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Chorea is defined as; involuntary movements of the distal parts of limbs which have arrhythmic, rapid, bouncing or smooth, simple or complex properties. Choreiform movements occur when putamen, globus pallidus and subthalamic nucleus are affected. Chorea can be observed during the course of metabolic and vascular diseases, neurodegenerative or hereditary diseases. Chorea may be a rare symptom of cerebral hypoperfusion. Transient ischemic attack is an event that occurs in short term characterized by a temporary ischemia of brain. A wide variety of symptoms can be seen depending on the localization of cerebral hypoperfusion. Hemichorea is a very rare finding observed during transient ischemic attacks. In this article hemichorea in a case of symptomatic transient ischemic attack is discussed with relevant literature.

Leech infestations can lead to several symptoms, including epistaxis, hemoptysis, hematemesis, vaginal bleeding and anemia. A five-year-old male patient presented to the emergency ward with bilateral bleeding from the nose in the form of leakage with a duration of one month, as well as bloody vomiting and blood in the sputum for two days prior to admission. The patient was pale, the nose and oropharyngeal mucosa were pale with fresh leakagetype bleeding and there was a similar clot in the nasopharynx. Laboratory examinations were normal. Examination of the oropharynx and nasopharynx was repeated to assess for active bleeding, and a leech 4x1 cm in size was found in addition to a clot. The leech was detached from the mucosa following administration of a hypertonic saline solution and removed with forceps. Leech infestation should be considered in cases of bleeding and anemia of unknown etiology in patients from rural areas.

Miller Fisher Syndrome (MFS) is an acute, autoimmune polyneuropathy usually associated with a good prognosis which is clinically characterized by ataxia, ophtalmoplegia, and areflexia. MFS has a monophasic course, double recurrence can be seen in rare cases. But three attacks are very rare. In this article, we discussed a rare case of MFS and approach to the treatment that recurred 3 times within a period of 8 years. It is emphasized that MFS cases may occur a recurring pattern, and plasma exchange should be definitely tried as a therapeutic approach when clinical deterioration occurs under intravenous immunoglobulin (IVIg) therapy Miller Fisher Sendromu (MFS) akut, genellikle iyi prognoz ile ilişkili otoimmün bir polinöropati olup, klinik olarak ataksi, oftalmopleji ve arefleksi ile karakterizedir. MFS monofazik seyirlidir, ikinci tekrar nadir vakalarda görülmektedir. Ancak, üç atak oldukça nadirdir. Bu yazıda, sekiz yıllık periotta üç kez tekrarlayan nadir bir MFS olgusu ve tedaviye yaklaşım tartışılmıştır. MFS’lu olguların tekrarlayıcı bir patern gösterebileceği ve plazma değişiminin intravenöz immünglobulin (IVIg) tedavisi altında klinik kötüleşmesi olan hastalarda tedavi edici bir yaklaşım olarak denenebileceği vurgulanmıştır

Objective: Stroke is a major cause of global morbidity and mortality. Ischemic stroke is usually marked by cell death associated with inflammation and oxidative stress, and the role of inflammation in neurological diseases has become increasingly obvious. In our study, we studied the monocyte / HDL ratio (MHR) which can support the theory of inflammation in stroke and can be used in clinical practice. MHR can be used a prognostic marker in stroke patients base on this theory. Methods: Our study registered 91 acute ischemic stroke patients (47 females and 44 males) and 50 healthy controls. Results: MHR was elevated in the patient group and correlated with high-sensitivity C-reactive protein (hsCRP). MHR was higher in patients with high a National Institutes of Health Stroke Scale (NIHSS) than those with a low NIHSS (p=0.050) as well as in patients with a larger infarct area and in than those with a smaller area (p=0.050). The MHR correlated with both the clinical condition and infarct area in acute ischemic stroke patients, which underscores the value of MHR as a new marker. Conclusions: This cross-sectional study of 91 acute ischemic stroke patients indicates that inflammation markers and MHR are correlated with clinical status and even radiological parameters. Amaç: İnme, dünyada major bir morbidite ve mortalite sebebidir. İskemik inmede genellikle inflamasyon ve oksidatif strese bağlı hücre ölümü görülür. Nörolojik hastalıklarda inflamasyonun rolü giderek daha da belirginleşmektedir. Çalışmamızda inmede inflamasyon teorisini destekleyebilen ve klinik uygulamada kullanılabilecek monosit / HDL oranını (MHO) inceledik. Gereç ve Yöntem: Çalışmamızda 91 akut iskemik inme hastası (47 kadın ve 44 erkek) ve 50 sağlıklı kontrol kaydedildi. Bulgular: Hasta grubunda MHO yüksek idi ve yüksek duyarlılıkta C-reaktif protein (hsCRP) ile korele idi. MHO, Ulusal Sağlık Enstitüleri İnme Ölçeği (NIHSS) skoru yüksek olan hastalarda, düşük NIHSS'li (p = 0.050) olanların yanı sıra, ve de daha büyük bir infarkt alanı olanlarda daha küçük infarkt alanına sahip olanlara (p = 0.050) göre daha yüksekti. MHO, yeni bir belirteç olarak, akut iskemik inme hastalarında, hem klinik durum hem de infarkt alanı ile koreledir. Sonuç: 91 akut iskemik inme hastasının, bu cross-sectional çalışması, inflamasyon belirteçlerinin ve MHO'nin; klinik durum ve hatta radyolojik parametrelerle körele olduğunu göstermektedir. WOS:000518456300018

Background and Objectives.—The objective of this study was to investigate the prevalence and sociodemographic characteristics of headaches among Turkish adolescents aged 12 to 17 years old in Bursa province of Turkey. Methods.—A multistep, stratified, cluster sampling method was used for subject selection. The estimated sample size for 12- to 14-year-old students was 1270 and for 15- to 17-year-old students was 1117. Our study sample included 6.5% of the secondary schools and 1.8% of the students aged 12 to 17 years old. The study was conducted in two phases; the questionnaire phase and the face-to-face interview phase. Results.—The prevalence of recurrent headache in the study population was 52.2%. Girls (59.8%) had significantly more recurrent headache than boys (45.1%) The prevalence of recurrent headache increased from 42.2% up to 60.7% by age. In multivariate logistic regression analysis age and gender differed significantly between adolescents with and without recurrent headache groups. Frequent episodic tension-type headache was the most common (25.9%) headache among Turkish adolescents, followed by migraine (14.5%). Conclusions.—Age and gender appeared to be demographic factors increasing adolescent headache prevalence. Frequent episodic-tension type headache was the most common headache followed by migraine. Our migraine prevalence was slightly higher than most of the previously reported prevalence rates. This might be due to the new classification criteria of headache released by International Headache Society.

Aim: The aim of this study is to identify the frequency of stroke among severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cases in Sakarya city, to find out the clinical characteristics of patients diagnosed with stroke and to contribute to the national database. Material and Methods: This retrospective study was carried out with 783 cases diagnosed with SARS-CoV-2 between April-June 2020 at the pandemic hospital in Sakarya city. Patients were compared in terms of age, National Institute of Health Stroke Scale (NIHSS), risk factors, radiological findings, inpatient treatment, intubation, and mortality rates. Results: Out of 26 cases of ischemic stroke, 11 (42.3%) were male and 15 (57.7%) were female. In terms of infarction localization, the cause was medial cerebral artery (MCA) in 4 (15.4%) patients, top of the basilar in 2 (7.7%) patients, basilar artery in 1 (3.8%) patient, lacunar in 9 (34.6%) patients and anterior system in 10 (38.5%) patients. There was no significant difference in terms of D-dimer and C-reactive protein (CRP) levels according to disease severity (both p=0.262). Three (0.38%) patients presented with stroke findings and were diagnosed with SARS-CoV-2. Cryptogenic stroke was detected in 8 (30.8%) of the SARS-CoV-2 cases. Stroke frequency was calculated as 3.3% among the SARS-CoV-2 cases in Sakarya city. Conclusion: This is the first study to identify the frequency of stroke among SARS-CoV-2 patients in Sakarya city and Turkey. Our study is important as it shows that preventing or treating ischemic stroke in SARS-CoV-2 cases contributes greatly to the reduction of mortality. Amaç: Bu çalışmanın amacı Sakarya ilindeki şiddetli akut solunum yolu sendromu koronavirüsü 2 (severe acute respiratory syndrome coronavirus 2, SARS-CoV-2) olgularında inme sıklığını tespit etmek, inme tanısı almış olan hastaların klinik özelliklerini ortaya koyabilmek ve ulusal veri tabanına katkıda bulunmaktır. Gereç ve Yöntemler: Bu çalışma, Sakarya ilindeki pandemi hastanesinde Nisan-Haziran 2020 tarihleri arasında SARS-CoV-2 tanısı alan 783 olgu ile geriye dönük olarak yürütüldü. Hastalar, yaş, Ulusal Sağlık Enstitüleri İnme Skalası (National Institute of Health Stroke Scale, NIHSS), risk faktörleri, radyolojik bulgular, yatarak tedavi, entübe olma durumları ve mortalite oranları bakımından karşılaştırıldı. Bulgular: Yirmi altı iskemik inmeli olgunun 11 (%42,3)’i erkek ve 15 (%57,7)’i kadın idi. Enfarkt lokalizasyonu bakımından 26 hastanın 4 (%15,4)’ü orta serebral arter (medial cerebral artery, MCA), 2 (%7,7)’si baziller tepe, 1 (%3,8)’i baziller arter, 9 (%34,6)’u laküner, 10 (%38,5)’u arka sistemden kaynaklanmaktaydı. D-Dimer ve C-reaktif protein (C-reactive protein, CRP) düzeyleri bakımından hastalık şiddetine göre anlamlı bir farklılık yoktu (her iki p=0,262). Üç (%0,38) hasta inme bulgusuyla gelip SARS-CoV-2 tanısı almıştı. SARS-CoV-2 olgularının 8 (%30,8)’inde kriptojenik inme tespit edildi. Sakarya ilinde SARS-CoV-2 olgularında inme sıklığı %3,3 olarak hesaplandı. Sonuç: Bu çalışma SARS-CoV-2 hastalarında inme sıklığını tespit etmeye yönelik Sakarya ilinde ve Türkiye’de yapılmış ilk çalışmadır. Çalışmamız, SARS-CoV-2 olgularında iskemik inmenin önlenebilmesi ve tedavi edilebilmesinin mortalitenin azalmasına belirgin katkı sunduğunu göstermesi bakımından önemlidir.

