Objective: To assess the efficacy of inhibitory repetitive transcranial magnetic stimulation (rTMS) and neuromuscular electrical stimulation (NMES) on upper extremity motor function in patients with acute/subacute ischemic stroke.Methods: Twenty-five ischemic acute/subacute stroke subjects were enrolled in this randomized controlled trial. Experimental group 1 received low frequency (LF) rTMS to the primary motor cortex of the unaffected side + physical therapy (PT) including activities to improve strength, flexibility, transfers, posture, balance, coordination, and activities of daily living, mainly focusing on upper limb movements; experimental group 2 received the same protocol combined with NMES to hand extensor muscles; and the control group received only PT. Functional magnetic resonance imaging (fMRI) scan was used to evaluate the activation or inhibition of the affected and unaffected primary motor cortex.Results: No adverse effect was reported. Most of the clinical outcome scores improved significantly in all groups, however no statistically significant difference was found between groups due to the small sample sizes. The highest percent improvement scores were observed in TMS + NMES group (varying between 48 and 99.3%) and the lowest scores in control group (varying between 13.1 and 28.1%). Hand motor recovery was significant in both experimental groups while it did not change in control group. Some motor cortex excitability changes were also observed in fMRI.Conclusion: LF-rTMS with or without NMES seems to facilitate the motor recovery in the paretic hand of patients with acute/subacute ischemic stroke. TMS or the combination of TMS + NMES may be a promising additional therapy in upper limb motor training. Further studies with larger numbers of patients are needed to establish their effectiveness in upper limb motor rehabilitation of stroke.
Toxocariasis caused by Toxocara canis or less frequently by T.catis is a common parasitic infection worldwide. Clinical spectrum in humans can vary from asymptomatic infection to serious organ disfunction depending on the load of parasite, migration target of the larva and the inflammatory response of the host. Transverse myelitis (TM) due to toxocariasis is an uncommon illness identified mainly as case reports in literature. In this report, a case of TM who was diagnosed as neurotoxocariasis by serological findings has been presented. A 44-year-old male patient complained with backache was diagnosed as TM in a medical center in which he has admitted two years ago, and treated with pregabalin and nonsteroidal drugs for six months. Because of the progression of the lesions he readmitted to another center and treated with high dose steroid therapy for three months. After six months of follow up, improvement has been achieved, however, since his symptoms reccurred in the following year he was admitted to our hospital. Magnetic resonance imaging (MRI) examination revealed a TM in a lower segment of spinal cord. He was suffering with weakness and numbness in the left lower extremity. There was no history of rural life or contact with cats or dogs in his anamnesis. Physical examination revealed normal cranial nerve functions, sensory and motor functions. There has been no pathological reflexes, and deep tendon reflexes were also normal. Laboratory findings yielded normal hemogram and biochemical tests, negative PPD and parasitological examination of stool were negative for cysts and ova. Viral hepatitis markers, anti-HIV, toxoplasma-IgM, CMV-IgM, rubella-IgM, EBV-VCA-IgM, VDRL, Brucella tube agglutination, echinococcus antibody, autoantibody tests and neuromyelitis optica test were negative. Examination of CSF showed 20 cells/mm3 (mononuclear cells), 45 mg/dl protein and normal levels of glucose and chlorine. In both serum and CSF samples of the patient Toxocara-IgG antibodies were detected by Western blot (WB) assay. Low molecular weight bands (30-40 kDa) were detected in both of the samples by repeated WB testing. CSF revealed more intense bands suggesting local antibody production. Therefore the patient was diagnosed as neurotoxocariasis, and treated with steroid and mebendazole for six weeks. Clinical improvement was detected in the case and thoracic MRI revealed significant improvement in myelitis signs two months after treatment. In conclusion, toxocariasis should be considered in the differential diagnosis of TM although the involvement of central nervous system is rare and serological testing should be performed properly in the serum and CSF samples for the diagnosis.
