Journal of Stroke and Cerebrovascular Diseases, 2020
Background: Isolated medullary hemorrhage (MH) is an uncommon presentation of spontaneous intrapa... more Background: Isolated medullary hemorrhage (MH) is an uncommon presentation of spontaneous intraparenchymal hemorrhage. The relationship between MH and neurological outcome is not well known. This study aims to assess predictive parameters for the outcome of medullary hemorrhage. Methods: We conducted an extensive search of the literature for cases with spontaneous, isolated MH. The study was conducted according to the statement of Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA). Forty-three cases diagnosed by CT or MRI have been reported in the literature, to which we add three confirmed by MRI. The ventrodorsal size of hemorrhage was taken into account as a parameter of outcome. Early neurologic deterioration (END) was defined as an incremental increase in the National Institutes of Health Stroke Scale score by 1 point in motor power, or 2 points in the total score within the first week after admission. Modified Rankin Score (mRS) 0À2 was presumed as favorable outcome (FO) and mRS 3À6 score as unfavorable outcome (UO) at discharge and at 3 months after stroke. Results: We enrolled 46 patients, and 17 (37%) patients were diagnosed with END. The cause of medullary hemorrhage was mostly vascular malformations, including cavernous malformation (33%) and arteriovenous malformation (11%). In univariate analyses, neither arteriovenous malformations (OR, 1.04; 95%CI, 0.10À10.53; P = 0.68) nor cavernomas (OR, 1.04; 95%CI, 0.22À4.89; P = 0.62) were associated with UO. Acute respiratory distress syndrome was higher in patients with UO group (44%) compared to those with FO group (16%), but this difference did not reach to a significant level (OR, 4.13; 95%CI, 0.85À20.04; P = 0.09). The diameter of hemorrhage was significantly larger (1 cm) in patients with UO compared to those with FO (OR, 16.67; 95%CI, 1.87À148.89; P = 0.003). Three months after stroke, 37 patients (80%) had FO and 9 (19.5%) had UO, and 5 (11%) died. Multiple logistic regression analysis using predetermined variables found to be significant in univariate analyses (END, consciousness disturbance at admission, hemorrhage size, and hypertension) showed that END at stroke onset was significantly associated with UO (OR, 4.97; CI95%, 1.13À21.94; P = 0.03). Conclusions: These results suggest that the END is a predictor for UO in patients with medullary hemorrhage. The extent of the medullary hemorrhage along the conduction tract may contribute to deterioration.
Background and purpose: Ischemic lesions rarely affect the cingulate cortex (CC) in isolation, re... more Background and purpose: Ischemic lesions rarely affect the cingulate cortex (CC) in isolation, restricting human lesion/behavioural change correlational analysis. The aim of this study was to determine clinical, neuropsychological and neuroimaging features of isolated cingulate infarcts. Methods: We studied, 3800 patients with first-ever ischemic stroke included in our Stroke Registry between 2012 and 2018. Among them we studied 7 patients with an acute isolated cingulate infarct confirmed by MRI. Results: Among all patients, 7 patients (0.01%) showed ischemic lesions in the territory of cingulate cortex territory, allowing us to delineate 2 substantial distributions; (1) Anterior cingulate cortex (ACC) infarction (4 patients [57%]) was presented low vigilance level with apathy, mutism, deficits in executive function, attention, and disturbances of working, episodic and verbal memory; (2) Posterior cingulate cortex (PCC) infarction (3 patients [43%]) developed topographic disorientation, visual memory deficit and affective-emotional behavioural changes. Conclusions: According rarely seen CC infarction events, we suggest that anterior and posterior CC are functionally separated and differences in clinical presentation are explained by considering; ACC plays a role in executive functions, episodic and working memory, set maintenance, and PCC is focused on spatial and verbal attention, and memory system. We considered that different patterns of cingulate infarcts are the result of variation in cingulate arterial supply or suggest a source of embolism.
Journal of Stroke and Cerebrovascular Diseases, 2016
Background and purpose: Homocysteine (Hcy) is closely associated with stroke. Despite the fact th... more Background and purpose: Homocysteine (Hcy) is closely associated with stroke. Despite the fact that Hcy has consistently been shown to predict development of recurrent stroke, prior studies on the association of Hcy and stroke subtypes have been inconclusive. Methods: Data from the Ege Stroke Registry were examined and 5-year follow-up data were analyzed. Multivariate survival analyses were undertaken using Cox proportional hazards models to determine the prognostic value of Hcy in different ischemic stroke subtypes. Results: Of the 9522 patients with stroke, 307 (27%) with hyperhomocysteinemia (hHcy) had recurrent stroke. Univariate Cox regression model showed that hHcy group was associated with recurrent stroke (crude hazard ratio [HR] 1.16; 95% CI 1.02-1.30). But there was no such association in multivariate regression models (adjusted HR 1.11; 95% CI .97-1.26). hHcy was not associated with any ischemic stroke subtypes at 5 years. Univariate Cox regression model showed that hHcy group was associated with overall cardiovascular events (crude HR 1.44; 95% CI 1.32-1.57). However, this association no longer existed in multivariate regression models (adjusted HR 1.01; 95% CI .93-1.12). Higher plasma Hcy group was significantly associated with higher mortality compared with normal plasma Hcy group (OR 1.83; 95% CI .45-2.32). Conclusions: Our results showed that elevated Hcy is not associated independently with stroke recurrence and overall cardiovascular events in patients with ischemic stroke. There was no association between the hHcy and stroke recurrence in the stroke subtypes within 5 years.
