The effects of conformation and intermolecular hydrogen bonding on the structure and IR spectra of flutamide; a study based on the matrix isolation technique, ab initio and DFT calculations

In this study, stable conformers of flutamide referred to as an anticancer drug were searched through a relaxed potential energy surface scan carried out at the B3LYP/6-31G(d) level of theory. This was followed by geometry optimization and thermochemistry calculations performed with the HF-SCF, MP2, B3LYP methods and the 6-31G(d), 6-311++G(d,p), aug-cc-pvTZ basis sets for each of the determined minimum energy conformers. The results revealed that flutamide has at least five stable conformers and two of them provide the major contribution to the observed matrix isolation infrared (IR) spectra of the molecule. The effects of conformational variety and intermolecular hydrogen bonding interactions on the observed IR spectra of flutamide were interpreted in the light of the vibrational spectral data obtained for the most stable monomer and dimer forms of the molecule at the same levels of theory. Pulay's "Scaled Quantum Mechanical-Force Field (SQM-FF)" method was used in the refinement of the calculated harmonic wavenumbers, IR intensities and potential energy distributions. This scaling method which proved its superiority to both anharmonic frequency calculations and other scaling methods helped us to correctly interpret the remarkable differences between the matrix IR spectra of flutamide in argon and the condensed phase IR spectra of the molecule in solvents such as KBr, H₂O, D₂O, ethanol and methanol.

An investigation on the structure and group vibrations of balenine molecule by matrix isolation IR spectroscopy, DFT and MP2 based calculations

Stable conformers of neutral balenine were scanned through molecular dynamics simulations and energy minimizations using Allinger's MM2 force field. For each of the found minimum-energy conformers, geometry optimization and thermochemistry calculations were performed by using B3LYP, MP2, G3MP2B3 methods, 6-31G(d), 6-311++G(d,p) and aug-cc-pvTZ basis sets. The calculation results have indicated that balenine has about twenty stable conformers whose relative energies are in the range of 0-9.5 kcal/mol. Three of these are thought to provide the major contribution to matrix isolation IR spectra of the molecule. Our solvent calculations using the polarized continuum model revealed the stable zwitterion structures which are predicted to dominate IR spectra of balenine in water and heavy water (D₂O) solvents. Pulay's SQM-FF method was used in scaling of the harmonic force constants and vibrational spectral data calculated for the neutral and zwitterion structures. These refined calculation data together with those obtained from anharmonic frequency calculations enabled us to correctly interpret the matrix isolation IR spectrum of balenine and the tautomerism-based changes observed in its KBr IR and solution (D₂O) IR spectra. The results revealed the crucial role of conformation and zwitterionic tautomerism on the structure and vibrational spectral data of the molecule.

Usefullness of peak mitral regurgitation velocity to left ventricular outflow tract time velocity integral ratio as a new prognostic marker for one year and long term mortality in failing heart

Background and aim

Systemic vascular resistance (SVR) is useful for risk estimation and therapy guidance in HF. It has been showed that the ratio of peak mitral regurgitation velocity (MRV) to left ventricular outflow tract velocity-time integral (LVOT VTI) correlated positively with SVR. We aimed to assess the association of MRV/LVOT VTI ratio with established prognostic markers and its prognostic role for predicting one year and long term composite end-points in patients with HF and reduced ejection fraction (HFrEF).

Material and methods

We prospectively enrolled a total of 72 patients with HFrEF and 10 control subjects. Patients were followed up patients for median 40.5 months. Primary composite endpoint (CEP) was defined as any of these outcomes including requiring mechanical circulatory support, cardiac transplantation and all-cause mortality.

Results

CEP(+) patients had higher MRV/LVOT VTI ratio than others (0.48±0.15 vs. 0.39±0.18 p=0.012). MRV/LVOT VTI ratio was positively correlated with functional status (β=0.539, p=0<001), serum BNP level (β=0.479, p<0.001),troponin I (β=0.415, p<0.001), and Uric acid level (β=0.235 p=0.018) and negatively correlated with SEATTLE score derived life expectancy (β=−0.248, p=0.032). Adjusted with other parameters, every 0.1 increase in MRV/LVOT VTI ratio increased the one-year CEP risk by 27% and long-term CEP risk by 24.6%. In Kaplan Meier analysis, patients with MRV/LVOTVTI ratio ≥0.39 had more long-term CEP compared to others.

Conclusion

MRV/LVOT VTI ratio seemed to be useful predictor of poor prognosis associated with other established HF prognostic markers.

Figure 1

Funding Acknowledgement

Type of funding source: None

An epidemiologic investigation of amyotrophic lateral sclerosis in Thrace, Turkey, 2006-2010

OBJECTIVE

The aim of the study was to investigate the incidence and prevalence of amyotrophic lateral sclerosis (ALS) in Thrace, Turkey in a five-year time period (2006-2010).