Nasopharyngeal carcinoma, the most common carcinoma to involve the skull base, may present with neuro-ophthalmic features. Most patients have multiple cranial nerve dysfunction, the fifth and sixth cranial nerves being most often affected (1-3). We report a case that presented with third cranial nerve palsy as the only neuro-ophthalmic feature. A 48-year-old man with no significant past medical history presented to our clinic with a complaint of diplopia and ipsilateral periocular pain of 3 days’ duration. The patient also reported having noticed a mass in the left submandibular area 6 months earlier. Neurologic examination revealed partial right ptosis and complete absence of adduction, supraduction, and infraduction of the right eye. The pupils in low illumination were equal at 4 mm and symmetrically reactive to light and near targets. Visual acuity, ophthalmoscopy, and cranial nerve and motor examination results were normal. Results of the remaining physical examination were within normal limits except for a painless mass over the left submandibular area. All laboratory values and were within the normal ranges. MRI of the brain and nasopharynx showed a large mass centered at the clivus region and spreading into the nasopharynx, invading the basis of the occipital bone, both sphenoid and posterior ethmoid sinuses, the medial part of the right cavernous sinus, and the petrous apex (Fig. 1A-B). The mass enhanced heterogeneously. The superior and inferior orbital fissures, optic nerves, and other intraorbital structures were spared. Significant bilateral lymphadenopathy of the neck was evident and some lymph nodes showed hypodense centers indicative of necrosis. A digital subtraction angiogram revealed no vascular abnormalities.FIG. 1: A. T2 axial MRI shows a tumor with mixed signal intensity that is invading the sphenoid and posterior ethmoid sinuses. B. Postcontrast coronal MRI shows an enhancing tumor centered at the clivus with partial right cavernous sinus invasion (arrow).Biopsy of the nasopharyngeal mass revealed a nonkeratinizing differentiated carcinoma (Fig. 2). The patient was referred to the oncology department for radiotherapy and chemotherapy.FIG. 2: Histopathology of a nasopharyngeal punch biopsy shows fibrous connective tissue with infiltrating cords of anaplastic cells (hematoxylin and eosin, 340).The third cranial nerve paralysis remained stable without improvement, and no other neurologic symptoms had occurred after 3 months. A retrospective study of 79 patients with nasopharyngeal carcinomas (4) disclosed that one quarter of these patients have neuro-ophthalmic manifestations. In a group of 564 patients with nasopharyngeal carcinomas (1), cranial nerve dysfunction was present in 12%. In 92% of the patients, neurologic deficits were confined exclusively to cranial nerves. Another study (5) showed that the most frequently affected cranial nerves were the fifth and sixth. Our patient is unusual in that the third cranial nerve was the only one involved. The extent of the tumor on MRI fails to indicate why the third cranial nerve was the only affected cranial nerve. Yesim Yetimalar Beckmann, MD Benian Deniz, MD Department of Neurology Atatürk Training and Research Hospital Izmir, Turkey [email protected] Fazil Gelal, MD Department of Radiology AtatÜrk Training and Research Hospital Izmir, Turkey Yaprak Seçil, MD Department of Neurology Atatürk Training and Research Hospital Izmir, Turkey
A technical description of a novel percutaneous technique of anterior odontoid screw fixation is given and the clinical and radiological results of this technique in 5 patients are described.The percutaneous anterior odontoid screw fixation technique was described as a cadaveric study in 1999. To the best of our knowledge, no patient series operated on by this technique has so far been presented in the English literature. We have percutaneously operated on 5 patients with unstable odontoid fractures between February 2004 and July 2006.There have not been any complications in our patients. The first four patients showed radiological evidence of fusion in their latest control.Percutaneous anterior odontoid screw fixation is a minimally invasive and feasible surgical procedure.
Central nervous system involvement in trichinosis is not rare. Brain lesions in trichinosis have been defined on computed tomography and magnetic resonance imaging (MRI) as multifocal small lesions located in the cerebral cortex and white matter. We present a case of trichinosis with multifocal lesions of the brain detected by MRI and diffusion weighted MRI. Evolutions of these lesions from acute through chronic stages on follow up studies are also presented. This is the first report describing sequential MRI findings and diffusion weighted imaging appearance of brain lesions in trichinosis. Sequential evaluation of conventional and diffusion MR data allowed us to conclude that multifocal lesions in the brain were related to multiple infarctions rather than true inflammatory infiltration of the brain parenchyma.
A simple estimation method of intracerebral hematoma volume known as XYZ/2 method has been described previously. This method has also been shown to be valid for the estimation of acute subdural hematoma volume. However, chronic subdural hematomas differ in shape and extension from acute subdural hematomas, which makes the validity of the same method in the estimation of hematoma volume questionable. We aimed to determine the value of XYZ/2 method to estimate the volume of chronic subdural hematoma when compared with computer-assisted volumetric analysis.Computed tomography scans of 28 patients with unilateral hemispheric chronic subdural hematoma were reviewed. Hematoma volumes were measured using 5 different XYZ/2 formulas and compared with volumes measured by computer-assisted analysis. Nonparametric correlation coefficient (Spearman's rho) was used in statistical comparison.All 5 formulas showed excellent correlation with the gold standard, proving the validity of XYZ/2 method in the estimation of chronic subdural hematoma volume (level of significance <0.001). Our results suggest that maximum hematoma length and width, which are not necessarily on the same slice, should be used rather than length and width of hematoma on the central slice when using XYZ/2 method in patients with chronic subdural hematoma.This study proves the validity of XYZ/2 technique for the estimation of chronic subdural hematoma volume as well.
Choroidal fissure cysts are often incidentally discovered. They are usually asymptomatic. The authors report a case of growing and hemorrhagic choroidal fissure cyst which was treated surgically. A 22-year-old female presented with headache. Cranial MRI showed a left-sided choroidal fissure cyst. Follow-up MRI showed that the size of the cyst had increased gradually. Twenty months later, the patient was admitted to our emergency department with severe headache. MRI and CT showed an intracystic hematoma. Although such cysts usually have a benign course without symptoms and progression, they may rarely present with intracystic hemorrhage, enlargement of the cyst and increasing symptomatology. Key Words: Choroidal fissure · Cyst · Temporal lobe · Hemorrhage.
