Clinical Neurological Examination Research Articles

Study of the association of serum level of nesfatin-1 and diabetic kidney disease in patients with type 2 diabetes

Background Nesfatin-1 is a newly found anorectic neuropeptide with potent metabolic regulatory effects, whose peripheral levels are shown to be elevated in diabetes. It is a newly discovered hypothalamic neuropeptide that regulates appetite. Its discovery has generated great interest in the scientific community because of its implication in energy and glucose homeostasis. Nesfatin-1 is an amino-acid peptide originating from the cleavage of nucleobindin2. It has a molecular weight of 9.8 kDa and the half-life of nucleobindin2 mRNA is ∼6 h. Interestingly, nesfatin-1 is also expressed in pancreatic β-cells, where it is localized with insulin in secretion vesicles. The structure of nesfatin-1 is also tripartite; the segment starting from the N-terminal end and going up to 23 amino acids is called N23, the middle segment covering the amino acids from 23 to 53 is called M30, and the segment from the 53rd to 82nd amino acids toward the carboxyl terminus is called C29. Objective We compared serum nesfatin-1 in patients with type 2 diabetes with evidence of diabetic kidney disease (DKD) [urinary albumin–creatinine ratio (UACR) >300 mg/day or reduced estimated glomerular filtration rate (eGFR) Patients and methods Ninety patients attending the outpatient clinics at Alexandria Main University Hospital and Alexandria Police Hospital, Egypt, were enrolled in this cross-sectional study to determine the association of serum level of nesfatin-1 and DKD in patients with type 2 diabetes. They were divided into three groups: group I included 30 type 2 diabetic patients with DKD. Group II included 30 type 2 diabetic patients without DKD. Group III included 30 nondiabetic healthy controls matched for age and sex with group I. Assessment included a thorough assessment of history, complete clinical examination, neurological examination, fundus examination, and laboratory investigations including metabolic profile and plasma nesfatin-1 by enzyme-linked immunosorbent assay. Results The study showed a statistically significant difference between the three studied groups in terms of age (P Conclusion Serum nesfatin-1 was not significantly higher in albuminuric type 2 diabetic patients compared with normoalbuminuric patients. Serum nesfatin also did not correlate with eGFR and creatinine in the different groups studied. Serum nesfatin-1 may not be useful as an early marker of DKD instead of albuminuria. More studies are needed to identify the role and the significance of nesfatin in diabetic patients.

The Iced Drink Test - A Bedside Test for Diagnosis of Bulbar Myasthenia

The diagnosis of Myasthenia gravis (MG) is chiefly based on clinical symptoms and neurological examination coupled with serological testing for the presence of auto-antibodies, electrodiagnostic studies consisting of repetitive nerve stimulation test (RNST) and single fiber electromyography (SFEMG) and pharmacologic tests such as the edrophonium test. The ice pack test, based on the scientific principle that cooling improves neuromuscular transmission in Myasthenia gravis (MG), is a low cost, sensitive and specific test used for differentiating myasthenic ptosis from other causes of ptosis. Based on the same principle, we propose the iced drink test as a quick, bedside test for differentiating bulbar weakness caused by myasthenia gravis from other causes of lower motor neuron type of bulbar weakness. The iced drink test, if validated, can prove to be useful in quick diagnosis of bulbar myasthenia.

The diagnostic efficacy of clinical findings and electrophysiological studies in carpal tunnel syndrome

Objective. The aim of the study was to examine the relation between clinical findings, neurological examination and electrophysiological studies in diagnosing carpal tunnel syndrome (CTS) and share our institutional experience in patients with CTS. Methods. Patients presenting with complaints of pain, paresthesia, and weakness in hands who diagnosed CTS between 2014 and 2015 were examined retrospectively. Demographic characteristics, clinical and neurological examination findings and electrodiagnostic evaluations were analyzed. Results. A total of 348 patients were included to the study. Weight and height measurements were significantly higher in patients with CTS on the right side ( p =0.05 and p =0.04, respectively). Right hand side was the most dominant lateralization in patients with CTS ( p =0.001) but there was no significant correlation for left side ( p >0.05). The score of visual analogue scale was positively correlated with the severity of CTS ( p =0.001). Thenar atrophy, hypoesthesia, positivity of Tinel and Phalen tests were also related to bilateral CTS ( p =0.001 for each). Conclusion. We agree that clinical features, neurological examination findings and electrophysiological studies are effective diagnostic means in patients with CTS.