Journal of Stroke and Cerebrovascular Diseases, 2015
Leukoaraiosis (LA) is closely associated with cognitive deficits. The association between LA and ... more Leukoaraiosis (LA) is closely associated with cognitive deficits. The association between LA and cognitive disorders, such as mild cognitive impairment (MCI) and dementia, after initial stroke has not been systematically studied. In this study, we sought to identify whether LA contributes to the occurrence of certain type of cognitive disorders after initial stroke. Data from our Stroke Registry were examined, and 5-year follow-up data for LA and cognitive disorders were analyzed. We performed Kaplan-Meier analysis and log-rank test to assess the predictive value of LA for risk of cognitive decline and the Cox proportional hazards model to test the risk factors studied as independent determinants of cognitive impairment. The frequency of patients with normal cognitive function decreased significantly at 5 years compared with initial stroke (78% vs 70%; odds ratio, 1.51; 95% confidence interval, 1.41-1.62). Of 8784 patients, 1659 (19%) had dementia and 964 (11%) had MCI at the final analysis. After 5 years of follow-up, survival analysis showed that all patients with LA had an increased probability of MCI compared with those without LA (P < .0001). Patients with LA had an increased chance of dementia compared with those without LA (P < .0001) at the end of follow-up. Cognitive decline probability was significantly higher in patients with severe LA compared with those with mild/moderate LA (P < .0001). Cox regression analyses showed that recurrence of stroke (hazard ratio [HR], 3.92 [95% CI, 3.26-4.72]), hypertension (HR, 1.11 [95% CI, 1.0-1.22]), LA (HR, 1.15 [95% CI, 1.05-1.25]), age (HR, 1.05 [95% CI, 1.04-1.06]), hypercholesterolemia (HR, .86 [95% CI, .77-.95]), higher LDL cholesterol (HR, 1.21 [95% CI, 1.11-1.32]), lower HDL cholesterol (HR, .90 [95% CI, .83-.98]), coronary heart disease (HR, .85 [95% CI, .77-.94]), and National Institutes of Health Stroke Scale score at admission (HR, .77 [95% CI, .72-.82]) were also significantly associated with cognitive impairments. Our findings suggest that patients with LA may be at risk of developing new cognitive impairments at long-term period after initial stroke. The evaluation of the concomitant risk factors, besides providing insights about the possible mechanisms behind the cognitive dysfunction present in LA, may be of help for the prevention of cognitive impairments.
Background and purpose The association between dyslipidemia (DL) and stroke recurrence is unclear... more Background and purpose The association between dyslipidemia (DL) and stroke recurrence is unclear, but may be influenced by different subtypes of stroke. This study aims to explore whether DL contributes to the recurrence of certain subtypes of ischemic stroke. Methods Data from the Ege Stroke Registry was examined, and five-years follow-up data for stroke recurrence was analyzed. Trial of Org 10172 in Acute Stroke Treatment criteria was used to classify the subtypes of all stroke. Recurrent stroke was defined as a new neurological deficit compatible to ischemic stroke or intracerebral hemorrhage. The association between DL and stroke recurrence in patients with different sroke subtypes was analyzed using univariable and multivariable logistic regression models. Survival curves were estimated with Kaplan–Meier methods, and survival analyses were undertaken using Cox proportional hazards models. Results Of the 9940 patients with ischemic stroke, 5838 (58·7%) had DL and 2202 (22·2%) e...
Two brothers with frontotemporal dementia and parkinsonism with an N279K mutation of the tau gene... more Two brothers with frontotemporal dementia and parkinsonism with an N279K mutation of the tau gene To the Editor: The article by Arima et al. 1 shows another Japanese family with frontotemporal dementia and parkinsonism linked to chromosome 17 (FTDP-17) with N279K mutation on the microtubule-associated protein tau gene. There are three other families with this mutation: a family with pallido-ponto-nigral degeneration (PPND), a French family with dementia with supranuclear palsy, and a Japanese family with pallido-nigroluysian degeneration. 2 All four families have pronounced parkinsonian signs in addition to dementia, personality and behavior changes, pyramidal dysfunction, supranuclear palsy, apraxia, dystonia, dysphasia, cachexia, and other features. Arima et al. 1 raise an important point regarding the response of the affected individuals with N279K mutation to antiparkinsonian therapy. One of their patients had responded beneficially to anticholinergic medications, amantadine, and levodopa. The positive response lasted 2 years. The patient was in the initial stage of the disease. Their second patient was also treated in the same stage of disease with levodopa (1 g/day for 4 weeks), but no positive response was seen. We reviewed the medical records of 39 affected patients from the PPND family. Satisfactory pharmacotherapeutic details were available on 25 individuals. One of the authors (Z.K.W.) examined 17 of these patients; 10 patients were seen on multiple occasions. The responses to pharmacotherapy are presented in the table. A beneficial response to dopaminergic therapy was seen in 10 patients, all during the initial stage of the disease. The average duration of this response was 10 months. The subgroup of families with FTDP-17 also had parkinsonian features. 2 All families described to date with an N279K mutation have prominent parkinsonian signs, including rigidity, bradykinesia, postural instability, and, in some, tremor. It is worthwhile to know that some of these patients responded at least temporarily to dopaminergic therapy. Because FTDP-17 is a progressive neurodegenerative condition with no known cure available, even a transient response to therapy is important for these patients and their caregivers. The transient response also suggests that striatal dopaminergic output pathways are relatively functionally intact in the initial stage of the illness. These neurons may show intermediate susceptibility to degeneration related to the N279K mutation. Arima et al. 1 demonstrated in their family that the subunit structure of tau filaments represents a pair of hollow tubules. We plan to conduct similar experiments to confirm this interesting observation. We compliment Arima et al. 1 for their comprehensive investigation of their family. We also invite them to continue their studies together with our PPND family, 3,4 applying longitudinal and multidisciplinary approaches.