Aim: Many studies have showed that myalgia is a common onset symptom in coronavirus disease 2019 (COVID-19). This study aimed to determine the frequency of muscle pain in patients followed with COVID-19 diagnosis, and to investigate the relationship between muscle pain and creatine kinase (CK), pH, lactate and lactate dehydrogenase (LDH) levels.Material and Methods: One hundred ten patients diagnosed with COVID-19 in our hospital were included retrospectively in this study. Presence of myalgia at the time of admission and on the 14th day of control were investigated. The first admission laboratory findings, 3rd day CK values and 14th day control CK values of all patients were recorded retrospectively from their files.Results: The study included 110 patients diagnosed with COVID-19. Fifty patients (45.5%) had muscle pain at the time of admission, and it was one of the most common musculoskeletal complaints. High CK results were obtained in 48 (43.6%) of the 110 patients at the time of admission. Thirty-two (66.7%) of 48 patients with high CK had muscle pain (p, Amaç: Birçok çalışma miyaljinin koronavirüs hastalığı 2019 (coronavirus disease 2019, COVID-19)’da sık görülen bir başlangıç semptomu olduğunu göstermiştir. Bu çalışmada COVID-19 tanısıyla takip edilen hastalarda kas ağrısı sıklığının belirlenmesi ve kas ağrısı ile kreatin kinaz (creatine kinase, CK), pH, laktat ve laktat dehidrogenaz (LDH) düzeyleri arasındaki ilişkisinin araştırılması amaçlandı.Gereç ve Yöntemler: Bu çalışmaya hastanemizde COVID-19 tanısı almış olan 110 hasta geriye dönük olarak dahil edildi. Başvuru sırasında ve 14. gün kontrolde miyalji yakınması olup olmadığı incelendi. Tüm hastaların ilk başvurudaki laboratuvar bulguları, 3. gün CK değerleri ve 14. gün kontrolündeki CK değerleri dosyalarından geriye dönük olarak kaydedildi.Bulgular: COVID-19 tanısı almış 110 hasta çalışmaya alındı. Elli hastada (%45,5) başvuru anında kas ağrısı vardı ve en sık görülen kas iskelet sistemi şikâyetlerinden biriydi. Yüz on hastanın 48'inde (%43,6) başvuru anında CK yüksekliği saptandı. CK yüksekliği saptanan 48 hastanın 32'sinde (%66,7) kas ağrısı vardı (p

Son yıllarda Multipl skleroz (MS) etyolojisinde, internal juguler ven (IJV) ve/veya azigos venlerde venöz drenaj bozukluğu olarak tanımlanan kronik serebrospinal venöz yetmezliğin (KSSVY) etkili olduğu ileri sürülmektedir. Bu teori, MS etyopatogenezinde etkili olduğu düşünülen otoimmün teoriyi toptan yadsıması nedeni ile ciddi tartışmalar başlatmıştır. Bu teori ile, MS etyopatogenezine farklı açılardan bakılması nedeniyle ilgi çekmiş ve bununla ilgili birçok çalışma başlatılmıştır. Çalışmamızda Doppler sonografi (DS), kranial MR venografi (MRV) ve selektif venografi (SV) ile MS hastalarında KSSVY’nin varlığının tespiti, ekstrakraniyal-intrakraniyal venöz yapıların yapısal- fonksiyonel açıdan incelenmesi, sağlıklı kişilerle karşılaştırılması amaçlanmıştır. 25 Relapsing Remitting MS hastasına DS, SV ve kraniyal MRV yapılırken, 20 sağlıklı kişiye kraniyal MR venografi ve Doppler sonografi yapıldı. Hastalarda DS’ de reflü varlığı açısından kontrol grubuna göre istatistiksel olarak anlamlı idi (p

The use of mobile phones has become an indispensable part of our lives, especially due to widespread use of the internet. We report the case of a 38-year-old male patient who developed internal carotid artery dissection after talking on the phone between her left shoulder and ear by laterally flexing the neck for 20 minutes. In addition to many positive effects of technology that facilitate the daily life, the development of neurological deficits may be observed with widespread use of mobile phones. Misuse of mobile phone should be considered in patients with carotid artery dissection.

Introduction: Cerebral venous and sinus thrombosis (CVST) may lead to cerebral edema and increased intracranial pressure; besides, ischemic or hemorrhagic lesions may develop. Intracerebral hemorrhages occur in approximately one-third of CVST patients. We assessed and compared the findings of the cerebral hemorrhage (CH) group and the CVST group. Materials and Methods: In the VENOST study, medical records of 1,193 patients with CVST, aged over 18 years, were obtained from 35 national stroke centers. Demographic characteristics, clinical symptoms, signs at the admission, radiological findings, etiologic factors, acute and maintenance treatment, and outcome results were reported. The number of involved sinuses or veins, localizations of thrombus, and lesions on CT and MRI scans were recorded. Results: CH was detected in the brain imaging of 241 (21.1%) patients, as hemorrhagic infarction in 198 patients and intracerebral hemorrhage in 43 patients. Gynecologic causes comprised the largest percentage (41.7%) of etiology and risk factors in the CVST group. In the CH group, headache associated with other neurological symptoms was more frequent. These neurological symptoms were epileptic seizures (46.9%), nausea and/or vomiting (36.5%), altered consciousness (36.5%), and focal neurological deficits (33.6%). mRS was ≥3 in 23.1% of the patients in the CH group. Discussion and Conclusion: CVST, an important cause of stroke in the young, should be monitored closely if the patients have additional symptoms of headache, multiple sinus involvement, and CH. Older age and parenchymal lesion, either hemorrhagic infarction or intracerebral hemorrhage, imply poor outcome.

Çalışmada 38 yazar bulunmaktadır. Bu yazarlardan sadece Bursa Uludağ Üniversitesi mensuplarının girişleri yapılmıştır. Purpose: The aim of this study is to evaluate the presence and prognostic impact of early seizures in cerebral venous sinus thrombosis patients (CVST). Method: VENOST is a retrospective and prospective national multicenter observational study. CVST patients with or without epileptic seizures (ES) were analyzed and compared in terms of demographic and imaging data, causative factors, clinical variables, and prognosis in a total of 1126 patients. Results: The mean age of the patients in the ES group was 39.73 +/- 12.64 and 40.17 +/- 14.02 years in the non-ES group (p > 0.05). Epileptic seizures were more common (76.6 %) in females (p < 0.001). Early ES occurred in 269 of 1126 patients (23.9 %). Epileptic seizures mainly presented in the acute phase (71.4 %) of the disease (p < 0.001). Majority of these (60.5 %) were in the first 24 h of the CVST. The most common neurological signs were focal neurologic deficits (29.9 %) and altered consciousness (31.4 %) in the ES group. Superior sagittal sinus (SSS) and cortical veins (CV) involvement were the most common sites of thrombosis and the mostly related etiology were found puerperium in seizure group (30.3 % vs 13.9 %). Patients with seizures had worse outcome in the first month of the disease (p < 0.001) but these did not have any influence thereafter. Conclusions: In this largest CVST cohort (VENOST) reported female sex, presence of focal neurological deficits and altered consciousness, thrombosis of the SSS and CVs, hemorrhagic infarction were risk factors for ES occurrence in patients with CVST.

WOS: 000450668300152 PubMed ID: 30261379 OBJECTIVE: This study aims to evaluate the long-term clinical and radiologic findings of cases diagnosed with spinal concussion and to describe the spinal cord injuries that are detected in the later course. METHODS: Data obtained from 91 cases, who had been diagnosed with spinal concussion, were retrospectively evaluated. These were placed in 2 groups according to the type of trauma (axial forces or vertical forces). Magnetic resonance imaging scans taken >6 months after the trauma were inspected. RESULTS: Axial and vertical forces result in different types of spine injuries. The effect of vertical forces on the spinal cord can involve longer segments and the effect of axial forces remains limited to a few segments. Vertical forces usually result in the development of syringomyelias in the late period, whereas axial forces may cause cavitation and stretch injuries to the spinal cord. CONCLUSIONS: Although patients with spinal concussion manifest complete recovery in the early period after the trauma, findings related to the spinal cord may appear in the later course. The direction of the forces that the spinal cord is subjected to may result in different cord injuries in the late period.

