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   Table of Contents - Current issue
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October-December 2020
Volume 37 | Issue 4
Page Nos. 155-234

Online since Tuesday, December 29, 2020

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REVIEW ARTICLE  

Neuroinflammation in Alzheimer's disease continuum p. 155
Aslihan Taskiran-Sag, Müge Yemişçi
DOI:10.4103/nsn.nsn_190_20  
Aging population brings an ever-increasing global burden of dementia, and Alzheimer's disease (AD) is the most frequent type worldwide. Many years of research have introduced characteristic cerebral histopathological and molecular changes in this disease. However, all attempts to establish an effective treatment have failed. In this review, we aim to address the basic evidence regarding the role of inflammatory mediators in AD and their link to the other pathogenetic pathways. Novel findings based on advanced biotechnology and bioinformatics are covered briefly, as well.
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ORIGINAL ARTICLES Top

Long latency reflexes in patients with postural instability and ataxia p. 164
Ersin Deneri, Nesibe Tilek, Aysel Çoban, Cengiz Tataroğlu
DOI:10.4103/NSN.NSN_44_20  
Objectives: Distal electrical stimulation of an upper extremity mixed nerve can generate a reflex response from the trapezius muscle. This reflex response may have a central neural pathway and can be affected by postural changes. Materials and Methods: In this study, long latency reflexes (LLRs) from both distal and trapezius muscle were evaluated in patients with Parkinson's disease (PD) with and without postural dysfunction and in patients with cerebellar ataxias. Thirty-three patients with PD, 10 patients with degenerative cerebellar ataxia and 22 healthy volunteers were included in the study. LLRs were recorded from ipsilateral thenar and trapezius muscles. Latencies and amplitudes of LLRs obtained from thenar (thenar LLR) and trapezius (trapezius LLR) muscles were analyzed. Results: In patients with PD, thenar LLRs showed significant shortening in the onset latencies and significant increase in the amplitudes in comparison with healthy controls. Trapezius LLRs did not show any significant difference in latencies or amplitudes; however, these responses showed a significant absence in one or two components in patients with Parkinson's disease with postural dysfunction. Additionally, this reflex was not recorded in patients with cerebellar ataxia. Conclusion: Trapezius LLRs can give some information regarding the physiology of neural circuits responsible for postural arrangement. Cerebellar connections may have a major role in the generation of trapezius LLRs.
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The role of vestibular evoked myogenic potential and the video head impulse test in patients with multiple sclerosis without radiologic findings p. 170
Reyhan Surmeli, Mehmet Sürmeli, Gözde Günay, Ayşe Destina Yalçın, Ayşe Aslı Şahin Yılmaz, Fatma Kulalı
DOI:10.4103/NSN.NSN_51_20  
Objective: The aim is to evaluate the vestibular system using the video head impulse test (vHIT) and vestibular evoked myogenic potentials (VEMP) in patients with multiple sclerosis (MS) without central vestibular involvement in magnetic resonance imaging (MRI), and to determine whether there was subclinical vestibular system impairment. Materials and Methods: The study comprised 27 patients with MS and 26 healthy participants. The participants had no lesions in the central vestibular system in an MRI taken in the past 3 months. Detailed neuro-otologic and neuro-ophthalmologic examinations were performed on all participants. Then, the Dizziness Handicap Inventory (DHI) was completed for subjective vestibular system evaluation. In addition, vHIT and cervical VEMP (cVEMP) were performed for objective vestibular system evaluation. The results were analyzed statistically. Results: The mean age of the patients in the MS group was 39.3 ± 11.4 years and 42.7 ± 9.7 years in the control group. The median DHI score was 4 (range, 0–8) in the MS group and 2 (range, 0–6) in the control group. There were no statistically significant differences between the DHI score averages of the groups. The mean vestibulo ocular reflex (VOR) gain in vHIT was 0.76 ± 0.21 in the MS group and 0.99 ± 0.13 in the control group. VOR gain was statistically significantly lower in patients with MS. The VOR gain cut-off level was considered as 0.8. Gain level was below the cut-off level in 53.7% of patients with MS. There was no cVEMP response in 31.5% of patients with MS. In addition, patients with MS had prolonged P1 and N1 latencies and decreased P1-N1 peak-to-peak amplitudes. Conclusion: We found subclinical involvement in electrophysiologic tests (vHIT and cVEMP) in patients with MS without MRI lesions and without subjective vestibular system symptoms. We believe that vHIT and cVEMP can be used for subclinical evaluation in patients with MS without central vestibular system involvement in MRI.