. We sought clinical and radiological findings of 150 consecutive patients with acute isolated ... more . We sought clinical and radiological findings of 150 consecutive patients with acute isolated pontine infarct who were admitted to our Stroke Unit over 6 years. In all patients CT, MRI and magnetic resonance angiography (MRA) were performed during the hospitalization. On clinico-radiological analysis regarding the pontine lesion boundaries there were five main clinical patterns that depended on the constant
In intracerebral hemorrhage, the neurological deficits are usually prolonged or permanent, and cl... more In intracerebral hemorrhage, the neurological deficits are usually prolonged or permanent, and classically, it is believed that the neurological findings are not transient [1-4]. On the other hand, rapid resolution of the neurological symptoms and signs within 24 h has been described in only one report including 2 cases [5]. However, intracerebral hemorrhage is not considered to be a cause of transient focal neurological signs and is not emphasized in the differential diagnosis of transient ischemic attacks (TIA) [1, 2]. By a systematic reevaluation of the Ege Stroke Registry which included 2,903 patients with infarcts and 897 patients with hemorrhages who were admitted to our stroke unit between January 1, 1991, and May 31, 1999 [6], we found 2 patients (0.2%) with putaminal hemorrhage in whom the neurological symptoms and signs resolved completely within 24 h. These cases of cerebral hemorrhage with transient signs (CHTS) represented 0.8% of putaminal hemorrhages (total 251 cases). Neurological features of patients during hospitalization were assessed by both authors. Systematic investigations included brain computed tomography (CT) on admission and during the follow-up, cerebral angiography, ECG monitoring for at least 24 h after admission, and standard blood and urine tests.
Background and Purpose: There are few data on the occurrence of microembolic signals (MES) in pat... more Background and Purpose: There are few data on the occurrence of microembolic signals (MES) in patients with lone atrial fibrillation (LAF). The aim of this work was to systematically study the frequency of MES in patients with symptomatic and asymptomatic LAF and to compare it with that of nonvalvular atrial fibrillation (NVAF). Methods: 37 consecutive acute stroke patients with LAF, 10 asymptomatic patients with LAF and 100 age-matched healthy controls were studied. Another 92 stroke patients with known NVAF were included in the study to compare patients with LAF regarding the presence of MES. Both middle cerebral arteries were monitored by transcranial Doppler ultrasound for at least 30 min at admission and after 1 week in symptomatic and asymptomatic patients with LAF. All patients with LAF were followed up for a mean duration of 18 months, and recurrent strokes were registered. Results: MES was detected in 11 (29%) symptomatic patients with LAF but only in 1 asymptomatic patient...
In patients with locked-in syndrome (LIS), it is not known exactly to what extent cognitive funct... more In patients with locked-in syndrome (LIS), it is not known exactly to what extent cognitive functions are preserved and it is not known exactly how much it has improved. We aimed to examine the clinical and cognitive features of LIS 1 year after stroke. One hundred patients with locked-in syndrome (LIS) were recruited between January 2008 and May 2019 among 8200 patients with ischemic stroke. Patients were classified into two groups as single pontine infarcts ( n = 72), and pontine plus multiple ischemic lesions (PMIL) ( n = 28). Since the patients had limited motor and verbal response, the cognitive status of the patients in the early and late stages was evaluated with the Short Neuropsychological Questionnaire for Disabled Patients (SNQDP) test. At the onset of stroke, orientation to time and place was normal in 43% of patients with a single infarct compared with 18% of those with PMIL (OR 3.48; 95% CI 1.10–10.18; P = 0.015). There was no sustained visual fixation or tracking in 53% of patients with a single pontine infarct and 82% of those with PMIL (OR 4.12; 95% CI 1.41–12.02; P = 0.005). After 1-year follow-up, there was significant difference between patients with a single infarct and those with PMIL regarding to perception and execution, especially complex command follow ( P = 0.042), attention span and concentration ( P = 0.30), intelligible verbalization ( P = 0.022). There was relatively high incidence (24%) of patients with a “good outcome” (mRS = 3) in those with single infarct. Given as in our study that many patients can show significant improvement in LIS, we recommend aggressive supportive measures, intense physical, speech and cognitive therapy to facilitate interaction with others and the environment.
Autoscopic phenomena or an “invisible doppelgänger” refer to the illusory reduplication of one... more Autoscopic phenomena or an “invisible doppelgänger” refer to the illusory reduplication of one's own body. Body image disorder involves distorted perception or decreased body awareness. In the literature, feeling of presence (FOP) is rarely presented with a circumscribed cerebral pathology due to acute vascular lesions, and concomitant FOP and disorders of the body image or the body schema (BIBS) have rarely been reported. We present three cases of both FOP and BIBS disorders. All patients reported the two types of symptoms almost simultaneously: The first patient had the symptom of somatoparaphrenia characterized by deny ownership of the hand and feeling that it does not belong to her, the second patient had the sign of fading limb presented with misuse of his left hand when it was not under visual control and could not mentally represent and locate this part of the body in space, and the third patient had autotopagnosia; he was unable to localize any touched area below the elb...