WOS: 000446931200007 Objective: Data obtained from cases wherein methyl methacrylate was used for cranioplasty are discussed along with the literature, and methods for preventing potential complications are presented. Methods: Records of patients who had been operated for cranioplasty between 2013 and 2017 were retrospectively analyzed. Early and late results of the cases were recorded. Area measurements of cranium defects were performed through computed tomography, scanography, or direct X-ray. The steps considered for preventing known complications are explained, and the results are discussed. Results: Cranioplasty with methyl methacrylate was administered to areas < 10 cm(2) in 29 cases, areas of 10-25 cm(2) in 25 cases, and areas > 25 cm(2) in 10 cases. Cranioplasty with methyl methacrylate was performed in the supratentorial area in 57 cases and in the infratentorial area in 7 cases. In 48 cases, partial cranioplasty was performed by administering methyl methacrylate along with autograft to the craniectomy defect. A subcutaneous drain was left for 2-3 days in all cases. During this period, dual antibiotherapy was administered. Symptoms of infection were not encountered in any case. No clinical symptoms associated with cranioplasty material were discovered in the late follow-up period. Conclusion: When methyl methacrylate is applied with appropriate methods and necessary precautions are taken, it proves as an inexpensive and effective cranioplasty material that can successfully be applied in large cranial defects, which reduces the risk of infection. This inexpensive material can be applied to repair partial craniotomy flap deformities to achieve better cosmetic outcomes.

WOS: 000452839400017 PubMed ID: 30067116 Purpose: Cerebrospinal fluid (CSF) fistula is one of the most common complications encountered after cranial surgeries. In cases where CSF fistula frequently appears due to surgical technique, dural sealants are used as auxiliary preparations to prevent CSF fistula and provide convenience to the surgeon. Materials and Methods: Data obtained from 128 number of cases where cyanoacrylate (CA) had been used for dural repair to prevent CSF fistula was evaluated, retrospectively. The cases of skull base and frontal sinus fractures where the primary repair had not been carried out were also included in the study. Results: The mean follow-up of all cases was 9,7 months. CSF fistula was not encountered in 121 of 128 cases. 4 of the cases developed CSF fistula in the early period. 3 of the cases presented with CSF fistula in the late period after discharge. No side effects due to hypersensitivity or preparation were encountered. Conclusion: CA can help dural repair against the development of CSF fistula by taking effect quickly. Also, it is a rapid anti-haemorrhagic agent. It can also be used after posterior fossa surgery, skull base surgery where dural repair is difficult, or during sinus repair.

WOS: 000432959600150 PubMed ID: 29626691 OBJECTIVE: The aim of the study is to discuss along with literature knowledge the post-traumatic clinical progression of cases with symptoms of transient spinal cord impact and cases of spinal concussion following exposure of the vertebral column to vertical forces. MATERIALS AND METHODS: A total of 43 cases, all falls from height, were diagnosed with spinal concussion. It was determined that the vertebral column had been exposed to the effects of vertical forces, and the spinal cord had been affected by vertical forces. In all cases, spinal magnetic resonance imaging and dynamic X-ray examinations were performed at the time of admission. Clinical symptoms of the cases were recorded by scoring based on the Torg Grading System. RESULTS: Cases were started on conservative treatment because radiologic symptoms that would explain the clinical symptoms could not be detected. Most frequently encountered were the neurologic symptoms related to the upper thoracic and lower cervical segments being affected. In 7 cases, urinary incontinence was also detected. Symptoms related to the spinal cord being affected were completely recovered in 1-3 days in all cases. CONCLUSION: As a result of the vertebral column being affected by vertical forces, the most frequently affected are the thoracic segments of the spinal cord. These cases show similarities to real spinal cord injury without radiographic abnormality cases when evaluated along with clinical and radiologic symptoms. Absolute differential diagnosis from real spinal cord injury without radiographic abnormality cases cannot be made until total neurologic recovery takes place.

WOS: 000466843100013 Immune thrombocytopenic purpura (ITP) is a syndrome that reduces platelet levels, and it is caused by the development of autoantibodies against thrombocytes. The ITP cases that present with subdural hematoma are rarely seen. It is necessary to start corticosteroid and intravenous immunoglobulin (IVIg) treatment early in the emergency cases, until a definite diagnosis is made. A 54-year-old female patient applied to the neurosurgery department with the complaint of dizziness that lasted for a week. The patient indicated that she had an upper respiratory tract infection a month ago. On her computed tomography examination, she was diagnosed with a large and septated subdural hematoma with different components of acute, subacuteand chronic bleeding with the ITP diagnosis. The patient had to undergo an urgent surgical procedure due to right hemiparesis and confusion caused by the finding of increased intracranial pressure. During pharmacotherapy for ITP, the patient was re-operated due to recurrent bleeding. The patient was discharged without any deficiency after the second operation. Thrombocytopenia cases are challenging with regard to surgical intervention. It is necessary to start corticosteroid treatment early in emergency cases, until the definite diagnosis is made. Corticosteroids inhibit the development of autoantibodies in the treatment of ITP but also increase the release of platelets from the vascular wall. Corticosteroid treatment together with IVIg treatment should be initiated, and in the case of an emergency surgical intervention, a thrombocyte replacement needs to be initiated immediately.

Objectives: Headache is the most common complaint in cerebral venous sinus thrombosis (CVST) and it may sometimes bethe only symptom in these patients. This retrospective and prospective study was an investigation of any differences in termsof clinical risk factors, radiological findings, or prognosis in patients with CVST who presented with isolated headache (IH) andcases with other concomitant findings (non-isolated headache [NIH]).Methods: A total of 1144 patients from a multicenter study of cerebral venous sinus thrombosis (VENOST study) were enrolled inthis research. The demographic, biochemical, clinical, and radiological aspects of 287 IH cases and 857 NIH cases were compared.Results: There were twice as many women as men in the study group. In the IH group, when gender distribution was evaluated byage group, no statistically significant difference was found. The onset of headache was frequently subacute and chronic in the IHgroup, but an acute onset was more common in the NIH group. Other neurological findings were observed in 29% of the IH groupduring follow-up. A previous history of deep, cerebral, or other venous thromboembolism was less common in the IH group thanin the NIH group. Transverse sinus involvement was greater in the IH group, whereas sagittal sinus involvement was greater in theNIH group. The presence of a plasminogen activator inhibitor (PAI) mutation was significantly greater in the IH group.Conclusion: IH and CVST should be kept in mind if a patient has subacute or chronic headache. PAI, which has an importantrole in thrombolytic events, may be a risk factor in CVST. Detailed hematological investigations should be considered. Additional studies are needed. Amaç: Baş ağrısı serebral venöz sinüs trombozunda (SVST) en sık görülen şikayettir ve bazen CVST ile başvuran hastalarda görülen tek semptom olabilir. Bu retrospektif ve prospektif çalışmada, izole başağrısı (IB) ile başvuran SVST olgularında ve baş ağrısı ile ilişkili diğer bulguları olan (izole olmayan başağrısı-İOBA) olgularda klinik risk faktörleri, radyoloji ve prognoz açısından herhangi bir farklılık olup olmadığını araştırdık. Gereç ve Yöntem: Serebral venöz sinüs trombozu (VENOST) çok merkezli çalışmasından 1144 hasta çalışmamıza alındı. Tüm demografik, biyokimyasal, klinik ve radyolojik yönler 287 IBA vakası ve 857 İOBA vakası için karşılaştırılmıştır. Bulgular: Toplam grup içinde kadın oranı iki kat daha yüksekti. İBA grubunda cinsiyet dağılımını yaş gruplarına göre değerlendirildiğinde istatistiksel olarak anlamlı bir fark bulunmadı. İBA grubunda, baş ağrısının başlangıcı sıklıkla subakut ve kronikti, ancak akut başlangıç, İOBA grubunda daha yaygındı. İBA grubunda% 29’luk takip sırasında diğer nörolojik bulgular eklenmiştir. Daha önce serebral, derin ve diğer venöz tromboembolizm öyküsü İBA grubunda İOBA grubuna göre daha azdı. Transvers sinüs tutulumu İBA grubunda daha yüksek iken sagital sinüs tutulumu İOBA grubunda daha fazlaydı. Plazminojen aktivatör inhibitörü (PAI) mutasyonu IBA grubunda anlamlı olarak daha yüksekti. Sonuç: Hastaların subakut veya kronik baş ağrısı varsa SVST tanısı için IBA akılda tutulmalıdır. Trombolitik olaylar için önemli bir role sahip olan PAI, SVST’da bir risk faktörü olabilir, bu nedenle ayrıntılı hematolojik araştırmalar düşünülmelidir. Daha ileri çalışmalara ihtiyaç vardır WOS:000644197800002 2-s2.0-85105266958

Objectives: In the present study, the authors presented the intrathecal gadolinium enhanced MR-myelography findings of patients with spontaneous intracranial hypotension. Materials and Methods: Intrathecal gadolinium enhanced MR-myelography (Gd-MR-myelography) examina-tions between October 2012 and September 2018 in patients having clinical and radiological findings of spontaneous intracranial hypotension were evaluated retrospectively. Sites and types of contrast leakages in 20 patients who met inclusion criteria were reviewed. All patients had undergone T1-fat suppressed sagittal images of cervical, thoracic and lumbar region after the off label intrathecal injection of 1 ml gadolinium-based contrast agent. Results: Patients (18 female, 2 male) are aged between 23 and 62 years-old (mean age: 41.1). Cerebrospi-nal fluid (CSF) leakages were cervical in 6 patients, thoracic in 5 patients, lumbar in 5 patients. One patient had leakage in multiple levels on both cervical and thoracic region and another patient on both cervical-thoracic and lumbar regions. No patients had adverse effects related to intrathecal injection of gadolinium. Conclusions: Gd-MR-myelography is effective imaging modality to reveal spinal CSF leakages in patients with spontaneous intracranial hypotension.

