Analiza refleksa treptaja u oboljelih od multiple skleroze [Analysis of the blink reflex in multiple sclerosis patients]

Multiple sclerosis (MS) is a chronic autoimmune disease of the central nervous system characterised by inflammation, demyelinisation and axonal degeneration. Neurophysiological methods are indispensable part of diagnostic algorithm in MS. The aim of this study was to examine the electrophysiological characteristics of the blink reflex (BR), compare them with the brainstem auditory evoked potentials (BAEP) and correlate with MRI findings. The study included 60 subjects with a clinically definitive MS divided into 2 subgroups: 19 subjects with symptoms of brainstem damage (MD subgroup) and 41 subjects without signs of brainstem damage (nonMD subgroup). As a control group 60 age and gender matched healthy subjects were included. Analysis of BR and BAEP was done on all participants. Data of MRI findings, regarding presence of demyelinating lesion in brainstem were analyzed in MD and nonMD subgroup. We analized latencies of R1, R2 and R2' of BR and IPL III-V of BAEP. The results showed statistically significant difference in the values of all components of BR measured in the MD and nonMD group compared to the control group as well as MD compared to nonMD group. The values of IPL III-V did not differ in either MD or nonMD group compared to the control group. Statistically significant difference was found in correlation of R1 component and MRI finding in both MS groups. Difference in IPL III-V latencies noted between MD and nonMD group was not statistically significant. BR analysis has been shown to be a more sensitive neurophysiological method in patients with MS than BAEP, regardless of the presence of brainstem damage

Miastenija gravis udružena s timomom i aplastičnom anemijom: prikaz slučaja

Myasthenia gravis is associated in 10 to 15 percent of patients with thymic tumors, rarely with aplastic anemia. We report a 45-year-old male diagnosed with myasthenia gravis ­associated with thymoma. We started treatment with pyridostigmine. After thymectomy, the patient ­received 30 irradiation sessions. In the postoperative course, he had mild worsening of myasthenia gravis, which improved with prednisone. Five months later, he developed severe aplastic anemia. He was dependent on blood supplement. After allogeneic transplantation of bone marrow, he improved but later he ­developed graft versus host disease. Myasthenia gravis was under good control with 480 mg of ­pyridostigmine per day.Miastenija gravis (MG) je u 10% do 15% bolesnika udružena s tumorima timusa, rijetko s aplastičnom anemijom. Prikazujemo 45-godišnjeg bolesnika s MG udruženom s timomom. Liječenje je započeto piridostigminom. Nakon timektomije je provedeno 30 zračenja. Poslijeoperacijski je imao blago pogoršanje MG koje se povuklo uz terapiju prednizonom. Pet mjeseci kasnije je razvio tešku aplastičnu anemiju. Postao je ovisan u krvnim derivatima. Nakon alogenične transplantacije koštane srži došlo je do poboljšanja, ali je kasnije razvio reakciju transplantata protiv primatelja. MG je bila dobro kontrolirana uz 480 mg piridostigmina na dan

Diferencijalna dijagnostika i dijagnostički algoritam za demijelinizacijske bolesti

Demyelinating diseases of the central nervous system include a wide spectrum of different disorders that may resemble multiple sclerosis (MS). The diagnosis of MS is based on typical clinical and paraclinical criteria. The simplified McDonald\u27s criteria, which combine clinical picture, NMR findings, CSF analysis and visual evoked potentials, are appropriate for daily neurologic routine. If some of these criteria are atypical, diagnostic algorithm should be extended to some other procedures to exclude other diseases that can mimic MS not only in symptoms, signs or course of the disease but also in laboratory findings. In such a case, an alternative, better explanation for the clinical manifestations should be considered and performing specific tests is helpful to exclude alternative diagnoses.Demijelinizacijske bolesti središnjega živčanog sustava čine širok spektar različitih poremećaja koji mogu nalikovati multiploj sklerozi. Dijagnoza multiple skleroze temeljena je na tipičnim kliničkim i parakliničkim kriterijima. Pojednostavljeni McDonaldovi kriteriji u kojima se klinička slika kombinira s nalazom magnetske rezonancije, nalazom cerebrospinalne tekućine i vidnim evociranim potencijalima korisni su u svakodnevnoj neurološkoj praksi. Ako je neki od tih kriterija atipičan, treba proširiti dijagnostički postupak kako bi se isključile druge bolesti koje mogu oponašati multiplu sklerozu ne samo u simptomima, znacima ili tijeku bolesti, nego i u nalazima laboratorijskih pretraga. U svakom slučaju. treba razmišljati o drugom, boljem objašnjenju kliničkih manifestacija te je izvedba specifičnih testova korisna u isključenju alternativne dijagnoze