The Journal of Neuropsychiatry and Clinical Neurosciences, 2022
OBJECTIVE The authors investigated for presence of cognitive impairment after occurrence of bilat... more OBJECTIVE The authors investigated for presence of cognitive impairment after occurrence of bilateral lesions of the genu of the internal capsule (GIC). Clinical and neuropsychological features of unilateral GIC lesions have previously been studied, but the cognitive profile of bilateral lesions of the GIC has not been fully explored. METHODS An investigation was conducted of neurocognitive deficits and computerized tomography MRI findings among 4,200 stroke patients with bilateral GIC involvement who were admitted to the hospital between January 2010 and October 2018. RESULTS Eight patients with bilateral lesions of the capsular genu were identified and their data analyzed. Overall, behavioral and cognitive dysfunction were characterized by impairment of frontal, memory, and executive functions. Attention and abstraction were present among all eight patients (100%); apathy, abulia, and executive dysfunctions, among seven (87.5%); global mental dysfunction and planning deficits, among six (75.0%); short-term verbal memory deficits and language dysfunctions, among five (62.5%); long-term verbal memory deficits, among four (50.0%); and spatial memory deficits, reading, writing, counting dysfunctions, and anarthria, among two (25.0%). Four of the patients (50.0%) without a history of cognitive disorder showed severe mental deterioration compatible with the clinical picture of dementia. A clinical picture of dementia was still present in these patients 6 months after stroke. CONCLUSIONS Bilateral lesions of the capsular genu appearing either simultaneously or at different times were significantly associated with executive dysfunctions.
Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques, 2021
ABSTRACT:Objective:Survivors of patients with artery of Percheron infarction (API) often have a p... more ABSTRACT:Objective:Survivors of patients with artery of Percheron infarction (API) often have a prolonged and disabling form of cognitive impairment that remains insufficiently characterized. We aimed to examine the clinical and cognitive features of API in the short and long term after stroke.Methods:We reviewed 6400 patients with a first-ever stroke included in the Stroke Registry between 2011 and 2021. The diagnosis of API was based on clinical diagnosis and imaging confirmation. All patients underwent neuropsychological assessment at hospital stay and 1 year after stroke. A z-score of each patients’ cognitive test point was calculated, and a z-score inferior to 2 was considered as pathological.Results:Of the 10 patients enrolled, all had cognitive impairment, consciousness, and behavioral disorders at stroke onset. Six patients had pure bilateral thalamic involvement while four had bilateral thalamic and rostral midbrain involvement. At 12 months, 50% of patients had global ment...
Lipoprotein-associated phospholipase A2 (Lp-PLA2) is a reported risk factor for dementia. However... more Lipoprotein-associated phospholipase A2 (Lp-PLA2) is a reported risk factor for dementia. However, the relationship between Alzheimer's disease (AD) and Lp-PLA2 is still debatable and, to the best of our knowledge, no study has evaluated the associations between levels of Lp-PLA2, proinflammatory cytokines, and neopterin in AD. In total, 59 patients with AD and 38 non-demented individuals were included in the case-control study. Fasting serum concentrations of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), neopterin, and Lp-PLA2 were determined using ELISA. The associations between AD and each of the variables were analyzed by logistic regression. The median Lp-PLA2 levels in AD and controls were similar (P=0.29, not significant). Median serum neopterin and IL-6 levels were significantly higher in patients with AD than in controls (P=0.0001 and P=0.03, respectively). In regression analyses, median neopterin levels, a lower level of education, and female gender were significantly associated with AD when compared with controls (OR, 31.44, 95% CI 3.59-275.28, P=0.002; OR, 4.35, 95% CI 1.13-16.61, P=0.032; OR, 7.25, 95% CI 1.88-28.00, P=0.004, respectively). In contrast to previous evidence suggesting its role in dementia and AD, Lp-PLA2 enzyme levels were higher in the controls, and no relationship between Lp-PLA2 and either proinflammatory cytokines or neopterin was identified in AD. Elevated neopterin levels may be considered inflammatory markers of AD.
Background and Purpose: To characterize clinically acute external (EcC) and extreme capsular (ExC... more Background and Purpose: To characterize clinically acute external (EcC) and extreme capsular (ExC) strokes in 9 patients with first-ever acute stroke. Methods: Nine patients with a lesion limited to the EcC-ExC region proven by diffusion-weighted imaging included in our registry, corresponding to 0.3% of 3,600 patients with ischemic stroke, were studied. Results: We found three main groups of clinical manifestations: (1) motor deficits in all patients (4 with faciobrachial, 2 with faciobrachiocrural, and 1 with brachiocrural, crural and facial paresis each); (2) hypesthesia in 3 patients with partial distribution concerning light touching without involvement of other sensory modalities; (3) transient speech disturbance at stroke onset in 1 patient and dysarthria in 2 patients. Small artery disease in 4 patients and artery-to-artery embolism in 3 patients probably from atherosclerotic carotid artery were the main stroke mechanism. Conclusions: Strokes restricted to the EcC-ExC region...
Background: Hyposchematia is a rare variant of aschematia in which patients underestimate the siz... more Background: Hyposchematia is a rare variant of aschematia in which patients underestimate the size of part or all of their body. The term also describes an abnormality in drawing tasks, in which patients underestimate the size of 1 side of an image and draw it too small. Little is known about the neuroanatomy of the syndrome. Case Reports: We report 2 patients who developed contralateral hyposchematia without spatial neglect after suffering an ischemic lesion involving the right insula. Both patients felt that the left side of their face and their left arm and leg were disproportionately smaller than their right. On a drawing task, both patients drew the left sides of objects smaller than the right; they perseverated on the left sides of the images, for example, adding extra left-sided petals to a daisy. Conclusions: In 2 reported patients, the cause of hyposchematia may be a lesion involving multiple insular circuits that affect the perception of extrapersonal space and self-related systems.
