DOI: 10.3897/folmed.68.e144993

Authors: Marina Coelho, Henrique Sousa, Tiago Mascarenhas, Pedro Avelar, Beatriz Marques, Carla Henriques

Abstract: High-grade gliomas are aggressive primary brain tumors that are extremely malignant, especially isocitrate dehydrogenase (IDH) wildtype glioblastoma. This case concerns a male 54-year-old with a history of substance abuse who was undervalued and diagnosed with a large glioblastoma following several months of inappropriate behavior. Although there has been some recent progress, a tumor of this size is still considered incurable and is currently a rare diagnosis in Western countries.

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DOI: 10.3897/folmed.68.e193784

Authors: Krasimir Avramov, Snezhana Terziyska, Ivan Yakov, Todor Georgiev, Aneliya Draganova, Kiril Terziyski

Abstract: Introduction: Restless legs syndrome (RLS) is a frequent yet underrecognized comorbidity in rheumatoid arthritis (RA), potentially driven by inflammation-mediated disturbances in iron metabolism. Aim: This study investigated the relationship between inflammatory markers and iron homeostasis in RA patients with and without RLS. Methods: This monocentric cross-sectional study included 32 RA patients, 12 of whom had RLS and 20 who did not. RLS was diagnosed using ICSD-3 criteria, and severity was measured using IRLSSG scores. Clinical data, disease activity (DAS28-CRP), reported sleep parameters, and laboratory markers (IL-6, TNF-α, serum iron, ferritin, and hepcidin-25) were analyzed. Between-group comparisons and receiver operating characteristic (ROC) analyses were performed. Results: The prevalence of RLS in our cohort was 37.5%. Compared to RA patients without RLS, those with RLS demonstrated significantly prolonged reported sleep latency (42.5 vs. 25.0 min, p<0.001, δ=0.86); higher disease activity (DAS28-CRP 4.64 vs. 3.82, p=0.0029, δ=0.64); elevated IL-6 (13.55 vs. 2.84 pg/mL, p=0.0022, δ=0.66); and hepcidin-25 levels (640 vs. 455 pg/mL, p=0.0382, δ=0.48) and lower serum iron (15.35 vs. 19.30 µmol/L, p=0.0292, δ=−0.47). Ferritin and TNF-α did not differ significantly. ROC analysis showed strong discrimination for reported sleep latency (AUC 0.93), IL-6 (AUC 0.83), and DAS28-CRP (AUC 0.82). Conclusions: RA patients with RLS demonstrate a distinct biological profile characterized by heightened inflammatory activity and functional iron deficiency. The IL-6–hepcidin–iron axis emerges as a central mechanistic pathway linking systemic inflammation to RLS pathophysiology. These findings support the concept that the magnitude of inflammatory activation, rather than its mere presence, contributes to RLS development in RA and highlight potential targets for improved diagnostic and therapeutic strategies.

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DOI: 10.3897/folmed.68.e193687

Authors: Todor Georgiev, Kiril Terziyski

Abstract: Aim: The aim of this study was to evaluate clinical and polysomnographic differences in sleep architecture between patients with chronic insomnia (CI) and healthy controls (HC), as well as between CI phenotypes with short and normal sleep duration. Materials and methods: This cross-sectional study included 35 patients with CI and 27 age- and sex-matched HC. All participants completed the Insomnia Severity Index (ISI) and Beck Depression Inventory (BDI) and underwent single-night home polysomnography. Based on 14-day sleep diaries, patients were categorized into insomnia with self-reported short sleep duration (ISSD; <6 h) and insomnia with self-reported normal sleep duration (INSD; ≥6 h). Group comparisons and correlation analyses were performed. Results: Compared with HC, CI patients showed significantly higher ISI and BDI scores, increased total wake time (TWT), wake after sleep onset (WASO), and N2 sleep duration, along with reduced N3 sleep and sleep efficiency (SE). No significant differences were observed in total sleep time or sleep latency. ISSD patients demonstrated significantly higher questionnaire scores, shorter TST, and reduced REM sleep compared with INSD. ISI correlated positively with BDI, TWT, SL, and WASO and negatively with sleep efficiency. Conclusion: CI is associated with objective alterations in sleep architecture, particularly increased nocturnal wakefulness and reduced deep sleep. The ISSD phenotype appears clinically more severe, with greater symptom burden and reduced REM sleep, supporting the value of combining subjective and objective measures in insomnia phenotyping.

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DOI: 10.3897/folmed.68.e173599

Authors: Hulya Özkan, Serefnur Ozturk

Abstract: Introduction: Stroke is the second most common cause of death in the world. Identifying the factors that influence stroke prognosis in advance is important to take the necessary precautions and improve the patient’s chances of survival. Aim: We investigated the clinical and laboratory parameters that predict mortality and prognosis in patients with acute stroke in a neurological intensive care unit (ICU). Materials and methods: A total of 219 adult acute stroke patients who were admitted to the neurological ICU over two years were included in the study. Each patient’s coma score was determined using the Glasgow Coma Scale (GCS) from day one to day 12. The patients’ clinical parameters, laboratory and brain scans results were recorded. On day 12, the characteristics of patients still alive and those who had died by that time were compared. Results: One hundred and forty-three of the patients died within 12 days of the stroke. In patients who died, fasting blood glucose, hemoglobin, blood urea, blood creatinine and triglyceride levels measured on the first day were higher than in patients who survived (p<0.05) and GCS calculated from the moment of hospitalization to day 11 was significantly lower (p<0.05). There was a negative correlation between GCS and laboratory parameters including fasting blood glucose, blood urea, triglycerides, leukocytes, and fibrinogen. Conclusion: We found a 65% mortality rate in patients with acute stroke. We demonstrated that the severity of the initial neurological condition is one of the most important poor prognostic factors, and abnormal laboratory parameters should be carefully monitored in patients because of their negative impact on short-term stroke prognosis.

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DOI: 10.3897/folmed.68.e163452

Authors: Bilinc Dogruoz Karatekin, Irem Azizagaoglu Akbulut, Seyma Nur Bayindir, Ismail Hakan Akbulut, Betul Ceyda Senyurt, Gulnihal Kesik, Afitap Icagasioglu

