The 18Th National Congress of the Romanian Society of Neurology

Romanian Society of Neurology Societatea de Neurologie din România

ROMANIAN JOURNAL of NEUROLOGY REVISTA ROMÂNĂ DE NEUROLOGIE Peer Reviewed Journal Volume XIX, Supplement, 2020

ISSN 1843-8148 | e-ISSN 2069-6094 | ISSN-L 1843-8148 DOI: 10.37897/RJN CNCSIS/CNCS Code 768 | Category B+ Official Website: https://RJN.com.ro Romanian Journal of Neurology is included in the Medical Journals Directory of the Romanian College of Physicians and is accredited as follows: annual subscription – 10 CME credits; authors of article – 80 CME credits. Revista Română de Neurologie este inclusă în Nomenclatorul Publicaţiilor Medicale al CMR şi este creditată astfel: abonament anual – 10 credite EMC; autori articol – 80 credite EMC.

EDITORIAL COUNCIL Honorary Founding Editor

† Prof. Ovidiu Alexandru BAJENARU, MD, PhD – Bucharest, Romania

Editor-in-Chief Prof. Bogdan Ovidiu POPESCU, MD, PhD – Bucharest, Romania

Scientific Associate Editor Prof. Dafin Fior MURESANU, MD, PhD –Cluj-Napoca, Romania

President of Romanian Society of Neurology Prof. Bogdan Ovidiu POPESCU, MD, PhD – Bucharest, Romania

EDITORIAL BOARD Florina ANTOCHI, MD – Bucharest, Romania Prof. Natan BORNSTEIN, MD, PhD – Tel-Aviv, Israel Prof. Vivian DRORY, MD, PhD – Tel-Aviv, Israel Prof. Jelena DRULOVIC, MD, PhD – Belgrade, Serbia † Prof. Franz GERSTENBRAND – Vienna, Austria Prof. Wolfgang GRISOLD, MD, PhD – Vienna, Austria Carolina IONETE, MD – Worcester, USA Prof. Pavel KALVACH, MD, PhD – Prague, Czech Republic Prof. Amos KORCZYN, MD, PhD – Tel-Aviv, Israel Prof. Vladimir KOSTIC, MD, PhD – Belgrade, Serbia Prof. Ioannis MILONAS, MD, PhD – Thessaloniki, Greece Lecturer Ioana MINDRUTA, MD, PhD – Bucharest, Romania Assoc. Prof. Cristina PANEA, MD, PhD – Bucharest, Romania Assoc. Prof. Cristian FALUP-PECURARIU, MD, PhD – Brasov, Romania Prof. Lacramioara PERJU-DUMBRAVA, MD, PhD – Cluj-Napoca, Romania Assoc. Prof. Daniel PIRICI, MD, PhD – Craiova, Romania Prof. Zvezdan PIRTOSEK, MD, PhD – Ljubljana, Slovenia Acad. Constantin POPA, MD, PhD – Bucharest, Romania † Prof. Cristian Dinu POPESCU – Iasi, Romania Prof. Maja RELJA, MD, PhD – Zagreb, Croatia Prof. Alexandru SERBANESCU, MD, PhD – Bucharest, Romania Prof. Mihaela SIMU, MD, PhD – Timisoara, Romania Prof. Aksel SIVA, MD, PhD – Istanbul, Turkey Assoc. Prof. Cristina TIU, MD, PhD – Bucharest, Romania Emil TOESCU, MD, PhD – Birmingham, UK Assoc. Prof. Valerica TUDORICA, MD, PhD – Craiova, Romania Prof. Laszlo VECSEI, MD, PhD – Szeged, Hungary

Secretary of Assistant Editors office Univ. Assist. Mihai VASILE, MD, PhD – Bucharest, Romania

