Korea uzrokovana arteriovenskom malformacijom: prikaz slučaja i pregled literature

Chorea is a movement disorder that can be caused by a large range of degenerative, vascular, metabolic and toxic disorders in basal ganglia. Arteriovenous malformations are rare vascular malformations the clinical presentation of which depends on the malformation characteristics and localization. Th ey are most commonly presented with intracranial hemorrhage, while focal neurological deficit is the rarest presentation. A case is reported of a 64-year-old female patient presented with hemichorea. Magnetic resonance imaging and digital subtraction angiography revealed the presence of arteriovenous malformation in the right temporal lobe.Korea je poremećaj pokreta koji može biti uzrokovan velikim rasponom degenerativnih, vaskularnih, metaboličkih i toksičnih poremećaja u bazalnim ganglijima. Arteriovenske malformacije su rijetke vaskularne malformacije klinička prezentacija kojih ovisi o karakteristikama i lokalizaciji malformacije. Najčešće se prezentiraju intrakranijskom hemoragijom, a najrjeđe fokalnim neurološkim defi citom. Prikazujemo slučaj 64-godišnje bolesnice koja se prezentirala hemikoreom. Učinjena magnetska rezonanca i digitalna subtrakcijska angiografi ja otkrila je prisutnost arteriovenske malformacije u medijalnom dijelu desnog temporalnog režnja

Uspješno liječenje akutnog diseminiranog encefalomijelitisa (ADEM) pravodobnom primjenom imunoglobulina – prikaz slučaja i pregled literature

Acute disseminated encephalomyelitis (ADEM) is an inflammatory demyelinating disease of the central nervous system that usually affects children and young adults. It most commonly has a monophasic course, although relapses are reported. Clinical presentation of the disease includes encephalopathy and multifocal neurological deficits. There are no established reliable criteria for diagnosis of ADEM and sometimes it is difficult to distinguish it from first attack of multiple sclerosis, especially in adults. The diagnosis of ADEM is based on clinical, radiological and laboratory findings. In the treatment of ADEM, high doses of corticosteroids, plasmapheresis and immunoglobulins are used. We report a case of a young adult female patient with ADEM who fully recovered after prompt administration of high dose methylprednisolone and immunoglobulins.Akutni diseminirani encefalomijelitis (ADEM) je upalna demijelinizirajuća bolest središnjega živčanog sustava koja obično pogađa djecu i mlade odrasle osobe. Najčešće ima monofazni tijek, iako su zabilježeni i relapsi bolesti. Klinička prezentacija bolesti uključuje encefalopatiju i multifokalne neurološke deficite. Pouzdani kriteriji za dijagnozu ADEM-a nisu utvrđeni i ponekad ga je teško razlikovati od prve atake multiple skleroze, osobito kod odraslih. Dijagnoza ADEM-a temelji se na kliničkim, radiološkim i laboratorijskim nalazima. U liječenju ADEM-a primjenjuju se visoke doze kortikosteroida, plazmafereza i imunoglobulini. Prikazujemo slučaj mlade odrasle bolesnice kod koje je potpun oporavak uslijedio nakon pravodobne primjene visoke doze metilprednizolona i imunoglobulina

ENCEPHALOPATHY CAUSED BY THE APPLICATION OF METRONIDAZOLE

Metronidazol je antibiotik koji se koristi u liječenju anaerobnih bakterijskih i parazitarnih infekcija. Kao rijetka nuspojava primjene ovog lijeka može se javiti encefalopatija. Najčešće primijećeni klinički simptomi uključuju dizartriju, nestabilnost u hodu i/ili ataksiju. Encefalopatiju uzrokovanu primjenom metronidazola potrebno je diferencijalno dijagnostički razlikovati od drugih mogućih uzroka encefalopatije. Uz kliničku sliku i podatak o primjeni metronidazola od pomoći su magnetska rezonancija mozga (MRI) - T2 i prikaz FLAIR te neurološka dijagnostika koja uključuje elektroencefalografi ju (EEG), laboratorijsku obradu i lumbalnu punkciju. Tipični nalazi MRI mozga u T2 i FLAIR tehnici pokazuju hiperintenzitet koji u većini slučajeva zahvaća nucleus dentatus malog mozga, dijelove moždanog debla te splenium corpus callosuma. Ponekad je potrebno učiniti i gensko testiranje kako bi se isključili i vrlo rijetki uzroci encefalopatije. Neurološke promjeneuzrokovane primjenom metronidazola najčešće su reverzibilne i povlače se nakon ukidanja metronidazola iz terapije. U liječenju ove vrste encefalopatije može se primijeniti metilprednizolon.Metronidazole is an antibiotic used for treating anaerobic bacterial and parasitic infections. A rare side effect of using this drug is encephalopathy. The most commonly observed symptoms include dysarthria, gait instability, and/or ataxia. Metronidazole induced encephalopathy should be differentiated from other possible causes of encephalopathy. Clinical picture with data on metronidazole application, as well as magnetic resonance imaging (MRI) of the brain, T2 and FLAIR sequences, neurological diagnostic procedures such as electroencephalography (EEG), laboratory tests and lumbar puncture should be performed. Typical brain MRI fi ndings in T2 and FLAIR technique show hyperintensity, which in most cases affects dentate nucleus of the cerebellum, parts of brainstem, and splenium corporis callosi. Genetic testing is sometimes required to distinguish some rare causes of encephalopathy. Neurological changes due to metronidazole application are most often reversible and vanish after metronidazole withdrawal. Use of methylprednisolone in treating this type of encephalopathy is sometimes helpful