Abstract: Introduction: Stroke is a major cause of long-term disability, often limiting individuals’ participation in social, occupational, and community life due to both functional impairments and environmental barriers. Understanding the interaction between these factors is crucial for optimizing rehabilitation outcomes. Aim: This study aimed to assess functional independence, quality of life, social participation, and environmental barriers in individuals with chronic stroke and to compare outcomes based on stroke duration (<5 years vs. >5 years). Material and methods: A total of 50 chronic stroke patients followed in a neurorehabilitation outpatient clinic were included. Sociodemographic and stroke-related data were collected. Functional Independence Measure (FIM), Short Form-12 (SF-12), Frenchay Activities Index (FAI), and Craig Hospital Inventory of Environmental Factors - Short Form (CHIEF-SF) were applied. Additionally, the patients were grouped by stroke duration to compare long-term outcomes. Results: The mean age of participants was 58.12±12.41 years. Mean FIM motor and cognitive scores were 58.12±24.24 and 31.12±7.45, respectively, with a total FIM score of 88.64±28.49. SF-12 physical and mental scores were 37.78±8.92 and 47.32±12.80. FAI and CHIEF-SF mean scores were 12.92±11.16 and 13.90±17.16, respectively. FIM motor score was significantly associated with age, employment, income, stroke duration, and affected side (p<0.05). FIM cognitive scores correlated with income (p<0.05); total FIM score was associated with sex, employment, and income (p<0.05). SF-12 physical scores were significantly related to employment (p<0.05). FAI was associated with age, sex, income, and stroke duration (p<0.05), while CHIEF-SF scores correlated with education, employment, and stroke duration (p<0.05). Patients with >5 years poststroke had significantly better FIM motor, cognitive, and total scores (p<0.001, p=0.031, p=0.001), and higher SF-12 physical scores (p=0.051). Conclusion: Stroke duration and socioeconomic context significantly influence participation and independence. Long-term survivors appear to develop adaptive strategies that mitigate environmental barriers. Integrative rehabilitation approaches that address both physical function and contextual challenges are crucial for improving long-term participation and autonomy in stroke survivors.

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DOI: 10.3897/folmed.68.e166867

Authors: Gallayaporn Nantachai, Michael Maes, Vinh-Long Tran-Chi, Arisara Amrapala, Asara Vasupanrajit, Solaphat Hemrungrojn, Chavit Tunvirachaisakul

Abstract: Introduction: Amnestic mild cognitive impairment (aMCI) is characterized by changes in lipids and oxidative stress (OS). It is crucial to exclude patients with major depression (MDD) to accurately evaluate these biomarkers in aMCI. Aims: To examine lipid and oxidative stress biomarkers associated with aMCI versus normal controls. Materials and methods: We performed a case-control analysis involving 61 individuals with aMCI (without MDD) and 60 healthy controls. We assessed the severity of aMCI, distress symptoms of old age, and lipid/OS biomarkers. Results: The levels of serum sulfhydryl (-SH) groups were significantly higher in individuals with aMCI, while the levels of malondialdehyde (MDA) were significantly lower in the same group. Serum advanced oxidation protein products, glutathione, and folic acid did not show any notable variations. In individuals with aMCI, we observed an elevated apolipoprotein B (ApoB)/apolipoprotein A (ApoA) ratio, as well as decreased levels of high-density lipoprotein cholesterol (HDL), ApoA, and a reverse cholesterol transport (RCT) index. The simultaneous presence of aMCI and subclinical depressive symptoms is marked by elevated levels of triglycerides and ApoB, as well as decreased levels of ApoA and HDL. A significant portion of the variability (24.9%) in a quantitative MCI severity score can be attributed to -SH groups, age (positively), MDA, and education (inversely). Conclusion: The alterations in MDA and -SH levels in aMCI may potentially disrupt redox signaling, which can affect cell signaling and homeostatic setpoints. The interaction between aMCI and subclinical depressive symptoms can lead to increased atherogenicity and reduced antiatherogenic protection.

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DOI: 10.3897/folmed.67.e164775

Authors: Dimitar Maslarov, Jane Maslarova-Gelov, Ivan Gelov, Natasha Angelova, Blagovesta Dafkova, Simona Nikolova, Desislava Drenska

Abstract: Abstract Introduction: Recently, recurrent ischemic stroke has attracted significant attention in both research and clinical settings. Aim: A comparative retrospective analysis of risk factors and clinical characteristics in elderly patients (≥65 years) experiencing a first-ever, second, third, and recurrent cerebral infarction. Materials and methods: This study included 260 patients with acute stroke admitted to the Neurology Clinic. Patients were classified into three groups: Group 1—first-ever stroke (n=212), Group 2—second stroke (n=35), and Group 3—third and subsequent stroke (n=13). A model focused on the most common vascular risk factors, etiological classifications, and assessment scales. Clinical, instrumental, and statistical methods were applied. Results: Two independent risk factors with strong prognostic relevance were identified: age and dyslipidemia (noted specifically between Group 1 and Group 2). Clinically important comorbidities with moderate impact on vascular risk included arrhythmias and conduction disorders, other cardiovascular diseases, and diabetes mellitus. No statistically significant differences were found among the three groups with respect to sex, arterial hypertension, smoking status, or affected vascular territories. The main TOAST criteria were large-artery atherosclerosis, cardioembolism, and small-vessel disease. Among patients in Groups 2 and 3, phenotypes A1, A2, S3, C1, and C2 (ASCOD) were identified as significant etiological factors. The incidence of subsequent cerebrovascular events was 18.46%. Conclusion: Recurrence of ischemic stroke is a significant barrier to the development of effective, long-term prognostic models, the implementation of secondary prevention strategies, and the advancement of therapeutic paradigms.

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DOI: 10.3897/folmed.67.e144469

Authors: Ivo I. Kehayov, Atanas N. Davarski, Georgi S. Slavov, Borislav D. Kitov

Abstract: Intradural disc herniation is a rare complication that, despite the precision of modern diagnostic tools, is usually confirmed intraoperatively. Therefore, we aimed to present a case of intradural disc herniation, reviewing the incidence, pathogenesis, clinical presentation, diagnostic options, and management. A 67-year-old man presented with a history of hypertension, rheumatoid arthritis, and previous surgery for a herniated disc at the L4–L5 level. He was suffering from severe low back pain radiating towards the legs for four weeks that was followed by progressive weakness of the lower extremities to the point of inability to walk unassisted. The neurological examination demonstrated weakness of the muscles of both thighs and distal legs, absent knee-jerk and Achilles reflexes bilaterally, hypoesthesia of L4, L5, and S1 dermatomes bilaterally, and inability for plantar and dorsiflexion of the feet, while the bowel and bladder control were preserved. Magnetic resonance imaging (MRI) showed signs suggestive of disruption of the posterior longitudinal ligament at the L3–L4 level, the presence of intradural air, and a ratio between the maximum diameter of the herniated disc and the maximum diameter of the dural sac of 0.75. These findings made us suspect an intradural herniated disc at the L3–L4 level that was confirmed intraoperatively. MRI findings that detect disruption of the posterior longitudinal ligament, presence of air in the intradural space, and a high ratio between the maximum diameters of the herniated disc and the dural sac are suggestive of the diagnosis, especially in the presence of two or more imaging findings.

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DOI: 10.3897/folmed.67.e151493

Authors: Todor Georgiev, Aneliya Draganova, Krasimir Avramov, Kiril Terziyski

Abstract: Chronic insomnia is the most common sleep disorder, affecting up to 10% of the global population, with more than one-third of the individuals worldwide reporting insufficient sleep as a common complaint. Due to its high prevalence, insomnia frequently co-exists with various somatic and psychiatric disorders, exhibiting a bidirectional relationship in which each condition influences the other. Depression, anxiety, cardiovascular diseases, and malignancies can serve as factors triggering insomnia complaints, according to the behavioral model for insomnia development. Moreover, chronic insomnia increases the risk of these diseases through several pathogenic mechanisms, including activated stress response, altered neurotransmitter signaling, and impaired emotion regulation. This interplay creates a vicious cycle of poor sleep, deteriorated health, and impaired quality of life. Recognizing the relationship between insomnia and overall well-being is essential for adopting optimal treatment methodology, as addressing insomnia can ameliorate associated mental and physical health issues. This review explores the bidirectional association of chronic insomnia with other somatic and mental diseases, illustrating how each can aggravate the other, and emphasizes the importance of effective insomnia management in improving overall health and quality of life.