Assistant Editors Lecturer Laura Cristina CEAFALAN, MD, PhD – Bucharest, Romania Univ. Assist. Irene DAVIDESCU, MD, PhD – Bucharest, Romania Laura DUMITRESCU, MD – Bucharest, Romania Athena Cristina MERGEANI, MD – Bucharest, Romania Florina MOLDOVAN, MD – Cluj-Napoca, Romania Horia NICOLAE, MD – Bucharest, Romania Alexandra OPRISAN, MD – Bucharest, Romania Lecturer Elena Cecilia ROSCA, MD, PhD – Timisoara, Romania Univ. Assist. Elena TERECOASA, MD, PhD – Bucharest, Romania

Managing Editor Mihai-Cristian POPESCU, MD – Bucharest, Romania

Contact person: Prof. Bogdan O. Popescu, MD, PhD Address: ROMANIAN SOCIETY OF NEUROLOGY Splaiul Independentei 169, Sector 5, Bucharest, Romania Fax: (+40) 21 312 81 02

AMALTEA Medical Publishing House | Editura Medicală AMALTEA Publishers: M.C. Popescu, MD, Cristian Carstoiu, MD

Executive Director: George Stanca Editors: Anca Haldan, MD Prepress: AMALTEA TehnoPlus Graphic Editors: Petronella Andrei, George Dorohoi DTP: Gabriela Capitanescu Marketing: Corina Valceanu, Nicholas Bolinteanu Distribution: Mihaela Stanca, Claudiu Stanescu ______subscriptions: [email protected] MANUSCRIPT SUBMISSIONS: [email protected]

https://RJN.com.ro Contents

SCIENTIFIC COMMITTEE OF THE 18th CONGRESS OF THE ROMANIAN SOCIETY OF NEUROLOGY______5

ORGANIZING COMMITTEE______6

SCIENTIFIC PROGRAM______7

THE 18th NATIONAL CONGRESS OF THE ROMANIAN SOCIETY OF NEUROLOGY ORAL PRESENTATIONS – ABSTRACTS ______13 POSTERS – ABSTRACTS Sections: • Neuroimmunology______26 • Sleep disorders______35 • Varia______36

Romanian Journal of Neurology – Volume XIX, Supplement, 2020 3

Sub egida: Under the Auspices of: Academiei Române şi a Romanian Academy & Universităţii de Medicină şi Farmacie „Carol Davila“, „Carol Davila“ University of Medicine and Pharmacy, Bucureşti Bucharest — — Societatea de Neurologie din România The Society of Neurology in Romania Fundaţia Societăţii Române de Neurologie Foundation of the Romanian Society of Neurology din România from Romania

Cel de-al XVIII-lea The 18th Congres Naţional National Congress of the al Societăţii de Neurologie Romanian Society of Neurology — —

17-19 noiembrie 2020 17th - 19th November, 2020 Bucureşti Bucharest

Număr special Special Issue Volum de rezumate Abstracts Volume

Ref: Ro J Neurol. 2020;19(Suppl.) DOI: 10.37897/RJN.2020.S 6 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

Scientific Committee of the 18th Congress of the Romanian Society of Neurology

President Honorary President ad-vitam Prof. Dr. Bogdan O. POPESCU Prof. Dr. Ovidiu BĂJENARU President of RSN, Bucharest Correspondent member of the Romanian Academy

, 2020 Former President of RSN, Cluj-Napoca th Prof. Dr. Dafin Fior MUREŞANU

Next President elect of RSN, Bucharest Conf. Dr. Cristina TIU

Members Acad. Prof. Dr. Constantin POPA, Bucharest Prof. Dr. Alexandru SERBANESCU, Bucharest Prof. Dr. Lăcrămioara PERJU-DUMBRAVĂ, Cluj-Napoca Prof. Dr. Mihaela SIMU, Timişoara Prof. Dr. Rodica BĂLAŞA, Tg. Mures Prof. Dr. Ioan BURAGA, Bucharest Conf. Dr. Cristina PANEA, Bucharest Conf. Dr. Dan CUCIUREANU, Iasi Conf. Dr. Valeria TUDORICĂ, Craiova Conf. Dr. Radu TĂNĂSESCU, Bucharest Dr. Florina ANTOCHI, Bucharest