PROPHYLAXIS OF MIGRAINE – A REVIEW OF LITERATURE

Cilj ovog prikaza literature je procijeniti mogućnosti profi lakse migrene. Prema preporukama International Headache Society (IHS) profi laksa migrene provodi se u bolesnika koji imaju ≥4 dana migrensku glavobolju na mjesec bilo da se radi o epizodičnoj ili kroničnoj migreni. Učinkovitim liječenjem smatra se smanjenje učestalosti migrenskih ataka za ≥50 %. Učinkovitima su se pokazali β-blokatori, kalcijski antagonisti, antiepileptici kao što su topiramat i valproat kao i gabapentin i pregabalin, te fl unarizin i antidepresivi. Učinkovitost levatiracetama, cervikalne miofascijalne anestezije te kožne elektrostimulacije i muskularne stimulacije još je u ispitivanju. Dvojben je učinak botulinum toksina. Istražuje se moguća primjena histamina, zatvaranje foramena ovale te primjena akupunkture, supraorbitalne i vagalne nervne stimulacije te transkranijske magnetske stimulacije. Istražuje se utjecaj kateholamina i melatonina te kontraceptiva, ribofl avina, dekstrometorfi na u nastanku migrenskih glavobolja. Potrebna je adekvatna procjena mogućih učinaka u profi laksi primjenom probiotika, koenzima Q10 i magnezija. Klinička istraživanja su pokazala da primjena humanih monoklonskih protutijela erenumaba, fremanezumaba i galkanezumaba pokazuju statistički značajnu učinkovitost (≥50 % učinkovitosti) u profi laksi migrene što je potrebno potvrditi u kliničkoj praksi.This literature review is aimed at assessing the possibilities of migraine prophylaxis. The International Headache Society (IHS) recommends performing migraine prophylaxis in patients suffering ≥4 migraine headaches per month, either episodic or chronic. The treatment is deemed successful when the migraine attacks are decreased by ≥50%. Effi ciency has been demonstrated for β-blockers, calcium antagonists, antiepileptics such as topiramate and valproate, as well as gabapentin, pregabalin, fl unarizine and antidepressants. The effi ciency of levetiracetam, cervical myofascial anesthesia, skin electrostimulation and muscular stimulation is still being tested. The effects of botulinum toxin are dubious. There is ongoing research of the possibility of using histamines, closing foramen ovale, acupuncture, supraorbital and vagal nerve stimulation and transcranial magnetic stimulation. Effects of catecholamine, melatonin, contraceptives, ribofl avin, dextromethorphan and melatonin in persisting migraine headaches are being researched as well. Required is an appropriate assessment of the possible effects of probiotics, coenzyme q10 and magnesium in migraine prophylaxis. Clinical researches have shown the use of human monoclonal antibodies erenumab, fremanezumab and galcanezumab to demonstrate a statistically signifi cant effi ciency (≥50%) in migraine prophylaxis, yet requiring further confi rmation in clinical practice

Depresija i umor uzrokovani opstrukcijskom apnejom tijekom spavanja u multiploj sklerozi

