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OBJECTIVE: Cerebral collateral circulation may affect subarachnoid hemorrhage (SAH) induced cerebral vasospasm and delayed cerebral ischemia. In this study our aim was to investigate the relationship between collateral status, vasospasm and delayed cerebral ischemia (DCI) in both aneurysmal and nonaneurysmal SAH. METHODS: Patients diagnosed as SAH with and without aneurysm were included and their data investigated retrospectively. After the patients diagnosed as SAH according to cerebral computed tomography (CT)/magnetic resonance imaging (MRI), they underwent cerebral angiography to check for cerebral aneurysm. The diagnosis of DCI was made according to the neurological examination and control CT/MRI. All the patients had their control cerebral angiography on days 7 to 10 in order to assess vasospasm and also collateral circulation. The American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology (ASITN/SIR) Collateral Flow Grading System was modified to measure collateral circulation. RESULTS: A total of 59 patients data were analyzed. Patients with aneurysmal SAH had higher Fisher scores and DCI was more common. Although there was no statistically significant difference between the patients with and without DCI in terms of demographics and mortality, patients with DCI had worse collateral circulation and more severe vasospasm. These patients had higher Fisher scores and more cerebral aneurysm overall. CONCLUSIONS: According to our data, patients with higher Fisher scores, more severe vasospasm, and poor cerebral collateral circulation may experience DCI more frequently. Additionally aneurysmal SAH had higher Fisher scores and DCI was seen more common. To improve the clinical results for SAH patients, we believe that physicians should be aware of the DCI risk factors.

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We evaluated the predictive factors of symptomatic intracranial hemorrhage (SICH) in endovascular treatment of stroke. We included 975 ischemic stroke patients with anterior circulation occlusion. Patients that had hemorrhage and an increase of ≥4 points in their National Institutes of Health Stroke Scale (NIHSS) after the treatment were considered as SICH. The mean age of patients was 65.2±13.1 years and 469 (48.1%) were women. The median NIHSS was 16 (13-18) and Alberta Stroke Program Early CT 9 (8-10). In 420 patients (43.1%), modified Rankin Scale was favorable (0-2) and mortality was observed in 234 (24%) patients at the end of the third month. Patients with high diastolic blood pressure (P<.05) had significantly higher SICH. SICH was significantly higher in those with high NIHSS scores (P<.001), high blood glucose (P<.001), and leukocyte count at admission (P<.05). Diabetes mellitus (DM) (OR 1.90; P<.001), NIHSS (OR 1.07; P<.05), adjuvant intra-arterial thrombolytic therapy (IA-rtPA) (OR, 1.60; P<.05), and puncture-recanalization time (OR 1.01; P<.05) were independent factors of SICH. Higher baseline NIHSS score, longer procedure time, multiple thrombectomy maneuvers, administration of IA-rtPA, and the history of DM are independent predictors of SICH in anterior circulation occlusion.

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According to International Classification of Headache Disorders (ICHD-III Beta version) headache attributed to hypoxia and/or hypercapnia is classified under the 4 title: 10.1.1 High altitude headache, 10.1.2 Airplane travel associated headache, 10.1.3 Diving headache and 10.1.4 Sleep apnoea headache. Headache associated with airplane travel is encountered infrequently in our clinical practice and firstly reported in 2004 as a case in the literature. The pathophysiology of headache associated with airplane travel is not yet clear. We presented this case in the aspect of the patient having both airplane travel and high altitude headaches and seen giant Virchow-Robin spaces in cranial MRI and disappearence of pain with a preventive treatment.

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AIM: There are many trials concerning peripheral nerve damage causes and treatment options. Unfortunately, nerve damage is still a major problem regarding health, social and economic issues. On this study, we used vascular graft and human cord blood derived stem cells to find an alternative treatment solution to this problem. MATERIAL AND METHODS: We used 21 female Wistar rats on our study. They were anesthetized with ketamine and we studied right hind limbs. On Group 1, we did a full layer cut on the right sciatic nerve. On Group 2, we did a full layer cut on the right sciatic nerve, and we covered synthetic vascular graft on cut area. On Group 3, we did a full layer cut on right sciatic nerve, and we covered the area with stem cell applied vascular graft. RESULTS: At the end of postoperative 8. weeks, we performed EMG on the rats. When we compared healthy and degenerated areas as a result of EMG, we found significant amplitude differences between the groups on healthy areas whereas there was no significant difference on degenerated areas between the groups. Then we re-opened the operated area again to reveal the sciatic nerve cut area, and we performed electron microscope evaluation. On the stem cell group, we observed that both the axon and the myelin sheet prevented degeneration. CONCLUSION: This study is a first on using synthetic vascular graft and cord blood derived CD34+ cells in peripheral nerve degeneration. On the tissues that were examined with electron microscope, we observed that CD34+ cells prevented both axonal and myelin sheath degeneration. Nerve tissue showed similar results to the control group, and the damage was minimal.