Vrijednost refleksa treptaja u ranoj dijagnostici multiple skleroze

The aim was to determine differences of blink reflex in clinically definite multiple sclerosis (CDMS) and clinically isolated syndrome (CIS) in patients presented with symptoms and signs of brainstem impairment. The study included 20 patients diagnosed with CDMS, 20 with CIS, and 20 healthy controls. We recorded latencies of early (R1) and late component ipsilaterally (R2) and contralaterally (R2’), and occurrence of irritative component (R3). We analyzed data on sex, age, signs of brainstem impairment and magnetic resonance imaging (MRI) findings for the presence of brainstem demyelinating lesions. There was no statistically significant difference between patient groups according to sex, age, symptoms of brainstem involvement and MRI findings. There was no statistically significant difference in R1 component latencies and R2 latencies on the right side. Latencies of R2 on the left and R2’ on the right were statistically longer in CDMS group. There was no difference in the appearance of R3 component. In conclusion, blink reflex was found to be a very sensitive and useful diagnostic tool in the assessment of brainstem structures, especially because abnormalities are seen not only in CDMS but also in CIS. Slowing of the late component as a sign of dysfunction in the efferent part of the reflex arc is not very specific but is a highly sensitive finding.Cilj je bio ispitati razliku refleksa treptaja u bolesnika s dijagnozom klinički definitivne multiple skleroze (CDMS) i klinički izoliranog sindroma (CIS) koji imaju simptome i znakove oštećenja moždanog debla. Istraživanje je obuhvatilo 20 bolesnika s dijagnozom CDMS, 20 s CIS i 20 zdravih ispitanika kao kontrolna skupina. Bilježili smo latencije rane (R1) i kasne komponente ipsilateralno (R2) i kontralateralno (R2’), kao i pojavu iritativne komponente (R3). Analizirali smo spol, dob, simptome i znakove oštećenja moždanog debla, nalaz magnetske rezonancije (MR) s obzirom na prisustvo demijelinizacijskih lezija u području moždanog debla. Nije utvrđena razlika među skupinama bolesnika s obzirom na spol, dob, prisustvo simptoma oštećenja moždanog debla te nalaz MR. Nije bilo razlike u latencijama komponente R1, kao ni u latencijama R2 na desnoj strani. Latencije komponente R2 na lijevoj strani i R2’ na desnoj strani bile su statistički duže u skupini ispitanika s CDMS. Nije bilo razlike u pojavnosti komponente R3. U zaključku, refleks treptaja je vrlo osjetljiv i koristan dijagnostički alat za procjenu funkcije moždanog debla, pogotovo zbog toga što se abnormalnosti ne vide samo u CDMS, nego i u CIS. Usporenje kasne komponente kao znak disfunkcije eferentnog dijela refleksnog luka, iako nije specifičan nalaz, pokazao se kao vrlo osjetljiv nalaz

Repeated intravenous thrombolytic therapy with rt-PA alteplase in treatment of early recurrent ischemic stroke