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The association between causes and electrophysiology in myoclonus: When and why electrophysiology? p. 176
Meral E Kiziltan, Aysegül Gündüz, M Hazal Ser, S Naz Yeni, Çigdem Özkara, Veysi Demirbilek, Cengiz Yalçınkaya, Günes Kızıltan
DOI:10.4103/NSN.NSN_82_20  
Objective: We aimed to identify the possible causes of myoclonus and related electrophysiological features in a cohort of young patients. Patients and Methods: We performed a retrospective analysis of all clinical and electrophysiological recordings of patients who had myoclonus and were under 60 years between 2005 and 2018. The clinical data included age at examination, gender, age at onset, and main neurological or systemic findings, underlying cause and electrophysiological features constituted surface electromyogram, long-loop reflexes, electroencephalography, and somatosensory-evoked potentials. Results: In the study period, we identified 155 patients with myoclonus. Myoclonus was most commonly related with epilepsy and movement disorders. Myoclonus with epilepsy was the leading cause between 10 and 30 years, whereas myoclonus with movement disorders was more common after 30 years. In our country, SSPE was an important cause of myoclonus under the 20 years of age. We identified cortico-subcortical subtype followed by cortical, cortical reflex, subcortical-basal ganglia, subcortical-brainstem and propriospinal subtypes, and correlated these subtypes with relevant disorders. Conclusion: The electrophysiological classification provides anatomical subtyping, which is favorable in diagnosing certain cases such as brainstem and propriospinal myoclonus. Certain characteristics such as reflex nature of myoclonus and accompanying features narrow the list of differentials and help in making the diagnosis.
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Sleep disorders in a shift worker population sample in Turkey p. 183
Duygu Kurt Gok, İlker Ünal, Kezban Aslan
DOI:10.4103/NSN.NSN_29_20  
Aims: This study aims to determine the sleep quality of night-shift workers, determine the prevalence and characteristics of sleep disorders related to shift work, and compare sleep characteristics between shift workers and day workers. Subjects and Methods: The study included 1473 individuals employed in three different areas (health, security, and labor) as shift (78.5%) or day (21.5%) workers in the city of Adana, Turkey. Data were collected using a structured questionnaire consisting of 132 questions. The questionnaire included demographic data, education level, socioeconomic status, shift schedule, accompanying health problems, sleep disorders and sleeping habits, the Epworth Sleepiness Scale, the Pittsburgh Sleep Quality Index, the Berlin Questionnaire, and the Restless Legs Syndrome (RLS) scale. Statistical Analysis Used: The SPSS for Windows 20.00 software package was used for statistical analyses. Results: Day workers and shift workers exhibited excessive daytime sleepiness in 17.1% and 24.9% (P = 0.004), poor sleep quality in 41.5% and 44.3% (P = 0.374), chronic insomnia in 8% and 16.2% (P < 0.001), RLS in 4.7% and 5.3% (P = 0.818), and sleep-disordered breathing in 7.3% and 7% (P = 0.864), respectively. Conclusions: Shift work significantly compromises sleep quality. In particular, fixed night shifts or rotating shift workers experience relatively higher rates of decline in subjective sleep quality, excessive daytime sleepiness, and chronic insomnia compared with day workers.