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OBJECTIVE: The thromboembolic events during neuroendovascular therapy (NET) are the major complications of concern that can be occasionally fatal. The thrombotic occlusion of the guide catheter for NET is thought to be the risk of the thromboembolic events. We have developed an idea for inventing the monitoring system of the continuous irrigation through the guide catheter. We herein present a unique invention of the guide catheter irrigation monitoring device. METHODS: We have developed ideas for preventing the thrombotic occlusion of the guide catheter. In order to design a convenient device working in the practical use, we have consulted and shared the ideas with the electrical engineers about putting the invention. RESULTS: The guide catheter irrigation monitoring device (GCIMD) consisted of three parts of optical sensor, main body and electric adapter. In brief, the basic principles of working of the GCIMD are as follows. The optical sensor is attached to the dripping chamber of the line to irrigation solution. The main body had the small light and speaker to make an alarm sounds. The sensor monitors the dripping of flush solution. If the dripping stops more than three seconds, a warning alarm has been activated. So, the operating physicians can concentrate and check the guide catheter irrigation. After the use of the GCIMD, there was no major thromboembolic complication in conjunction with the thrombotic occlusion of the guide catheter in our institute. CONCLUSION: We have developed a brilliant invention of the GCIMD for NET.

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Objective The transfemoral approach is a common route for catheterization of the supra-aortic vessels in neuroendovascular therapy. However, in some cases, the patient's anatomy prevents transfemoral catheterization or distal access to the carotid s. In such cases, direct carotid exposure (DCE) for neuroendovascular approaches may be used to treat cerebrovascular diseases. Methods We present 11 cases in which we were unable to perform the distal approach and DCE was the preferred neuroendovascular treatment procedure. Results DCE was performed on 11 patients with cerebral aneurysm (n = 8), carotid cavernous fistula (CCF) (n = 1), malignant brain tumor (n = 1), and carotid angioplasty and stenting (n = 1). Ten patients were female; one was male. Ages ranged from 63 to 87 years (mean: 71.36 years). Coil embolization was performed on patients with cerebral aneurysm and CCF. The patient with a malignant brain tumor underwent polyvinyl alcohol particle embolization. The only complication was a carotid artery dissection that occurred in one patient during stenting. Conclusion DCE for neuroendovascular approaches can be used as an alternative for patients with tortuous vasculature access in the femoral route. In such patients, a combination of neuroendovascular treatment and surgery in a hybrid operating room with angiography is preferred.

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AIM: The regression of meningioma has been reported in literature before. In spite of the fact that the regression may be involved by hemorrhage, calcification or some drugs withdrawal, it is rarely observed spontaneously. CASE REPORT: We report a 17 year old man with a cervical meningioma which was incidentally detected. In his cervical MRI an extradural, cranio-caudal contrast enchanced lesion at C2-C3 levels of the cervical spinal cord was detected. Despite the slight compression towards the spinal cord, he had no symptoms and refused any kind of surgical approach. The meningioma was followed by control MRI and it spontaneously regressed within six months. There were no signs of hemorrhage or calcification. CONCLUSION: Although it is a rare condition, the clinicians should consider that meningiomas especially incidentally diagnosed may be regressed spontaneously.

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BACKGROUND: The recurrent Heubner's artery is the distal part of the medial striate artery. Occlusion of the recurrent artery of Heubner, classically contralateral hemiparesis with fasciobrachiocrural predominance, is attributed to the occlusion of the recurrent artery of Heubner and is widely known as a stroke syndrome in adults. However, isolated occlusion of the deep perforating arteries following mild head trauma also occurs extremely rarely in childhood. CASE REPORT: Here we report the case of an 11-year-old boy with pure motor stroke. The brain MRI showed an acute ischemia in the recurrent artery of Heubner supply area following mild head trauma. His fasciobrachial hemiparesis and dysarthria were thought to be secondary to the stretching of deep perforating arteries leading to occlusion of the recurrent artery of Heubner. CONCLUSION: Post-traumatic pure motor ischemic stroke can be secondary to stretching of the deep perforating arteries especially in childhood.