To our knowledge, there is no study investigating whether fatigue and depression as the most commonly reported symptoms in multiple sclerosis (MS) and obstructive sleep apnea (OSA) patients have arisen from primary mechanisms of MS or from secondary associated conditions such as OSA in MS patients. The aim of our survey study was to determine whether depression and fatigue in MS patients were associated with clinical features of OSA or with MS. We conducted a self-administered survey using four validated questionnaires (STOP-BANG, Epworth Sleepiness Scale, Fatigue Severity Scale and The Center for Epidemiologic Studies Depression Scale-Revised) in 28 consecutive outpatients with proven MS. The prevalence of MS patients at an increased risk of OSA was 29% and age was positively correlated with this risk (p=0.019). None of the clinical features of MS patients (subtype, disability status, disease duration, modifying therapy, other medication) was correlated with depression and fatigue. On the contrary, excessive daytime sleepiness as a hallmark of OSA was significantly and positively associated with the level of depressive symptoms (p=0.004) and level of fatigue (p=0.015). Also, depression was significantly and positively correlated with the increased risk of OSA (p=0.015) and age of MS patients (p=0.016). Finally, a significant positive correlation was found between fatigue severity and level of depressive symptoms (p=0.003). OSA is a common disorder in MS patients. The clinical features and risk factors for OSA in MS patients are associated with the two most commonly reported symptoms of depression and fatigue, thus supporting the hypothesis that both symptoms are due to a secondary condition in MS.Sukladno našim saznanjima nema studije koja je istraživala nastaju li umor i depresija kao najučestaliji simptomi kod bolesnika s multiplom sklerozom (MS) i opstrukcijskom apnejom tijekom spavanja (OSA) primarnim mehanizmima MS ili iz sekundarnih povezanih stanja kao što je OSA kod bolesnika s MS. Cilj naše anketne studije bio je utvrditi jesu li depresija i umor u bolesnika s MS povezani s kliničkim obilježjima OSA ili MS. Proveli smo anketu pomoću četiri validirana upitnika (STOP-BANG, Epworthova ljestvica pospanosti, ljestvica težine umora i revidirana ljestvica depresije Centra za epidemiološke studije) u 28 uzastopnih ambulantnih bolesnika s klinički i paraklinički dokazanom MS. Učestalost bolesnika s MS s povećanim rizikom od nastanka OSA bila je 29%, a dob je bila u pozitivnoj korelaciji s tim rizikom (p=0,019). Nijedna od kliničkih značajka bolesnika s MS (podtip, status invaliditeta, trajanje bolesti, modificirajuća terapija, drugi lijekovi) nije bila u korelaciji s depresijom i umorom. Naprotiv, pretjerana pospanost tijekom dana kao obilježje OSA bila je značajno i pozitivno povezana s razinom simptoma depresije (p=0,004) i razinom umora (p=0,015). Također, depresija je značajno i pozitivno korelirala s povećanim rizikom od OSA (p=0,015) i dobi bolesnika s MS (p=0,016). Konačno, utvrđena je značajna pozitivna korelacija između težine umora i simptoma depresije (p=0,003). OSA je čest poremećaj kod bolesnika s MS. Kliničke značajke i čimbenici rizika za OSA u bolesnika s MS povezani su s dva najčešće prijavljivana simptoma depresije i umora, podupirući tako hipotezu da su oba simptoma posljedica sekundarnog stanja u MS

ENCEPHALOPATHY CAUSED BY THE APPLICATION OF METRONIDAZOLE

Metronidazol je antibiotik koji se koristi u liječenju anaerobnih bakterijskih i parazitarnih infekcija. Kao rijetka nuspojava primjene ovog lijeka može se javiti encefalopatija. Najčešće primijećeni klinički simptomi uključuju dizartriju, nestabilnost u hodu i/ili ataksiju. Encefalopatiju uzrokovanu primjenom metronidazola potrebno je diferencijalno dijagnostički razlikovati od drugih mogućih uzroka encefalopatije. Uz kliničku sliku i podatak o primjeni metronidazola od pomoći su magnetska rezonancija mozga (MRI) - T2 i prikaz FLAIR te neurološka dijagnostika koja uključuje elektroencefalografi ju (EEG), laboratorijsku obradu i lumbalnu punkciju. Tipični nalazi MRI mozga u T2 i FLAIR tehnici pokazuju hiperintenzitet koji u većini slučajeva zahvaća nucleus dentatus malog mozga, dijelove moždanog debla te splenium corpus callosuma. Ponekad je potrebno učiniti i gensko testiranje kako bi se isključili i vrlo rijetki uzroci encefalopatije. Neurološke promjeneuzrokovane primjenom metronidazola najčešće su reverzibilne i povlače se nakon ukidanja metronidazola iz terapije. U liječenju ove vrste encefalopatije može se primijeniti metilprednizolon.Metronidazole is an antibiotic used for treating anaerobic bacterial and parasitic infections. A rare side effect of using this drug is encephalopathy. The most commonly observed symptoms include dysarthria, gait instability, and/or ataxia. Metronidazole induced encephalopathy should be differentiated from other possible causes of encephalopathy. Clinical picture with data on metronidazole application, as well as magnetic resonance imaging (MRI) of the brain, T2 and FLAIR sequences, neurological diagnostic procedures such as electroencephalography (EEG), laboratory tests and lumbar puncture should be performed. Typical brain MRI fi ndings in T2 and FLAIR technique show hyperintensity, which in most cases affects dentate nucleus of the cerebellum, parts of brainstem, and splenium corporis callosi. Genetic testing is sometimes required to distinguish some rare causes of encephalopathy. Neurological changes due to metronidazole application are most often reversible and vanish after metronidazole withdrawal. Use of methylprednisolone in treating this type of encephalopathy is sometimes helpful