Background. Early diagnosis of cerebral venous sinus thrombosis (CVST) associated with reproductive health-related risk factors (RHRF) including pregnancy, puerperium, and oral contraceptive (OC) use can prevent severe neurological sequelae; thus, the symptoms must be documented in detail for each group. Methods. Out of 1144 patients with CVST, a total of 777 women were enrolled from a multicenter for the study of cerebral venous sinus thrombosis (VENOST). Demographic, biochemical, clinical, and radiological aspects were compared for 324 cases with RHRF and 453 cases without RHRF. Results. The mean age of the RHRF (-) group (43.2 ± 13 years) was significantly higher than of the RHRF (+) group (34±9 years). A previous history of deep venous thrombosis (3%), isolated cavernous sinus involvement (1%), cranial neuropathy (13%), comorbid malignancy (7%), and its disability scores after 12 months (9%) were significantly higher in the RHRF (-) group. The RHRF (+) group consisted of 44% cases of puerperium, 33% cases of OC users and 23% of pregnant women. The mean age was found to be higher in OC users (38±9 years). A previous history of deep venous thrombosis was slightly higher in the pregnancy subgroup (4%). Epileptic seizures were more common in the puerperium group (44%). Conclusion. The results of our study indicate that the risk of CSVT increases parallel to age, OC use, and puerperium period. In addition, when considering the frequency of findings and symptoms, epileptic seizures in the puerperium subgroup of the RHRF (+) group and malignancies in the RHRF (-) group may accompany the CSVT. In daily practice, predicting these risks for the CSVT and early recognition of the symptoms will provide significant benefits to patients.

Amaç: Bu çalışmanın amacı, akut iskemik inmeli hastalarda National Institutes of Health Stroke Ölçeği (NIHSS) ile doku Doppler miyokard performans indeksi ile değerlendirilen miyokard fonksiyonları arasındaki ilişkiyi araştırmaktır.Gereç ve Yöntem: Çalışmaya akut iskemik inme geçiren 128 hasta (erkek,55; kadın, 73; yaş, 68 ± 19) alındı. 20 hasta çalışmadan çıkarıldı. NIHSS skoruna göre hastalar iki gruba ayrıldı (Grup 1, NIHSS skor, Purpose: The aim of this study is to investigate the relationship between myocardial function assessed by tissue Doppler imaging myocardial performance index (TDI-MPI) and National Institutes of Health Stroke Scale (NIHSS) score in patients with acute ischemic stroke. Materials and Methods: The study comprised 128 patients (males, 55; females, 73; 68 ± 19 years) with acute ischemic stroke. 20 patients were excluded. Patients were divided into two groups based on the calculated NIHSS score (Group 1, NIHSS score < 16; Group 2, NIHSS score ≥ 16). Demographic, clinical, and laboratory data for all patients were collected. Cardiac function was evaluated by transthorasic echocardiography within 48 hours of admission to the neurology care unit.Results: There were no significant differences among demographic parameters of patients. Tissue Doppler myocardial performance index was significantly higher in Group 2 patients than in Group 1 patients (0.62±0.28 vs 0.46±0.16).Conclusion: Our results suggest that TDI-MPI is associated with stroke severity on admission in patients with acute ischemic stroke. TDI-MPI is an indicator of global myocardial dysfunction with a different from LVEF. TDI-MPI, which includes both systolic and diastolic time intervals to assess the global cardiac dysfunction.

Background and Purpose— To compare hemorrhagic and nonhemorrhagic reversible cerebral vasoconstriction syndromes (RCVS) with a view to understand mechanisms. Methods— This single-center retrospective study included 162 patients with RCVS. Clinical, brain imaging, and angiography data were analyzed. Results— The mean age was 44±13 years, 78% women. Hemorrhages occurred in 43% including 21 patients with intracerebral hemorrhage (ICH) and 62 with convexal subarachnoid hemorrhage (cSAH). The frequency of triggers (eg, vasoconstrictive drugs) and risk factors (eg, migraine) were not significantly different between hemorrhagic and nonhemorrhagic RCVS or between subgroups (ICH versus non-ICH, isolated cSAH versus normal scan). Hemorrhagic lesions occurred within the first week, whereas infarcts and vasogenic edema accumulated during 2 to 3 weeks ( P P =0.11). ICH and cSAH occurred earlier than infarcts ( P ≤0.001), and ICH earlier than vasogenic edema ( P =0.009). Angiogram analysis showed more severe vasoconstriction in distal versus proximal segments in all lesion types (ICH, cSAH, infarction, vasogenic edema, and normal scan). The isolated infarction group had more severe proximal vasoconstriction, and those with normal imaging had significantly less vasoconstriction. Multivariable analysis failed to uncover independent predictors of hemorrhagic RCVS; however, female sex predicted ICH ( P =0.048), and angiographic severity predicted infarction ( P =0.043). Conclusions— ICH and cSAH are common complications of RCVS. Triggers and risk factors do not predict lesion subtype but may alter central vasomotor control mechanisms resulting in centripetal angiographic evolution. Early distal vasoconstriction is associated with lobar ICH and cSAH, and delayed proximal vasoconstriction with infarction.

Background: Acute disseminated encephalomyelitis (ADEM) is a rare demyelinating disease of the central nervous system, commonly attributed to infections or vaccinations. Toxic or allergenic compounds can also trigger a response in the immune system and may cause demyelination. We present a case with ADEM after using oral herbal medications. Case Report: A 25 year-old male developed bilateral central facial palsy and severe quadriparesis after taking herbal drugs (containing echinacea and many other herbal ingredients) for two weeks. He had used the extract to increase his potency and reproductivity. He had no past history of recent immunization or viral infection. The clinical findings, cerebrospinal fluid (CSF) analysis and brain magnetic resonance imaging (MRI) were compatible with ADEM. The neurological findings were improved after seven doses of pulse methylprednisolone treatment. To our knowledge, this is the third report in the literature that links herbal therapy and demyelinating disease. Conclusion: Most of the ADEM cases related to herbal therapy in the literature similarly used echinacea. It is our opinion that other ingredients of the herbal extract used by our case, besides echinacea, could have the potential to cause a trigger in the immune system. Further studies are needed to clarify the immunological effects of different kinds of herbal compounds, as well as the effects of different parts of the plants and the results of various dosages. Moreover, ingredients should also be tested for toxicity, adverse effects and drug interactions.

The determination of the extent of brain tissue that is ischemic, but still viable and therefore under risk for irreversible injury (i.e., penumbra), is one of the major goals in acute stroke imaging (1). Advances in technology and the availability of perfusion imaging, either by computed tomography (CT) or magnetic resonance imaging (MRI), are major steps in this regard, and multi-modal imaging by CT or MRI is gaining importance as a tool in the development of both prognostic and therapeutic algorithms in acute stroke (2). Despite these developments, there are certain roadblocks in the utilization of perfusion imaging, with MRI in particular, in acute stroke patients. These include the unavailability of resources, primarily MRI scanners, in emergency departments; the need for technical and medical personnel for the postprocessing and interpretation of perfusion images, which can partially be overcome by automated imaging softwares; and the use of intravenous contrast agents, which are highly critical in patients with renal failure. Disregarding perfusion imaging by arterial spin labeling, other imaging signatures of compromised tissue perfusion that can be detected by MRI sequences that do not necessitate the use of contrast administration might provide clinicians with alternative and more practical tools in this setting. One of these signatures is the hyperintense vessel sign (HVS) observed on fluid-attenuated inversion recovery (FLAIR) imaging, which is considered to reflect slow and compensatory blood flow within leptomeningeal collaterals distal to the proximal occlusion (3). Prior studies have shown that patients with HVS evident on FLAIR are more likely to have a diffusion/perfusion mismatch, and although not consistently documented in all published literature, they are at risk of infarct progression (4, 5). Another imaging feature suggestive of impaired tissue perfusion is the presence of marked hypointense vessels on susceptibility-weighted imaging (SWI), which is believed to represent veins with increased deoxyhemoglobin concentration secondary to an increased oxygen extraction fraction within the ischemic tissue (6–8). Although various studies have separately evaluated the influence of these imaging features on clinical and tissue prognosis, none have formally analyzed their prognostic role in the same patient cohort and evaluated whether these imaging markers reflect similar aspects of impaired tissue perfusion or contain information independent of each other. In this study, we aimed to identify the correlation between the extent of HVS on FLAIR and hypointense vessels on SWI, and to determine whether these imaging features provide independent prognostic information in patients with ischemic stroke.

In this study, we aimed to investigate the effectiveness of etofenamate and compare it with methyl prednisolone in the experimental spinal cord trauma model. A total of 31 Wistar Albino rats weighed between 220 and 270 gr were used in this study. The rats were divided into three groups as the control; posttraumatic normal saline (NS), trauma + E; posttraumatic etofenamate; and trauma + methylprednisolone, posttraumatic methylprednisolone. All medications were given into the peritoneum. Six hours after trauma and drug administration, approximately 2 cm of cord segment in the area subjected to dorsal laminectomy was dissected from the dura spinal cord and removed. The samples were histopathologically examined. In this study, significant differences were found both between trauma + NS and trauma + methylprednisolone, and between trauma NS and trauma + etofenamate, and trauma + methylprednisolone and trauma + etofenamate groups according to the Ivan Damjanov criteria and in terms of petechial hemorrhage, diffuse bleeding, loss in the regulation of grey and white matters, edema, necrosis, and cystic degeneration findings. According to the Ivan Damjanov criteria, trauma + NS group was found as Grades 2-3, trauma + etofenamate group as Grade 1, and trauma + methylprednisolone as Grades 1-2. Neuroprotective effect of etofenamate was found to be stronger than that of methyl prednisolone in rats with induced posttraumatic spinal cord damage (Tab. 4, Ref. 24). Keywords: etofenamate, methylprednisolone, spinal trauma, rats.