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DOI: 10.3897/folmed.67.e134607

Authors: Anand Verma, Seema Singh, Dibakar Borthakur, Harisha Kusuma

Abstract: Anatomical variation of the peripheral nerves are important because they may have therapeutic implications. The variation of the brachioradialis muscle (BRM) and the superficial branch of the radial nerve (SBRN) was noted during a regular teaching dissection of the upper extremity of a cadaver. There was splitting of the brachioradialis tendon (BRT), and the SBRN emerged, and it eventually became cutaneous. Following that, it bifurcated and ran superficial to the extensor retinaculum and gave off digital branches. The SBRN may be compressed by the BRM/BRM tendon contraction, which may result in Wartenberg’s syndrome. This anatomical variation likely results from a complex interplay of genetic factors, molecular signals, and embryological development. For the purpose of differentiating between pain and paresthesia on the dorsoradial aspect of the hand, awareness of this neuromuscular variation is clinically significant.

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DOI: 10.3897/folmed.67.e127238

Authors: George Tokas, Ioannis Mavridis, Theodossios Birbilis

Abstract: Coccydynia or coccyx pain is a rare form of low back pain located below the sacrum and above the anus. The causes of this condition vary, including previous trauma, underlying conditions (such as infection or neoplasm), and idiopathic causes. Our purpose was to describe the successful treatment of chronic refractory coccydynia with the application of sacral area neuromodulation. A 54-year-old female patient had a 9-year history of chronic drug-resistant coccydynia associated with low back pain and right-sided sciatica. Her clinical examination revealed bilateral pain on palpation of the sacroiliac joint areas. Following a successful trial, the patient underwent implantation of a peripheral nerve field stimulation (PNFS) system under local anesthesia. The electrodes were placed bilaterally at the sacroiliac joint area (S1-S2 level), which was the optimal position at the site of maximal pain, and the implantable pulse generator was placed in a subcutaneous pocket at the right gluteal area. She showed significant pain relief immediately postoperatively, became pain-free a few days later, and remained pain-free at 6-month follow-up. Data regarding neuromodulation, and particularly PNFS, as a treatment for coccydynia and other non-specified kinds of low back pain are still limited. Our case is therefore useful to depict this minimally invasive technique as a modern option in the armamentarium of specialists who treat patients suffering from chronic refractory pain syndromes. PNFS seems to be a promising therapeutic option for chronic refractory coccydynia and larger studies are necessary to confirm the value of this finding.

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DOI: 10.3897/folmed.67.e130280

Authors: Alejandro Rojas-Urrea, Daniela Arias-Mariño, Lorena García-Agudelo, Ivan Camilo Gonzalez-Calderon

Abstract: Cerebral salt wasting syndrome is described as a hyponatremic condition in the context of a central nervous system injury. It is caused by a renal loss of sodium, and the primary distinguishing factor among similar conditions, such as the syndrome of inappropriate antidiuretic hormone secretion, is a reduction in the extracellular fluid volume. We describe here the case of a young adult who suffered brain injuries as a result of a gunshot and developed cerebral salt wasting syndrome during his in-hospital stay. Any type of cerebral attack can lead to hyponatraemic syndrome, but the most common are subarachnoid hemorrhages and neurological and meningeal tuberculosis infections. Treatment of the cerebral salt wasting syndrome leads to both hypovolemia and hyponatremia correction. The first line of management included hydric reposition with saline solution, either isotonic or hypertonic, depending on the severity of the symptoms.

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DOI: 10.3897/folmed.66.e124015

Authors: Petya Argirova, Angel Todev, Yordan Kalchev, Simona Zlatanova, Mariyana Stoycheva-Vartigova

Abstract: COVID-19 presents with respiratory symptoms and signs in the majority of cases. The central nervous system can be affected directly or indirectly, which is demonstrated by a number of neurological abnormalities and complications. The aim of this study is to present a clinical case of SARS-CoV-2-associated encephalitis and highlight the severity of this neurological illness over the course of COVID-19. Etiological diagnosis methods include examination of the nasopharyngeal swab and cerebrospinal fluid by PCR. A 45-year-old man with fever, altered consciousness, and tonic-clonic seizures was admitted to the Clinic of Infectious Diseases, St George University Hospital, Plovdiv. The diagnosis of COVID-19 encephalitis is based on typical clinical and laboratory data, positive SARS-CoV-2 PCR, and exclusion of other likely causative agents into the cerebrospinal fluid. The patient was discharged two weeks after admission without neurological sequelae. The case confirms the clinical variety of COVID-19 and the possibility of severe neurological manifestations. Encephalitis is a rare but potentially life-threatening condition. Physicians should be aware of encephalitis in SARS-CoV-2 patients with neurological symptoms.

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DOI: 10.3897/folmed.66.e124311

Authors: Miroslava Hristova, Radka Massaldjieva, Lyubomir Chervenkov, Penka Atanassova

Abstract: Post-acute COVID syndrome (PACS), or long COVID, is a newly defined condition emerging as a widespread post-pandemic diagnosis with prevalent neuro-psychiatric symptoms and possible neuroinflammation-associated pathogenetic mechanisms. We present the clinical case of a 29-year-old male patient who had mild COVID-19 infections, autoimmune illness (psoriasis), and suffered a post-COVID aggravation of psoriasis, along with other non-specific neuropsychiatric problems. The patient underwent computer-based neuropsychological testing (the CogState Battery), brain magnetic resonance imaging (MRI), and a clinical interview since he fulfilled the criteria for a PACS diagnosis. The acquired data showed poor results on most of the neuropsychological subtests during his follow-up visit, structural changes in the MRI, and a possible immune dysregulation with increased levels of immunoglobulin G. These results confirm that the nonspecific neuro-psychiatric post-COVID complaints are associated with objective findings.

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DOI: 10.3897/folmed.66.e116329

Authors: Bünyamin Tosunoğlu, Melih Altıkardeş, Elif Pınar Arık, Nilay Kaya, Levent Ertuğrul İnan

Abstract: Multiple symmetric lipomatosis (MLS), also known as Launois-Bensaude syndrome or Madelung disease, is a rare metabolic condition characterized by generally symmetrical, non-encapsulated fat accumulations in the patient’s body. Is there a link between neurological disorders and multiple symmetric lipomatosis, as we demonstrate with our 75-year-old male patient who had an ischemic stroke and was also diagnosed with MLS? Our goal here is to provide an answer to this question.