General Secretary RSN Treasurer Dr. Mihai VASILE Dr. Adina ROCEANU

Organizing Committee

Dr. Raluca NISTOR, Bucharest Dr. Amalia ENE, Bucharest

Marţi, 17 Noiembrie 2020 / Tuesdaz, November 17 November Marţi, 17 Noiembrie 2020 / Tuesdaz, Dr. Athena RIBIGAN, Bucharest Dr. Elena TERECOASĂ, Bucharest Maria NIŢOI, Bucharest Romanian Journal of Neurology – Volume XIX, Supplement, 2020 7

Programul ştiinţific / Scientific program

08.45 – 09.00 Deschiderea oficială a Congresului SNR 2020 Prof. Dr. Bogdan Ovidiu POPESCU, Prof. Dr. Dafin MUREŞANU, Conf. Dr. Cristina TIU Sesiunea EFNR , 2020 09.00 – 09.30 New vistas in stroke recovery th Prof. Dr. Dafin MUREȘANU 09.30 – 10.00 Post stroke cognitive impairment – current concepts and treatment approaches Prof. Dr. Natan BORNSTEIN 10.00 – 10.30 After CARS – new insights and new evidence Prof. Dr. Volker HOMBERG 10.30 – 11.00 Genetic small vessel diseases: Updates in CADASIL and related conditions Prof. Dr. Antonio FEDERICO Conferința de onoare „Gheorghe Marinescu“ 11.00 – 12.00 Sleep and stroke: „Guilty by association“ Prof. Dr. Claudio BASSETTI (Elveția) EAN-SNR Session 12.00 – 12.20 EAN mission and vision 2020 Prof. Dr. Dafin MUREȘANU 12.20 – 12.40 Infections and neurodegeneration Prof. Dr. Bogdan Ovidiu POPESCU 12.40 – 13.00 Do we need a new philosophy for neurorehabilitation after stroke? Prof. Dr. Dafin MUREȘANU 13.00 – 13.15 Pauză Sesiunea Tulburări ale somnului Moderatori: Conf. Dr. Cristina PANEA, Şef Lucr. Dr. Ioana MÎNDRUȚĂ 13.15 – 13.35 Tulburarea de somn cu cefalee – cum o abordăm? Conf. Dr. C. PANEA, Dr. R. GURGU, Dr. V. TIU, Dr. S. PETRESCU 13.35 – 13.55 Tulburările de somn și epilepsia Şef Lucr. Dr. Ioana MÎNDRUȚĂ, Dr. Irina POPA 13.55 – 14.15 Somnul în parkinsonismul degenerativ Prof. Dr. Lăcrămioara PERJU-DUMBRAVĂ, Dr. N. TOHĂNEAN, Dr. D. LASCU, Dr. M. ȘTEȚCA 14.15 – 14.35 Tulburări respiratorii în bolile neuro-musculare (apneea în somn și hipoventilația alveolară) – abord diagnostic și terapeutic Dr. Ștefan Dumitrache RUJINSKI Marţi, 17 noiembrie 2020 / Tuesdaz, November 17 November Marţi, 17 noiembrie 2020 / Tuesdaz, 14.35 – 14.45 Pauză 14.45 – 15.05 Studiul somnului în diagnosticul tulburării comportamentale de somn REM Dr. Irina OANE, Dr. Andrei DANEASA, Dr. Flavius BRATU, Dr. Camelia LENTOIU, Prof. Dr. Ovidiu BĂJENARU, Şef Lucr. Dr. Ioana MÎNDRUŢĂ 8 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