Objective: Acute stroke is an important cause of morbidity and mortality. Myocardial injury is an important complication of acute cerebrovascular events. In this study, we aimed to investigate the relationship between myocardial function assessed by myocardial performance index (MPI) and National Institutes of Health Stroke Scale (NIHSS) score in patients with acute ischemic stroke. Method: The study comprised 97 patients (males, 42; females, 55; 65 ± 16 years) diagnosed with acute ischemic stroke. 17 patients were excluded. Patients were divided into two groups based on the calculated NIHSS score (Group 1, NIHSS score < 16; Group 2, NIHSS score ≥ 16). Demographic, clinical, and laboratory data for all patients were collected. Cardiac function was evaluated by transthorasic echocardiography within 48 hours of admission to the neurology care unit. Results: There were no significant differences among demographic parameters of patients. MPI was significantly higher in Group 2 patients than in Group 1 patients (0.59±0.25 vs 0.48±0.20, p=0.004). Conclusion: Our results suggest that MPI is associated with stroke severity on admission in patients with acute ischemic stroke. MPI is an indicator of global myocardial dysfunction with a different from LVEF. MPI, which includes both systolic and diastolic time intervals is an option to assess the global cardiac dysfunction. Amaç: Akut inme morbidite ve mortalitenin önemli nedenlerinden biridir. Miyokardiyal hasarlanma, akut serebrovasküler olayların önemli bir komplikasyonudur. Yapmış olduğumuz bu çalışmanın amacı, akut iskemik inmeli hastalarda Ulusal Sağlık İnme Enstitüleri Ölçeği (NIHSS) ve miyokard performans indeksi (MPİ) ile değerlendirilen miyokard fonksiyonları arasındaki ilişkiyi araştırmaktır. Yöntemler: Çalışmaya akut iskemik inme tanılı 97 hasta (erkek,42; kadın,55; yaş, 65 ± 16) alındı. 17 hasta çalışmadan çıkarıldı. NIHSS skoruna göre hastalar iki gruba ayrıldı (Grup 1, NIHSS skor

Nocturnal blood pressure (BP) changes are an indicator of autonomic dysfunction. We aim to investigate the correlation between nocturnal blood pressure (BP) variability, vitamin D levels and Parkinson’s disease severity (PD) in this study. Thirty-five patients with PD participated in the study. Disease severity was evaluated by United Parkinson’s Disease Rating Scale (UPDRS) and Hoehn and Yahr Scale (HYS). Equivalent levodopa dose was calculated and 25-hydroxyvitamin D levels were measured. The Non-Motor Symptom Questionnaire (NMSQ) was applied to all patients. Ambulatory BP monitoring for 24 h was established. Patients were divided into three groups according to nocturnal BP results: dippers (normal finding—a decline in mean nighttime BP of more than 10%); non-dippers (pathological—a decline in mean nighttime BP of less than 10%); reverse dippers (pathological—an increase in mean nighttime BP) .The mean score of the NMSQ was higher in the group with HYS > 2 (p = 0.050). Four patients were dipper, 17 patients were non-dipper and 16 patients were reverse dipper. There was no significant difference between the three groups in terms of age, gender, disease duration, age of the disease onset, disease stage, disease duration, dopamine agonist usage, levodopa equivalent dose, vitamin D level and NMSQ scores. NMSQ scores are high in advanced PD. Ambulatory BP monitoring is useful in detecting autonomic dysfunction. The number of patients with non-dipping and reverse dipping is high in PD, independent from PD severity, drug dose, vitamin D and the other NMS symptoms.

WOS:000575558200009 PubMed ID: 32550778 Introduction: The prevalence of migraine was found to be more than three-fold higher in women as compared with men, and in addition to differences in prevalence rates, the characteristics and associated features might also differ between the sexes. The aim of this study was to compare sex-specific features of migraine and demographic parameters in a nationwide population-based study in Turkey. Methods: Among 5323 subjects, a total of 871 patients who were diagnosed as having definite migraine according to the diagnostic criteria of the International Classification of Headache Disorders-III (ICHD-III) were included in our study. The demographic characteristics, associated features, and triggers of migraine were examined with regard to sex. Results: The study group comprised 640 women (73.5%) and 231 men (26.5%), with a female to male ratio of 2.8:1. Attack duration, mean migraine disability assessment scores (MIDAS), frequencies of nausea, vomiting, osmophobia, vertigo/dizziness, and allodynia were found significantly different between women and men. When we compared these parameters between men and postmenopausal women, all these parameters were still significant except nausea. Odor was statistically more frequent as a reported trigger in women, whereas excessive sleep was a statistically more frequent triggering factor in men. The rates of depression and allergy were significantly higher in women when compared with men. Conclusion: Longer attack duration, higher MIDAS scores, and the frequencies of nausea, vomiting, osmophobia, vertigo/dizziness, and allodynia were more significant in women and this variance in sex persisted after menopause. Also, some trigger factors and co-morbidities differed between the sexes. These findings might result from complex genetic factors besides sociocultural influences, biologic, and sociocultural roles. Future studies should continue to explore biologic and genetic factors with respect to sex in migraine.

WOS:000370271100029, PubMed ID: 27511507, Background/aim: The aim of this study is to establish follow-up protocols for adult patients with common variable immunodeficiency (CVID) in a recently founded adult immunology clinic in the Central Anatolia Region of Turkey, where a clinical immunology center for adults was not available previously. Materials and methods: A total of 25 patients with CVID aged 18 years and older were included in this study. The file format consisted of 13 pages and was developed for the purpose of the study. Separate sections were designated for identity information, medical history, disease course, previous and current laboratory and imaging studies, follow-up plans, detection and management of complications/ comorbidities, and treatment results. Results: The mean age of the patients was 36.6 ± 13.4 years. The delay in diagnosis was 107 ± 95.6 months. In 92% of patients, initial symptoms resulting in admission to healthcare facilities were infections. Seventeen of 25 patients (68%) had bronchiectasis at the beginning of follow-up. Conclusion: Early identification of complications and comorbidities in patients with CVID will significantly improve quality of life and survival. Close observation and standardized protocols for follow-up are essential components of management.

Background The outcome of childhood acute lymphoblastic leukemia has improved because of intensive chemotherapy and supportive care. The frequency of adverse events has also increased, but the data related to acute central nervous system complications during acute lymphoblastic leukemia treatment are sparse. The purpose of this study is to evaluate these complications and to determine their long term outcome. Patients and Methods We retrospectively analyzed the hospital reports of 323 children with de novo acute lymphoblastic leukemia from a 13-year period for acute neurological complications. The central nervous system complications of leukemic involvement, peripheral neuropathy, and post-treatment late-onset encephalopathy, and neurocognitive defects were excluded. Results Twenty-three of 323 children (7.1%) suffered from central nervous system complications during acute lymphoblastic leukemia treatment. The majority of these complications (n = 13/23; 56.5%) developed during the induction period. The complications included posterior reversible encephalopathy (n = 6), fungal abscess (n = 5), cerebrovascular lesions (n = 5), syndrome of inappropriate secretion of antidiuretic hormone (n = 4), and methotrexate encephalopathy (n = 3). Three of these 23 children (13%) died of central nervous system complications, one from an intracranial fungal abscess and the others from intracranial thrombosis. Seven of the survivors (n = 7/20; 35%) became epileptic and three of them had also developed mental and motor retardation. Conclusions Acute central neurological complications are varied and require an urgent approach for proper diagnosis and treatment. Collaboration among the hematologist, radiologist, neurologist, microbiologist, and neurosurgeon is essential to prevent fatal outcome and serious morbidity.

Acute motor axonal neuropathy (AMAN) is a subtype of Guillain-Barre syndrome. Characteristic electrophysiological features of AMAN are reduced amplitude or absence of muscle action potentials. Our patient described progressive weakness in his leg and was not able to independently walk; he had a feeling weakness in his arms within 24 h after the onset of symptoms. He was diagnosed with AMAN according to the clinical and electrophysiological features. He could independently walk after two years following intensive physical therapy and monitoring. Neurologists and physiatrist should conduct long term monitoring and rehabilitation for patients with AMAN because neurological deficits may persist for a long time. AMAN was first reported to occur in patients having peripheral axonal dysfunction without demyelinating findings in the electroneuromyograph (ENMG) and is seen mostly during summers in the rural areas of China. Some cases were reported from some countries out of Asia, such as Mexico, in spite of the absence of seasonal predisposition. AMAN is characterized by acute motor paralysis, loss of reflexes or hyporeflexia, and peripheral axonal involve- ment without demyelinating findings in ENMG. In a study the median age of patients with AMAN in China was found to be 10 years (3). In this study, it was aimed to present an 8-year-old patient with AMAN and who had muscle weakness in the lower extremity at the beginning and then developed tetraplegia as a result of pure motor involvement without sensory involvement in a short time. The patient was treated with intravenous immunoglobulin (IVIG) therapy. CASE REPORT An 8-year-old male patient presented to our outpatient clinic with complaints of incapability of walking and moving his hands and arms. The patient who had not experienced such a complaint before complained about loss of strength that had suddenly occurred in his right leg a week ago. He stated that the weakness spread to the other leg and arms within the first 24 h after the onset of the symptoms. He told that he did not have any pain at the onset of symptoms but that he began to feel pain as the weakness progressed. The investigation of his medical history revealed no previous infection, surgical intervention, or vaccination. Moreover, he did not have a history of fever, vomiting, and diarrhea before the illness; no serious pathological history was found in his family and relatives. The patient was conscious, and he was completely oriented and cooperative. His systemic examination results were normal. The eyes were at the midline and moving to every direction. The patient could count fingers at 6 m. His pupils were isocoric; direct and indirect light reflexes were positive, and the examination of the fundus was normal. No pathological changes were detected on cranial nerve examination.