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Objective Essential Palatal Tremor (PT) is a disorder in which radiological brain images appear normal but the clicking noise caused by peritubal, palatal muscle contractions remains the main complaint of patients. The condition occurs rarely in childhood. This paper demonstrates such a rare case with bilateral presentation of essential PT in a 12-yr-old girl could successfully be treated with botulinum toxin therapy at Otorhinolaryngology Department in 2013, as she was still asymptomatic after 16 months. Besides, being minimally invasive with negligible side effects, this choice of treatment with botulinum toxin A (BTA) leads to a long-term symptom free outcome from essential PT.

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OBJECTIVE: The transradial catheterization (TRC) is becoming widespread, primarily for neurointerventions. Therefore, the evaluation of radial artery puncture in clinical practice and a better understanding of the anatomy are important to improve the safety of neuroendovascular surgery. METHODS: Ten formalin-fixed adult Korean cadavers were dissected to expose radial artery (RA), brachial artery (BrA) and subclvian artery (ScA), bilaterally. Vessel lengths and diameters were meaured using a caliper and distance between the specific point of vessels and the anatomical landmarks including the radial styloid process, the medial epicondyle of the humerus, the sternoclavicular joint, and the vertebral artery orifice were also measured. RESULTS: The average length between the radial (RAPS) and the BrA puncture sites (BrAPS) and between the vertebral artery orifice (VAO) and the BrA bifurcation (BrAB) did not differ between sides (p>0.05). The average length between the radial styloid process (RSP) and the RAPS was 13.41±2.19 mm, and the RSP was 26.85±2.47 mm from the median nerve (MN). The mean length between the medial epicondyle (ME) and the BrAPS as 44.23±5.47 mm, whereas the distance between the ME and the MN was 42.23±4.77 mm. The average VAO-ScA angle was 70.94±6.12°, and the length between the ScA junction (SCJ) and the VAO was 60.30±8.48 mm. CONCLUSION: This study provides basic anatomical information about the radial artery and the brachial route and can help improving new techniques, selection of size and shape of catheters for TRC. This can help neurointerventionists who adopt a transradial neuroendovascular approach and offers comprehensive and safe care to their patients.

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Several types of intraspinal cyst develop within the spinal canal from the craniovertebral junction to the sacrum. These lesions occur in both children and adults. Arachnoid cysts are one of them and are more frequent in the paediatric population, being a relatively uncommon lesion in adults. The arachnoid cyst may be located intradurally or extradurally. The intradural type may be congenital or from spinal trauma, infection or spondylosis. Although intradural arachnoid cysts are often asymptomatic, they may give early symptoms when they exist with synchronous pathologies constricting the spinal canal gradually as in cervical spondylosis. In this report, a 60-year-old man with an arachnoid cyst of the cervicothoracic spine is presented. His cyst remained undiagnosed because of the nonspecific nature of the symptoms. It was only when he developed right hemiparesis that a posterior fluid collection compressing the spinal cord was found in Magnetic resonance imaginig. An intradural extramedullary cyst was removed with successful surgery and cord compression and symptoms were reversed. We discuss radiological diagnosis and surgical treatment of an arachnoid cyst in this report.

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La hipertensión es uno de los principales problemas de salud pública, que afecta a muchas personas en todo el mundo. Se sabe que es un importante factor de riesgo para el desarrollo de enfermedades cerebrovasculares y cardiovasculares. Su clasificación como «primaria» o «secundaria» depende del proceso subyacente. En el 5-10% de los pacientes hipertensos, se trata de un problema «secundario» a otro proceso de creciente frecuencia en los centros de atención terciaria. Las causas más frecuentes de la hipertensión secundaria son: enfermedades del parénquima renal, estenosis de la arteria renal, hiperaldosteronismo primario, feocromocitoma y el síndrome de Cushing. La poliarteritis nodosa puede afectar a cualquier órgano y en diferentes grados. A continuación presentamos a un paciente joven hipertenso al que se le ha diagnosticado poliarteritis nodosa, cuya angiografía muestra múltiples microaneurismas que afectan al tronco celíaco, a la arteria renal y a la arteria mesentérica superior, asociada a un síndrome de encefalopatía posterior reversible de entidad neurológica poco visto (AU)