METHODS

Study population included residents of three provinces (Edirne, Tekirdag, Kırklareli) in the Thrace region. Cases were ascertained from all of the neurologic centers and hospitals of these provinces. Demographic and clinical information was collected for each patient. Newly diagnosed ALS patients who are fulfilling the El Escorial revised diagnostic criteria were enrolled into the study.

RESULTS

We identified a total of 145 patients (93 males, 52 females). The mean age at diagnosis was 57.0 ± 13.6. According to El Escorial criteria, 60.0% of the cases were definite ALS, 24.8% were probable, and 15.2% were possible ALS. Thirty-two cases were bulbar (22.1%), 113 cases (77.9%) were spinal onset. Mean time delay from onset to diagnosis was 12.0 ± 11.2 months. Age-gender standardized incidence rates with reference to Turkey, USA 2008 census were 1.9 (95% confidence interval (CI), 1.8-2.1), 1.9 (95%CI, 1.8-2.2) for overall. There were 112 living ALS patients at the end of the study. Crude point prevalence was calculated as 7.3 per 100,000 population (95%CI, 5.9-8.7).

CONCLUSIONS

This is the first study to provide fundamental data about demographic and clinical characteristics about ALS in Thrace region of Turkey. Incidence and prevalence of ALS in Thrace region of Turkey appear to be comparable with European countries.

A vibrational spectroscopy study on anserine and its aqueous solutions

In this study based on vibrational spectroscopic measurements and Density Functional Theory (DFT), we aimed for a reliable interpretation of the IR and Raman spectra recorded for anserine in the solid phase and water (H2O) and heavy water (D2O) solutions. Initial DFT calculations at the B3LYP/6-31G(d) searched possible conformers of the anserine zwitterion using a systematic conformational search. The corresponding equilibrium geometrical parameters and vibrational spectral data were determined for each of the stable conformers (in water) by the geometry optimization and hessian calculations performed at the same level of theory using the polarized continuum model (PCM). The same calculations were repeated to determine the most energetically preferred dimer structure for the molecule and the associated geometry, force field and vibrational spectral data. The harmonic force constants obtained from these calculations were scaled by the Scaled Quantum Mechanical Force Field (SQM) method and then used in the calculation of the refined wavenumbers, potential energy distributions, IR and Raman intensities. These refined theoretical data, which confirm the zwitterion structure for anserine in the solid phase or aqueous solvents, revealed the remarkable effects of intermolecular hydrogen bonding on the structural properties and observed IR and Raman spectra of this molecule.

The value of electroencephalography in differential diagnosis of altered mental status in emergency departments

OBJECTIVE

To evaluate the value of electroencephalography in patients with altered mental status in emergency departments.

METHODS

Demographical characteristics, types and aetiologies of seizures, and clinical outcomes of the patients were recorded. Patients were divided into 4 groups according to the complaints of admission: findings and symptoms of seizure; stroke and symptoms of stroke-related seizures; syncope; and metabolic abnormalities and other causes of altered mental status. The electroencephalography findings were classified into 3 groups: epileptiform discharges; paroxysmal electroencephalography abnormalities; and background slowing. Electroencephalography abnormalities in each subgroup were evaluated. SPSS 21 was used for statistical analysis.

RESULTS

Of the total 190 patients in the study, 117 (61.6%) had pathological electroencephalography findings. The main reason for electroencephalography in the emergency department was the presence of seizure findings and symptoms in 98 (51.6%) patients. The ratio of electroencephalography abnormality was higher in patients who were admitted with complaints of metabolic abnormality-related consciousness disturbances (p < 0.001). A total of 124 (65.3%) patients had neuroimagings. Electroencephalography abnormalities were found to be significantly higher in patients with neuroimagings compared to those without neuroimagings (p < 0.003).

CONCLUSION

Despite advanced neuroimaging techniques, electroencephalography is still an important tool in the differential diagnosis of altered mental status such as epileptic seizures, metabolic abnormalities, pseudo-seizures and syncope.

Cerebral fat embolism syndrome after long bone fracture due to gunshot injury

Cerebral fat embolism syndrome is a lethal complication of long-bone fractures and clinically manifasted with respiratory distress, altered mental status, and petechial rash. We presented a 20-year-old male admitted with gun-shot wounds to his left leg. Twenty-four hours after the event, he had generalized tonic clonic seizures, decorticate posture and a Glascow Coma Scale of seven with localization of painful stimuli. Subsequent magnetic resonance imaging of the brain showed a star-field pattern defining multiple lesions of restricted diffusion. On a 4-week follow-up, he had returned to normal neurological function. Despite the severity of the neurological condition upon initial presentation, the case cerebral fat embolism illustrates that, cerebral dysfunction associated with cerebral fat embolism illustrates reversible.

