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BACKGROUND: Tuberculosis is still a major cause of serious illness in developing countries. The objective of this study was to assess the clinical, laboratory, radiological and prognostic features of tuberculous meningitis (TBM) in immuncompetent adult patients. PATIENTS AND METHODS: Sixty-one patients with confirmed or presumed TBM seen over a 12-year period at the Neurology Department of Bakirkoy Research and Training Hospital for Psychiatric and Neurological Disease, Istanbul, Turkey, were analyzed retrospectively. Patients were grouped according to the severity of meningitis on admission (stages I, II and III). They were also divided into two groups according to the presence of paradoxical response (progressive increase of lymphocytes or increase of polymorphonuclear cells instead of lymphocytes) in CSF samples. A combination of five antituberculosis drugs was used in the 1st month of treatment. Patients received antituberculosis therapy for at least 12 months. The outcome of the patients was defined on the basis of the 12-month Barthel index (BI) score (BI < 12 poor; BI >/= 12 good). For statistical analysis death was included in the poor outcome group. RESULTS: Paradoxical response in CSF findings was seen in 20 patients. There was no statistically significant difference between the outcome of the patients with and without CSF paradoxical response; however, new tuberculomas developed more frequently in the first group (p < 0.05). The overall mortality was 27.8%. Stage of disease was found to be independently associated with the 12-month outcome (OR 7.2; 95% CI 1.7-30.3, p = 0.007). CONCLUSION: In developing countries such as Turkey, tuberculosis is still an important public health issue. Early suspicion and appropriate long-term antituberculosis therapy together with corticosteroids may reduce mortality and morbidity in TBM patients. [ABSTRACT FROM AUTHOR]

Abstract: The case of a 32-year-old man who died as a result of an unusual occupational accident during his shift on a marble quarry is reported. The worker stated a sharp and sudden pain on his shoulder while working with a diamond wire saw machine and died after being taken to a hospital. There was a round-shaped, foreign body entry hole, which looked like an angled gunshot entrance wound, with a diameter of 1.5 cm, in the middle between the neck and the left shoulder. The projectile, which penetrated through the left lung and thoracic aorta, was found within the left thoracic cavity. This case is reported due to its rarity and the possibility of its misinterpretation, and to remind forensic pathologists of the importance of having a systematic approach to each individual case., Competing Interests: The authors report no conflict of interest., (Copyright © 2021 Wolters Kluwer Health, Inc. All rights reserved.)

Abstract: In swimming pools, malfunctions in the pool water drainage system can result with severe injuries, or even death, and mostly children are affected by these accidents. In this case report, the death scene and postmortem examination findings of a 12-year-old girl, who was trapped by her feet in the pool water drainage system, are reported. The external examination revealed ecchymotic areas with abrasions on both lower legs and both feet, suggesting suction of both feet through the uncovered pool drainage system opening. To prevent such accidents, safety practices related to the water circulation system should be developed in swimming pools and similar areas; children should be supervised at all times; and emergency medical teams, as well as lifeguards, should be available for immediate intervention., Competing Interests: The authors report no conflict of interest., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Background and Purpose: Anterior cerebral infarct (ACA) infarcts are reported very rare that is due to the compensatory collateral circulation provided by the anterior communicating artery. There are very few studies reporting the long-term follow-up results of ACA infarcts regarding their aetiology, clinical features and prognosis. Most studies reported in the literature vary between several months to one year., Methods: A total of 27 patients with ACA infarcts were registered (14 women and 13 men). The mean age of the patients was 68.5 (age range: 45-89 years)., Results: Bilateral ACA infarcts were reported in four patients (14.8%), right ACA infarct in 11 (40%) patients and left ACA infarct in 12 patients (44%). During the initial examination 15 patients (55.5%) were found to have apathy, 13 patients (48%) had incontinence, nine patients (33.3%) had primitive reflexes, 11 patients (40.7%) had aphasia, while six patients (22.2%) were found to suffer from neglect. At the end of one-year follow-up, five patients (22.7%) were reported to have apathy, 6 patients (27.2%) had incontinence, one patient (4.5%) had primitive reflexes, while one patient (4.5%) was found to have permanent aphasia, and no patients was found to suffer from neglect., Conclusion: Here we present our clinical data regarding the aetiology, specific clinical characteristics (including the speech disorders) and prognosis of 27 patients with ACA infarcts during a relatively longer follow-up period (3 months - 30 months) in compared to previous literature. We show that there are differences in the etiological factors of ACA infarcts between the Asian and European communities. Regarding speech disorders which are frequently reported during ACA infarcts, our study results are in agreement with other studies suggesting that this clinical picture is more than a real aphasia and associated with general hypokinesia and reduction in psychomotor activity.