Clinical Assessment of Low Back Pain: A Neurosurgical Point of View

AbstractThe diagnosis of low back pain (LBP) is complex and multifactorial, and a clear etiology responsible for the symptoms is often not detectable. Clinical history and neurological examination are essential for differential diagnosis, because they allow the identification of the specific pathology. The radiological investigation allows to confirm diagnosis, but the indication must always be correlated with clinical findings to not perform unnecessary diagnostic procedures. Management of LBP can involve many specialists – neurosurgeon, orthopedist, physiatrist, physiotherapist – everyone with different knowledge and experience because very often the cause is multifactorial. However, it is mandatory to clarify diagnosis of LBP; in this way, the clinical pathway is fundamental to understand pathogenesis and to determine appropriate treatment.

The Displays of Connective Tissue Dysplasia (Hypermobility) in Patients with Vertebral Syndrome of Lumbosacral Spine

In recent years medical practitioners more often pay their attention on role of pathology of different organs and systems of human’s body which are associated with connective tissue dysplasia. The importance of this problem is caused by the great prevalence of connective tissue dysplasia, systemacity of damage, high probability of different diseases’ formation. Connective tissue dysplasia is the violation of the connective tissue structure during embryonic and postnatal periods because of genetically modified fibrillogenesis of extracellular matrix, leading to homeostasis disorder on tissue and organ levels with the progressive course. There was held the clinical neurological examination with 120 patients, who had neurological features of vertebral syndrome of lumbosacral spine.
 Analysis of the clinical examination results demonstrated that patients with vertebral syndrome of lumbosacral spine (p<0,05) more common can occur pathology of joints and varicose veins of the lower extremities. Significantly (p<0,05) (scoliosis, kyphosis, kyphoscoliosis, tendency to dislocation, stretching the ligaments) increase the duration of treatment and the expression of a pain syndrome. The results of examination and monitoring of patients in the dynamics of the treatment showed that patients with vertebral syndrome of lumbosacral spine (p<0,05) more often have anatomical changes in the lumbosacral spine than patients without evidence of DST.

Clinical Presentation, Magnetic Resonance Angiography, Ultrasound Findings, and Stroke Patterns in Patients with Vertebral Artery Dissection

Background/Aims: Vertebral artery dissection (VAD) is an important cause of ischemic stroke. In this observational study, clinical data, magnetic resonance (MR) and ultrasound (US) imaging findings and ischemic patterns were analyzed. Methods: Forty-seven patients with a diagnosis of VAD underwent clinical examination, US, MR of the brain and neck and MR angiography (MRA) of the cervical arteries. Vascular abnormalities and ischemic brain lesions were noted. Data were evaluated separately and compared for spontaneous and traumatic VAD subgroups. Results: The most common overall clinical symptom was vertigo followed by neck pain. In the traumatic subgroup, vertigo was relatively rare (p = 0.022). Most common MRA findings were vessel irregularity and vessel occlusions. Ischemic lesions occurred significantly more frequently after spontaneous than after traumatic VAD (p = 0.009). Unilateral VAD was significantly more common in non-dominant vertebral arteries (p < 0.001). Mortality after trauma was not only due to VAD complications but also due to other trauma-related injuries. Conclusion: The variability of MR and US imaging findings in patients with VAD is illustrated. The algorithm of management should be based on a multimodality approach involving patient history and clinical neurological examination. Several types of vessel abnormalities and ischemic lesion in diverse locations may point to arterial dissection, and the differential diagnosis of VAD must be kept in mind.

Schizencephaly Associated with Polymicrogirya – Cause for Late-Onset Epileptic Seizures in Adult. A Case Report.

Abstract The article presents the case of a 61-year old female patient, with no history of neurological illness, who presents a rapid onset of two convulsive seizures, triggered by a psychological trauma. The first convulsive seizure is repeated within 24 hours. The general, as well as the neurological clinical examination have not found any pathological signs. MRI scanning of the brain pointed to right-parietal schizencephaly, associated with polymicrogyria, the believed causes of the epileptic seizures.

An Attempt of Early Detection of Poor Outcome after Whiplash.