Journal of Stroke and Cerebrovascular Diseases, 2020
Background: Isolated medullary hemorrhage (MH) is an uncommon presentation of spontaneous intrapa... more Background: Isolated medullary hemorrhage (MH) is an uncommon presentation of spontaneous intraparenchymal hemorrhage. The relationship between MH and neurological outcome is not well known. This study aims to assess predictive parameters for the outcome of medullary hemorrhage. Methods: We conducted an extensive search of the literature for cases with spontaneous, isolated MH. The study was conducted according to the statement of Preferred Reporting Items for Systematic Reviews and Meta Analysis (PRISMA). Forty-three cases diagnosed by CT or MRI have been reported in the literature, to which we add three confirmed by MRI. The ventrodorsal size of hemorrhage was taken into account as a parameter of outcome. Early neurologic deterioration (END) was defined as an incremental increase in the National Institutes of Health Stroke Scale score by 1 point in motor power, or 2 points in the total score within the first week after admission. Modified Rankin Score (mRS) 0À2 was presumed as favorable outcome (FO) and mRS 3À6 score as unfavorable outcome (UO) at discharge and at 3 months after stroke. Results: We enrolled 46 patients, and 17 (37%) patients were diagnosed with END. The cause of medullary hemorrhage was mostly vascular malformations, including cavernous malformation (33%) and arteriovenous malformation (11%). In univariate analyses, neither arteriovenous malformations (OR, 1.04; 95%CI, 0.10À10.53; P = 0.68) nor cavernomas (OR, 1.04; 95%CI, 0.22À4.89; P = 0.62) were associated with UO. Acute respiratory distress syndrome was higher in patients with UO group (44%) compared to those with FO group (16%), but this difference did not reach to a significant level (OR, 4.13; 95%CI, 0.85À20.04; P = 0.09). The diameter of hemorrhage was significantly larger (1 cm) in patients with UO compared to those with FO (OR, 16.67; 95%CI, 1.87À148.89; P = 0.003). Three months after stroke, 37 patients (80%) had FO and 9 (19.5%) had UO, and 5 (11%) died. Multiple logistic regression analysis using predetermined variables found to be significant in univariate analyses (END, consciousness disturbance at admission, hemorrhage size, and hypertension) showed that END at stroke onset was significantly associated with UO (OR, 4.97; CI95%, 1.13À21.94; P = 0.03). Conclusions: These results suggest that the END is a predictor for UO in patients with medullary hemorrhage. The extent of the medullary hemorrhage along the conduction tract may contribute to deterioration.
Background and purpose: Ischemic lesions rarely affect the cingulate cortex (CC) in isolation, re... more Background and purpose: Ischemic lesions rarely affect the cingulate cortex (CC) in isolation, restricting human lesion/behavioural change correlational analysis. The aim of this study was to determine clinical, neuropsychological and neuroimaging features of isolated cingulate infarcts. Methods: We studied, 3800 patients with first-ever ischemic stroke included in our Stroke Registry between 2012 and 2018. Among them we studied 7 patients with an acute isolated cingulate infarct confirmed by MRI. Results: Among all patients, 7 patients (0.01%) showed ischemic lesions in the territory of cingulate cortex territory, allowing us to delineate 2 substantial distributions; (1) Anterior cingulate cortex (ACC) infarction (4 patients [57%]) was presented low vigilance level with apathy, mutism, deficits in executive function, attention, and disturbances of working, episodic and verbal memory; (2) Posterior cingulate cortex (PCC) infarction (3 patients [43%]) developed topographic disorientation, visual memory deficit and affective-emotional behavioural changes. Conclusions: According rarely seen CC infarction events, we suggest that anterior and posterior CC are functionally separated and differences in clinical presentation are explained by considering; ACC plays a role in executive functions, episodic and working memory, set maintenance, and PCC is focused on spatial and verbal attention, and memory system. We considered that different patterns of cingulate infarcts are the result of variation in cingulate arterial supply or suggest a source of embolism.
Journal of Stroke and Cerebrovascular Diseases, 2016
Background and purpose: Homocysteine (Hcy) is closely associated with stroke. Despite the fact th... more Background and purpose: Homocysteine (Hcy) is closely associated with stroke. Despite the fact that Hcy has consistently been shown to predict development of recurrent stroke, prior studies on the association of Hcy and stroke subtypes have been inconclusive. Methods: Data from the Ege Stroke Registry were examined and 5-year follow-up data were analyzed. Multivariate survival analyses were undertaken using Cox proportional hazards models to determine the prognostic value of Hcy in different ischemic stroke subtypes. Results: Of the 9522 patients with stroke, 307 (27%) with hyperhomocysteinemia (hHcy) had recurrent stroke. Univariate Cox regression model showed that hHcy group was associated with recurrent stroke (crude hazard ratio [HR] 1.16; 95% CI 1.02-1.30). But there was no such association in multivariate regression models (adjusted HR 1.11; 95% CI .97-1.26). hHcy was not associated with any ischemic stroke subtypes at 5 years. Univariate Cox regression model showed that hHcy group was associated with overall cardiovascular events (crude HR 1.44; 95% CI 1.32-1.57). However, this association no longer existed in multivariate regression models (adjusted HR 1.01; 95% CI .93-1.12). Higher plasma Hcy group was significantly associated with higher mortality compared with normal plasma Hcy group (OR 1.83; 95% CI .45-2.32). Conclusions: Our results showed that elevated Hcy is not associated independently with stroke recurrence and overall cardiovascular events in patients with ischemic stroke. There was no association between the hHcy and stroke recurrence in the stroke subtypes within 5 years.