15.05 – 15.25 Tulburările de somn la pacienţii cu encefalite autoimune / Sleep disturbances in patients with autoimmune encephalitis Dr. Laura CRĂCIUN, Dr. L. COZMA, Dr. C. MITU, Dr. A. DANAU, Dr. R. MIHAILESCU, Dr. A. VLADILA, Dr. A. TEODOSIU, Prof. Dr. B.O. POPESCU 15.25 – 15.45 Diferențe în modularea conectivității de către somn a rețelelor cerebrale epileptogene și nonepileptogene Dr. Anca ARBUNE 15.45 – 15.55 Pauză , 2020

th Simpozioane educaționale – Scleroză multiplă Moderatori: Prof. Dr. Rodica BĂLAȘA, Conf. Dr. Cristina TIU 15.55 – 16.15 Impactul terapiei imunomodulatoare asupra atrofiei cerebrale în scleroza multiplă Conf. Dr. Cristina TIU 16.15 – 16.35 Păstrarea funcționalității pacientului cu scleroză multiplă prin maximizarea rezervei neurologice – efectul medicației imunomodulatoare dincolo de inflamația locală Asist. Univ. Dr Simona PETRESCU 16.35 – 16.55 Managementul sclerozei multiple recurent remisive în contextul apariţiei de noi opţiuni terapeutice Prof. Dr. Rodica BĂLAȘA 16.55 – 17.15 Este scleroza multiplă o boală progresivă de la început? Conf. Dr. Cristina TIU 17.15 – 17.25 Pauză 17.25 – 17.45 Provocări şi oportunităţi în diagnosticarea şi tratamentul sclerozei multiple secundar progresive Conf. Dr. Cristina TIU 17.45 – 18.05 Afecțiunile din spectrul neuromielitei optice (NMOSD) – o nouă provocare? Prof. Dr. Rodica BĂLAȘA 17.45 – 18.05 Tratarea manifestărilor clinice și subclinice în PPMS Dr. Florina ANTOCHI 18.05 – 18.25 Explorarea datelor din lumea reală în scleroza multiplă Prof. Dr. Rodica BĂLAȘA 18.25 – 18.35 Concluzii + Discuții finale Marţi, 17 noiembrie 2020 / Tuesdaz, November 17 November Marţi, 17 noiembrie 2020 / Tuesdaz, Romanian Journal of Neurology – Volume XIX, Supplement, 2020 9

Programul ştiinţific / Scientific program

Curs satelit – Neuroimunologie Moderatori: Prof. Dr. Carolina IONETE, Prof. Dr. Radu TĂNĂSESCU , 2020 09.30 – 09.50 Imunitatea înnăscută și imunitatea adaptativă pentru clinician – principii th Dr. Alina BOTEANU 09.50 – 10.10 B cells mediating neurological diseases Prof. Dr. Carolina IONETE 10.10 – 10.30 T cells mediating neurological diseases Prof. Dr. Cris CONSTANTINESCU 10.30 – 10.40 Pauză 10.40 – 11.00 Cytokines in health and disease in neurology Prof. Dr. Douglas GOLENBOCK 11.00 – 11.20 Autoanticorpii în neurologie Prof. Dr. Radu TĂNĂSESCU 11.20 – 11.40 Encefalitele autoimune în practica clinică de rutină Asist. Univ. Dr. Liviu COZMA, Dr. I. MITREA, Dr. D. MITREA, Dr. I. PARASCHIV-ORBAN, Dr. C. MITU, Prof. Dr. B.O. POPESCU 11.40 – 12.00 Examen final 12.00 – 12.40 Pauză