The main concern with whiplash is that a large proportion of whiplash patients experience disabling symptoms or whiplash-associated disorders (WAD) for months if not years following the accident. Therefore, identifying early prognostic factors of WAD development is important as WAD have widespread clinical and economic consequences. In order to tackle that question, our study was specifically aimed at combining several methods of investigation in the same WAD patients at the acute stage and 6 months later. Our longitudinal, open, prospective, multi-center study included 38 whiplash patients, and 13 healthy volunteers matched for age, gender, and socio-economic status with the whiplash group. Whiplash patients were evaluated 15–21 days after road accident, and 6 months later. At each appointment, patients underwent a neuropsychological evaluation, a full clinical neurological examination, neurophysiological and postural tests, oto-neurological tests, cervical spine cord magnetic resonance imaging (MRI) with tractography (DTI). At 6 months, whiplash patients were categorized into two subgroups based on the results of the Diagnostic and Statistical Manual of Mental Disorders as having either favorable or unfavorable progression [an unfavorable classification corresponding to the presence of post-concussion symptom (PCS)] and we searched retrospectively for early prognostic factors of WAD predicting the passage to chronicity. We found that patients displaying high level of catastrophizing at the acute stage and/or post-traumatic stress disorder associated with either abnormalities in head or trunk kinematics, abnormal test of the otolithic function and at the Equitest or a combination of these syndromes, turned to chronicity. This study suggests that low-grade whiplash patients should be submitted as early as possible after the trauma to neuropsychological and motor control tests in a specialized consultation. In addition, they should be evaluated by a neuro-otologist for a detailed examination of vestibular functions, which should include cervical vestibular evoked myogenic potential. Then, if diagnosed at risk of WAD, these patients should be subjected to an intensive preventive rehabilitation program, including vestibular rehabilitation if required.

The use of electroneurography for differentiation of neuropathic pain component in patients with chronic pain syndromes of the lumbar-sacral localization

Aim of research: to study the possibility to use the separate methods of electroneurography, namely nociceptive flexor reflex (NFR) for determination of neuropathic component of pain in patients with the chronic pain syndrome of lumbar-sacral localization.Materials and methods: 103 patients with the chronic vertebrogenic lumbar-sacral pain syndrome (CVLSPS) and 30 practically healthy persons were examined. According to the results of clinical-neurological examination all patients were divided in groups that corresponded to the first four groups of Classification of spine disease of Quebec special commission (CSDQSC). The determination of state of peripheral neuromotor apparatus was realized using electroneurography of the calf nerve, after that the NFR study was realized.Results: the speeds of impulse passing on the calf nerve did not differ between patients with CVLSPS and the control group. The reliable decrease of pain threshold (PT) (7,65±1,77), reflex threshold (RT) (9,67±2,0) and ratio of pain threshold/reflex threshold (PT/RT) (0,77±0,11) were revealed in the group of patients with CVLSPS comparing with the group of practically healthy examined persons (8,90±0,94, 10,38±1,05 and 0,86±0,07 respectively). At the analysis of NFR parameters between the groups of patients with CVLSPS the statistically significant differences in PT and RT parameters were not found. PT/RT ratio was statistically reliably lower in IV group (0,73±0,12) comparing with other three groups of patients.Conclusions: patients with CVLSPS have the reliably lower values of PT and RT and PT/RT ratio comparing with practically healthy persons. PT/RT ratio is the most specific parameter of NFR for differentiation of nociceptive and neuropathic pain components

Consciousness disorders from neurological view

"Disturbances of consciousness of unknown origin" require an interdisciplinary approach due to the broad variety of possibly underlying causes. Primary neurological pathologies account for about half of the cases, which emphasizes the key role of the neurologist in the primary assessment and planning of the diagnostic and therapeutic strategy. The most important goal is to quickly identify patients with extremely time-critical conditions like ischemic stroke, bacterial meningitis or space occupying intracranial hemorrhage. The most important tool to generate a working hypothesis is the clinical neurological examination. However, even in apparently neurological presentations like e.g. first ever epileptic seizure, underlying even non-neurological pathologies have to be considered.