Phrenic neuropathy in diabetic and prediabetic patients without neuromuscular complaint

Neuropathy, one of the major reasons of morbidity in diabetes mellitus (DM), is associated with prediabetic conditions as well as DM. The present study aims to compare phrenic and peripheral nerves in prediabetic, diabetic patients and healthy controls. A total of 37 diabetic, 40 prediabetic patients and 18 healthy controls were enrolled in the study. All subjects underwent conventional sensory and motor nerve conduction studies. Bilateral phrenic and peripheric nerve conduction studies were performed. In both right and left phrenic nerves, the amplitudes were lower in prediabetic and diabetic patients than control subjects, respectively (p: 0.005 and p: 0.001). Both of the phrenic nerve conductions were altered similarly. The results of our study demonstrate that phrenic nerves are affected like peripheric nerves in prediabetic and diabetic patients. We suggest reminding phrenic neuropathy in newly onset respiratory failure in diabetic and prediabetic patients.

Raman micro-spectroscopic analysis of cultured HCT116 colon cancer cells in the presence of roscovitine

Raman micro-spectroscopic analysis of cultured HCT116 colon cancer cells in the presence of roscovitine, [seliciclib, 2-(1-ethyl-2-hydroxy-ethylamino)-6-benzylamino-9-isopropylpurine], a promising drug candidate in cancer therapy, has been performed for the first time. The aim of this study was to investigate modulations in colon cancer cells induced by roscovitine. Raman spectra of the cultured HCT116 colon cancer cells treated with roscovitine at different concentrations (0, 5, 10, 25 and 50 μM) were recorded in the range 400-1850 cm(-1). It was shown that the second derivative profile of the experimental spectrum gives valuable information about the wavenumbers and band widths of the vibrational modes of cell components, and it eliminates the appearance of false peaks arising from incorrect baseline corrections. In samples containing roscovitine, significant spectral changes were observed in the intensities of characteristic protein and DNA bands, which indicate roscovitine-induced apoptosis. Roscovitine-induced apoptosis was also assessed by flow cytometry analysis, and analysis of propidium iodide staining. We observed some modifications in amide I and III bands, which arise from alterations in the secondary structure of cell proteins caused by the presence of roscovitine.

Cost of acute ischemic and hemorrhagic stroke in Turkey

OBJECTIVE

The aim of this study is to examine the direct medical costs and outcomes of patients with stroke.

MATERIAL AND METHODS

The records of the patients admitted with ischemic and hemorrhagic stroke to the University of Trakya, School of Medicine, Department of Neurology were reviewed retrospectively in year 2007. Direct medical costs (total costs, radiological, laboratory, medicine, and other) were calculated, additionally cost per life saved and per life-year saved were calculated for stroke patients.

RESULTS

The study group consisted of 328 patients (169 male/159 female) and mean age was 66.5 ± 12.4 years. Length of hospital stay was 10.7 ± 7.5 days. Mortality rate was 20.4% and the mRS score of the patients was 3.2 ± 2.1. The average cost of stroke was US$ 1677 ± 2964 (29.9% medicine, 19.9% laboratory, 12.8% neuroimaging, and 38% beds and staff). Cost per life saved and per life-year saved were US$ 2108 and US$ 1070, respectively.

CONCLUSION

This is the first study in order to determine direct medical cost of stroke in Turkey, therefore, it may be guideline for disease-cost management of stroke.

COMPARATIVE NEUROPHYSIOLOGICAL STUDY FOR THE DIAGNOSIS OF MILD POLYNEUROPATHY IN PATIENTS WITH DIABETES MELLITUS AND GLUCOSE INTOLERANCE

This article evaluates diagnostic sensitivity of minimal F-wave latency, sural/radial amplitude ratio (SRAR), dorsal sural/radial amplitude ratio (DSRAR), sympathetic skin response (SSR), and R-R interval variability (RRIV) for detecting early polyneuropathy in patients with glucose intolerance and diabetic patients. F-wave latencies were more prolonged in diabetic patients with normal and abnormal nerve conduction studies than control subjects (p < .001). SRAR was lower, SSR latency was more prolonged, and RRIV was lower in diabetic patients with abnormal nerve conduction studies than healty controls (p < .001). SSR latency was more prolonged and RRIV was lower in diabetic patients with normal nerve conduction studies than healty controls (p < .01, p < .05, respectively). DSRAR was lower in diabetic patients with normal and abnormal nerve conduction studies than control subjects (p < .001). DSRAR was also lower in patients with glucose intolerance than control subjects (p < .01). DSRAR was the most sensitive and specific test in either of diabetic patients with normal nerve conduction studies (sensitivity 66%, specificity 90%) and diabetic patients with abnormal nerve conduction studies (sensitivity 100%, specificity 90%). DSRAR is the most reliable method for detection of early nerve pathology. Patients with glucose intolerance might have subclinical neuropathy that can be demonstrated with DSRAR analysis.