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The ratios of estradiol and progesterone to testosterone influence the severity of facioscapulohumeral muscular dystrophy Highly accessed article p. 190
Ceren Hangul, Selen Bozkurt, Ugur Bilge, Sebahat Ozdem, Hasan Altunbas, Hilmi Uysal, Filiz Koc, Sibel Berker Karauzum
DOI:10.4103/NSN.NSN_37_20  
Background: Facioscapulohumeral muscular dystrophy (FSHD) occurs as a consequence of genetic deletion of D4Z4 repeats on chromosome 4q35. Onset of FSHD is earlier in males, suggesting that testosterone may trigger the disease. In accordance, the rapid progression of disease in women after menopause suggests a protective role for estrogen and progesterone. No studies have examined levels of all these hormones in relation with the severity of FSHD. Aims: To evaluate the possible correlation between the severity of FSHD with sex hormones, age, and genetic deletion on chromosome 4q35. Subjects and Methods: D4Z4 repeat units were investigated in 33 patients (19 males/14 females) with FSHD. In the blood samples, luteinizing hormone, follicle-stimulating hormone, free estriol, estradiol, free testosterone and total testosterone, progesterone, 17-OH progesterone, prolactin, albumin, and fibrinogen were measured. The severity of FSHD was identified using a Clinical Severity Score (CSS) scaling system. Spearman's correlation and regression analyses were performed as statistical analyses. Results: Age (P = 0.001, r = 0.541) and total testosterone (P = 0.045, r = 0.351) were positively correlated, and the progesterone/total testosterone (P = 0.025, r = −0.390) and estradiol/total testosterone ratios (P = 0.025, r = −0.389) were negatively correlated with the severity of FSHD. Conclusions: Our results indicate that age, total testosterone, ratios of estradiol and progesterone to total testosterone, but not deletion on chromosome 4q35, have a significant relation with the severity of FSHD. Given that both estrogen and testosterone treatment are considered in therapy, our results suggest that estrogen and progesterone but not testosterone are likely to be more effective on the severity of FSHD.
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Botulinum toxin injections for neurological disorders: Experience between 1994 and 2019 p. 197
Cem Boluk, Yesim Gökçe, Aysegül Gündüz, Nurten Uzun Adatepe, Feray Karaali Savrun, Asim Kaytaz, Meral E Kızıltan
DOI:10.4103/NSN.NSN_36_20  
Aim: Reported results of botulinum toxin (BoNT) injections vary widely in different studies and in different neurological disorders. The aim of this study was to investigate the efficacy and safety of BoNT injections for each neurological disorder and to report our experience in this area since 1994. Materials and Methods: All patients who were injected with BoNT since 1994 were included in this retrospective study. Age, gender, etiology, specific diagnosis, time from first symptom to first injection, type of BoNT (onabotulinum toxin-abobotulinum toxin), doses, treatment response, and complications were extracted from patient files. Etiologies were classified into five main groups: hyperkinetic movement disorders, focal spasticity, painful conditions, sialorrhea, and hyperhidrosis. Positive treatment response was defined as any objective clinical improvement determined by the attending physician and declared by the patient. Results: We determined that 1792 patients were considered for BoNT injections. Among them, 341 were not found to be suitable for injections or did not accept to have the procedure done. In total, 1451 different patients were included in the study. The most common indications for BoNT injection were hyperkinetic movement disorders (72.3%) and focal spasticity (15.2%). Other disorders included painful conditions, hyperhidrosis, and sialorrhea. In 74.3% of the patients, the only injected toxin was onabotulinum toxin, whereas 10.2% of the patients were injected only with abobotulinum toxin. In 14.7% of the patients, the injection type was changed from one to the other, due to ineffectiveness or unavailability. Response rates were 95.4% for focal spasticity, 92.6% for hyperkinetic movement disorders, 81.1% for painful conditions, 66.7% for hyperhidrosis, and 63.1% for sialorrhea. Severe complications were seen in 0.6% of the patients. Conclusion: BoNT injections seem to be effective in all of the neurological disorders which we investigated. Except for mild cosmetic complications, BoNT is generally safe in experienced hands.