INFLUENCING FACTORS ON LIFE QUALITY IN PATIENTS WITH EXTRAPYRAMIDAL DISTURBANCES

Quality of life of patients with extrapyramidal hyperkinesia (EPH) depends on variety of different factors with leads to development of social-economic problems. 76 patients with different forms of hyperkinesia were observed. Clinical neurologic and neuropsychological examination and estimation of life quality questioner scale were conducted. Results show that quality of life of patients with EPH depends on clinical and non-clinical factors. Analysis reveal, that main factor is inheritance, so patients and all close relatives must go through genealogic and clinical examination. Timely done differential diagnosis and correctly conducted therapy gradually increase quality of life of patients with EPH.

Semiautomated Magnetic Resonance Imaging Assessment of Carotid Plaque Lipid Content

The composition of a carotid plaque is important for plaque vulnerability and stroke risk. The main aim of this study was to assess the potential of semiautomated segmentation of carotid plaque magnetic resonance imaging (MRI) in the assessment of the size of the lipid-rich necrotic core (LRNC). Thirty-four consecutive patients with carotid stenosis of 70% or higher, who were scheduled for carotid endarterectomy, underwent a clinical neurological examination, Color duplex ultrasound, 3-T MRI with an 8-channel carotid coil, and blood tests. All examinations were performed less than 24 hours prior to surgery and plaques were assessed histologically immediately following endarterectomy. Plaques were defined as symptomatic when associated with ipsilateral cerebral ischemic symptoms within 30 days prior to inclusion. The level of agreement between the size of the LRNC and calcification on MRI to the histological estimation of the same tissue components, plaque echolucency on ultrasound, and symptoms was assessed. The size of the LRNC on MRI was significantly correlated to the percentage amount of lipid per plaque on histological assessment (P = .010, r = .5), and to echogenicity on ultrasound with echolucent plaques having larger LRNC than echogenic plaques (P = .001, r = -.7). In this study, we found that semiautomated MRI assessments of the percentage LRNC in carotid plaques were significantly correlated to the percentage LRNC per plaque on histological assessment, and to echogenicity on ultrasound with echolucent plaques having larger LRNC than echogenic plaques.

A 10-yr follow-up study for the detection of peripheral neuropathy in young patients with type 1 diabetes.

The main objective of this work was to follow-up the development of diabetic neuropathy (DN) and its severity in patients with type 1 diabetes over 10 yr. Our intention was also to observe risk factor changes and verify which of them influence the development of neuropathy. The other objective was longitudinal study of electrophysiological parameters, focusing on the early diagnosis of DN. The prospective study comprised of 62 young patients with type 1 diabetes mellitus (DM) aged 13.9 ± 5.89 yr, with diabetes duration of 5.56 ± 5.11 yr, treated with an intensified insulin regimen. All patients underwent a detailed clinical neurological examination, nerve conduction study (NCS) and biothesiometry three times (baseline, after 5 yr, after 10 yr). During the follow-up there was an increase in DN prevalence from 24.2% to 62.9% (p < 0.001). The proportion of patients with subclinical neuropathy increased from 17.7% to 46.8% (p < 0.001) and patients with clinical neuropathy from 6.5% to 16.1% (p < 0.001). The main contribution factors for rapid growth of the DN prevalence were poor glycaemic control, diabetes duration and patient's age. Regarding the conduction parameters, the most significant changes were observed in sural nerve SNAP amplitude (-5.2 m/s, p < 0.001) and sural nerve conduction velocity (-8.2 uV, p < 0.001). In contrast, the least significant changes were in peroneal nerve CMAP amplitude (-0.65 mV, p = 0.008). The results of the study demonstrated a progressive increase in the DN prevalence over time, in particular its subclinical stages. The long-term poor glycaemic control was a determining factor in the rapid DN development. The sensory conduction parameters deteriorated faster than the motor parameters. The present study is one of few of those in type 1 DM, which in relation to risk factors assess not only the presence of neuropathy, but also its severity. The results support the necessity of a regular diagnostic search for DN in diabetic children.