Hypertension (HT) represents a major public health problem affecting many individuals worldwide. It is well known to be an important risk factor for the development of cerebrovascular and cardiovascular diseases. Classifying hypertension as ‘primary’ or ‘secondary’ depends on the underlying mechanism. In 5 to 10% of hypertensive patients, HT develops ‘secondary’ to a separate mechanism that has been encountered with increasing frequency in the tertiary refferral centers. The frequent causes of secondary hypertension include renal parenchymal disease, renal artery stenosis, primary hyperaldosteronism, phaeochromocytoma and Cushing's syndrome. Polyarteritis nodosa (PAN) can involve any organ and in varying degrees. Here we present a young hypertensive patient diagnosed as PAN with the angiographic findings of multiple microaneurysms involving celiac, renal and superior mesenteric arteries and associated with a rarely seen neurological entity-PRES syndrome (AU)

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Hypertension (HT) represents a major public health problem affecting many individuals worldwide. It is well known to be an important risk factor for the development of cerebrovascular and cardiovascular diseases. Classifying hypertension as ‘primary’ or ‘secondary’ depends on the underlying mechanism. In 5 to 10% of hypertensive patients, HT develops ‘secondary’ to a separate mechanism that has been encountered with increasing frequency in the tertiary refferral centers. The frequent causes of secondary hypertension include renal parenchymal disease, renal artery stenosis, primary hyperaldosteronism, phaeochromocytoma and Cushing's syndrome. Polyarteritis nodosa (PAN) can involve any organ and in varying degrees. Here we present a young hypertensive patient diagnosed as PAN with the angiographic findings of multiple microaneurysms involving celiac, renal and superior mesenteric arteries and associated with a rarely seen neurological entity-PRES syndrome.

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Lithium (Li) and lamotrigine (LTG) have neuroprotective properties. However, the exact therapeutic mechanisms of these drugs have not been well understood. We investigated the antioxidant properties of Li (40 and 80 mg/kg/day) and LTG (20 and 40 mg/kg/day) in a rat model of global cerebral ischemia based on permanent bilateral occlusion of the common carotid arteries (BCAO). Nitric oxide (NO), malondialdehyde (MDA), glutathione (GSH), glutathione reductase (GSH-R), catalase (CAT) and superoxide dismutase (SOD) levels were measured as an indicator of oxidative-nitrosative stress in both prefrontal cortex (PFC) and hippocampus after 28 days of treatment. The spatial learning disability was also assessed at the end of the study by Morris water maze (MWM) test. All oxidative-nitrosative parameters were found to be higher in the groups under treatment than in sham. Both drugs caused a decrease in PFC NO and MDA elevation, meanwhile the increase in GSH, GSH-R, CAT and SOD levels was significantly more evident in treated groups. We also found higher PFC GSH-R and hippocampal SOD levels in BCAO + Li (80 mg/day) treated group when compared with BCAO + LTG 40 mg/day. MWM test data showed a similar increase in spatial learning ability in all groups under treatment. We found no other statistical difference in comparison of treated groups with different dosages. Our findings suggested that Li and LTG treatments may decrease spatial learning memory deficits accompanied by lower oxidative-nitrosative stress in global cerebral ischemia. Both drugs may have potential benefits for the treatment of vascular dementia in clinical practice.

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OBJECTIVE: Insulin resistance (IR) has effects on inflammation and oxidative stress which have importance in acute stroke. Our aim was to investigate the relationships between IR, inflammation, oxidative stress and stroke severity in acute ischemic stroke patients. METHODS: We examined the relationships between inflammation, oxidative stress and stroke severity in 75 acute stroke patients with and without IR. Serum levels of oxidative stress markers (nitric oxide (NO), malondialdehyde (MDA), glutathione (GSH)) were measured as well as the cytokines interleukin-6 (IL-6) and interleukin-10 (IL-10). RESULTS: The levels of IL-10 (13.7±19.11 vs 51.20±89.32 pg/ml, p<0.00) in IR group were significantly reduced. Patients with IR had higher levels of NO (30.26±17.63 vs 22.57±14.5 µmol/L, p=0.04) and IL6 (27.44±57.13 vs 8.68±11.8 pg/ml, p<0.00) and higher NIHSS scores (11.40±5.35 vs 8.81±5.76, p=0.04) when compared with noninsulin resistant group. IL-10 was found negatively correlated with HOMA. Additionally, the parameters with positive correlations with HOMA were NIHSS, IL-6 and NO. CONCLUSIONS: Inflammation and oxidative stress are more evident in acute stoke patients with insulin resistance which may cause worse stroke severity. Our data also suggest that IL-10 as an antiinflammatory cytokine can be much lower in insulin resistance in acute phase of ischemic stroke. However it can be elevated as an adaptive mechanism in metabolic syndrome as a chronic condition.

