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Clinical Neuroscience

NOVEMBER 30, 2020

The applications of transcranial Doppler in ischemic stroke


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

NOVEMBER 20, 2015

[A rare complication of a rare disease; stroke due to relapsing polychondritis]


[Relapsing polychondritis (RP) is an episodic and progressive inflammatory disease of cartilaginous structures. Its diagnosis is based primarily on clinical features such as laboratory parameters, biopsy. Neurological complications occur in 3% of the cases and are classified as an important cause of death. The cranial nerve disorders are most common but hemiplegia, ataxia, myelitis, polyneuritis, seizures, confusion, hallucination and headache can also happen. The aetiology of central nervous system involvement is still unknown. Moreover stroke has rarely reported in these patients. The diagnosis of stroke is challenging because of its rarity among these patients. Perhaps vasculitis is the common underlying mechanism. Also meningitis and encephalitis can occur during the course of RP. A 44 year-old woman was admitted with uncontemplated left hemiparesis, redness, swelling, and tenderness of the metacarpophalangeal and interphalangeal joints of the right hand and the cartilaginous portion. White blood cell count, C-reactive protein and the erythrocyte sedimentation rate were elevated. Vasculitis biomarkers were normal in our patient. Carotid and vertebral artery doppler ultrasonography, cranial and cervical MR Angiography were normal. Echocardiography showed a mild mitral valve prolapse and regurgitation. Our patient had the history of auricular polychondritis but she had not been diagnosed. Hemiparesis was her first neurological manifestation that led her to doctors for diagnosis. Our patient fulfilled the criteria of RP so no biopsy was needed. She was treated with oral prednisolone (80 mg/day) and aspirin (300 mg/day) and now she is on 10 mg prednisolone and 150 mg azathioprine. Two months later her physical and neurological symptoms returned to normal.]

Lege Artis Medicinae

MARCH 10, 2020

[Summary data of Hungary's comprehensive health screening program (MAESZ) 2010-2019]

BARNA István, KÉKES Ede, HALMY Eszter, BALOGH Zoltán, KUBÁNYI Jolán, SZŐTS Gábor, NÉMETH János, PÉCSVÁRADY Zsolt, MAJOROS Attila, DAIKI Tenno, ERDEI Ottilia, DANKOVICS Gergely

[The comprehensive screening program of Hun­gary (MAESZ) 2010-2020-2030 is a unique initiative in Hungary and worldwide too. This largest humanitarian program provides by the latest technology free scree­ning tests for all residents in Hungary. The program developed by 76 pro­fessional organizations offers 38 scree­ning tests to every participants free of charge, in a special designed screening truck. Screening program performed by MAESZ includes cardiovascular, ophthalmologic, dermatologic, gynecologic, and neurologic investigations, lab tests, audiometry, blood pressure and arterial stiffness measurements, and venous Doppler ultrasound examinations. More­over, screening tests for lactose intolerance, colon malignancy, inflammatory bowel disease, reflux disease, urine incontinency, prostatic cancer and physical activity level were evaluated. Starting 2020, a dental screening station will be added to the mobile unit for early detection of oral cancers. Beyond screening tests, special attention is paid to assess health threatening risk factors, such as smoking, alcohol con­sumption, physical inactivity, un­healthy nutrition, and obesity. The program demonstrates the key elements of first aid from reanimation to bandage of burns in cooperation with professional and civil organisations. Furthermore, during the waiting time, participants get lifestyle recommendations and a health booklet with a bar code enabling the immediate computer analysis of test outcomes. Since the 2018/2019 school year the official prevention program for children entitled “Travel around the Empire of Health” was started. During its 10 years, the MAESZ performed 7 million free of charge screening tests on 1,886 scenes, enrolled 560,000 participants, invested 16,000 hours for prevention, handed out 1,200,000 health booklets and 391,000 prevention info packages to thousands of fami­lies. More than 20,000 health professionals (GPs, nurses, dietetics, health development agents, public health government officials, Accident Prevention Committee of National Police Headquarters, General Directorate of Social Affairs and Child Protection and non-governmental organizations) have been participated. The program designed to improve social health aims to help more and more Hun­garian citizens to be informed about their health status and to reminds them of the importance of prevention. ]

Clinical Neuroscience

JULY 30, 2019

Effects of CHADS2 score, echocardiographic and haematologic parameters on stroke severity and prognosis in patients with stroke due to nonvalvular atrial fibrillation