Clinical and neurological predictors of outcome in the acute phase of cerebellar hemorrhage

Objective: To study new data about clinical and neurological predictors of outcome in the acute phase of cerebellar hemorrhage.Materials and methods: We analyzed the data of the clinical-neurological examination and the results of the treatment of 95 patients with cerebellum hemorrhage (CH) in the acute phase.Results: According to the Glasgow Outcome Scale (GOS) favorable outcome was in 55 (57.9%) patients, poor — in 12 (12,6%) and fatal — in 28 (29,5%) (5–4, 3–2 and 1 points). We showed significant difference with respect to the level of consciousness according to the Glasgow Coma Scale (GCS) (p=0,000), systolic blood pressure (p=0,013), lesion of the cranial nerves (p=0,000), movement disorders (p=0,008), Babinski reflex (p=0,001), sensitivity disturbance (p=0,001) and pelvic organ dysfunction (p=0,000).Conclusions. GCS score of greater than 13 points, normal flexor plantar response and absence of cranial nerves lesion are strong predictive factors of favorable outcome.

Electrophysiologic pattern and prevalence of subclinical peripheral neuropathy in children and adolescents with type I diabetes mellitus in Iran.

Objectives:To evaluate electrophysiologic pattern of subclinical diabetic peripheral neuropathy (DPN) in children and adolescents with type 1 diabetes mellitus (T1DM) based on nerve conduction study.Methods:In this cross sectional study, 40 children and adolescents (62.5% female with mean age of 12.73 ± 0.43 years) with T1DM for at least 5 years attending the Pediatrics Clinics. Tabriz University of Medical Sciences, Tabriz, Iran, between 2014 and 2015 were recruited. Demographic and laboratory findings were recorded and all patients underwent clinical neurological examination and electrophysiologic studies.Results:According to electrophysiologic studies, DPN was found in 57.5% of patients including early stage of neuropathy (15%), mild sensory axonal neuropathy (25%), mild sensory motor axonal neuropathy (10%), and moderate sensory motor axonal neuropathy (7.5%). Age, duration of diabetes, fasting blood sugar, and glycosylated hemoglobin levels had no significant difference between patients with and without DPN. Reduced deep tendon reflexes were observed in the upper limb (30%) and lower limb (47.5%) of patients, which were both significantly higher in DPN patients (upper limb [p=0.03] and lower limb [p=0.04]). The most frequent electrophysiologic findings were unobtainable H-reflex, low amplitude sural, and median sensory responses.Conclusion:Subclinical DPN is a common complication found in children and adolescents with TIDM and peripheral sensory axonal neuropathy is the most frequent type. Nerve conduction study is recommended for early detection of DPN and prevention of its progress.

Testing cranial nerve VII: It is all in the wording

During our practice of clinical neurological examination we frequently observed that patients, upon testing of cranial nerve VII, when instructed to “wrinkle their forehead” (to evaluate the innervation of the M. frontalis), seem to falsely “frown” (i.e. innervate the corrugator supercilii). Here, we set out to prospectively evaluate prevalence and characteristics of this phenomenon.Using a semi-structured questionnaire, we show that the majority of colleagues at our center shared our observation. Further, we demonstrate that of 113 unselected prospectively examined patients in fact 54.9% showed false frowning. This effect was irrespective of gender and only marginally influenced by age, chief complaint and clinical setting. Of note, all patients with initial frowning (or other “incorrect” reaction), when instructed to “raise their eye-brows”, showed correct wrinkling.In summary, we were able to prospectively assess a highly prevalent artifact of the clinical exam, highlighting the critical significance of the correct wording during the neurological exam.

Proposal for electrodiagnostic evaluation of patients with suspected ulnar neuropathy at the elbow.

To develop an evidence-based electrodiagnostic (EDx) approach to patients with suspected ulnar neuropathy at the elbow (UNE). We prospectively recruited patients with suspected UNE, took a history and performed clinical neurologic, EDx and ultrasonographic (US) examinations. Ulnar motor and mixed nerve 5 × 2 cm, 2 × 4 cm and 10 cm studies across the elbow were compared regarding sensitivity and precise localization of UNE. In 175 evaluated patients, the highest sensitivity/precise localization was demonstrated by the motor 5 × 2 cm study (93%/92%), followed by the 2 × 4 cm study (89%/83%) and the 10-cm study (82%/0%). The sensitivities of mixed ulnar nerve studies to diagnose/precisely localize UNE were 12-23%/27-36% lower than the corresponding motor studies. Based on our data, we suggest starting EDx evaluation of UNE with a motor 2 × 4 cm study (recording from either the abductor digiti minimi or the first dorsal interosseous muscles), with two additional stimulation sites being added if the initial result is negative. This results in a motor 4 × 2 cm study. In all suspected UNE patients, an antidromic sensory study to the 5th finger should also be performed. The proposed EDx protocol is robust, sensitive and time efficient. We hope that it will improve the diagnosis of UNE.