WOS: 000432959600152 PubMed ID: 29627631 OBJECTIVE: Cases presenting contralateral radicular symptoms are rarely encountered. It is difficult to decide on the correct side in cases where surgical intervention will be performed. The aim of the study is to explain the symptomatology in cases of lumbar disc herniations causing contralateral radicular symptoms by a hypotenusal effect. MATERIALS AND METHODS: In total, 27 cases were included in the study. Eight cases underwent surgical interventions performed on the side where disc herniation was radiologically detected. Nineteen cases were treated conservatively. Disc herniations were radiologically evaluated in 3 different groups, and the effect on the root on the symptomatic side was explained by a hypotenusal theory. Correlations among symptomatology, clinical findings, magnetic resonance imaging, and electromyography were discussed. RESULTS: Clinical improvement was observed in all cases that were operated on the side where disc herniation was detected radiologically. Neurologic examination findings in the postoperative period also revealed the correctness of the selected surgical approach. Electromyography is insufficient to explain clinical findings and to decide on the surgical side. CONCLUSION: Lumbar disc herniations, which lead to contralateral radicular symptoms, should be operated from the side where the disc is radiologically detected. The top of the disc is responsible for symptomatology. Surgical excision of the top of the disc removes the contralateral root traction and root compression on the same side.

WOS: 000432959600133 PubMed ID: 29614362 BACKGROUND: Patients with spinal cord injury without radiological abnormality (SCIWORA) show varying clinical prognostic courses independent of radiological findings. The fact that patients cannot be evaluated using a specific terminologic standard has led to the emergence of the real SCIWORA definition. In this study, clinical progressions of 11 patients diagnosed with SCIWORA were analyzed, and terminologic differences were discussed. METHODS: The clinical findings of 11 adults with a diagnosis of SCIWORA at the time of diagnosis and in the long term were analyzed according to the ASIA classification scheme. The presence of a correlation between radiological findings from the early and late periods and the clinical findings was investigated. High-dose methyl-prednisolone treatment was administered to all newly diagnosed patients in the early period, and the clinical response was observed. Clinical, prognostic, and radiological comparisons with SCIWORA cases reported in the literature were conducted. RESULTS: Seven patients received a diagnosis of cervical SCIWORA, and 4 patients had thoracal SCIWORA. Neuro-logic findings at the time of diagnosis and in the early and late periods vary independent of radiological findings. In the cases where significant neurologic recovery was not observed within the first 3 days, significant recovery also was not seen in the later period. In the cases where neurologic recovery was seen, improvements in sphincter function and sensory and motor deficits were observed. CONCLUSIONS: In patients diagnosed with SCIWORA, early neurologic response is the determining factor for prognosis. Clinical findings and prognosis demonstrate no correlation with radiological findings.

WOS: 000432942700073 PubMed ID: 29486314 OBJECTIVE: To study the prognoses of patients with subdural hematoma (SDH) who were not operated on at the time of the first diagnosis and the causes of enlarged hematomas in some patients during the follow-up period. MATERIALS AND METHODS: The records, service files, and radiologic examination results of the patients with diagnoses of SDH were reviewed. The SDH patients were recorded under 5 different categories: acute SDH (ASDH), subacute SDH (SSDH), chronic SDH (CSDH), acute component with chronic SDH (A-CSDH), and subacute component with chronic SDH (S-CSDH). The symptoms, clinical findings, and progression in the patients were correlated with radiologic examinations. RESULTS: A total of 291 patients received diagnoses of SDHs: 80 patients with acute, 29 patients with subacute, and 163 patients with chronic hematoma. Thirty-five patients had diagnoses of SDH with a combination of different components. It was determined that in the follow-up period, patients with A-CSDH showed the greatest increase in hematoma size over time and required surgical intervention the most often. CONCLUSION: SDHs reveal different prognoses in different age groups. Multicomponent SDHs are within the group that shows the greatest increase in size in the follow-up period. SDHs and CSDHs cause recurrent hemorrhages by sustaining the tension on the bridging veins. The greater the hematoma volume, the greater the growth potential of the hematoma tends to be. CSDHs that do not manifest changes in volume for a long time can be monitored without surgical intervention as long as the clinical picture remains stable.

Objective: This study aimed to evaluate laboratory oligoclonal band (OCB) patterns together with related IgG results and compare these results with data obtained through final clinical diagnosis. Also, to evaluate electrophoretic patterns based on reibergrams and the diagnostic value of OCBs in patients with multiple sclerosis (MS). Methods: Patients were grouped based on their diagnosis. Six classic patterns were determined. Oligoclonal band patterns and related IgG results were evaluated and these results were later compared with final clinical diagnoses. Results: A total of 1022 patients with known diagnoses were studied. Electrophoretic patterns and band counting based on Reibergram depictions were significantly different among patients with MS and other neurologic diseases. For all patients with MS, the OCB band positivity rate was 82.4%. Additionally, in the MS group, a significantly higher percentage (36.60%) of OCB positivity with more than 10 bands was detected. When reibergram results in the intrathecal IgG synthesis area and OCB counts (>10) were evaluated together, the diagnostic sensitivity (37%) and specificity (95%) were increased. Conclusion: OCB positivity, band counts, and Reibergram depictions contribute further to the diagnosis of ms when performed together for the neurologic diseases spectrum. OCB count, IgG index values, and Reibergram depictions should all be included in cerebrospinal fluid electrophoresis reports. The combined use of several laboratory test results are expected to provide valuable input for differential diagnosis of neurologic diseases.

Objective: In this study, 33 patients with a diagnosis of spontaneous intracerebral hematomas were investigated retrospectively and factors affecting morbidity and mortality were determined. Materials and methods: In this study, 33 patients with a diagnosis of SIH in intensive care unit (ICU) of Ahi Evran University Medical Faculty Hospital were retrospectively reviewed between the dates of 01.09.2016 and 30.11.2017. The factors affecting morbidity and mortality in these patients were studied in detail by reviewing the patients’ age, gender, admission condition, GCS score, personal background, hematoma location, hematoma volume, presence/absence of intraventricular hemorrhage, type of therapy and discharge condition. Results: The study included 18 female (54.5%) and 15 male patients (45.5%) whose ages were in the range of 43-91. Seen in 21 patients (63.6%), blackout was the leading cause for the admission. As a result of the neurological examination on admission, of all the patients, GCS scores of 11 patients (33.3%) were in the range of 3-7; it was between 8-13 in 17 patients (51.5%) and between 14-15 in 5 patients (15.1%). When their personal bacgrounds were reviewed, hypertension in 19 patients (57.6%) was seen as the most common etiological factor. We observed lobar region was the most frequent site for the spontaneous intracerebral hematomas. 3 patients (9.1%) were applied surgical operation, 4 patients (12.1%) were applied External Ventricular Drainage and 26 patients (78.8%) were followed up with medical treatment. The follow-up length of the patients varied in the range of 3-72 days. While 13 patients (39.4%) were discharged with a full-recovery and 5 patients with morbidity (15.%), the other 15 patient (45.5%) died. Conclusion: As a conclusion, it could be said that while hematoma volume, hematoma location and presence/absence of intraventricular hemorrhages have significant effect on morbidity and mortality in SIHs, the most significant factor is the patients’ GCS on admission. In our study, age had no significant effect on mortality and morbidity. © 2018, Scientific Publishers of India. All rights reserved.

WOS: 000429109500005, PubMed ID: 29350020, Background and objective. Many studies have shown associations between HLAB*15: 02, HLA-A*31: 01 and carbamazepine (CBZ)-induced delayed cutaneous hypersensitivity reactions. The aim of this study is to evaluate a possible association between delayed cutaneous reactions to antiepileptic drugs (AEDs) and certain HLA-A and HLA-B alleles in the Turkish population. Methods. The study consisted of 3 groups: Group I (reactive group) included the patients who had documented delayed cutaneous reactions to any antiepileptic drug. Group II (non-reactive group) included the patients who have been on antiepileptic treatment at least for three months without any adverse reactions. Group III consisted of healthy subjects. The HLA-A and B alleles were analyzed in all groups. Results. Forty patients (29 female) had experienced different hypersensitivity reactions due to AEDs: maculopapular exanthema (26 patients), Stevens-Johnson syndrome (6 patients), drug rash with eosinophilia and systemic symptoms (7 patients), toxic epidermal necrolysis (1 patient). Lamotrigine (11) and CBZ (10) were the most common culprit drugs involved in the reactions. The HLA-B*15: 02 was not present in any of the study groups. However, HLA-B* 35: 02 was found in 4 patients from the reactive group, while it was not observed in non-reactive patients and was detected in only one healthy subject (p = 0.021). Conclusion. Although our preliminary results did not indicate a strong allele association with AED hypersensitivity, HLA-B* 35: 02 appears to be a candidate allele for MPE /DRESS /DIHSS induced by AED's in Turkish population. Further studies with a larger sample size may result in more comprehensive data about the genetic tendency for AED hypersensitivity in the Turkish population., Istanbul UniversityIstanbul University [36857], This study was supported by the Research Found of the Istanbul University. Project no: 36857.