Introduction - The aim of this study is to evaluate utility of CHADS2 score to estimate stroke severity and prognosis in patients with ischemic stroke due to non-valvular atrial fibrillation (AF) in addition to evaluate effects of hematologic and echocardiographic findings on stroke severity and prognosis. Methods - This prospective study included 156 ischemic stroke cases due to non-valvular AF in neurology ward of Trakya University Medical School between March 2013-March 2015. National Institute of Health Stroke (NIHS) score was used to evaluate severity of stroke at admission. Carotid and vertebral Doppler ultrasonography findings, brain computed tomography (CT) and magnetic resonance imaging (MRI) of the cases were evaluated. Left atrial diameter and ejection fraction (EF) values were measured. CHADS2 score was calculated. Modified Rankin Scale was used to rate the degree of dependence. Effects of age and sex of the patients, presence of diabetes mellitus (DM), Congestive Heart Failure (CHF), Cerebrovascular Disease (CVD) and C-reactive protein (CRP) levels on CHADS2, NIHS, and mRS were evaluated. Results - In patients with age ≥75, mean NIHS score was 3.3 points and mean mRS score was 1.02 points higher, than in patient below 75 years of age. Compared with the mild risk group, cases in the high risk group had older age, higher serum D-dimer, fibrinogen and CRP levels and lower EF. A positive relation was detected between stroke severity and Hemorrhagic Transformation (HT), previous CVD history, and presence of CHF. A significant association was found between increased stroke severity and Early Neurological Deterioration (END) development. Older age, higher serum fibrinogen, D-dimer, CRP and lower EF values were associated with poor prognosis. History of CVD and presence of CHF were associated with poor prognosis. END development was found to be associated with poor prognosis. In the high-risk group, 30.3% (n = 33) had END. Among those in the high-risk group according to the CHADS2 score, END development rate was found to be significantly higher than in the moderate risk group (p <0.05). There was a strong positive correlation between CHADS2 and NIHS scores. mRS score increased with increasing CHADS2 score and there was a strong correlation between them. Effect of stroke severity on prognosis was assessed and a positive correlation was found between NIHS score and mRS value. Discussion - Our study demonstrated the importance of CHADS2 score, haemostatic activation and echocardiographic findings to assess stroke severity and prognosis. Knowing factors which affect stroke severity and prognosis in patients with ischemic stroke may be directive to decide primary prevention and stroke management.

Clinical Neuroscience

JULY 30, 2018

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

MAY 30, 2018

[Relationship between patent foramen ovale and cryptogenic stroke in a retrospective hospital-based study]


[Objective - After routine workup, 23-25% of ischemic strokes etiology remains unknown, i.e. cryptogenic. However, according to international results pathogenic patent foramen ovale (PFO) reveals in 25% of these cases. Aim of our retrospective study to prove the substantial etiological role of PFO-related stroke (PFO-RS) in cryptogenic strokes (CS), and to identify age related differences in stroke etiology. Methods - All new ischemic strokes of 2014-2015 were classified by ASCOD (Atherosclerosis, Small-vessel disease, Cardiac pathology, Other, Dissection) phenotyping. CS was defined when the etiology was unknown. With the help of special ultrasound techniques and RoPE (Risk of Paradoxical Embolism) score the portion of PFO-RS were determined in the examined CS population. Moreover, etiological distribution and differences between age groups (<40, 40-60, >60 years) were described. Results - During the examined period, 8.12% of 985 new ischemic strokes were categorized as CS. 41.38% of examined CS were found to be PFO-related. PFO-RS were considerably more frequent in the younger age groups than in the older age groups. The probability of appearance of PFO-RS were significantly higher in younger age than in case of age independency. Our results verify the substantial etiological role of PFO-RS in CS, and confirm the essential role of contrast enhanced functional transcranial Doppler in the routine diagnostic workup. Age related differences in stroke etiology were found to be statistically significant (p=0.000, df=14), in which small-vessel disease, cardiac pathology, dissection, other pathologies, CS and PFO-RS were contributed significantly. Based on our results, till in young age rare etiologies are typical, while in older age classical etiologies are mainly characteristic.]