Cold, hard cash: Clinical assessment of stereognosis using common objects and coins in older subjects

Stereognosis, tactile gnosis, or the ability to identify objects or discriminate between objects using touch alone, is an important hand function commonly assessed on clinical neurological examination [1]. Reduced stereognosis is associated with reduced manual dexterity in older subjects [2] and impairment of this function can be disabling, particularly in tasks requiring fine manual dexterity where vision is limited, obscured or impaired. Stereognosis is a complex neurological process, involving peripheral touch receptors such as Meissner’s corpuscles, cutaneous nerves, larger nerves particularly the median nerve, the dorsal column nuclei and neurones, medial leminisceal pathway, the thalamus and cerebral cortex and damage to any of these can impair tactile discrimination. When euro coins were released in 2002 they were designed with different diameters, weights and milled edges to allow people with visual impairment to discriminate between them using stereognosis (Fig. 1). It is known that the density of Meissner’s corpuscles reduces significantly in subjects over 50 years and that, in experimental conditions, tactile sensitivity is decreased in older subjects [3] although median nerve function and conduction velocity is

The Role of BDNF Gene Polymorphism in Formation of Clinical Characteristics of Migraine

Objective: There is evidence that brain-derived neurotrophic factor (BDNF) has a role in migraine pathophysiology. In our research, association of substitutions in BDNF gene (rs6265, rs11030107, rs2049046) with clinical parameters of migraine is considered. Background: Brain-derived neurotrophic factor (BDNF) is a neurotrophin presented widely in central nervous system. BDNF regulates axonal growth and differentiation; synapse formation; activity of dopaminergic, serotoninergic, GABA-ergic, and cholinergic neurons. Apparently, BDNF participates in the development of the primary forms of headaches. Patients and Methods:The research included 155 patients with migraine (according to ICHD-III, 2013). The control group consisted in 203 unexamined individuals. Patients underwent clinical neurological examination and blood sampling. Genotypes were determined using PCR-RFLP method. Results: We did not find a significant association between studied SNPs and migraine. We showed that the TT-genotype of rs2049046 influences the migraine chronification the episodes transform by regression of prodromal period, and the endurance of episodes themselves shortens. The GG genotype of rs6265 has no significant influence on the formation and manifestation of migraine. Possession of G-allele of rs1030107 influences the formation of drug abuse and higher frequency of photo- and phonophobia during the migraine episode. Conclusions: Our results suggest that the substitutions rs2049046 and rs1030107 in BDNF gene play role in formation of clinical manifestations of migraine.

Prenatal ultrasound evaluation of segmental level of neurological lesion in fetuses with myelomeningocele: development of a new technique.

To report our preliminary experience in the use of prenatal ultrasound examination to assess lower-limb movements in fetuses with myelomeningocele. We aimed to determine the accuracy of this method to establish the segmental level of neurological lesion, as this is the best known predictor of the future ability to walk. This was a preliminary, observational study including fetuses with myelomeningocele operated on prenatally. The patterns of movements present and absent in the affected fetuses' lower limbs were evaluated systematically by ultrasound examination. According to the known nerve function associated with each muscle group, the segmental level of neurological lesion was established before birth. The agreement for the segmental levels assigned, between the prenatal ultrasound technique and the classical neurological clinical examination after birth (gold standard), was tested using the weighed kappa (wκ) index. Seventy-one fetuses with myelomeningocele were evaluated at the Hospital Universitari Vall d'Hebron. After counseling, the parents opted for prenatal surgery (26 cases), termination of pregnancy (43 cases) or postnatal repair (two cases). Five patients did not fulfil the inclusion criteria for prenatal surgery and three were excluded after birth. In the 18 fetuses that underwent surgery and were analyzed, the agreement between prenatal and postnatal segmental levels assigned was 91.7% for the right limb (wκ = 0.80) and 88.9% for the left limb (wκ = 0.73). The agreement found between prenatal and postnatal assignment of level of lesion in this preliminary study suggests that neurological sonographic evaluation is feasible before birth. This may provide accurate individualized information about the motor function and future ambulation prognosis of fetuses with myelomeningocele.