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Agomelatine is superior to melatonin in pain suppression: An experimental study p. 203
Ali Okan Yucel, Devrim Demir-Dora, Mehmet Ferit İsbir, Babür Dora
DOI:10.4103/NSN.NSN_49_20  
Objective: Agomelatine is a synthetic analog of melatonin with selective agonist action on melatonin MT1 and MT2 receptors and antagonistic effect on serotonin 5HT2c receptors. Similar to melatonin, it also has antinociceptive properties. There are only a few studies comparing the antinociceptive effects of agomelatine to melatonin. Methods: Male Wistar albino rats were grouped into seven treatment groups and a control group (8 animals each). Treatment groups received intraperitoneal injections of agomelatine 25 mg/kg, 35 mg/kg and 50 mg/kg; agomelatine 35 mg/kg + luzindole 10 mg/kg; melatonin 60 mg/kg and 90 mg/kg and melatonin 60 mg/kg + sertraline 10 mg/kg. Animals were placed on a hot plate and time to pain avoidance behavior was measured. Results: Agomelatine 25 mg/kg, 35 mg/kg and 50 mg/kg were significantly superior to placebo (all p < 0. 0001); agomelatine 35 mg/kg and 50 mg/kg were significantly superior to melatonin 60 mg/kg (p < 0.05 and p < 0.01, respectively) and melatonin 90 mg/kg (p < 0.001 and p < 0.001, respectively) in prolonging reaction times. Agomelatine 50 mg/kg was superior to melatonin 60 mg/kg + sertraline 10 mg/kg (p < 0,05); on the contrary; agomelatine 25 mg/kg was significantly inferior to this combination in prolonging reaction times (p = 0,041). Melatonin 90 mg/kg but not 60 mg/kg was significantly superior to placebo in prolonging reaction times (p < 0.0001). Both agomelatine 50 mg/kg and 35 mg/kg were superior to agomelatine 25 mg/kg (p < 0.0001 and p = 0.002, respectively), but the difference between agomelatine 50 mg/kg and 35 mg/kg was not significant. Conclusions: We demonstrated that agomelatine is superior to melatonin on pain behavior in a dose -dependent manner using an experimental pain model. The a ddition of a serotonergic agent increased the antinociceptive effect of melatonin in regard to agomelatine, but high doses of agomelatine were still more effective, suggesting a dose -dependent effect of agomelatine on 5-HT2c receptors.
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Management of hardware infections in deep-brain stimulation: A 4-year, single-center experience p. 208
Vural Hamzaoglu, Hakan Özalp, Okan Doğu, Nevra Öksüz, Sabri Aydın, Tolga Akbıyık, Ahmet Dağtekin, Emel Avcı, Celal Bağdatoğlu
DOI:10.4103/NSN.NSN_43_20  
Objectives: The introduction of deep-brain stimulation (DBS) was a milestone in the treatment of movement disorders, intractable epilepsy, and severe psychiatric disorders. We aimed to identify risk factors for hardware infection in patients with these conditions who underwent DBS at our center over a 4-year period. Materials and Methods: Bilateral DBS was performed in seventy patients by the Department of Neurosurgery at the Mersin University School of Medicine between April 2016 and January 2020. The surgical indication was Parkinson's disease in 48 patients, dystonia in 11 patients (10 primary generalized and 1 secondary), and tremor in 11 patients (10 essential tremor and 1 other). Results: Infection was detected in eight patients (11.4%). There were no hardware complications other than infection or postoperative intracerebral hematomas. The entire device was explanted in four (50%) patients with infection; device explantation occurred at 3, 13, 19, and 42 months after surgery. The other 4 (50%) patients who developed infection were successfully treated with antibiotics without complication. A patient with primary dystonia who underwent bilateral globus pallidus interna DBS sustained a severe acute subdural hematoma due to trauma 45 days after electrode implantation but prior to stimulation. We elected not to explant the device after hematoma evacuation; delayed stimulation programming was successful. Conclusion: DBS surgeries are susceptible to complications related to the anatomic target, hardware, and the procedure itself. Infection is the most common complication; however, there is no established protocol for its treatment. Antibiotics and partial removal of the device may be a rational approach.
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Craniopharyngiomas: Analysis of 68 surgical cases p. 215
Emrah Akcay, Hakan Yılmaz, Hüseyin Berk Benek, Alper Tabanlı, Alaettin Yurt
DOI:10.4103/NSN.NSN_56_20  
Objective: Although craniopharyngiomas are benign pathologies, they have surgical challenges due to their locations, infiltrations, and potential for neuroendocrine problems. We evaluated the surgical outcomes, complications, the neuroendocrine problems in patients who underwent total or subtotal resection, and to reveal the ideal treatment regimen. Materials and Methods: We retrospectively reviewed 68 patients who received pathologic results of craniopharyngioma between 1999 and 2019 in our neurosurgery clinic. The demographic characteristics, hormone levels, resection ratio (total/subtotal), residue and recurrence rate, and the complications after surgery were used in the analysis. Results: Twenty-six (38.2%) patients underwent total tumor removal, and 42 (61.8%) had subtotal removal. Fifteen (22%) patients had recurrence. Of the total tumor removal group, only one patient was determined as having recurrence. We detected hypothalamic–pituitary system deficiency in 15 patients with total removal and nine patients with subtotal removal. Of the 37 patients who had lesions smaller than 4 cm, only one died and 30 were in good health after surgery. Of the 31 patients who had lesions larger than 4 cm, five died and 15 were in poor or moderate health. Conclusion: Tumor size is one of the most important factors affecting surgical results. Subtotal tumor removal is associated with tumor recurrence and total removal with serious hypothalamic deficiency symptoms.