Development of entrapment neuropathies in acute stroke patients

BACKGROUND

Stroke is the third most common cause of mortality and is one of the most common causes of morbidity in the world. Polyneuropathies and entrapment neuropathies are known as the complications of stroke.

AIMS OF THE STUDY

In this study we aimed to evaluate the development of entrapment neuropathies in severe stroke patients within the first month of the event.

METHODS

Twenty first-ever stroke patients were included in the study. The nerve conduction studies were performed within the first 48 h and repeated 1 month later.

RESULTS

At the end of the first month, seven of the 20 patients had median nerve entrapment at the wrist, five had ulnar nerve entrapment at the elbow and seven had peroneal nerve entrapment at the fibular head in the hemiparetic side. Three patients had median nerve entrapment at the wrist, one patient had ulnar nerve entrapment at the elbow, and none had peroneal nerve entrapment in the non-paretic side.

CONCLUSION

Our results confirm that, in severe hemiparetic patients, the entrapment neuropathies may be commonly seen, especially in the paretic extremities. The early rehabilitation programs against the development of entrapment neuropathies may be beneficial in stroke patients.

[Cerebral infarction due to traumatic carotid artery dissection: case report and review of current management]

With the advent of improved neuroradiological methods, it has been determined that frequency of traumatic carotid artery dissections is higher than previously observed. Since delayed neurological deficits may develop in some asymptomatic undiagnosed cases, it is essential to consider the possibility of the carotid artery dissection and evaluate it properly in suspicious cases. In this article, a case of internal carotid artery dissection and subsequent cerebral infarction following a motor vehicle accident is presented. Pathogenesis, clinical features, diagnostic method choices and treatments in this rare but severe condition are discussed in light of the relevant literature in order to convey current knowledge.

Changing cerebral blood flow velocity detected by transcranial Doppler ultrasound during head up tilt in patients with multiple sclerosis

BACKGROUND AND PURPOSE

Multiple sclerosis (MS) is a chronic inflammatory disease of central nervous system. We aimed to investigate the cerebral blood flow velocity (CBFV) changes in MS by transcranial Doppler.

METHODS

Twenty patients with MS, 20 age-matched healthy controls were included in the study. In both groups, blood flow velocities (BFVs) of middle cerebral arteries (MCAs) were evaluated. The changes of blood pressure, heart rate along with the changes in BFV of MCA were recorded after the patients were raised to upright position.

RESULTS

In both groups, upon raising the tilt table to the upright position, the mean CBFV values were found to be lower in comparison with the recorded baseline values (P values <0.05). The decline in the mean CBFV values was more significant in patients with MS (P = 0.01).

CONCLUSION

Our study showed upon raise of the tilt table, the mean BFVs decreased more in MS patients than control group with a more prominent change in the subgroup of MS patients with expanded disability scale scores > or =2. By use of transcranial Doppler ultrasound, it may be possible to evaluate BFV changes in patients with MS.

Sympathetic skin response and RR interval variation in patients with cardiac syndrome X

Sympathetic skin response (SSR) and R-R interval variation (RRIV) are noninvasive electrophysiological tests used in the assessment of sympathetic and parasympathetic nervous system function, respectively. Cardiac syndrome X (CSX) is usually diagnosed in the presence of typical angina pectoris, a positive response to exercise testing, and normal-appearing coronary angiograms without spasm induced by hyperventilation or ergonovine. Alterations of autonomic nervous system control of cardiac function have been described in CSX. The aim of the study was to investigate autonomic nervous system function in patients with CSX. Nine patients with CSX (2 men, 7 women) and healthy controls (11 men, 19 women) were included in the study. SSRs were recorded from palm of hands by stimulation of the median nerve. RRIV recordings were taken from precordium during both rest position (R%) and deep inspiration of 6 times per minute (D%). In addition D% - R% and D%/R% values were calculated. SSR amplitude of CSX was lower than in controls (3.64 +/-4.78 vs 6.36 +/-3.4 mV, p = 0.017). There was no difference between groups for SSR latency values (CSX: 1,366 +/-99; controls: 1,383 +/-85 msec). Also, R% (CSX: 13.04 +/-6.3; controls: 12.92 +/-3.91) and D% (CSX: 16.63 +/-8.88; controls: 21.43 +/-7.3) values were similar in the 2 groups. However, D% - R% (CSX: 3.59 +/-10.11; controls: 8.51 +/-7.01) and D%/R% (CSX: 1.45 +/-0.93; controls: 1.78 +/-0.69) values were slightly lower in patients with CSX but were not statistically significant. A linear correlation was found between SSR amplitude and D%/R% (r = 0.336, p = 0.036). The authors conclude that, among patients with CSX, there are alterations of autonomic nervous control of skin as well as of other organs (ie, heart). SSR and RRIV testing can be done easily in the neurophysiology laboratory to assess the sympathetic and parasympathetic system, respectively.

