad­vance care planning (ACP) of the end-of-life treatments. The study reviews the latest scientific results, with special regard to resources that may be helpful in the course of conversations between doctor and patient on end-of-life preferences, and in the preparation for decision making. ]

Lege Artis Medicinae

[The effects of angiotensin receptor blockers on the nervous system in hypertension and dementia]

KOVÁCS Tibor

[The renin-angiotensin system (RAS) is one of the most important mechanisms regarding the pathomechanism and treatment of hyprtension. The most of the elements of the RAS are found in the nervous system too. The effect of angiotensin converting enzyme inhibitors and angiotensin receptor blockers (ARBs) is based on the inhibition of the RAS. ARBs might have a special role in the central nervous system because they do not decrease the production of angiotensin but inhibit its harmful effects mediated through the AT1 receptor while allowing the stimulation of AT2 receptors with resulting pleiotrophic actions. Hypertension is the most important risk factor for stroke and has a negative effect on cognitive functions. Antihypertensive treatment has an effect on the nervous system; in addition to the consequences of the reduced blood pressure, ARBs might provide additional advantages in stroke and dementia prevention.]

Clinical Neuroscience

[The first identified Central-Eastern European patient with genetically confirmed dentatorubral-pallidoluysian atrophy]

ZÁDORI Dénes, TÁNCZOS Tímea, JAKAB Katalin, VÉCSEI László, KLIVÉNYI Péter

[Aims - Dentatorubral-pallidoluysian atrophy (DRPLA) is an inherited neurodegenerative disorder characterized by a trinucleotide repeat expansion. The disease mainly occurs amongst the Japanese and is extremely rare in the European population. The characteristic clinical symptoms are cerebellar ataxia, dementia, choreoathetoid movements, epileptic seizures and myoclonus. The aim of this study is to present the first genetically confirmed Hungarian case of DRPLA. Case report - The middle-aged female patient developed the characteristic clinical symptoms except myoclonus over her late thirties with positive family history. The major finding in the skull magnetic resonance imaging was the atrophy of infratentorial brain structures with the consequential dilation of related cerebrospinal fluid spaces. A detailed neuropsychological examination was also performed and it revealed moderate cognitive dysfunctions, mild depression and anxiety. As underlying conditions, Huntington’s disease and common spinocerebellar ataxia forms all came into consideration, but all the result of the respective genetic tests were negative. However, the test for mutation in the ATN1 gene revealed pathological heterozygous CAG repeat expansion. Conclusion - This case study serves as the first description of genetically confirmed DRPLA in the Central-Eastern region of Europe, the clinical features of which seems to be very similar to the previously reported cases.]