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DOI: 10.3897/folmed.66.e106231

Authors: Bünyamin Tosunoğlu, Fadima Serap Basut, Beyza Başer, Melih Altikardeş, Levent Ertuğrul Inan

Abstract: Sneddon syndrome may present with neurological findings such as transient ischemic stroke, strokes, seizures and/or headaches. However, a purplish, spider web-like skin finding called livedo reticularis may accompany the skin and precede neurological findings. Sneddon syndrome often affects women. Since it is vasculopathy affecting small and medium vessels, other organ findings may accompany. We present a 44-year-old Sneddon syndrome patient with monoparesis in her left lower extremity, livedo reticularis on her back and legs, and hypertension.

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DOI: 10.3897/folmed.65.e108196

Authors: Karina A. Atanasova-Ivanova, Sonya Ivanova Hristova-Chakmakova, Ivan G. Milanov

Abstract: Introduction: Parkinson’s disease in its advanced stage is a progressive condition that can be treated with levodopa. The long-term complications of this treatment are difficult to manage. A new device-aided therapy has recently been developed to minimize these effects. Aim: The purpose of this study was to assess the efficacy and safety of the intestinal gel containing levodopa - carbidopa - entacapone, as well as to see if it had any impact on the disease’s non-motor symptoms. Additionally, we sought to identify the criteria for selecting among the various treatments that were offered. Materials and methods: This study includes the first five patients who started receiving the levodopa-carbidopa-entacapone gel for Parkinson’s disease in the Department of Neurology and Psychiatry at St Naum University Hospital for Active Treatment in Sofia, Bulgaria. To evaluate the influence of motor and non-motor symptoms of the disease, we used neurological examination and the Movement Disorder Society - Unified Parkinson’s Disease Rating Scale. The Parkinson’s Disease Quality of Life Questionnaire was used to assess the quality of life of the patients. Results: All patients showed improvement in their motor functions, quality of life, and sleep problems in comparison with those receiving oral levodopa. No patient experienced an increase in the dyskinesias. The postural stability continued to be impaired. For now, the medication has shown a protective effect against the levodopa-induced polyneuropathy. The main side effects were diarrhea and weight loss. Conclusions: Levodopa-carbidopa-entacapone therapy is a promising new modality of treatment for advanced Parkinson’s disease. The medication has been found to improve the patients’ motor functions and exert a positive effect on some non-motor symptoms. The drug has shown a good safety profile and tolerance. There is still a lack of clear criteria for choosing between the levodopa-carbidopa-entacapone and levodopa-carbidopa intestinal gels.

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DOI: 10.3897/folmed.65.e100100

Authors: Teodora Yaneva-Sirakova, Galina Zlatancheva, Kiril Karamfiloff, Latchezar Traykov, Ivo Petrov, Dobrin Vassilev

Abstract: Introduction: Carotid stenting may produce significant bradycardia and/or hypotension. This may have negative short- and long-term effects for the elderly high-risk patients. Their cerebral hemodynamics is with exhausted adaptive capacity because of the multiple cardiovascular risk factors, advanced age, and significant stenosis. Aim: This was a retrospective study aimed at finding whether periprocedural hypoperfusion or hypotension at the time of carotid stenting had any significance for the acute neurological outcome and mid-term general mortality in advanced-age patients who were at high risk for surgical endarterectomy. Materials and methods: We studied 138 consecutive patients with significant carotid stenosis from January 2015 to July 2019. The mean (SD) age was 67.41 (10.70) years. The mean follow-up period was 31 months (922 days). The patients were hemodynamically monitored periprocedurally according to a local protocol. Vasopressors were added if a prolonged hypotension was measured. Statistical data were analyzed using SPSS IBM v. 19 (p=0.05, CI 95%). Results: The male patients were 94 (68%). The number of patients with hypotension periprocedurally or in the first 6 hours post-procedure was 55 (42%). The mean blood pressures were 135/83 mmHg before, 116/76 mmHg during, and 121/73 mmHg after the procedure. Kaplan-Maier analysis showed no significant differences in the mid-term general mortality rate between patients with and patients without transitory hypotension. There wasn’t any difference in the postprocedural neurological outcome either. Conclusions: The presence of hypotension during carotid stenting was not linked to a negative neurological outcome. It also did not increase mid-term all-cause mortality in elderly patients (mean age, 67 years). The finding could be attributed to the relatively brief period of hypotension, the prompt administration of vasopressors, or the prevention of brain edema and hyper-reperfusion during carotid stenting in terms of elevated blood pressure; however, this remains to be determined.

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DOI: 10.3897/folmed.65.e84810

Authors: Eray Halil, Ekaterina Viteva, Georgi Vasilev, Krasimir Shukerski, Penka Atanassova

Abstract: We report the case of a 47-year-old man who was admitted to our clinic with an intractable headache, nausea, and sporadic vomiting, as well as speech difficulties and a ‘floating’ sensation. This man had no prior medical history. MRI of the brain showed evidence of over 20 supra- and infratentorial capsulated ring-enhancing lesions. All other paraclinical investigations done in our clinic were unremarkable and we excluded our first assumption of neurocysticercosis, as well as other parasitic infections. The patient was then referred to the Oral and Maxillofacial Surgery Clinic for an excisional biopsy of a submandibular formation, which was later verified to represent a lymph node metastasis from a poorly differentiated adenocarcinoma. A chest X-ray failed to demonstrate any significant pathology and the immunohistochemical constellation of the lymph node metastasis excluded the possibility of the primary tumor originating in the lung or the prostate. Due to the unresolved diagnostic query, a whole-body PET/CT was performed demonstrating a formation with malignant characteristics in the basal segment of the left lung, reaching the pleura and the left hilum, as well as solitary enlarged mesenteric and mediastinal lymph nodes. Following clinical consultations, it was determined that the patient was inoperable and chemotherapy and palliative CNS irradiation were recommended.

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DOI: 10.3897/folmed.65.e93659

Authors: Elad Mashiach, Timothy Kravchenko, Christopher E. Talbot, John L. Gillick

Abstract: Complications following lateral retroperitoneal transpsoas lumbar fusion (LLIF) surgery include femoral nerve apraxia, bowel/bladder injury, ureteral injury, and potentially, as illustrated in this case report, Guillain-Barré syndrome. Guillain-Barré syndrome (GBS) is an autoimmune inflammatory condition that typically presents after infection, or, less frequently, post-operatively. We report a case of GBS following elective lumbar fusion through the lateral retroperitoneal transpsoas approach (LLIF). A 56-year-old patient presented with left lower extremity (LLE) weakness on post-operative day 12. EMG showed bilateral upper extremity muscle recruitment, worse distally. Following a treatment with intravenous immunoglobulin (IVIG), the patient gradually improved, and her condition was favorable at 6-month post-operative follow-up. CSF analysis and EMG should be part of the workup for patients presenting with lower extremity neuropathy following LLIF.