Sesiunea de neuroimunologie (1) Moderatori: Conf. Dr. Sorin TUŢĂ, Prof. Dr. Corina ROMAN FILIP 12.40 – 13.00 Efectul patogen al receptorului CCR6+ în scleroza multiplă Dr. Laura BĂRCUȚEAN 13.00 – 13.20 Plasmafereza și dubla filtrare în bolile neurologice Prof. Dr. Corina ROMAN-FILIP 13.20 – 13.40 The behavior of different subtypes of cultured T helper cells for precision treatment in multiple sclerosis patients Prof. Dr. Rodica BĂLAȘA, Prof. Dr. Minodora DOBREANU 13.40 – 14.00 Despre oameni, microbi și paraziți – despre imunoreglare în scleroza multiplă Prof. Dr. Radu TĂNĂSESCU 14.00 – 14.20 Aspecte imunologice în arterita cu celule gigante Conf. Dr. Sorin TUȚĂ 14.20 – 14.40 Pauză

Sesiunea de neuroimunologie (2) Moderatori: Conf. Dr. Cristina TIU, Dr. Florina ANTOCHI 14.40 – 15.00 Modificări imunologice în AVC acut

Miercuri, 18 noiembrie 2020 / Wednesday, November 17 November 18 noiembrie 2020 / Wednesday, Miercuri, Conf. Dr. Cristina TIU, Dr. Cristina GHIȚĂ, Dr. Larisa PURCARU, Dr. Iulian ENACHE, Asist. Univ. Dr. Elena TERECOASĂ 10 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

15.00 – 15.20 Manifestări neurologice în vasculopatia asociată deficitului de ADA2 Asist. Univ. Dr. Elena TERECOASĂ, Dr. Cristina GHIȚĂ, Dr. Larisa PURCARU, Dr. Iulian ENACHE, Conf. Dr. Cristina TIU 15.20 – 15.40 Encefalita Rasmussen – particularități de diagnostic și tratament Dr. Nicolae GRECU 15.40 – 16.00 Lupusul eritematos – complicații neurologice , 2020

th Asist. Univ. Dr. Athena RIBIGAN, Dr. Raluca BADEA, Dr. Daniela ŞTEFAN, Dr. Cristina DAVIDOIU, Dr. Bogdan CĂŞARU, Dr. Florina ANTOCHI 16.00 – 16.20 Pauză

16.20 – 16.50 Adunarea generală SNR Simpozioane educaționale – Patologia vasculară Moderatori: Conf. Dr Sorin Tuță, Conf. Dr. Cristina Tiu 16.50 – 17.10 Tromboliza în condițiile pandemiei cu SARS-CoV-2 Conf. Dr. Cristina TIU 17.10 – 17.30 Complianța pacienților la tratamentul anticoagulant în prevenția secundară a accidentului vascular cerebral ischemic Conf. Dr. Sorin TUȚĂ 17.30 – 17.50 Rolul anticorpilor monoclonali în terapia accidentelor vasculare cerebrale Asist. Univ. Dr. Elena Oana TERECOASĂ 17.50 – 18.00 Concluzii + Discuții finale

Miercuri, 18 noiembrie 2020 / Wednesday, November 17 November 18 noiembrie 2020 / Wednesday, Miercuri, Romanian Journal of Neurology – Volume XIX, Supplement, 2020 11

Programul ştiinţific / Scientific program

Sesiunea de rezidenți Moderatori: Prof. Dr. Bogdan Ovidiu POPESCU, Conf. Dr. Cristina TIU 09.00 – 09.20 Foramen ovale patent – cauză de AVC ischemic acut la adultul tânăr Dr. Bogdan CĂȘARU, Dr. Raluca BADEA, Dr. Dana ȘTEFAN, Dr. Athena RIBIGAN, Dr. Florina ANTOCHI , 2020