Journal of Stroke and Cerebrovascular Diseases, 2015
Leukoaraiosis (LA) is closely associated with cognitive deficits. The association between LA and ... more Leukoaraiosis (LA) is closely associated with cognitive deficits. The association between LA and cognitive disorders, such as mild cognitive impairment (MCI) and dementia, after initial stroke has not been systematically studied. In this study, we sought to identify whether LA contributes to the occurrence of certain type of cognitive disorders after initial stroke. Data from our Stroke Registry were examined, and 5-year follow-up data for LA and cognitive disorders were analyzed. We performed Kaplan-Meier analysis and log-rank test to assess the predictive value of LA for risk of cognitive decline and the Cox proportional hazards model to test the risk factors studied as independent determinants of cognitive impairment. The frequency of patients with normal cognitive function decreased significantly at 5 years compared with initial stroke (78% vs 70%; odds ratio, 1.51; 95% confidence interval, 1.41-1.62). Of 8784 patients, 1659 (19%) had dementia and 964 (11%) had MCI at the final analysis. After 5 years of follow-up, survival analysis showed that all patients with LA had an increased probability of MCI compared with those without LA (P < .0001). Patients with LA had an increased chance of dementia compared with those without LA (P < .0001) at the end of follow-up. Cognitive decline probability was significantly higher in patients with severe LA compared with those with mild/moderate LA (P < .0001). Cox regression analyses showed that recurrence of stroke (hazard ratio [HR], 3.92 [95% CI, 3.26-4.72]), hypertension (HR, 1.11 [95% CI, 1.0-1.22]), LA (HR, 1.15 [95% CI, 1.05-1.25]), age (HR, 1.05 [95% CI, 1.04-1.06]), hypercholesterolemia (HR, .86 [95% CI, .77-.95]), higher LDL cholesterol (HR, 1.21 [95% CI, 1.11-1.32]), lower HDL cholesterol (HR, .90 [95% CI, .83-.98]), coronary heart disease (HR, .85 [95% CI, .77-.94]), and National Institutes of Health Stroke Scale score at admission (HR, .77 [95% CI, .72-.82]) were also significantly associated with cognitive impairments. Our findings suggest that patients with LA may be at risk of developing new cognitive impairments at long-term period after initial stroke. The evaluation of the concomitant risk factors, besides providing insights about the possible mechanisms behind the cognitive dysfunction present in LA, may be of help for the prevention of cognitive impairments.
Background and purpose The association between dyslipidemia (DL) and stroke recurrence is unclear... more Background and purpose The association between dyslipidemia (DL) and stroke recurrence is unclear, but may be influenced by different subtypes of stroke. This study aims to explore whether DL contributes to the recurrence of certain subtypes of ischemic stroke. Methods Data from the Ege Stroke Registry was examined, and five-years follow-up data for stroke recurrence was analyzed. Trial of Org 10172 in Acute Stroke Treatment criteria was used to classify the subtypes of all stroke. Recurrent stroke was defined as a new neurological deficit compatible to ischemic stroke or intracerebral hemorrhage. The association between DL and stroke recurrence in patients with different sroke subtypes was analyzed using univariable and multivariable logistic regression models. Survival curves were estimated with Kaplan–Meier methods, and survival analyses were undertaken using Cox proportional hazards models. Results Of the 9940 patients with ischemic stroke, 5838 (58·7%) had DL and 2202 (22·2%) e...
Two brothers with frontotemporal dementia and parkinsonism with an N279K mutation of the tau gene... more Two brothers with frontotemporal dementia and parkinsonism with an N279K mutation of the tau gene To the Editor: The article by Arima et al. 1 shows another Japanese family with frontotemporal dementia and parkinsonism linked to chromosome 17 (FTDP-17) with N279K mutation on the microtubule-associated protein tau gene. There are three other families with this mutation: a family with pallido-ponto-nigral degeneration (PPND), a French family with dementia with supranuclear palsy, and a Japanese family with pallido-nigroluysian degeneration. 2 All four families have pronounced parkinsonian signs in addition to dementia, personality and behavior changes, pyramidal dysfunction, supranuclear palsy, apraxia, dystonia, dysphasia, cachexia, and other features. Arima et al. 1 raise an important point regarding the response of the affected individuals with N279K mutation to antiparkinsonian therapy. One of their patients had responded beneficially to anticholinergic medications, amantadine, and levodopa. The positive response lasted 2 years. The patient was in the initial stage of the disease. Their second patient was also treated in the same stage of disease with levodopa (1 g/day for 4 weeks), but no positive response was seen. We reviewed the medical records of 39 affected patients from the PPND family. Satisfactory pharmacotherapeutic details were available on 25 individuals. One of the authors (Z.K.W.) examined 17 of these patients; 10 patients were seen on multiple occasions. The responses to pharmacotherapy are presented in the table. A beneficial response to dopaminergic therapy was seen in 10 patients, all during the initial stage of the disease. The average duration of this response was 10 months. The subgroup of families with FTDP-17 also had parkinsonian features. 2 All families described to date with an N279K mutation have prominent parkinsonian signs, including rigidity, bradykinesia, postural instability, and, in some, tremor. It is worthwhile to know that some of these patients responded at least temporarily to dopaminergic therapy. Because FTDP-17 is a progressive neurodegenerative condition with no known cure available, even a transient response to therapy is important for these patients and their caregivers. The transient response also suggests that striatal dopaminergic output pathways are relatively functionally intact in the initial stage of the illness. These neurons may show intermediate susceptibility to degeneration related to the N279K mutation. Arima et al. 1 demonstrated in their family that the subunit structure of tau filaments represents a pair of hollow tubules. We plan to conduct similar experiments to confirm this interesting observation. We compliment Arima et al. 1 for their comprehensive investigation of their family. We also invite them to continue their studies together with our PPND family, 3,4 applying longitudinal and multidisciplinary approaches.