Background and Purpose: Epilepsy with photosensitivity (PSE) is one of the reflex epilepsy types with pathophysiology still unexplained. In our study we aimed to evaluate the clinical, electroencephalogram (EEG) and prognosis of patients with PSE diagnosis., Methods: A total of 44 patients with PSE diagnosis according to international classification were included in this retrospective and cross-sectional study. The age, gender, syndrome, clinical and EEG characteristics of patients, and treatment response were investigated., Results: The mean age was 22.09±6.49 years for 28 females and 16 males included in the study. Of patients, 17 had idiopathic photosensitive occipital lobe epilepsy (IPOLE), 11 had juvenile myoclonic epilepsy (JME), 11 had other PSE and 5 had juvenile absence epilepsy (JAE), with the most common visual trigger factors television and sunlight. In terms of seizure type, the most common was generalized tonic clonic seizure (GTCS), with myoclonus, absence and other seizure types observed. There was family history present in 17 patients and valproic acid was most commonly used for treatment., Conclusion: As noted in the literature, our data show that PSE has defined age group and clinical presentation, good prognosis but requires correct choice of medication for treatment. It is thought that good description of these epilepsy types will reduce misdiagnosis and mistreatment rates.

The paramedian artery arises from P1 segment of posterior cerebral artery and supplies a variable extent of thalamus but usually the dorsomedian, median, internal medullary lamina and the intralaminar nuclei. The typical clinical picture of unilateral paramedian thalamic infarctions consist of arousal and memory disorders, language or visuospatial disorders depending on the side of the lesion accompanied with gaze palsies and sensory-motor deficits. Ipsilateral ptosis associated with paramedian thalamic infarctions has been rarely reported. We report a 31 years old patient presenting with unilateral ptosis and right sided facial numbness associated with right paramedian thalamic infarction.

Background: Hunger strike is a very serious entity which may lead to severe diseases and death., Aims: The aim of this study is to document the clinical, neurophysiological, neuroradiological, and neuropsychological aspects of prolonged hunger strike., Material and Method: We investigated the clinical and laboratory characteristics of 25 hungerstrikers hospitalized during refeeding process. One sample t-test, independent samples t-test, Mann-Whitney and Pearson correlation tests were used for statistical analyses., Results: Twelve of them had a continuous hunger strike ranging between 190-366 days. The other 13 had quitting intervals for various reasons with a continuous hunger ranging between 65-265 days with a total hunger duration of 153-382 days. The mean loss of body mass index (BMI) was 40.98 +/- 9.3%. Imbalance, sleep disorders, somatosensory disturbances, and adynamia were the most common complaints. At admission, one third experienced ophthalmoparesis, about half of them had paresis, one quarter had truncal ataxia. At discharge 16% had persistent ophthalmoparesis and 36% nystagmus. Only four patients (16%) could walk independently. There was no serious MRI, EEG findings. Most prominent EMG findings were the decrease in median and sural nerve cnap, median and fibular cmap, and fibular ncv values. They showed mild impairment in MMTS and most of them had attention deficit and frontal type memory impairment., Conclusion: It can be concluded that vitamin B intake, independent of the quantity and timing, lowers the morbidity and mortality of hunger strikers.