th 09.20 – 09.40 Manifestări de debut neurologic ale crioglobulinemiei mixte în infecția ocultă cu virus C Dr. E.I. ISTRATE, Dr. A.M. PARTOACA, Dr. I.A. OLARU, Dr. G.M. BONDOC, Dr. L.A. NISTOREC, Dr. A.M. DOBRI, Dr. A. POPESCU, Dr. M.M. MANEA, Conf. Dr. S. TUŢĂ 09.40 – 10.00 M-a părăsit? Sindromul mâinii străine – prezentare de caz Dr. A.M. CHIRIAC, Dr. C. LUCHIAN, Dr. D. NACONECINII, Dr. L. BOLOHAN, Conf. Dr. D.I. CUCIUREANU 10.00 – 10.20 Demersul diagnostic în limfoamele sistemului nervos central - o serie de cazuri / Diagnostic approach to central nervous system lymphomas: A case series Dr. Delia TULBĂ, Dr. L. COZMA, Dr. Z. COFOIAN-AMET, Dr. A. FLOREA, Dr. C. LUPU, Dr. R. MIHĂILESCU, Dr. D. MITREA, Dr. I. MITREA, Dr. A. VLĂDILĂ, Dr. C. MITU, Prof. Dr. B.O. POPESCU 10:20 – 10.40 Influența valorilor TA asupra prognosticului AVC acut Şef Lucr. Dr. Horia NICOLAE, Dr. I. IONIȚĂ, Dr. A.B. ARAMĂ, Dr. C. PANEA 10:40 – 11.00 Encefalita autoimună: diagnostic, tratament și prognostic – din perspectiva unității de monitorizare a epilepsiei Dr. I-F.BRATU, Dr. C. LENȚOIU, Dr. I. OANE, Dr. A. DĂNEASA, Dr. A. ROCEANU, Dr. D. MOROȘANU, Prof. Dr. O.A. BĂJENARU, Şef Lucr. Dr. I. MÎNDRUȚĂ 11.00 – 11.10 Pauză

Sesiunea Varia Moderatori: Conf. Dr. Cristina PANEA, Conf. Dr. Dan CUCIUREANU 11.10 – 11.30 Capcane de diagnostic și tratament în hemoragia subarahnoidiană de convexitate Dr. Cristina LAZA, Dr. M. PREOTESOIU, Dr. L.N. NIȚU-DUMBRAVĂ, Dr. R.A. BAZ, Dr. G. BUTOI, Dr. C. PASCU, Dr. A. DOCU-AXELERAD 11.30 – 11.50 Importanța monitorizării TCD intraoperatorie – noi orizonturi în cercetare Dr. R. BADEA, Dr. A. RIBIGAN, Dr. S. MIHAILĂ-BÂLDEA, Dr. C. UDROIU, Dr. F. ANTOCHI 11.50 – 12.10 Dysphagia therapy in a stroke rehabilitation unit: What factors influence dysphagia severity on discharge? Dr. C. Politi GHEMULET, Dr. S. HAMDY, Dr. G. NTAIOS, E. KOROMPOKI,

Joi, 19 noiembrie 2020 / Thursday, November 19 November Joi, 19 noiembrie 2020 / Thursday, G.I. MEREKOULIAS, Dr. I. VLAXOMITROS, Dr. E. MICHOU 12.10 – 12.30 Influența tulburărilor cognitive asupra acuzelor dureroase la pacientul cu boală Parkinson Dr. H. NICOLAE, Dr. I. IONIŢĂ, Dr. M. ROŞANU, Conf. Dr. C.PANEA 12.30 – 12.50 Erori frecvente în îngrijirea intensivă neurologică Dr. V. TIU, Dr. S. PETRESCU, Dr. V. MIHAI, Conf. Dr. C. PANEA 12 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

12.50 – 13.10 Polineuropatia din boala Parkinson: Evaluare și impactul asupra calității vieții Dr. Oana-Maria VANTA, Dr. Nicoleta TOHĂNEAN, Prof. Dr. Lăcrămioara PERJU-DUMBRAVĂ 13.10 – 13.20 Pauză