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DOI: 10.3897/folmed.65.e86576

Authors: Georgi Slavov

Abstract: Introduction: In experimental autoimmune encephalomyelitis, neurological deficit correlates with axonal loss and the CD8+ T cells are a likely mediator of axonal damage. In relapsing-remitting multiple sclerosis, there is a correlation of the immune inflammatory activity in the lesion foci with the axon transection. Aim: To evaluate the changes occurring in the serum concentrations of TNF-α, IFN-γ, IL17, TGF-β1, IL4, and IL10 during relapse and remission, and their correlations with the degree of neurological deficit. Materials and methods: In an open, prospective, case-control study conducted between 2012 and 2014, we examined 86 people: 46 patients (33 women and 13 men) and 40 healthy individuals (20 women and 20 men). Serum cytokine concentrations were analyzed using ELISA – once in the controls, twice in the patients during the relapse and remission of the condition. The collected data were analyzed using SPSS 19.0. We used the Kolmogorov-Smirnov test, the independent sample t-test, the Spearman and Pearson correlation, the Mann-Whitney test, and regression analysis. Results: Immune imbalance was found in the patients compared to the healthy controls in both relapse and remission. During the relapse, the IFN-γ levels were significantly increased compared to the levels in remission (p=0.017). During remission, the deficit was statistically significantly improved (p<0.001) and the anti-inflammatory IL4 and TGF-β1 were increased compared to their levels in the exacerbation period (p=0.006 and p=0.009, respectively). There was a causal relationship between the serum concentrations of TNF-α and EDSS in relapse (Vanetto-significance). During this phase, the regression analysis established two factors that had statistically significant influence on the deficit severity – TNF-α and IL17 (t=2.093, p=0.042; t=−2.140, p=0.038). Conclusions: IL17 and TNF-α serum concentrations are significant factors for the neurological deficit severity. The levels of IFN-γ, IL4, and TGF-β1 during both periods are criteria for evaluation of the immune inflammatory activity.

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DOI: 10.3897/folmed.65.e96954

Authors: Eray Halil

Abstract: Acute ischemic stroke is of great clinical and societal importance due to its high incidence and mortality rates, as well as the fact that those who are affected suffer from permanent acquired disability. Modern trends explicitly state that the disease’s diagnostic plan should use a multidisciplinary approach. The therapeutic steps that ultimately determine the clinical outcome are defined by an accurate diagnosis of acute ischemic stroke. Highly specialized facilities for the diagnosis and treatment of acute ischemic stroke (Stroke Units) are in operation in countries that make significant investments in healthcare. Imaging the brain parenchyma at risk, or the so-called ischemic penumbra, in acute ischemic stroke is one of the main tasks of the multimodal computed tomography approach. The most rapid method for imaging the ischemic penumbra is computed tomography perfusion (CTP). This modality provides information about the anatomy and the physiologic state of the brain parenchyma. The current literature review offers a comprehensive overview of the various aspects of computed tomography perfusion in acute ischemic stroke and, more specifically, about the differential diagnosis of acute ischemic strokes and diseases that mimic strokes, predicting the risk of hemorrhagic transformation, the computed tomography perfusion used in intravenous thrombolysis (IVT) beyond the therapeutic window, wake-up strokes (WUS) and strokes of unknown onset (SUKO), and the reported predictive parameters of CTP in correlation with the clinical outcome in acute ischemic stroke.

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DOI: 10.3897/folmed.64.e68268

Authors: Milena Draganova-Filipova, Vanina Bojilova, Plamen Zagorchev

Abstract: Alzheimer’s disease (AD) is the most common neurodegenerative disease with controversial etiology. One theory claims that AD is due to brain aging affecting mainly the functions of mitochondria, therefore, the factors leading to mitochondrial ageing should lead to the development of Alzheimer’s disease. Another theory is that different mitochondrial DNA haplogroups can be predisposition for the onset of the condition. Here we focused on the possible connection between AD and UV radiation using the data on the monthly UV index in Europe, its correlation with mortality rate due to AD and mitochondrial DNA haplogroups distribution. If a link between the two theories is proved, it will mean that UV radiation is a risk factor not only for skin cancer but also for a large group of neurodegenerative diseases amongst which is the Alzheimer’s disease.

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DOI: 10.3897/folmed.64.e67881

Authors: Slaven Pikija, Marieta V. Peycheva, Rousan Aghayan-Ugurluoglu, Bernhard Ganser, Eugen Trinka

Abstract: Central retinal artery occlusion is a rare ophthalmological complication of sickle cell disease, usually provoked by additional contributing risk factors and its treatment remains controversial. We describe a patient with sickle cell disease and a spontaneous central retinal artery occlusion of his left eye that probably has good result from intravenous thrombolysis. We want to add sickle cell disease as rare etiological cause of central retinal artery occlusion and perpetuate evidence of intravenous recombinant tissue plasminogen activator administration in this condition.

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DOI: 10.3897/folmed.64.e66002

Authors: Vasilena Petrova, Krasimir Genov

Abstract: Introduction: Proton magnetic resonance spectroscopy (PrMRS) detects changes in brain metabolite levels in vivo. Aim: The aim of the present study was to evaluate the brain metabolites choline ((Cho), creatine (Cr), and N-acetyl aspartate (NAA) in lesion free normal appearing white matter (NAWM) in patients with relapsing-remitting multiple sclerosis (RRMS) versus healthy controls. The second aim was to explore the impact of sex on brain metabolite changes. Materials and methods: Fifty RRMS patients received PrMRS evaluation of their brain NAWM regions. The results were compared with the findings in 28 healthy demographically matched controls. Results: We found elevated levels of Cho, Cr, and NAA in NAWM of MS patients in comparison with healthy controls. The NAA/Cr and Cr/NAA ratios were collated. A statistically significant difference between both groups was found only for NAA/Cr and Cr/NAA ratios. It is due to metabolite changes in the female MS patients. Conclusions: The results of the present study using PrMRS proved metabolic changes in NAWM. Accompanying pathological process should be assumed, preceding plaques of demyelination. The gender impact needs further investigation.

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DOI: 10.3897/folmed.64.e64271

Authors: Marieta V. Peycheva, Lyubomir Chervenkov, Zdravka Harizanova, Ferihan Ahmed-Popova, Zahari I. Zahariev

Abstract: The ultrasound fusion imaging (UFI) system is a new promising imaging modality that combines live ultrasound investigations with preregistered CT, MRI, or PET images. In this study, we want to present our initial experience with the new method that combines the transcranial color-coded sonography (TCCS) in different insonation planes and the 3T-weighted MRI cerebral images. The study validates the diagnostic capabilities of the system to detect different normal cerebral structures in healthy volunteers. In the present paper, we also discuss the advantages of US fusion imaging technology and its clinical applications in Neurology.

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DOI: 10.3897/folmed..e64431

Authors: Georgios Sioutas, Alexandrina Nikova, Theodossios Birbilis

Abstract: Brain tumours are a heterogenic group, a subtype of which is arising from glial cells. Pediatric low-grade gliomas are the most common primary CNS tumour group in childhood, representing 25% to over 30% of pediatric CNS tumours. Pediatric high-grade gliomas are relatively rare and have a poor prognosis. Epidemiological studies have reported various potential risk factors, such as demographics, ionizing and nonionizing radiation, allergic conditions, and infections, immunologic, parental, genetic, and developmental risk factors. These risk factors are relatively unclear and understudied; thus, this narrative review aims to summarize all studies connecting risk factors and pediatric gliomas.