Aim/Background: Restless legs syndrome (RLS) is a frequent neurological and sleep disorder. Metabolic disorders are known to be related to sleep disorders. We prospectively evaluated whether obesity and its possible cofactors were related to the presence of RLS. Materials and Methods: The study included 143 obese and 94 non-obese individuals. Obese patients had a BMI of 30 and over, while non-obese patients had a BMI lower than 30. Patients with arthritis and pregnancy were excluded but not those with diabetes mellitus. Participants who met diagnostic criteria recommended by the International RLS Study Group were diagnosed as having RLS. Depression, anxiety, daytime sleepiness, insomnia and sleep quality were evaluated in detail. Results: The mean age of obese patients was 40.52years and that of non-obese patients was 39.76years. The mean body mass index was 36.77 in the obese group and 25.71 in the non-obese group. The occurrence of depression, anxiety, sleep quality, and insomnia scores were significantly higher in obese individuals. The evaluations of daytime sleepiness, sleep efficiency and sleep latency were not significantly different between the groups. Discussion: Although the presence of RLS was correlated with obesity and vascular risk factors at a significant level, it was also shown that depression, anxiety and insomnia were significantly frequent in obese patients (although not daytime sleepiness). Further studies are needed.

WOS: 000407019200036, PubMed ID: 28583818, Background: Based on a number of small observational studies, cerebral venous sinus thrombosis has diverse clinical and imaging features, risk factors, and variable outcome. In a large, multicenter cerebral venous thrombosis (VENOST) study, we sought to more precisely characterize the clinical characteristics of Caucasian patients. Methods: All data for the VENOST study were collected between the years 2000 and 2015 from the clinical follow-up files. Clinical and radiological characteristics, risk factors, and outcomes were compared in terms of age and sex distribution. Results: Among 1144 patients 68% were women, and in older age group (>50 years) male patients were more prevalent (16.6% versus 27.8%). The most frequent symptoms were headache (89.4%) and visual field defects (28.9%) in men, and headache (86.1%) and epileptic seizures (26.8%) in women. Gynecological factors comprised the largest group in women, in particular puerperium (18.3%). Prothrombotic conditions (26.4%), mainly methylenetetrahydrofolate reductase mutation (6.3%) and Factor V Leiden mutation (5.1%), were the most common etiologies in both genders. 8.1% of patients had infection-associated and 5.2% had malignancy-related etiology that was significantly higher in men and older age group. Parenchymal involvement constitutively hemorrhagic infarcts, malignancy, and older age was associated with higher Rankin score. Epileptic seizures had no effect on prognosis. Conclusions: Clinical and radiological findings were consistent with previous larger studies but predisposing factors were different with a higher incidence of puerperium. Oral contraceptive use was not a prevalent risk factor in our cohort. Malignancy, older age, and hemorrhagic infarcts had worse outcome. (c) 2017 National Stroke Association. Published by Elsevier Inc. All rights reserved.

PubMedID: 24914756 OBJECT: Promising clinical results were reported in watertight closure of anterior skull base defects (ASBDs) with bisphenol-a-glycidyl-dimethacrylate (bis-GMA)-based materials to prevent the cerebrospinal fluid leaks. However, interrelation of these materials with surrounding bones in histologic level, referred to as the osteointegration, has not been reported in the anterior skull base. In addition, an illustrative case with an ASBD that was repaired using a bis-GMA composite has been presented. METHODS: Twenty New Zealand rabbits were divided into 4 groups: control and sham groups consisted of 2 and 6 rabbits, respectively. The "skull base defect" group (n = 6) underwent a unifrontal craniectomy and an iatrogenic ASBD followed by creating a dural defect to obtain a cerebrospinal fluid leak. Similar bony and dural defects were acquired in the "repair with bis-GMA based allograft" group (n = 6), but the bony defect was closed with bis-GMA-based allograft. RESULTS: All animals in the "skull base defect" group died in 3 weeks after surgery. There were no animal losses in the "repair with bis-GMA based allograft" group at the sixth month. Histologic evaluation revealed complete osteointegration of bis-GMA composite with surrounding bones. CONCLUSIONS: bis-GMA based allograft achieved a watertight repair of the ASBD. Histologic findings of this study showed that bis-GMA composite is a reliable material to be used in the closure of anterior skull base bony defects. © 2014 Mutaz B. Habal, MD.

Purpose: There is evidence of autonomic dysregulation in temporal lobe epilepsy. The structures removed during temporal lobectomy are important centers of central cardiovascular control; therefore surgery may conceivably alter the cardiovascular autonomic function. The effects of temporal lobectomy on autonomic cardiac control are controversial. We investigated the effects of temporal lobectomy on heart rate variability (HRV) in the early and late postoperative periods. Methods: We used 1-h ECG recordings to assess heart rate variability by spectral analysis in 24 consecutive patients who underwent temporal lobectomy due to intractable temporal lobe epilepsy. ECG recordings were performed before and twice (early and late) after surgery. The results were compared with age and sex matched controls. Results: When compared with controls, all the time and frequency domain indices (SDRR, RMSSD, TP, LF and HF) were significantly lower in the patient group before surgery. Findings were similar in the early and late post-operative periods except that the LF/HF ratio increased in the patient group after the late post-operative period. Within the patient group, compared to pre-operative results, normalized HF was increased in the early post-operative period; however in the late post-operative period, LF/HF ratio was increased. Conclusions: These findings show that in patients with intractable temporal lobe epilepsy, HRV is decreased globally in both sympathetic and parasympathetic domains. While the total HRV remains reduced throughout the postoperative periods, the LF/HF ratio, i.e., sympathovagal balance is altered, in favor of parasympathetic side early after surgery, but towards the sympathetic side after the first postoperative month. (C) 2013 British Epilepsy Association. Published by Elsevier Ltd. All rights reserved.

IMPORTANCE The ability of present-day etiologic stroke classification systems to generate subtypes with discrete stroke characteristics is not known. OBJECTIVE To test the hypothesis that etiologic stroke subtyping identifies different disease processes that can be recognized through their different clinical courses. DESIGN, SETTING, AND PARTICIPANTS We performed a head-to-head evaluation of the ability of the Causative Classification of Stroke (CCS), Trial of Org 10172 in Acute Stroke Treatment (TOAST), and ASCO (A for atherosclerosis, S for small-vessel disease, C for cardiac source, and O for other cause) classification systems to generate etiologic subtypes with different clinical, imaging, and prognostic characteristics in 1816 patients with ischemic stroke. This study included 2 cohorts recruited at separate periods; the first cohort was recruited between April 2003 and June 2006 and the second between June 2009 and December 2011. Data analysis was performed between June 2014 and May 2016. MAIN OUTCOMES AND MEASURES Separate teams of stroke-trained neurologists performed CCS, TOAST, and ASCO classifications based on information available at the time of hospital discharge. We assessed the association between etiologic subtypes and stroke characteristics by computing receiver operating characteristic curves for binary variables (90-day stroke recurrence and 90-day mortality) and by calculating the ratio of between-category to within-category variability from the analysis of variance for continuous variables (admission National Institutes of Health Stroke Scale score and acute infarct volume). RESULTS Among the 1816 patients included, the median age was 70 years (interquartile range, 58-80 years) (830 women [46%]). The classification systems differed in their ability to assign stroke etiologies into known subtypes; the size of the undetermined category was 33% by CCS, 53% by TOAST, and 42% by ASCO (P < .001 for all binary comparisons). All systems provided significant discrimination for the validation variables tested. For the primary validation variable (90-day recurrence), the area under the receiver operating characteristic curve was 0.71 (95% CI, 0.66-0.75) for CCS, 0.61 (95% CI, 0.56-0.67) for TOAST, and 0.66 (95% CI, 0.60-0.71) for ASCO (P = .01 for CCS vs ASCO; P < .001 for CCS vs TOAST; P = .13 for ASCO vs TOAST). The classification systems exhibited similar discrimination for 90-day mortality. For admission National Institutes of Health Stroke Scale score and acute infarct volume, CCS generated more distinct subtypes with higher between-category to within-category variability than TOAST and ASCO. CONCLUSIONS AND RELEVANCE Our findings suggest that the major etiologic stroke subtypes are distinct categories with different stroke characteristics irrespective of the classification system used to identify them. We further show that CCS generates discrete etiologic categories with more diverse clinical, imaging, and prognostic characteristics than either TOAST or ASCO.

Posttraumatic stress disorder (PTSD) is a condition that occurs after a traumatic event, and its diagnostic criteria include attention and memory deficits as well as symptoms of anxiety. We aimed to review the literature related to attention, memory, and executive functions in PTSD. Although studies on the subject are limited (in that there is no uniformity in terms of trauma type, selection of the control groups or types of neuropsychological tests used), most reported similar deficits in PTSD subjects in terms of memory and executive functions including attention. Since the presence of psychiatric comorbidities may disrupt neuropsychological functions, results of studies that have not controlled comorbidity may be questionable. However, studies that excluded the comorbid conditions reported similar deficits in cognitive functions in PTSD patients. The relationship between recovery from PTSD symptoms and change in cognitive functions has been examined in only a few studies, and most have reported an improvement for both memory and executive functions in remitted patients. The improvement in executive functions, however, has been limited by the difficulty of task. Cognitive deficits have been among the major causes of disabilities in PTSD patients. Therefore, the amount of improvement in cognitive dysfunctions by current treatments of PTSD deserves more attention.