. We sought clinical and radiological findings of 150 consecutive patients with acute isolated ... more . We sought clinical and radiological findings of 150 consecutive patients with acute isolated pontine infarct who were admitted to our Stroke Unit over 6 years. In all patients CT, MRI and magnetic resonance angiography (MRA) were performed during the hospitalization. On clinico-radiological analysis regarding the pontine lesion boundaries there were five main clinical patterns that depended on the constant
In intracerebral hemorrhage, the neurological deficits are usually prolonged or permanent, and cl... more In intracerebral hemorrhage, the neurological deficits are usually prolonged or permanent, and classically, it is believed that the neurological findings are not transient [1-4]. On the other hand, rapid resolution of the neurological symptoms and signs within 24 h has been described in only one report including 2 cases [5]. However, intracerebral hemorrhage is not considered to be a cause of transient focal neurological signs and is not emphasized in the differential diagnosis of transient ischemic attacks (TIA) [1, 2]. By a systematic reevaluation of the Ege Stroke Registry which included 2,903 patients with infarcts and 897 patients with hemorrhages who were admitted to our stroke unit between January 1, 1991, and May 31, 1999 [6], we found 2 patients (0.2%) with putaminal hemorrhage in whom the neurological symptoms and signs resolved completely within 24 h. These cases of cerebral hemorrhage with transient signs (CHTS) represented 0.8% of putaminal hemorrhages (total 251 cases). Neurological features of patients during hospitalization were assessed by both authors. Systematic investigations included brain computed tomography (CT) on admission and during the follow-up, cerebral angiography, ECG monitoring for at least 24 h after admission, and standard blood and urine tests.
Background and Purpose: There are few data on the occurrence of microembolic signals (MES) in pat... more Background and Purpose: There are few data on the occurrence of microembolic signals (MES) in patients with lone atrial fibrillation (LAF). The aim of this work was to systematically study the frequency of MES in patients with symptomatic and asymptomatic LAF and to compare it with that of nonvalvular atrial fibrillation (NVAF). Methods: 37 consecutive acute stroke patients with LAF, 10 asymptomatic patients with LAF and 100 age-matched healthy controls were studied. Another 92 stroke patients with known NVAF were included in the study to compare patients with LAF regarding the presence of MES. Both middle cerebral arteries were monitored by transcranial Doppler ultrasound for at least 30 min at admission and after 1 week in symptomatic and asymptomatic patients with LAF. All patients with LAF were followed up for a mean duration of 18 months, and recurrent strokes were registered. Results: MES was detected in 11 (29%) symptomatic patients with LAF but only in 1 asymptomatic patient...
In patients with locked-in syndrome (LIS), it is not known exactly to what extent cognitive funct... more In patients with locked-in syndrome (LIS), it is not known exactly to what extent cognitive functions are preserved and it is not known exactly how much it has improved. We aimed to examine the clinical and cognitive features of LIS 1 year after stroke. One hundred patients with locked-in syndrome (LIS) were recruited between January 2008 and May 2019 among 8200 patients with ischemic stroke. Patients were classified into two groups as single pontine infarcts ( n = 72), and pontine plus multiple ischemic lesions (PMIL) ( n = 28). Since the patients had limited motor and verbal response, the cognitive status of the patients in the early and late stages was evaluated with the Short Neuropsychological Questionnaire for Disabled Patients (SNQDP) test. At the onset of stroke, orientation to time and place was normal in 43% of patients with a single infarct compared with 18% of those with PMIL (OR 3.48; 95% CI 1.10–10.18; P = 0.015). There was no sustained visual fixation or tracking in 53% of patients with a single pontine infarct and 82% of those with PMIL (OR 4.12; 95% CI 1.41–12.02; P = 0.005). After 1-year follow-up, there was significant difference between patients with a single infarct and those with PMIL regarding to perception and execution, especially complex command follow ( P = 0.042), attention span and concentration ( P = 0.30), intelligible verbalization ( P = 0.022). There was relatively high incidence (24%) of patients with a “good outcome” (mRS = 3) in those with single infarct. Given as in our study that many patients can show significant improvement in LIS, we recommend aggressive supportive measures, intense physical, speech and cognitive therapy to facilitate interaction with others and the environment.
Autoscopic phenomena or an “invisible doppelgänger” refer to the illusory reduplication of one... more Autoscopic phenomena or an “invisible doppelgänger” refer to the illusory reduplication of one's own body. Body image disorder involves distorted perception or decreased body awareness. In the literature, feeling of presence (FOP) is rarely presented with a circumscribed cerebral pathology due to acute vascular lesions, and concomitant FOP and disorders of the body image or the body schema (BIBS) have rarely been reported. We present three cases of both FOP and BIBS disorders. All patients reported the two types of symptoms almost simultaneously: The first patient had the symptom of somatoparaphrenia characterized by deny ownership of the hand and feeling that it does not belong to her, the second patient had the sign of fading limb presented with misuse of his left hand when it was not under visual control and could not mentally represent and locate this part of the body in space, and the third patient had autotopagnosia; he was unable to localize any touched area below the elb...