Simpozioane educaționale Moderatori: Conf. Dr. Adriana DULĂMEA, Asist. Univ. Dr. Mihai VASILE 13.20 – 13.40 Vertijul la granița dintre specialități; Sindromul vestibular central – o provocare de fiecare dată , 2020

th Şef Lucr. Dr. Horia NICOLAE 13.40 – 14.00 Vertigo at the border between specialties; Inner ear – window to the brain / Vertijul la graniţa dintre specialităţi; Urechea internă – fereastra către creier Prof. Dr. Julia Dlugaiczyk 14.00 – 14.20 Faţa văzută şi nevăzută a durerii neuropatice – între recomandări, dovezi şi practica clinică. De la dovezi la recomandări Asist. Univ. Dr. Mihai VASILE 14.20 – 14.40 Faţa văzută şi nevăzută a durerii neuropatice – între recomandări, dovezi şi practica clinică. De la recomandări la practica clinică Dr. Amalia ENE 14.40 – 14.50 Pauză

Simpozioane educaționale Moderatori: Prof. Dr. Bogdan Ovidiu POPESCU, Şef Lucr. Dr. József SZÁSZ 14.50 – 15.10 Actualități în managementul clinic al bolii Parkinson avansate Prof. Dr. Bogdan POPESCU 15.10 – 15.30 Provocări și soluții în controlul simptomelor bolii Parkinson avansate Șef Lucr. Dr. József SZÁSZ 15.50 – 16.10 Rolul proteinei SMN în atrofia musculară spinală (SMA) Dr. Crisanda VALCIU 16.10 – 16.30 Tratamentul cu toxină botulinică tip A în spasticitatea la adult Prof. Dr. Bogdan POPESCU 16.30 – 16.45 Ceremonia de decernare a premiilor pentru postere Prof. Dr. Bogdan Ovidiu POPESCU 16.45 – 17.00 Închiderea oficială a congresului Conf. Dr. Cristina TIU Joi, 19 noiembrie 2020 / Thursday, November 19 November Joi, 19 noiembrie 2020 / Thursday, Romanian Journal of Neurology – Volume XIX, Supplement, 2020 13

The 18th National Congress of the Romanian Society of Neurology

ORAL PRESENTATIONS – ABSTRACTS (in alphabetical order of the first author)

reduce mortality and morbidity related to invasive inter- The importance of intrasurgical TCD ventional procedures. monitoring – new horizons in research Raluca BADEA1,2, Athena RIBIGAN1,2, Sorina MIHĂILĂ-BÂLDEA1, Cristian UDROIU1, Sleep and stroke: „Guilty by association“ Florina ANTOCHI1 Prof. Claudio L.A. BASSETTI 1 University Emergency Hospital, Bucharest, Romania Department of Neurology, University Hospital, Bern, 2 “Carol Davila” University of Medicine and Pharmacy, Switzerland Bucharest, Romania Research of the last 20 years has shown that sleep- Introduction. Transcatheter aortic valve implanation wake disorders (SWD) and stroke are frequently associ- (TAVI) is a modern minimally invasive therapeutic alter- ated and that their relationship may be causal and bidi- native for the treatment of tight aortic stenoses. rectional. Despite the obvious advantages associated with TAVI On the one hand, SWD such as sleep disordered (percutaneous approach, avoidance of laborious sur- breathing (SDB), long sleep duration, and sleepiness/ gery, much simplified postoperative care for patients hypersomnia represent an independent risk factor for treated by classical surgical methods), neurological stroke. On the other hand, SDB, sleepiness/hypersom- complications are described in the literature, such as nia, insomnia, and restless legs syndrome (RLS) can ischemic stroke, transient ischemic attack, or silent appear “de novo” after stroke. Furthermore, SDB (and ischemic brain damage. possibly also other SWD) appear to negatively affect Long-term transcranial Doppler monitoring to detect stroke outcome and risk of recurrence. Finally, experi- abnormal embolic signals is a relatively new concept, mental and clinical studies give increasing support to first appeared in 2004, which allows real-time detection the hypothesis that sleep (and its disturbances) modu- of possible spontaneous intracerebral emboli during lates the acute ischemic cascade and neuroplasticity surgery. processes underlying stroke recovery. Methods. This work presents the results of the anal- More data, including interventional studies, are ysis of data collected from TCD records of five patients needed to assess the impact that a systematic manage- who received treatment with TAVI. Patients were moni- ment of SWD may have on stroke prevention and post- tored by peri- and post-procedural transcranial Doppler stroke outcome. While still incomplete, the evidence of to determine the most embolic surgery times and the a significant link between sleep, SWD and stroke is clinical and paraclinical factors that influence or are strong to call for more awareness and interdisciplinary associated with an increased number of cerebral emboli. collaborations between sleep, circadian and stroke clini- Results. Spontaneous microembolisms have been cians and scientists. observed during all surgery times. The highest incidence of spontaneous microembolism occurred during prosthesis expansion and cardiac resynchronization by pacing. Spontaneous and distant microembolisms were observed at the end of the surgery act, but with a different sound and appearance than the emboli intrasurgi- cally detected. Conclusions. The present study provides additional information on intraoperative brain damage and may allow the development of strategies to prevent and 14 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