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Reliability and validity of the Turkish version of the movement imagery questionnaire-3: Its cultural adaptation and psychometric properties Highly accessed article p. 221
Burcu Dilek, Cigdem Ayhan, Yavuz Yakut
DOI:10.4103/NSN.NSN_30_20  
Objective: Motor imagery (MI) is the mental representation of a movement without any body movement, and it has been recently used as a therapeutic intervention in rehabilitation. The Movement Imagery Questionnaire-3 (MIQ-3) is the most recent, modified version of the MIQ-revised, second edition, which is commonly used to measure the imagery ability of patients with movement dysfunction. The purpose of the study was to translate the MIQ-3 into Turkish and evaluate its test and retest reliability and validity for the Turkish-speaking population. Methods: Among 185 healthy participants, 181 completed the procedures. The questionnaire was applied to 86 participants with 1-week interval to evaluate internal consistency and test–retest reliability. The construct validity of the MIQ-3 was tested by confirmatory factor analysis (CFA). Results: The internal consistency of the Turkish MIQ-3 was satisfactory (Cronbach's alpha was 0.87 for test and 0.86 for retest reliability). The internal consistency of subscales for test–retest reliability (internal visual items, external visual items, and kinesthetic items) was 0.73–0.68, 0.74–0.72, and 0.79–0.73, respectively. Test–retest reliabilities of each item ranged from 0.84 to 0.95. In terms of criterion validity, there was an excellent correlation between subscales and total scale correlations, which ranged from 0.50 to 0.90 (P < 0.001). The validity of the MIQ-3 was examined with CFA, and the results supported a three-factor model of movement imagery ability. Conclusion: The Turkish MIQ-3 has an excellent reliability and good-to-excellent validity in evaluating MI ability.
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CASE REPORTS Top

What can vestibular-evoked myogenic potentials tell us about vestibular schwannomas? p. 228
Roza Ucar, Feray Güleç-Uyaroğlu, Neşe Çelebisoy
DOI:10.4103/NSN.NSN_68_20  
A 27-year-old female presented with complaints of dizziness and tinnitus in the right ear. The neurological examination and the audiometry were completely normal. Ocular vestibular-evoked myogenic potential (oVEMP) obtained by the stimulation of the right ear was absent, whereas bilateral cervical VEMPs and left-sided oVEMP response were normal. With the absence of hearing loss and absent oVEMP on the affected side, the superior vestibular nerve involvement was decided. Magnetic resonance imaging revealed a vestibular schwannoma (VS) in the right cerebellopontine angle 32 mm × 31 mm in size. The patient was presented to show the contribution of cheap vestibular tests in the diagnosis of VSs as well as the prediction of the involved nerve. It was also interesting to see a tumor with a diameter exceeding 3 cm not causing hearing loss.
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Trigeminal trophic syndrome and neurotrophic keratopathy following stroke p. 231
Ipek Gungor-Dogan, Sezgi Sarıkaya-Solak
DOI:10.4103/NSN.NSN_96_20  
Neurotrophic ulceration of the face and cornea are rare complications of trigeminal nerve damage. Their rarity makes them potentially underreported and misdiagnosed conditions. The neurogenic basis and self-manipulating nature of facial ulceration also require a rapid diagnosis to provide a rare syndrome-specific approach. Pain management for paresthesias and educating patients about their self-manipulating behaviors are key management strategies for successful treatment and improved outcomes under the multidisciplinary approach.
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REVIEWERS Top

Reviewers for the year: 2020 p. 234

DOI:10.4103/2636-865X.305395  
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