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DOI: 10.3897/folmed.64.e62461

Authors: Abdullah Alajmi, Adnan Khuraibet, Todor Shamov, Rossen Rousseff

Abstract: Abstract The Riche-Cannieu anastomosis is a neural connection between the deep branch of the ulnar nerve and the recurrent motor branch of the median nerve to the thenar. Rarely, it provides complete or nearly complete ulnar innervation of the thenar muscles (all-ulnar hand). This may lead to confusing clinical and electrodiagnostic findings in patients with median or ulnar nerve pathology, or during workup for suspected nerve lesions. Two patients referred for electrodiagnostic assessment of carpal tunnel syndrome and one patient with suspected peripheral neuropathy presented with absent or very low compound motor action potential from the thenar after median nerve stimulation. This occurred in spite of normal thenar muscles’ bulk and function, in one hand (one subject) or both hands (two subjects). Ulnar nerve stimulation at wrist and elbow while recording over abductor pollicis brevis, first and second lumbrical muscles and needle electromyography allowed us to recognize Riche-Cannieu anastomosis and avoid diagnostic errors. The rare innervation variant of all-ulnar hand should be considered in less typical presentations of hand disorders, especially when there is a discrepancy between the clinical findings and the expected electrodiagnostic changes.

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DOI: 10.3897/folmed.64.e62981

Authors: Alexandrina S. Nikova, Georgios Sioutas, Michael Karanikas, Theodossios Birbilis

Abstract: Management of glioblastoma should be aggressive and personalised to increase the quality of life. Many new therapies, such as active immunotherapy, increase the overall survival, yet they result in complications which render the search for the optimal treatment stra-tegy challenging. In order to answer whether the available treatment options should be administered in a specific row, we performed a literature search and meta-analysis. The results show that overall survival among the different treatment groups was equal, while the rates of complications were unequal. After surgery, when active immunotherapy was administered before radiation, radiation and chemotherapy, complication rates were lower. For newly diagnosed glioblastoma in adults, applying active immunotherapy after total resection but before the other complementary treatment options is associated with lower complication rates.

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DOI: 10.3897/folmed.64.e58611

Authors: Krasimir Genov, Maria Dimitrova

Abstract: Introduction: Cognitive impairment has been found in all stages and subtypes of multiple sclerosis (MS). It has a broad negative impact on the lives of people with MS independent of physical symptoms. Perhaps the most severe and far-reaching effect is unemployment, which results in extensive personal, social, and financial costs. Cognition has been linked to unemployment in many countries and shown to mediate the effects of disability on employment status. Aim: The primary aim of this study was to assess social functioning in the context of activities of daily living and employment in patients with MS and to find a correlation between them and cognitive performance in these patients. The secondary aim was to find an association between employment and factors such as demography, emotional factors, and disease progression. Materials and methods: The research included a study group of 100 patients with MS meeting the defined exclusion and inclusion criteria, and a control group of 40 healthy subjects. Disability was assessed with the Expanded Disability Status Scale (EDSS). The employment status was appraised in interviews with the subjects. The patients were divided into two groups: employed (working on a full-time or part-time job) and unemployed (not-working). The study aimed to assess the cognitive performance of all subjects. We examined cognitive domains such as short-term memory, psychomotor speed, and executive functions with a battery of neuropsychological tests. Results: We found a connection between performance on neuropsychological tests and employment and engagement in activities of daily living. Another main conclusion of our study is that unemployed are older patients with longer duration of disease. They have excessive fatigue and unsatisfied results and impairment of memory functions. As to the reasons we found in our study for losing a job, some identified factors are the presence of excessive fatigue (44%), movement disorders (41%), cognitive impairment (30%), pain (15%), dizziness (15%), dexterity (11%), emotional disorders, bowel and bladder disorders (7%), visual deficit (7%), and heat sensitivity (4%). Conclusions: Unemployed patients have severe depressive symptoms.

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DOI: 10.3897/folmed.64.e59677

Authors: Maria Dimitrova, Violeta Yotova, Kristina Dimitrova

Abstract: The aim of presenting this case was to show the difficulties in making the differential diagnosis of viral meningitis during the COVID pandemic situation. We report a case of a young man with clinical features of viral meningitis and with epidemiological history of COVID-19 in his family. The patient complained of fever, headache, photophobia, nausea, myalgia, and fatigue. He gave a history of diarrhea and vomiting two weeks before admission and close relatives with COVID-19. The neurological examination revealed a meningeal irritation syndrome. The diagnostic tests we performed were as follows: nasopharyngeal swab and PCR of cerebrospinal fluid (CSF) for SARS CoV-2, computed tomography scan of the head, general CSF examination, viral tests, and microbiology of CSF, enzyme-linked immunosorbent assay (ELISA) IgM and IgG. The results were consistent with viral meningitis due to HSV-1 in simultaneously found high titres of plasma SARS CoV-2 specific IgA and SARS CoV-2 specific IgG and active viral serum infection for CMV and EBV.

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DOI: 10.3897/folmed.64.e59492

Authors: Sachin Parmar, Rakesh Prajapati, Manisha Kalarias

Abstract: Introduction: Lagenaria siceraria (Molina) Standley (Cucurbitaceae) is a traditional vegetable plant, popularly known as bottle gourd (English) and lauki (Hindi). It is a climbing herb characterized with a number of therapeutic properties. Traditionally Lagenaria siceraria (LS) fruits were used for their cardioprotective, hepatoprotective, diuretic, and purgative effects, but there is very little scientific data available on its neuroprotective potential. Aims: The present study aimed to assess the neuropharmacological profile of the sterol-enriched chloroform fraction of methanolic extract of Lagenaria siceraria fruits in animal experimental models. Materials and methods: Neuropharmacological screening was conducted in specific reported animal models. Adult Wistar albino rats were subjected to behaviour despair test and elevated plus maze test. Thiopental-induced sedation, locomotor activity, and rota rod test were conducted on Swiss albino mice. Similarly, pentylenetetrazole-induced convulsions and maximal electroshock-induced seizures in Swiss albino mice were performed to evaluate the anti-epileptic potential. Results: The results of the study demonstrated that the anxiolytic activity of phytocompound-enriched chloroform fraction of methanolic extract of Lagenaria siceraria fruits (100, 200, and 400 mg/kg per os) was characterized by increased time spent in and increased number of entries into the open arms of the elevated plus maze prototype as compared to the control group (p<0.001). Chloroform fraction (100-400 mg/kg, p.o.) showed the dose-dependent significant reduction in duration of immobility (p<0.001) in the behaviour despair test. Similarly, the chloroform fraction was found to exert a significant reduction in motor co-ordination (p<0.001) and prolongation of thiopental-induced sleeping time (p<0.001) during the animal studies. Moreover, the test fraction significantly increased (p<0.001) the onset of myoclonic seizures in pentylenetetrazole-induced convulsions model as well as in the maximal electroshock-induced seizures model at all three dose levels selected. Interestingly, the chloroform fraction neither produced any overt motor dysfunction nor any kind of extra pyramidal symptoms in any of the animal models during pharmacological screening. Preliminary phytochemical screening of the fraction showed presence of saponins, phytosterols, terpenoids, fats, and trace amount of polyphenolic compounds. HPTLC fingerprinting analysis was also carried out. Conclusions: This is the first study exploring the neuroprotective potential of Lagenaria siceraria fruits by showing the anxiolytic, anti-depressant, sedative, and anti-epileptic-like activities, confirming the traditional claims. Future prospectus and investigations will give emphasis on isolation of the bioactive phytocompounds and their precise mechanisms involved in the neuroprotective activities.