The Journal of Neuropsychiatry and Clinical Neurosciences, 2022
OBJECTIVE The authors investigated for presence of cognitive impairment after occurrence of bilat... more OBJECTIVE The authors investigated for presence of cognitive impairment after occurrence of bilateral lesions of the genu of the internal capsule (GIC). Clinical and neuropsychological features of unilateral GIC lesions have previously been studied, but the cognitive profile of bilateral lesions of the GIC has not been fully explored. METHODS An investigation was conducted of neurocognitive deficits and computerized tomography MRI findings among 4,200 stroke patients with bilateral GIC involvement who were admitted to the hospital between January 2010 and October 2018. RESULTS Eight patients with bilateral lesions of the capsular genu were identified and their data analyzed. Overall, behavioral and cognitive dysfunction were characterized by impairment of frontal, memory, and executive functions. Attention and abstraction were present among all eight patients (100%); apathy, abulia, and executive dysfunctions, among seven (87.5%); global mental dysfunction and planning deficits, among six (75.0%); short-term verbal memory deficits and language dysfunctions, among five (62.5%); long-term verbal memory deficits, among four (50.0%); and spatial memory deficits, reading, writing, counting dysfunctions, and anarthria, among two (25.0%). Four of the patients (50.0%) without a history of cognitive disorder showed severe mental deterioration compatible with the clinical picture of dementia. A clinical picture of dementia was still present in these patients 6 months after stroke. CONCLUSIONS Bilateral lesions of the capsular genu appearing either simultaneously or at different times were significantly associated with executive dysfunctions.
Canadian Journal of Neurological Sciences / Journal Canadien des Sciences Neurologiques, 2021
ABSTRACT:Objective:Survivors of patients with artery of Percheron infarction (API) often have a p... more ABSTRACT:Objective:Survivors of patients with artery of Percheron infarction (API) often have a prolonged and disabling form of cognitive impairment that remains insufficiently characterized. We aimed to examine the clinical and cognitive features of API in the short and long term after stroke.Methods:We reviewed 6400 patients with a first-ever stroke included in the Stroke Registry between 2011 and 2021. The diagnosis of API was based on clinical diagnosis and imaging confirmation. All patients underwent neuropsychological assessment at hospital stay and 1 year after stroke. A z-score of each patients’ cognitive test point was calculated, and a z-score inferior to 2 was considered as pathological.Results:Of the 10 patients enrolled, all had cognitive impairment, consciousness, and behavioral disorders at stroke onset. Six patients had pure bilateral thalamic involvement while four had bilateral thalamic and rostral midbrain involvement. At 12 months, 50% of patients had global ment...
Lipoprotein-associated phospholipase A2 (Lp-PLA2) is a reported risk factor for dementia. However... more Lipoprotein-associated phospholipase A2 (Lp-PLA2) is a reported risk factor for dementia. However, the relationship between Alzheimer's disease (AD) and Lp-PLA2 is still debatable and, to the best of our knowledge, no study has evaluated the associations between levels of Lp-PLA2, proinflammatory cytokines, and neopterin in AD. In total, 59 patients with AD and 38 non-demented individuals were included in the case-control study. Fasting serum concentrations of interleukin-6 (IL-6), tumor necrosis factor-alpha (TNF-α), neopterin, and Lp-PLA2 were determined using ELISA. The associations between AD and each of the variables were analyzed by logistic regression. The median Lp-PLA2 levels in AD and controls were similar (P=0.29, not significant). Median serum neopterin and IL-6 levels were significantly higher in patients with AD than in controls (P=0.0001 and P=0.03, respectively). In regression analyses, median neopterin levels, a lower level of education, and female gender were significantly associated with AD when compared with controls (OR, 31.44, 95% CI 3.59-275.28, P=0.002; OR, 4.35, 95% CI 1.13-16.61, P=0.032; OR, 7.25, 95% CI 1.88-28.00, P=0.004, respectively). In contrast to previous evidence suggesting its role in dementia and AD, Lp-PLA2 enzyme levels were higher in the controls, and no relationship between Lp-PLA2 and either proinflammatory cytokines or neopterin was identified in AD. Elevated neopterin levels may be considered inflammatory markers of AD.
Background and Purpose: To characterize clinically acute external (EcC) and extreme capsular (ExC... more Background and Purpose: To characterize clinically acute external (EcC) and extreme capsular (ExC) strokes in 9 patients with first-ever acute stroke. Methods: Nine patients with a lesion limited to the EcC-ExC region proven by diffusion-weighted imaging included in our registry, corresponding to 0.3% of 3,600 patients with ischemic stroke, were studied. Results: We found three main groups of clinical manifestations: (1) motor deficits in all patients (4 with faciobrachial, 2 with faciobrachiocrural, and 1 with brachiocrural, crural and facial paresis each); (2) hypesthesia in 3 patients with partial distribution concerning light touching without involvement of other sensory modalities; (3) transient speech disturbance at stroke onset in 1 patient and dysarthria in 2 patients. Small artery disease in 4 patients and artery-to-artery embolism in 3 patients probably from atherosclerotic carotid artery were the main stroke mechanism. Conclusions: Strokes restricted to the EcC-ExC region...
Background: Hyposchematia is a rare variant of aschematia in which patients underestimate the siz... more Background: Hyposchematia is a rare variant of aschematia in which patients underestimate the size of part or all of their body. The term also describes an abnormality in drawing tasks, in which patients underestimate the size of 1 side of an image and draw it too small. Little is known about the neuroanatomy of the syndrome. Case Reports: We report 2 patients who developed contralateral hyposchematia without spatial neglect after suffering an ischemic lesion involving the right insula. Both patients felt that the left side of their face and their left arm and leg were disproportionately smaller than their right. On a drawing task, both patients drew the left sides of objects smaller than the right; they perseverated on the left sides of the images, for example, adding extra left-sided petals to a daisy. Conclusions: In 2 reported patients, the cause of hyposchematia may be a lesion involving multiple insular circuits that affect the perception of extrapersonal space and self-related systems.
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Papers by Emre Kumral