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Therapeutic apheresis (TA) is used as primary and adjunctive therapy in the treatment of several diseases and syndromes. We retrospectively evaluated the results of therapeutic apheresis (TA) including therapeutic plasma-exchange (TPE), double filtration plasmapheresis (DFPP), therapeutic thrombocytapheresis and leukocytapheresis as 11-year activity during 2000-2011. A total of 845 TA procedures were performed in 114 patients (67 male and 47 female, with mean age 51±17 years). Adverse events (AE) were seen in 8.6% of procedures. None of the patients died from any complication. TA is safely carried out in our center in several diseases which are similar to previous reports.

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Lipomas are rare, and they rarely arise in deep soft tissue. Only few cases associated with obstructive sleep apnea (OSA) have been reported. Because of radiologic examinations (computed tomography and magnetic resonance imaging) in a case with OSA, a rarely observed large lipoma was encountered in the retropharyngeal region. In the case that was followed, the apnea-hypopnea index was measured. The radiologic examination of the upper airway of the case with OSA symptoms was presented.

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The aim of this study was to elucidate the possible association between carpal tunnel syndrome (CTS) and ulnar neuropathy at the wrist because of the contradictory results of previous studies. Thus, a retrospective case-control study was arranged with an electromyographic database including patients between 2003 and 2009. Patients were selected according to initial diagnosis and the examiner's criteria, and data were plotted by computer. One thousand nine hundred twenty-four patients were evaluated for CTS and 1,024 patients for diabetic CTS or diabetic polyneuropathy. CTS and ulnar neuropathy co-occurrence and CTS alone at the wrist was found in 54/404, 19/50, 20/27 patients, respectively. Logistic regression analysis revealed that having CTS was associated with a doubled risk of ulnar neuropathy at the wrist in both idiopathic CTS and diabetic CTS groups but not in diabetic polyneuropathy. Being male and of advanced age were other risk factors for ulnar neuropathy at the wrist. Correlation analysis (age and sex were controlled) revealed decreased but significant correlations between median and ulnar sensory amplitudes in CTS cases in all groups.

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Axial muscles like the trapezius have different reflexive and functional properties. The aim of this study was to analyze the long latency reflexes obtained from the trapezius by the electrical stimulation of upper and lower extremity peripheral nerves. Thirty-one healthy volunteers were included in the study. Surface EMG activity of both trapezius muscles was recorded and averaged after electrical stimulation of the median and peroneal mixed nerves. The recordings were performed during supine and erect posture in nine subjects to evaluate of the effect of postural differences on reflex response. Reflex recordings were also performed in six subjects from some other muscles together with the trapezius by the stimulation of the peroneal nerve. Reflex responses including three components were recorded from the trapezius muscle (unilateral or bilateral) by electrical stimulation of the peroneal nerve. The most stable of them was the second component (23/31) which had a latency of 72.6 ± 7.9 ms for the ipsilateral, and 74.2 ± 8.5 ms for the contralateral trapezius (15/31). For median stimulation, the first component recorded at 32.0 ± 6.7 ms was the most stable (25/31). The second component was more frequently recorded on the contralateral side (14/31). Erect posture increased the amplitude of these components. Upper and lower extremity proprioceptive inputs modulate the EMG activity of the trapezius. This modulation probably related with postural adjustments.

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Microscopic polyangiitis is a small vessel vasculitis which is rarely associated with ischemic stroke. Cerebrovascular disease has rarely been reported in connection with this disease. It may cause fatal hemorrhage, hemorrhagic conversion and multiple lacunar infarcts. We report here a 55-year-old woman with left medullary oblangata infarction without any symptoms of microscopic polyangiitis. During hospitalization, retinal ischemia, mononeuritis multiplex and pulmonary infiltration developed. Sural nerve biopsy was concomitant with small vessel vasculitis. Elevated CRP and sedimentation and positive P-ANCA led to confirmation of a diagnosis of microscopic polyangiitis. Our patient is a rare case of microscopic polyangiitis presenting with medullary infarction. Although the characteristics of this disease are well-known, the first symptom can be a medullary infarction, which has not been reported in literature before.

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