The 2019 year guidelines (American Heart Association / American Stroke Association – AHA/ASA) do not recommend treating recurrent acute ischemic stroke with alteplase in patients who had previ- ous stroke in last 3 months (1,9). According to the European Stroke Organisation`s (ESO) guidelines (year 2021), there is no clear consensus. The risk of reocclusion occurs in 14-34% of patients in whom recanalisation with alteplase has been achieved (1). In this paper we present the case of our 70-year old patient with early stroke recurrence and repeated thrombolytic therapy 9 hours after the first dose of alteplase

Repeated intravenous thrombolytic therapy with rt-PA alteplase in treatment of early recurrent ischemic stroke

The 2019 year guidelines (American Heart Association / American Stroke Association – AHA/ASA) do not recommend treating recurrent acute ischemic stroke with alteplase in patients who had previ- ous stroke in last 3 months (1,9). According to the European Stroke Organisation`s (ESO) guidelines (year 2021), there is no clear consensus. The risk of reocclusion occurs in 14-34% of patients in whom recanalisation with alteplase has been achieved (1). In this paper we present the case of our 70-year old patient with early stroke recurrence and repeated thrombolytic therapy 9 hours after the first dose of alteplase

Bolest Moyamoya u bolesnika s tumorom mozga: prikaz slučaja

A 40-year-old male presented to emergency room with epileptic grand mal seizure. He had untreated hypertension, and prior diagnostic investigation showed duplex renal arteries of the right kidney with hyperreninemia in the left renal vein. He was nonsmoker, with moderate alcohol intake. Neurologic examination was normal except for high blood pressure and tongue bite. Electroencephalogram was nonspecific. Nuclear magnetic resonance (NMR) showed vascular lesions in the white matter and infratentorially an expansive lesion with no postcontrast imbibition in the right cerebellar hemisphere. Neurosonography revealed hypoplasia of both internal carotid arteries (ICA), mean diameter <2 mm, subtotal stenosis at the origin of both ICA, and development of collateral path, typical for moyamoya disease. Magnetic resonance angiography (MRA) and digital subtraction angiography (DSA) confirmed the neurosonography diagnosis. Immunologic tests for vasculitis were negative, while hematologic examination showed 4G allele for PAI-1. Serum lipids were elevated. We recommended neurosurgical operation of brain tumor. Histopathologic finding showed meningioma. This case is interesting because of the rare complex cerebrovascular disease, i.e. coexistence of hypoplasia of both ICA, bilateral subtotal stenosis of ICA, intracranial moyamoya disease, and brain tumor.Muškarac u dobi od 40 godina pregledan je u hitnoj ambulanti zbog epileptičnog napada tipa grand mal. Bolovao je od neliječene hipertenzije, ranijom dijagnostičkom obradom verificirana je dvostruka bubrežna arterija desno i hipereninemija u lijevoj bubrežnoj veni. Bio je nepušač s umjerenom konzumacijom alkohola. Neurološki pregled je bio uredan osim povišenih vrijednosti krvnog tlaka i traga ugriza jezika. Elektroencefalogram je bio nespecifičan. Magnetskom rezonancijom mozga nađene su vaskularne lezije u bijeloj tvari te infratentorijalno u desnoj cerebelarnoj hemisferi ekspanzivni proces bez postkontrastne imbibicije. Neurosonološkim ispitivanjem potvrđena je hipoplazija obiju unutarnjih karotidnih arterija (ACI) s prosječnim promjerom <2 mm, subtotalna stenoza polazišta obiju ACI i razvoj kolateralnog puta, što je tipično za bolest moyamoya. Magnetska angiografija (MRA) i digitalna subtrakcijska angiografija (DSA) su potvrdile neurosonološku dijagnozu. Imunološki testovi za vaskulitis su bili negativni, dok je hematološkom obradom nađen 4G alel za plazminogen aktivator inhibitor-1 (PAI-1). Serumski lipidi su bili povišeni. Preporučili smo mu operaciju tumora mozga. Histopatološki nalaz je ukazivao na meningeom. Ovaj slučaj je zanimljiv zbog rijetke složene cerebrovaskularne bolesti, odnosno supostojeće hipoplazije obiju ACI, bilateralne subtotalne stenoze obiju ACI, intrakranijske bolesti moyamoya te tumora mozga