WOS:000450095400009, PubMed ID: 30042641, Introduction: This study presents the current prevalence of anxiety,mood, and personality disorders as well as factors associated with theexistence of psychiatric disorders in patients with benign paroxysmalpositional vertigo (BPPV).Methods: The study sample comprised 46 patients with BPPV and 74control subjects. Anxiety and mood disorders were ascertained via theStructured Clinical Interview for the Diagnostic and Statistical Manual(DSM) of Mental Disorders, Fourth Edition/Clinical Version. Personalitydisorders were diagnosed via the Structured Clinical Interview for DSM,Revised Third Edition, Personality Disorders.Results: Of the 46 patients, 18 (39.1%) had at least one mood or anxietydisorder and 13 (28.3%) had at least one personality disorder. The mostcommon Axis I and Axis II disorders in the patient group were majordepression in 8 (17.4%) and obsessive–compulsive personality disorderin 10 (21.7%) patients, respectively. It was found that major depression(p0.021), generalized anxiety disorder (p0.026) and obsessive–compulsive personality disorder (p0.001) were more prevalent in theBPPV group compared with the control group.Conclusion: Results suggest that psychiatric disturbances should becarefully checked in patients with BPPV due to the relatively high rateof comorbidity., Amaç: Bu çalışma benign paroksismal pozisyonel vertigo (BPPV)hastalarında psikiyatrik bozuklukların varlığı ile ilişkili faktörlerin ve anksiyete, duygudurum ve kişilik bozukluklarının mevcut yaygınlığını sunmaktadır. Yöntem: Araştırma örneklemi 46 BPPV hastası ve 74 kontrol olgusundan oluşmuştur. Anksiyete ve duygudurum bozuklukları Structured Clinical Interview for the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition/Clinical Version yoluyla tespit edildi. Kişilik bozuklukları tanısı Structured Clinical Interview for DSM, Revised Third Edition Personality Disorders ile konuldu. Bulgular: Kırk altı hastanın 18’in (%39,1) de en az bir duygudurum yada anksiyete bozukluğu ve 13’ün (%28,3) de en az bir kişilik bozukluğu vardı. Eksen I ve Eksen II tanıları olarak en sık, sırasıyla 8 (%17,4) hastada majör depresyon ve 10 (%21,7) hastada obsesif kompulsif kişilik bozukluğu vardı. Major depresyon (p:0,021), yaygın anksiyete bozukluğu (p:0,026) ve obsesif kompulsif kişilik bozukluğu (p:0,001) yaygınlığının kontrol grubu ile karşılaştırıldığında BPPV grubunda daha sık görüldüğü bulunmuştur. Sonuç: Sonuçlar; BPPV tanılı hastaların, psikiyatrik bozuklukların yüksek oranlı komorbiditeleri nedeniyle dikkatle değerlendirilmeleri gerektiğini ortaya koymaktadır.

Prophylactic therapy response varies in migraine patients. The present study investigated the relationship between the resistance to the drugs commonly used in prophylactic therapy and the possible polymorphic variants of proteins involved in the metabolism of these drugs. Migraine patients with the MDR1 3435TT genotype exhibited a better treatment response to topiramate than migraine patients with the CC and CT genotypes ( p =0.020). The MDR1 C3435T polymorphism was also found to be a higher risk factor for topiramate treatment failure in a comparison of the number of days with migraine ( β 2 =1.152, p =0.015). However, there was no significant relationship between the treatment response to topiramate and either the CYP2D6 or CYP2C19 polymorphism, and there were no significant correlations between the treatment responses to amitriptyline, propranolol, and valproic acid and the MDR1 , CYP2D6 and CYP2C19 gene polymorphisms. This is the first study to investigate the effect of the polymorphic variants on prophylactic therapy response in migraine patients.

Introduction The reversible cerebral vasoconstriction syndromes, including postpartum angiopathy, have been characterized over the last decade. Women are predominantly affected. Some studies suggest that postpartum angiopathy carries a worse prognosis. Patients and methods We compared the clinical, neuroimaging, and angiographic features of 36 men, 110 non-pregnant women and 16 postpartum women included in our single-center cohort of patients with reversible cerebral vasoconstriction syndromes encountered from 1998 to 2016. Results As compared to men, non-pregnant women were older (48 ± 11 vs. 34 ± 13 years, p Discussion/Conclusion The observed gender differences in reversible cerebral vasoconstriction syndromes may result from hormonal or non-hormonal factors. Hormonal imbalances may trigger reversible cerebral vasoconstriction syndromes. Given the absence of significant differences in the female subgroups, hormonal factors do not appear to significantly affect the course or outcome of reversible cerebral vasoconstriction syndromes.

Objective:Factors predicting poor outcome in patients with the reversible cerebral vasoconstriction syndrome (RCVS) have not been identified.Methods:In this single-center retrospective study, we analyzed the clinical, brain imaging, and angiography data in 162 patients with RCVS. Univariable and multivariable regression analysis were performed to identify predictors of persistent (nontransient) clinical worsening, radiologic worsening, early angiographic progression, and poor discharge outcome (modified Rankin Scale score 4–6).Results:The mean age was 44 ± 13 years; 78% of patients were women. Persistent clinical worsening occurred in 14% at 6.6 ± 4.1 days after symptom onset, radiologic worsening in 27% (mainly new infarcts), and angiographic progression in 15%. Clinical worsening correlated with angiographic progression and new nonhemorrhagic lesions. Age and sex did not independently predict any type of worsening. Infarction on baseline imaging predicted poor outcome. Prior serotonergic antidepressant use predicted clinical and angiographic worsening but not poor outcome. Intra-arterial vasodilator therapy independently predicted clinical worsening and poor discharge outcome but was offered to more severe cases. Glucocorticoid treatment proved to be an independent predictor of clinical, imaging, and angiographic worsening and poor outcome. Of the 23 patients with clinical worsening, 17 received glucocorticoids (15 within the preceding 2 days). There were no significant differences in baseline brain lesions and angiographic abnormalities between glucocorticoid-treated and untreated patients.Conclusion:Patients with RCVS at risk for worsening can be identified on basis of baseline features. Iatrogenic factors such as glucocorticoid exposure may contribute to worsening.

BACKGROUND AND PURPOSE: Studies shows ictal behavior and symptoms are affected by patient sex in temporal lobe epilepsy. The purpose of our study was to determine whether alterations in the WM as assessed by DTI display different patterns in male and female patients with unilateral HS. MATERIALS AND METHODS: Patients with unilateral HS were categorized as women with right HS (n12), men with right HS (n10), women with left HS (n12), and men with left HS (n10). DTI of the brain along 64 noncollinear directions was obtained from 44 patients and 37 sex-matched control participants. We used TBSS to analyze whole-brain WM. Regions with significant changes of FA and MD, and their mean FA, MD, total number of significant voxels, and asymmetry indices were determined for each group. RESULTS: All groups showed bilateral and extensive reductions of FA and elevated MD in the WM, more prominent ipsilateral to the affected hippocampus. The total number of voxels with decreased FA in patients compared with that of control participants was higher in women with right HS (24,727 vs 5,459) and in men with left HS (27,332 vs 14,013) than in their counterparts. Changes in MD associated with right HS were more extensive in both men and women (right vs left HS, women: 16,926 vs 5,458; men: 5,389 vs 4,764) than in those with left HS. In patients with right HS, the ipsilateral cingulum, uncinate fasciculus, internal and external capsules, and right acoustic radiation were involved extensively in women. CONCLUSIONS: Women and men showed different patterns in extent of WM alterations associated with HS. ABBREVIATIONS: AI asymmetry index; EEG, electroencephalography; FA fractional anisotropy; HS hippocampal sclerosis; MD mean diffusivity; TBSS tract-based spatial statistics; TLE temporal lobe epilepsy

Substantial experimental data and recent clinical evidence suggesting that tissue reperfusion is a better predictor of outcome after thrombolysis than recanalization necessitate that patency of microcirculation after recanalization should be reevaluated. If indeed microcirculatory blood flow cannot be sufficiently reinstituted despite complete recanalization as commonly observed in coronary circulation, it may be one of the factors contributing to low efficacy of thrombolysis in stroke. Although microvascular no-reflow is considered an irreversible process that prevents tissue recovery from injury, emerging evidence suggests that it might be reversed with pharmacological agents administered early during recanalization. Therefore, therapeutic approaches aiming at reducing microvascular obstructions may improve success rate of recanalization therapies. Importantly, promoting oxygen delivery to the tissue, where entrapped erythrocytes cannot circulate in capillaries, with ongoing serum flow may improve survival of the underreperfused tissue. Altogether, these developments bring about the exciting possibility that benefit of reperfusion therapies can be further improved by restoring microcirculatory function because survival in the penumbra critically depends on adequate blood supply. Here, we review the available evidence suggesting presence of an 'incomplete microcirculatory reperfusion' (IMR) after focal cerebral ischemia and discuss potential means that may help investigate IMR in stroke patients after recanalization therapies despite technical limitations. Journal of Cerebral Blood Flow & Metabolism (2012) 32, 2091-2099; doi:10.1038/jcbfm.2012.139; published online 10 October 2012