Idiopathic Tolosa-Hunt syndrome (ITHS) is a very rare cause of painful ophthalmoplegia characterized by unilateral orbital pain, ipsilateral oculomotor paralysis and prompt response to steroids. In this paper we report 4 additional cases of ITHS. This rare cause of painful ophthalmoplegia effects the cranial nerves due to a granulomatous lesion of unknown etiology in the cavernous sinus or superior orbital fissure. The International Headache Society redefined the diagnostic criteria for ITHS but it is still mostly a diagnosis of exclusion. Careful evaluation and follow-up is essential for diagnosis. Optimal therapy duration and dosage and prophylactic treatment in recurrent cases needs further research.

Simple ictal or interictal automatisms are commonly seen in epilepsy, whereas complex automatisms are rare. Simple ictal vocalizations or appendicular automatisms have been reported to be due to mesial temporal lobe epilepsy. However, seizure-associated singing and dancing is very rare. We report a seventeen-year-old patient with ictal singing and rhythmic swinging of the arms as a dancing gesture. The video-EEG recording showed ictal left temporal lateralization and neuropathology confirmed left mesial temporal sclerosis.

Among 4200 consecutive patients admitted to three hospitals with acute ischemic stroke, we found only 11 patients in whom magnetic resonance imaging (MRI) had proved that they had medial medullary infarction (MMI). In our centers, patients with MMI were less than 1% of those with vertebrobasilar stroke. The infarcts documented by MRI were unilateral in 10 patients and bilateral in one. On clinico-topographical analysis there were four clinical patterns: (1) Classical Dejerine's syndrome was the most frequent, consisting of contralateral hemiparesis, lemniscal sensory loss and ipsilateral lingual palsy in 7 of the eleven patients. (2) Pure hemiparesis was present in 2 patients; (3) Sensorimotor stroke was present in 1 patient with contralateral hemiparesis, hypesthesia and mild decrease in pain sensation without lingual palsy; (4) Bilateral MMI syndrome in 1 patient, accompanied by tetraparesis, bilateral loss of deep sensation, dysphagia, dysphonia and anarthria. Presumed causes of MMI were intrinsic branch penetrator artery disease with concomitant vertebral artery stenosis in 6 of the 11 patients, vertebral artery occlusion in 2, dolichoectatic vertebrobasilar arteries in 2, a source of cardiac embolism in 1. Prognosis at 3 months was favorable in 8 patients, but the patient with bilateral MMI syndrome had persisting motor deficit causing limitation of daily activities, and 2 died from systemic causes. The classical triad of acute MMI facilitates the diagnosis, although the recognition of this syndrome in patients with incomplete manifestations can be difficult and occurs more frequently than commonly thought. Moreover, vertebral artery atherosclerosis and branch atheromatous disease of the penetrating arteries are the main causes of medullary infarction.

Cortical silent period (SP) following transcranial magnetic stimulation is mainly due to cortical inhibitory mechanisms. SP may have a value for detecting inhibitory mechanisms in epileptic patients with or without treatment. The aim of this study was to evaluate the effect of both the epilepsy and the antiepileptic medication on these inhibitory mechanisms. The subgroups studied consisted of (a) normal subjects, (b) unmedicated epileptic patients, (c) epileptic patients with uncontrolled seizures under medication, (d) epileptic patients with controlled seizures under medication. SP following transcranial magnetic stimulation was measured in all subjects. The SP values from shortest to the longest were in the following order: 1) normal subjects; 2) epileptic patients with controlled seizures under medication; 3) unmedicated epileptic patients; 4) epileptic patients with uncontrolled seizures under medication. Our findings probably indicate the enhanced interictal inhibitory mechanisms in epilepsy which is resistant to antiepileptic medication.