Acute onset myositis associated with brucellosis, quite a rare diagnosis

Brucellosis is a zoonosis that is transmissible to humans. It is a disease with multi-systemic involvement caused by the genus Brucella. Neurological complications, including meningitis, meningo-encephalitis, myelitis-radiculoneuritis, brain abscess, epidural abscess and meningo-vascular syndromes, are rarely encountered. We present a patient presenting with acute onset myositis. This kind of presentation has not previously been reported in the English language literature. We conclude that the diagnosis of neuro-brucellosis should be considered in patients presenting with muscle weakness.

Hereditary neuropathy with liability to pressure palsies in a Turkish patient (HNPP): a rare cause of entrapment neuropathies in young adults

Hereditary neuropathy with liability to pressure palsies (HNPP) is an autosomal dominant nerve disease usually caused by 1,5 Mb deletion on chromosome 17p11.2.2-p12, the region where the PMP-22 gene is located. The patients with HNPP usually have relapsing and remitting entrapment neuropathies due to compression. We present a 14-year-old male who had acute onset, right-sided ulnar nerve entrapment at the elbow. He had electrophysiological findings of bilateral ulnar nerve entrapments (more severe at the right side) at the elbow and bilateral median nerve entrapment at the wrist. Genetic tests of the patient demonstrated deletions in the 17p11.2 region. The patient underwent decompressive surgery for ulnar nerve entrapment at the elbow and completely recovered two months after the event. Although HNPP is extremely rare, it should be taken into consideration in young adults with entrapment neuropathies.

Carpal tunnel syndrome and metabolic syndrome

Carpal tunnel syndrome (CTS) is the most common entrapment neuropathy. Many factors such as diabetes mellitus, hypothyroidism, hormonal replacement therapy, corticosteroid use, rheumatoid arthritis and wrist fractures may cause CTS. Metabolic syndrome includes abdominal obesity, dyslipidemia, hyperglycemia, and hypertension that may cause CTS. In this study, we aimed to evaluate the relation between CTS and metabolic syndrome. We studied 107 (96 female and 11 male) right-handed patients who had a clinical and electrophysiologically confirmed diagnosis of CTS. We then divided the patients into two groups (patients with and without metabolic syndrome) according to the criteria of ATP III definition. Eighty (75%) of the patients with CTS had metabolic syndrome. Among the 80 patients with metabolic syndrome, CTS was found in 150 hands (43 mild, 58 moderate and 49 severe cases). Among the 27 patients without metabolic syndrome, CTS was found in 43 hands (27 mild, 14 moderate and 2 severe cases). The electrophysiological parameters (median nerve distal motor latency, median nerve motor amplitude, median nerve motor conduction velocity, median nerve sensory onset latency, median nerve sensory amplitude and median nerve sensory conduction velocity) were worse in patients with metabolic syndrome (P < 0.05). In conclusion, metabolic syndrome was found to be three times more common in patients with CTS and CTS was more severe in patients with metabolic syndrome when compared with those without metabolic syndrome.

Simultaneous onset of hemorrhagic and ischemic strokes

Primary brain hemorrhage and infarction only very rarely occur simultaneously. We report a patient with the simultaneous onset of hemorrhagic and ischemic strokes who had uncontrolled hypertension and atrial fibrillation. Neuroradiologic investigations revealed a large right thalamic hematoma with ventricular extension and an infarct in the territory of the left internal carotid artery. The patient died at the end of the second day because of herniation in spite of anti-edema and antihypertensive medication.

Deep cerebral vein thrombosis associated with iron deficiency anaemia in adults

Cerebral venous thrombosis (CVT) is rare and has a wide spectrum of symptoms, therefore it is difficult to diagnose. Thrombosis of the deep cerebral veins occurs very rarely: it has been reported that approximately 6% of patients with CVT have deep CVT, and the prognosis for patients with this condition is poor. CVT has been reported in association with dehydration, a hypercoagulable state, mastoiditis, tumour invasion of a venous sinus, use of oral contraceptives, pregnancy, puerperium, head trauma, vasculitis, and intracranial and systemic infections. However, in the literature, there are few reported cases of CVT in association with iron deficiency anaemia, especially in adults. We present here two patients with bilateral thalamic and basal ganglionic lesions due to thrombosis of the deep cerebral veins. Both of our patients had severe hypochromic microcytic anaemia due to iron deficiency, and both had a good prognosis after 2 months.