Kompletni atrioventrikulski blok i asistolija tijekom epileptičkog napadaja: prikaz slučaja

Cardiac arrhythmias during or after epileptic seizures are one of the possible pathomechanisms of sudden unexpected death in epilepsy. These arrhythmogenic epilepsies are most commonly associated with sinus tachycardia, but atrioventricular block and asystole can also be seen. Although a rare occurrence, these arrhythmias can lead to significant morbidity and mortality, but also can be potentially preventable with pacemaker implantation. Here we describe a patient with recurrent epileptic seizures, diagnosed with ictal third-degree atrioventricular block and asystole during seizure, which required a permanent cardiac pacemaker.Srčane aritmije tijekom ili nakon epileptičkih napadaja jedan su od mogućih patomehanizama neočekivane smrti u bolesnika s epilepsijom. Ove aritmogene epilepsije najčešće su povezane sa sinus tahikardijom, ali se mogu uočiti i atrioventrikulski blok i asistolija. Iako se rijetko pojavljuju, ove aritmije mogu dovesti do značajnog pobola i smrtnosti, ali se također mogu prevenirati ugradnjom srčanog stimulatora. Ovdje opisujemo bolesnika s ponavljajućim epileptičkim napadajima i dijagnosticiranim atrioventrikulskim blokom trećeg stupnja i asistolijom tijekom napadaja kojemu je bilo potrebno ugraditi trajni srčani stimulator

NEUROFEEDBACK IN TREATING MIGRAINE HEADACHE – A PILOT STUDY

Cilj: Cilj ovog istraživanja bio je objektivizirati terapijski učinak neurofeedbacka na liječenje migrenske glavobolje u bolesnika s migrenskom glavoboljom. Metode: Kao instrument istraživanja koristio se anonimni anketni upitnik, strukturiran i modificiran za potrebe ovog istraživanja. Na kraju su uporabljena dva standardizirana testa: test za procjenu onesposobljenosti bolesnika s migrenom (MIDAS - Migraine Disability Assessment Test), te upinik o ispitivanju utjecaja glavobolje (HIT6: Headache Impact Test) koji se koristi za mjerenje utjecaja glavobolje na sposobnost obavljanja zadataka na radnom mjestu/ u školi i u socijalnim situacijama. Rezultati: Prosječan broj glavobolja tijekom jednog mjeseca kod većine ispitanika je 11 (5 do 6 puta), uz najčešće trajanje od 4 do 24 sata, kako navodi 16 ispitanika. Prosječni je intenzitet glavobolje za 10 ispitanika srednje jaka bol, a za 15 ispitanika jaka bol. Dob nije statistički značajan faktor onesposobljenosti migrenama izuzev izostanka iz škole/posla. Povezanost je utvrđena samo za parametar izostanaka s posla/škole zbog glavobolja u zadnja 3 mjeseca (dani) gdje pozitivne vrijednosti koeficijenta korelacije (ro) upućuju na zaključak da je veći broj izostanaka s posla/ škole u zadnja 3 mjeseca kod pacijenata s višim stupnjevima obrazovanja. Nakon provedene terapije utvrđena je statistički značajna razlika samo u parametrima smanjenja produktivnosti na poslu/u školi zbog glavobolja u zadnja 3 mjeseca (dani) (p=0,001). Zaključak: Testiranjem utjecaja terapije neurofeedbackom na onesposobljenost migrenama utvrđen je statistički značajan pad HIT6 rezultata, kao i pad vrijednosti svih parametara utjecaja migrena na život - MIDAS rezultati.Objective: The aim of the study was to objectify therapeutic effect of neurofeedback and to treat migraine headaches in patients with migraine. Methods: We used anonymous questionnaire, structured and modified for the purpose of this study. In the end, we used two standardized tests, i.e. the test for assessment of disability in patients with migraine (MIDAS, Migraine Disability Assessment Test) and the questionnaire testing the impact of headache (HIT6, Headache Impact Test), used to measure the impact of headaches on the ability to perform tasks at work/school and in social situations. Results: Concerning the average number of headaches per month, the majority of patients (n=11) had headache 5-6 times, usually lasting for 4 to 24 hours, as reported by 16 subjects. The average headache intensity was reported as severe pain by 10 patients and strong pain by 15 patients. Age was not a statistically significant factor for disabling migraines except for school/work absenteeism. The connection was only established for work/school absenteeism due to headaches in the last three months (days), where positive values of the correlation coefficient (ro) suggested that greater work/school absenteeism in the last three months was recorded in patients with a higher level of education. After the treatment, a statistically significant difference was only found in the reduction of work/school productivity because of headaches in the last three months (days) (p=0.001). Testing the impact of neurofeedback therapy on disability due to migraine revealed a statistically significant decrease in HIT6 results, as well as in the value of all segments of the migraine impact on life, i.e. MIDAS results