Stroke- the most important cause of the newly diagnosed epilepsy in the elderly

About 35% of all newly diagnosed epileptic seizures in people older than 60 years are caused by stroke. The incidence of the early epileptic seizures is 2.4–5.4%, and for the late seizures 3–4.5%. Seizures after stroke are most often simple partial seizures with or without secondary generalization, and less often complex partial seizures. In early seizure these are acute biochemical cellular changes, and in late seizures gliosis. Althoung the risk for developing epilepsy was 17–35% after early seizures, the risk of developing epilepsy after late seizures increased to 65–90%. Combination of coronary heart disease, hypertonia and cardiovascular disease occur in 65% of patients over 75 year old. Intrah spitalmortality in patients with stroke with epileptic seizures was 37.9% compared to patients without seizures (14.4%). Early seizures cause highermortality than late seizures which can be explained by sinergistic effect of of the damaged tissue due to the seizure and vascular ischaemia. European authors in 2007 indicate that lavetiracetam, lamotrigine and gabapentin were first line drugs, followed by topiramate and valproate in elderly patients. Oxcarbazepine and carbamazepine were not highly recommended because of the associated hyponatremia, cardiac disorders and interaction potentials. The standard antiepileptic drug for focal epilepsy is still carbamazepine, and valproate is most commonly used for generalized epilepsy- even in older patients. Epidemiological studies on epilepsy treatment in the elderly show steady increase in the number of patients. Therefore, elderly patients require special attention. Monotherapy in lowdoses is often sufficient, enzyme inducing drug are used too frequently

Preporuke za dijagnostiku i liječenje multiple skleroze

Multiple sclerosis (MS) is a chronic demyelinating neurologic disorder that mainly affects young individuals (aged 20 to 50 years). Approximately 85% of patients experience an initial course with relapses and remissions (relapsing-remitting multiple sclerosis). Guidelines for the management of MS should be focused on three main areas: (a) the diagnosis of MS; (b) treatment of relapses; and (c) long-term preventive treatment including clinical follow up, dose adjustment, drug switch, control of therapeutic efficacy, and disease progression. Diagnosis should be established according to clinical and paraclinical criteria. Discussion on therapeutic recommendations is focused on the disease-modifying agents in acute phases and drugs for long-term treatment and symptomatic treatment. Differential diagnoses must be taken into account on making the diagnosis of MS. Therefore, diagnosis of MS should be established on clinical and radiological diagnostic criteria, cerebrospinal fluid analysis and evoked potentials.Multipla skleroza (MS) je kronična demijelinizirajuća neurološka bolest koja najčešće pogađa mlade bolesnike (u dobi 20-50 godina). Oko 85% bolesnika boluje od oblika bolesti obilježenog relapsima i fazama remisije (relapsno remitentni oblik bolesti, RRMS). Smjernice za zbrinjavanje bolesnika oboljelih od MS moraju biti usredotočene na tri glavna područja: a) postavljanje ispravne dijagnoze, b) liječenje relapsa, c) dugotrajno preventivno liječenje uključujući praćenje bolesnika, prilagodbu doze lijeka, po potrebi promjenu lijeka, kontrolu učinka liječenja na progresiju bolesti. Dijagnoza bolesti postavlja se na temelju kliničkih i parakliničkih kriterija. Posebna je pozornost posvećena lijekovima za liječenje relapsa bolesti, lijekovima za preventivno dugoročno liječenje te simptomatskoj terapiji. Kod postavljanja dijagnoze MS treba uzeti u obzir diferencijalne dijagnoze. Stoga bi se dijagnoza MS trebala temeljiti na kliničkim i radiološkim dijagnostičkim kriterijima, analizi cerebrospinalne tekućine i evociranim potencijalima