Evaluation of vasomotor reactivity by transcranial Doppler sonography in patients with acute stroke who have symptomatic intracranial and extracranial stenosis

OBJECTIVE

In patients with large artery disease, determining the cerebral hemodynamic state and following its alterations may be a good marker for predicting long-term outcome. The aim of our study was to compare the changes in vasomotor reactivity (VMR) of patients with symptomatic intracranial and extracranial artery stenosis. We also examined whether VMR after stroke influences the long-term prognosis for these patients.

METHODS

Forty-one patients were included in the study. To determine the cerebral hemodynamic state, transcranial Doppler ultrasound examinations and acetazolamide tests were performed after acute stroke and repeated after 6 months. We compared the VMR on admission and at 6 months, together with changes in VMR, of the patients with symptomatic intracranial and extracranial artery stenosis. By calculating the Barthel index at 6 months, we examined whether VMR had an effect on an improvement in their quality of life.

RESULTS

We observed a significantly higher initial VMR of the ipsilateral hemisphere in patients with intracranial stenosis (22.4 +/- 9.1 versus 13.4 +/- 12.8; P = .013). At 6 months, the VMR obtained from the ipsilateral hemisphere was better in patients with extracranial stenosis than in the patients with intracranial stenosis (P = .01). The ipsilateral VMR measured on admission showed a positive correlation with the Barthel index at 6 months (P = .007; r = 0.434).

CONCLUSIONS

Our study showed that VMR in patients with acute stroke who have extracranial and intracranial artery stenosis measured by using a transcranial Doppler examination may have value in predicting long-term outcome.

Changing cerebral blood flow velocity by transcranial Doppler during head up tilt in patients with diabetes mellitus

OBJECTIVE

Diabetes mellitus is an independent risk factor for poor prognosis in patients with ischemic stroke. It is known that diabetes mellitus directly affects cerebral vasculature as a secondary, long-term complication of cerebral circulation, and causes cerebral blood flow abnormalities. The abnormalities of cerebral autoregulation also poorly affects the prognosis of ischemic stroke. In this study, we aimed to show the cerebral autoregulation with transcranial Doppler (TCD) ultrasound in diabetic patients with autonomic nervous system abnormalities, determined with electrophysiological studies.

MATERIAL AND METHOD

Twenty healthy controls and 39 patients, who had at least 2 years of diabetes mellitus, were evaluated (age ranges: 42-75 years). The patients were divided into two groups according to sympathetic skin response and R--R interval variation studies: (1) patients with autonomic neuropathy; (2) patients without autonomic neuropathy. Blood flow velocities were measured during supine position and after the patients were raised upright position on head up tilt table. Arterial blood pressures and heart rates were also evaluated.

RESULTS

Mean blood flow velocities of diabetic patients with autonomic neuropathy were found more decreased at 90s after the patients were raised upright position.

DISCUSSION

Autonomic neuropathy due to diabetes mellitus affects cerebral autoregulation, and by this way cerebral perfusion loses protection against hemodynamical changes.

Two patients with tremor caused by cortical lesions

Myoclonic tremor due to cortical lesions is a rare condition and must be distinguished from other causes of tremor. This is because the treatment strategies of tremor may differ due to the various etiologies. We present here two cases with myoclonic tremor caused by parietal cortical lesions showing tremulous finger movement provoked by action and posture. Clinical and electrophysiological features of the patients were reported and compared with the features of the patients with cortical tremor in association with cortical reflex myoclonus. Both of our patients responded well to anticonvulsants such as valproate and clonazepam. In patients with acute postural tremor, cortical lesions such as mass occupying lesions, ischemic lesions and arteriovenous malformations should be taken into consideration.

Six-month follow-up study in patients with symptomatic intracranial arterial stenosis

Ischaemic stroke due to intracranial atherosclerosis is estimated to comprise 8-12% of all ischaemic strokes. It is known that the risk of recurrence is extremely high in patients with ischaemic stroke caused by intracranial stenosis. In the present study we aimed to evaluate the clinical and radiological findings over a 6-month follow-up period in patients with intracranial atherosclerosis. Prospective data for the ischaemic stroke patients admitted to our clinic between 2001 and 2004 were collected. The localization of stenosis/occlusion detected by magnetic resonance angiography (MRA) was recorded and patients were divided into two groups according to the presence of one or more arterial stenoses on MRA. The patients were followed up for 6 months at regular intervals and stroke recurrence and deaths were noted. Of the 47 patients, 11 had posterior circulation stenosis and 36 had anterior circulation stenosis. Thirty-three patients had only one intracranial artery stenosis, whereas 14 had more than one intracranial artery stenosis. Of the 38 patients who completed the 6-month follow-up period, 13 had recurrent stroke, and 10 died. The rate of stroke recurrence in patients with intracranial artery stenosis may be higher than in patients with stroke due to other aetiologies, and stenosis of multiple intracranial arteries increases the rate of recurrence.