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DOI: 10.3897/folmed.64.e57544

Authors: Seyed Ali Akbar Mahmudi, Hatef Ghasemi Hamidabadi, Ardeshir Moayeri, Maryam Nazm Bojnordi, Maria Zahiri, Zahra Madani, Mina Vardiani

Abstract: Introduction: It is well documented that some forced exercises can have bad effects on the genital system. Melatonin is a potent antioxidant that is effective in reducing the physical stress. Aim: The aim of this study was to evaluate the supportive effect of melatonin on the quality of spermatogenesis, including count, motility, morphology, viability, and apoptosis of sperm following a forced treadmill exercise. Materials and methods: A total of 40 adult male Sprague-Dawley rats were used in this experimental study. All rats were divided into five groups: control group, sham M group, melatonin (M) group, forced treadmill exercise group (Ft), and melatonin with forced treadmill exercise (MFt) group. The experimental group was trained to force treadmill stress for one hour of forced treadmill exercise daily, five days weekly for eight weeks. Then the sperm quality parameters were measured after dissection and removal of epididymis. Spermatogenesis and germ cell apoptosis were evaluated using Miller and Johnsen’s score and TUNEL staining separately. Results: Results showed the count, motility, morphology, and viability of sperm in forced treadmill-melatonin administrated group, significantly enhanced by melatonin treatment compared to the treadmill exercise group (p≤0.01). Also the number of apoptotic germ cells significantly decreased in treadmill exercised-melatonin administrated group compared to the treadmill exercised group. Conclusions: These results suggest that administration of melatonin can protect the testis against the detrimental effect of forced treadmill exercise in adult male rats.

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DOI: 10.3897/folmed.63.e58637

Authors: Zdravka Vasileva

Abstract: Epilepsy is a chronic neurological disease with recurrent seizures. Its incidence, the social and psychological aspects of epilepsy-associated stigmatization in society, the medical risk of severe seizures, and the challenges in treatment confirm its medical and social significance. The pathogenesis of the diseases is associated with abnormal activity of a population of neurons due to various mechanisms, the most frequent being oxidative stress, glutamate excitotoxicity, and mitochondrial dysfunction. In the last 3-4 decades, the possible connection between epilepsy and melatonin – a neurohormone secreted by the pineal gland – has been sought and studied. Various physiological functions of melatonin in humans have been proven – regulation of circadian rhythms (diurnal, seasonal), sleep and wakefulness, participation in the processes of thermoregulation, tumour growth and aging, sexual activity and reproductive functions. It also has immunomodulatory, cytoprotective and antioxidant activity. The results from the studies with experimental models with animals conducted so far in search of a correlation between melatonin and epileptogenesis are mainly in support of the hypothesis of its anticonvulsant effect. The studies with humans are diverse in design, with a smaller number of participants, and the results are not always in explicit support of this hypothesis. The correlation between melatonin concentration and the course of the disease in patients with epilepsy has been discussed. The possibility of adding melatonin to anti-epileptic therapy has also been studied recently.

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DOI: 10.3897/folmed.63.e55696

Authors: Ana Shopova, Silvia Shopova, Irina Stefanova, Rumyana Kuzmanova

Abstract: Hyperinsulinaemic hypoglycaemia (HH) occurs as a consequence of unregulated insulin secretion from pancreatic beta cells. It is the most common cause of severe and prolonged hypoglycemia in newborns. HH is a major risk factor for brain damage and subsequent neurological disability, which is why the identification, rapid diagnosis, and timely treatment of patients with HH are essential for the prevention of brain damage. The present case gives a brief description of a patient with congenital HH with an established mutation in the ABCC8 gene encoding the SUR1 subunit of the K-ATP channel. The genealogical tree, the clinical picture, the diagnostic cascade, the neurological consequences and their development in dynamics are considered, with special emphasis on the epileptic syndrome and mental status. Advances in molecular genetics, radiological imaging techniques, conservative treatment, or laparoscopic surgery may completely change the clinical approach to children with severe congenital forms of HH.

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DOI: 10.3897/folmed.63.e56110

Authors: Tahir Dalkiran, Kursat Bora Carman, Velid Unsal, Ergul Belge Kurutas, Yasar Kandur, Cengiz Dilber

Abstract: Introduction: Very few studies have evaluated the association between mercury exposure and oxidative stress in humans, particularly in children. Aim: This is the first report where we aimed to determine the oxidative stress status of children who were accidentally exposed to elemental mercury. Materials and methods: In the present study, the study group was composed of 86 randomly selected children poisoned by mercury; the control group was composed of 78 children who had no history of mercury exposure. At admission, blood samples were collected. Blood superoxide dismutase activity, catalase enzyme activity, and glutathione peroxidase activity were measured by Fridovich, Beutler, and Lawrence Burk methods respectively, and the results were given as U/g Hb. Malondialdehyde level was measured by Ohkawa methods, and the results were given as mmol/ml.Results: Catalase activity was significantly lower in the patient group compared to the control group (1.28±0.62 vs. 3.90±0.86 U/g Hb, p=0.010). In exposed children, SOD activity was significantly higher than the controls (5936±810 vs. 2226±464 U/g Hb, p=0.03), while the GSH-Px activity was significantly lower (13.01±3.21 vs. 34.97±7.32 U/g Hb, p=0.013). The MDA levels of the mercury group were significantly higher than the MDA levels of the control group (2.85±0.84 vs. 2.05±0.79 mmol/ml, p=0.04). Conclusions: The results of the present study showed that acute mercury poisoning causes an alteration of oxidative stress status in children exposed to elemental mercury.

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DOI: 10.3897/folmed.63.e57985

Authors: Orlina Chaneva

Abstract: Sleep is a reversible behavioural state of perceptual disengagement from and unresponsiveness to the environment, which is required for neural plasticity and memory consolidation. Sleep disorders are common in patients with epilepsy. The main causes of sleep disturbances are coexisting sleep disorders, impact of seizures and epileptic activity, and the effects of antiepileptic drugs. Sleep and epilepsy have reciprocal effects – on one hand electrical brain activity during sleep is a strong modulator of epileptic activity and on the other epileptic activity during sleep may disrupt sleep architecture. The most common side effects of anticonvulsants include alterations in sleep architecture and variation in the degree of daytime sleepiness. Their effects on sleep and daytime sleepiness are variable and it is often difficult to distinguish whether the improved seizure control and epileptic activity is a direct result of anticonvulsants or associated with improved sleep quality. Levetiracetam is a new generation anticonvulsant used to treat both focal and generalized epilepsy. Its satisfactory safety and tolerability explain its wide usage in the clinical practice and necessitates more profound knowledge on its effects on sleep quality. There have been few reports about its effects on sleep architecture and daytime sleepiness. A short summary of the studies concerning this topic is presented. Main disadvantages of the studies are: the small sample size, comparison of the results obtained in healthy volunteers with patients with epilepsy, short observation duration, variations of dosage, different evaluation modalities and concomitant AED therapy. Future prospective studies on subjective and objective effects of Levetiracetam on sleep architecture and daytime sleepiness are needed to better understand its impact on sleep in order to improve epilepsy patients’ quality of life, seizure control and sleep disturbances.