Clinical Neuroscience

MAY 30, 2018

Evaluation of ischemic stroke patients with systemic cancer

UFUK Emre, TASKIN Gunes, IREM Pinar, FURUZAN Kokturk, ESENGUL Liman, ORHAN Yağiz

Purpose - In cancer patients, an ischemic stroke can be seen as both a direct effect of cancer and a complication of treatment. This condition can negatively affect the follow-up and treatment of these patients. For this research, we aimed to evaluate the clinical features, stroke types and etiological features of ischemic stroke patients with histories of cancer or found to have cancer during the aetiological investigation. Materials and methods - We retrospectively evaluated 100 patients (57 males, 43 females) who were hospitalized with acute stroke and determined to have the presence of cancer or a cancer history during the aetiological investigation between 2011 and 2016. All the demographic features, stroke types and localizations, National Institutes of Health Stroke Scale (NIHSS) scores, Rankin Scale scores, durations of cancer and cancer treatments were recorded. Results - The mean age of the patients was 67.07 ± 10.9 years old, the median NIHSS score was 5, and the median Rankin Scale score was 4. While 79% of patients had ischemic stroke risk factors, 21% did not. Atherosclerotic stroke was the most common stroke type (49%, n=49) and cryptogenic strokes were detected in 21% (n=21). In addition, 63% of the patients had chronic cancer (later than 6 months), 31% of the patients had recent cancer histories (less than 6 months), and 29% of the patients had metastases. Among all the malignancies, lung cancer (n=23), gastrointestinal cancer (n=20) and gynaecological-breast cancer (n=16) were the three most common. Moreover, 37% of the patients underwent chemotherapy, 29% underwent radiotherapy, and 88% of the patients had Carotid/Vertebral Doppler USG abnormalities. Conclusion - Similar to what is stated in the literature, an atherosclerotic stroke was the most common type of stroke in the cancer patients. Stroke risk factors were not detected in 21% of the patients, and in the majority of the patients, atherosclerotic changes in the carotid artery were observed in the Doppler examinations. In the aetiology and prognosis of ischemic stroke, it is important to keep in mind the existence of cancer in addition to the classical stroke risk factors.

Clinical Neuroscience

SEPTEMBER 30, 2017

Title of the article: Bilateral acute angle-closure glaucoma induced by duloxetine

ATUM Mahmut, VILDAN Tunc, ENES Demiryurek, ALAGOZ Gursoy

Introduction - To present a rare case of bilateral acute angle-closure glaucoma secondary to duloxetine administered for the treatment of depression. Case presentation - A 46 year old woman developed bilateral closed angle glaucoma after 15 days of duloxetine usage. Intraocular pressures (IOP) were 52 and 55 mm Hg in right and left eyes respectively, with shallow anterior chamber and angle closure on gonioscopy. Discontinuing duloxetine treatment, initiation of antiglaucomatous treatment and bilateral Nd:YAG Laser iridotomy obtained normalized IOP and anterior chamber depth. Conclusion - Duloxetine, used in the treatment of depression can be responsible for acute angle-closure glaucoma by leading to mydriasis and ciliary effusion.

Journal of Nursing Theory and Practice

FEBRUARY 28, 2016

[Care of the fistula, advantages of the monitoring and the surveillance with thermodilution technique]


[Introduction: The best choice of vascular access for haemodialysis patients is the native arteriovenous fistula (AVF). Therefore, monitoring and surveillance of vascular accesses has a high priority. Aim of the research: The aim of our study was to evaluate the AVF surveillance protocol of our dialysis clinic. Research and sampling methods: We began AVF monitoring and surveillance in our dialysis clinic in February 2003. Until May 2015 we evaluated the data of 307 patients. Results: Besides the regular physical investigation of fistulas we performed measurements of vascular access flow (Qa) with thermodilution technique. In cases of suspected stenosis we performed Colour Doppler Ultrasonography and/or fistulography. Stenosis was verified in 154 cases at 344 patients. Percutan transluminal angioplasty was performed in 241 cases at 127 patients. Creation of a new fistula was necessary only in 24 cases at 21 patients. Within the last three years the percentage of patients treated via AVF has risen from 75% to 84%. Conclusions: Regular monitoring and surveillance of vascular accesses and the timely correction of its complications are able to reduce thrombosis of fistulas and the necessity of using central venous catheters. ]

Clinical Neuroscience

SEPTEMBER 30, 2014

[Retinal ganglion cell layer and visual function in patients with progressive external ophthalmoplegia caused by common mtDNA deletion]

FARZANEH Naghizadeh, VARGA Edina Tímea, MOLNÁR Mária Judit, HOLLÓ Gábor

[Aim - Mitochondrial (mt) disorders are metabolic conditions with multiorgan involvement, which often cause neuroophtalmological symptoms. The aim of the study was to investigate the relation between progressive external ophthalmoplegia (PEO), visual pathway and mitochondrial DNA (mtDNA) mutations in patients younger than 55 years of age. Methods - Five female patients (35 to 53 years of age) with mithochondrial disease were investigated. Automated threshold perimetry (Octopus G2 test), scanning laser polarimetry (GDx-VCC and GDx-ECC) and Fourier-domain optical coherence tomography (RTVue-100 OCT) were used in addition to detailed ophthalmological examination and evaluation of visually evoked potentials (VEP). Frequent mutations of the mtDNA were investigated in the patients’ blood and muscle samples. Results - PEO of various severity levels was found in all patients, using clinical tests. Genetic testing showed “common deletion” of mtDNA in all cases. For both eyes of 4 patients functional and structural ophthalmic tests had normal results. In one patient decreased visual acuity, reduced retinal nerve fiber layer thickness and prolonged L3 VEP latency time were found without optic disc damage and visual field deterioration. Conclusion - In 4 of our 5 patients with PEO due to common deletion of mtDNA retinal ganglion cells and visual function remained normal for a long period of life.]