Dorsal sural nerve conduction study in vitamin B12 deficiency with megaloblastic anemia

Peripheral neuropathy is frequently observed in B(12) deficiency. In spite of this, there is little knowledge about peripheral neuropathy in B(12) deficiency because the severity of clinical involvement of the central nervous system clearly outweighs signs and symptoms due to peripheral nervous system involvement. We primarily investigated peripheral neuropathy with dorsal sural conduction study, which is a new method for detection of early peripheral neuropathy, in B(12) deficiency with megaloblastic anemia. Conventional nerve conduction studies and tibial sensory-evoked potential (SEP) recording were also performed. Twenty-eight B(12)-deficient patients (15 male, 13 female, mean age 65.8 years) with megaloblastic anemia and 18 age- and sex-matched controls were included in the study. Although dorsal sural sensory nerve action potentials (SNAPs) were not recorded in 15 (54%) of 28 patients, only 9 (32%) of them were found to have polyneuropathy by conventional conduction studies. Furthermore, patients with dorsal sural SNAP had mean lower amplitude, mean longer latency, and slower velocity response when compared with controls. Twenty patients (71%) were diagnosed as having myelopathy by the combination of tibial SEP and neurological findings. Two patients whose dorsal sural SNAPs were not recorded had normal tibial SEP responses; therefore, these patients were considered to have isolated peripheral neuropathy. As a result, we conclude that dorsal sural nerve conduction study is a reliable method for detection of early peripheral neuropathy in B(12) deficiency.

Proximal myotonic dystrophy associated with parkinsonism

Although mental changes and cognitive disorders are seen frequently in myotonic dystrophy (MD) there are only three cases of MD associated with parkinsonism reported in the literature. We report another case of this extremely rare combination.

Clinical and neuroradiological predictors of mortality in patients with primary pontine hemorrhage

BACKGROUND AND PURPOSE

Primary pontine hemorrhage (PPH) accounts approximately for about 5-10% of intracranial hemorrhages, and PPHs are known to have a much less uniform prognosis. We aimed to evaluate the clinical and radiological predictors affecting the mortality in 32 patients with PPH.

MATERIAL AND METHODS

We retrospectively evaluated the data of 32 patients with PPH admitted to our clinic between 1994 and 2004. We divided the patients into two groups: (1) patients who survived (14 patients), and (2) patients who died (18 patients). The two groups were compared for age, gender, diabetes mellitus, hypertension, initial clinical status, initial GCS, pupillary abnormalities, ophthalmoparesis, volume and localisation of hemorrhage, intraventricular and extrapontine extension, necessity of mechanical ventilation and hydrocephalus. The hematoma volumes were measured with the formulation described by Broderick.

RESULTS

Eighteen patients (56%) died and 14 patients (44%) survived. The patients who died (61.3 +/- 8.8) were older than the survivors (56.4 +/- 11.0), but the difference was not statistically significant. The mean GCS was 4.4 +/- 0.2, the mean hematoma volume was 9.9 +/- 3.3 ml for patients who died and the mean GCS was 10.1 +/- 3.3, the mean hematoma volume was 3.3 +/- 1.2 ml for survivors (p < 0.001). Coma on admission (p = 0.001), extrapontine extension (p = 0.001), intraventricular extension (p = 0.019), necessity of mechanical ventilation (p = 0.007), hydrocephalus (p = 0.024), massive and bilateral tegmental localisation (p = 0.006) were found statistically significant predictors for mortality with univariate comparison, and coma on admission (p = 0.038) was the only significant predictor with multivariate regression analysis.

CONCLUSION

In patients with PPH, it is important to know the prognostic factors for mortality for planning the treatment protocol, and coma and bad clinical status on admission was found the only significant prognostic predictor for mortality with multivariate regression analysis.

Brachial Plexus Injury During Open Heart Surgery - Controlled Prospective Study

BACKGROUND

Postoperative brachial plexus injury is often reported because the brachial plexus is stretched by sternotomy and the use of sternal retractors during open heart surgery. In many studies, brachial plexus injuries have been demonstrated by postoperative electrophysiological studies in susceptible patients. In this study, we estimated the incidence, severity, and type of brachial plexus injuries by routine preoperative and postoperative electrophysiological studies of patients undergoing open heart surgery.