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DOI: 10.3897/folmed.63.e54994

Authors: Ekaterina I. Viteva, Zahari I. Zahariev

Abstract: Introduction: There are no reliable prospective studies on the effectiveness of LEV in Bulgarian adult patients with drug-resistant epilepsy.Aim: The study aimed at conducting an open, prospective study on various aspects of levetiracetam (LEV) effectiveness in Bulgarian patients with drug-resistant epilepsy. Materials and methods: The study was performed with patients with epilepsy recruited from those attending the Department of Neurology at the University Hospital in Plovdiv, Bulgaria. The patients completed diaries about seizure frequency, severity, and adverse events. There were regular documented visits at 3 or 6 months during the first year of treatment with LEV and at 6 months afterwards, with dynamic assessment of seizure frequency, severity, adverse events, and EEG recordings. Results: LEV was applied as an add-on therapy in 135 patients (86 males, mean age 35 years). There was a relatively mild and persisting dynamic improvement of seizure severity, a satisfactory seizure frequency reduction in 49.6% of participants, a persisting mean seizure frequency reduction (48-58%) from 6 to 36 months of treatment and a high responder rate (53-60%) during the same period. New seizure types (focal with impaired awareness with /without evolution to bilateral tonic-clonic seizures) occurred in 4 patients. There were adverse events (dizziness, memory impairment, aggressiveness, numbness, non-epileptic seizures, depression, anxiety, speech disturbances, visual hallucinations, sleepiness, pelvic muscles weakness, confusion, sleep disturbances, loss of appetite, unstable gait, hair loss, acne, generalized rash) in 13.33% of patients.Conclusions: LEV treatment is associated with: low and persisting improvement of seizure severity, a good and persisting improvement of seizure frequency, a possible worsening of seizure control, a possible appearance of new seizure types, a good safety and tolerability.

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DOI: 10.3897/folmed.62.e50349

Authors: Maria Dimitrova, Dobromir Iliev

Abstract: We report a case of a patient with a relapse of neuromyelitis optica. The relapse was initially treated with intravenous corticosteroids. A therapy with intravenous gamma globulin was started as there was no symptomatic improvement. The patient responded well to the treatment with no significant side effects. Worldwide experience with gamma globulin treatment of neuromyelitis optica is limited and randomised control trials are lacking, therefore accumulation of data from case reports is of paramount importance.

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DOI: 10.3897/folmed.62.e50175

Authors: Ekaterina Viteva, Zahari Zahariev

Abstract: Introduction: There are no reliable prospective studies on the effectiveness of topiramate in Bulgarian adult patients with drug-resistant epilepsy.Aim: The aim of the study was to conduct an open, prospective study on various aspects of topiramate (TPM) effectiveness in Bulgarian patients with drug-resistant epilepsy. Patients and methods: The study included patients with epilepsy who attended the Clinic of Neurology at the University Hospital in Plovdiv, Bulgaria. Patients completed diaries for seizure frequency, seizure severity, and adverse events. There were regular documented visits at 3 or 6 months during the first year of TPM treatment and at 6 months afterwards, with a dynamic assessment of seizure fre-quency, severity, adverse events, and EEG recordings. Results: TPM was used as an add-on treatment in 120 patients (69 males, mean age 37 years). There was a relatively mild and stable dynamic improvement of seizure severity, a satisfactory seizure frequency reduction in 37% of participants, a stable mean seizure fre-quency reduction (47%) from month 6 to month 24 of treatment and a stable responder rate (48-51%) during the same period. New seizure types (focal with impaired awareness with/without evolution to bilateral tonic-clonic seizures) occurred in 5 patients. There were adverse events (dizziness/vertigo, irritability, speech disturbances, memory impairment, concentration problems, tremor, loss of appe-tite and weight, weakness, numbness, bradypsychia, confusion, visual hallucinations, sleepiness, insomnia, headache, itching, unstable gait, nausea, and vomiting) in 20% of patients. Conclusions: TPM treatment is associated with low and stable improvement of seizure severity, good and stable improvement of sei-zure frequency, possible worsening of seizure control and appearance of new seizure types, good safety and tolerability.

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DOI: 10.3897/folmed.62.e49453

Authors: Valentin Todorov, Maria Dimitrova, Viktoria Todorova, Eleonora Mihaylova

Abstract: Introduction: There is some evidence suggesting an association between cerebrovascular diseases and the development of depression on the one hand, and between depression and post-stroke recovery on the other. Post-stroke depression can occur in the early post-stroke period or in the later stages of recovery (over 9 months after the incident).Aim: To find a connection between stroke and the development of anxiety and depression in the early period after the development of neurological deficit and to evaluate several scales for their potential usefulness in the screening of post-stroke patients for early signs of depression and anxiety.Materials and methods: We conducted a study on the presence of depression in 117 patients, divided into 2 groups: 73 of these patients were admitted due to ischemic stroke, while the other 44 were controls matching the patients in age, sex and education status. The inclusion and exclusion criteria were defined clearly. We included patients that consented to undergo psychiatric evaluation be-tween 24 hours and 7 days after the onset of neurological symptoms. Both groups were assessed by the Montgomery-Asberg Depression Rating Scale (MADRS), Hamilton Anxiety Rating Scale (HAM-A), Hospital Anxiety and Depression Scale – Depression Subscale and Combined Scale (HADS-D, HADS-T).Results: On evaluation with HADS-D we noted the largest difference between the two groups with a very high statistical significance and a medium effect size (7.92±4.44 points vs. 4.86±4.27 points for the control group, p<0.001, r= -0.417). Anxiety and depressive symp-toms were found also with MADRS and HAM-A.Conclusions: Anxiety and depressive symptoms were found in the early post-stroke period. MADRS, HADS-D, and HAM-A are suf-ficiently specific and sensitive in the evaluation of post-stroke anxiety and depression.

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DOI: 10.3897/folmed.62.e49451

Authors: Valentin Todorov, Maria Dimitrova

Abstract: The immunology of stroke can be approached in several ways. By viewing stroke from an immunological standpoint, we are trying to achieve new insights in its pathogenesis and reach new therapeutic options. To review and summarize the findings from publications on immunology of stroke. Infections are a well-known risk factor for stroke. This is due to activated immune cells interacting with throm-bocytes and releasing coagulation factors, which affect the formation of the thrombus. Aseptic inflammation in the ischemic lesion leads to cellular invasion of the area and triggers a pro-inflammatory response, which has an impact on further destruction of ischemic brain tissue. Another aspect of stroke is systemic immune suppression, which is a predisposing factor towards a systemic bacterial infection. Infection itself is also an independent risk factor for negative clinical outcomes and increased mortality. The immunological approach to the topic of ischemic stroke holds significant value for future research.

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