METHODS

Patients undergoing coronary artery bypass grafting (CABG) surgery (Group 1), heart valve surgery (Group 2), or peripheral vascular surgery (Group 3) were included in the investigation. Electrophysiological studies of both upper extremities were performed five days before and three weeks after the operation.

RESULTS

Peripheral nerve problems were found preoperatively in 23 of the 112 patients (21 %). These problems persisted, but similar findings were obtained postoperatively from the left upper extremities of six of the 42 CABG (14 %) and two of the 24 heart valve (8 %) patients who had had normal preoperative evaluations. The patients with injured nerves were older and had undergone longer operation times. There were no differences between the patients with injured nerves and the others with respect to mammary artery harvesting or other operative variables.

CONCLUSIONS

There are no reports in the literature of routine preoperative and postoperative electrophysiological studies in large patient groups to evaluate brachial plexus injury during open heart surgery. It is known that heart surgery sometimes causes partial brachial plexus injury, especially in the lower trunk. However, these peripheral nerve problems are usually not considered clinically important and are not investigated. Patients undergoing open heart surgery must be closely followed up for peripheral nerve injury during the postoperative period.

Normal values for single fiber EMG parameters of frontalis muscle in healthy subjects older than 70 years

OBJECTIVE

Single fiber EMG (SFEMG) is a potent electrophysiological method to evaluate impaired neuromuscular transmission, and allows sensitive diagnosis of neuromuscular transmission abnormalities such as myasthenia gravis. The jitter and fiber density values are different for various muscles and age groups and the reference values increase with age. In this study, we evaluated the reference values of jitter and fiber density of frontalis muscle in healthy subjects older than 70 years.

METHODS

We evaluated the jitter and fiber density of frontalis muscle in 32 healthy subjects. Twenty-two of them were between 70 and 79 years old (mean +/- SD, 73.9 +/- 1.7), and 10 of them were older than 80 years (mean +/- SD, 82.2 +/- 1.2).

RESULTS

Normal limit of jitter (95% confidence limit) was calculated as 40.4 micros for healthy subjects between 70 and 79 years old and 43.7 micros for healthy subjects older than 80 years and normal limit of fiber density (95% confidence limit) were calculated as 1.90 for subjects between 70 and 79 years old and 2.14 for subjects older than 80 years.

CONCLUSIONS

We designated the reference values of jitter and fiber density for frontalis muscle in healthy subjects older than 70 years. Our reference values may have value to diagnose neuromuscular transmission abnormalities in elderly patients.

SIGNIFICANCE

SFEMG is sensitive for neuromuscular transmission abnormalities and it is important to know the reference values of frontalis muscle in healthy subjects older than 70 years.

Hepatic myelopathy with spastic paraparesis

Progressive myelopathy is a rare neurological complication of chronic liver disease with portal hypertension and there is no special diagnostic tool for hepatic myelopathy. Neuropathological studies of the patients with hepatic myelopathy have demonstrated demyelination of the lateral corticospinal tracts with various degree of axonal loss. Transcranial magnetic stimulation (TMS) is widely utilized as an indicator of changes in excitability and conductivity of the motor pathways. TMS studies are also used for the diagnosis of hereditary spastic paraparesis in the literature. In this study, we described two patients who presented with spastic paraparesis; TMS studies suggested that they had myelopathy and diagnosed as hepatic myelopathy when all the other possible diagnoses were ruled out.

Factors affecting haemorrhagic transformation in middle cerebral artery infarctions

OBJECTIVE

Haemorrhagic transformation (HT) affects treatment and prognosis in patients with acute ischaemic stroke. The factors affecting haemorrhagic transformation in infarcts due to occlusion of middle cerebral artery (MCA) stem or branch were investigated.

MATERIALS AND METHODS

Of 412 patients who were followed in our clinic between January 2001 and December 2001 with acute ischaemic stroke, 86 patients with occlusion in MCA stem or branch were enrolled in this study. These patients were divided into 2 groups, those with HT (n = 35) and without HT (n = 51). Age, sex, systemic arterial hypertension, diabetes mellitus, blood glucose level in the acute period, renal and liver function tests, systolic and diastolic arterial blood pressure in the acute period, previous cerebrovascular disease, leukoaraiosis, modified Rankin Disability Score (mRDS) and stroke subtype were evaluated.

RESULTS

High blood glucose level in the acute period and presence of leukoaraiosis on cranial computerized (CCT) tomography were detected as risk factors in development of HT. HT was seen more frequently in MCA stem infarction than branch infarction. mRDS were worse in the group with HT. In multivariate analysis, there were independent relationships between mean blood glucose level on admission, mRDS, presence of diabetes mellitus, and MCA stem infarction and development of haemorrhagic transformation in patients with MCA territorial infarction.