The behavior of different subtypes of cultured T The pathogenic effect of CCR6+ receptor in helper cells for precision treatment in multiple multiple sclerosis – preliminary results of an sclerosis patients experimental model of lymphocyte isolation from Rodica BĂLAŞA1,2, Doina MANU1,3, Rozalia GABOR3, multiple sclerosis patients Minodora DOBREANU1,3 Laura BĂRCUȚEAN1, Minodora DOBREANU2,3, 1 “G.E. Palade” University of Medicine Pharmacy Science Doina MANU2,3, Rodica BĂLAȘA1,2 and Technology, Targu Mures, Romania 1 Department of Neurology, Emergency Clinical County 2 Department of Neurology, Emergency Clinical County Hospital, Targu Mures, Romania Hospital, Targu Mures, Romania 2 “G.E. Palade” University of Medicine Pharmacy Science 3 Center for Advanced Medical and Pharmaceutical and Technology, Targu Mures, Romania Research, Targu Mures, Romania 3 Center for Advanced Medical and Pharmaceutical Research, Targu Mures, Romania Multiple sclerosis (MS) is a chronic and heteroge- nous neuroinflammatory and neurodegenerative dis- Introduction. The curtain of uncertainty rises slowly ease of the brain and spinal cord. In the pathophysiology above multiple sclerosis (MS) physiopathology. The of MS, T cells are involved early but also in the long- pro-inflammatory effect of T lymphocytes is actively term host immune response. Substantial evidence im- mediated by the blood-brain-barrier and is subjected to plicating Th17cells, as well as IFN-γ IL-17 double-posi- the effect of various chemoattractant cytokines. CCR6 tive Th17.1 cells, in MS pathogenesis has accrued. enhances the proinflammatory Th17 cells breach The aim of our study was to isolate, culture and ana- through the choroid plexus. In MS, activated Th17 lym- lyze subsets of human T lymphocites harvested from phocytes therefore overexpress the CCR6 chemokine naïve patients diagnosed with remitting MS (RMS), receptor. Cladribine (CLD) is a purine nucleoside ana- assessment of a higher direct resolutive peripheral se- logue that disrupts the metabolic cycle of the lympho- cretor profile of cells and, to determine the phenotypic cytes. cellular changes in these cells together with the charac- Material and methods. Venous blood samples were terisation of the cytokines secreted in the presence of a harvested from newly diagnosed RR-MS patients and certain DMT. healthy controls (HC). The peripheral blood mononu- Material and methods. Phenotypic profile assess- clear cells were isolated, activated, cultivated and either ment of Th cells was determined from 32 RRMS naïve exposed to CLD (CLD+) or remained unexposed (CLD-). patients newly diagnosed and 12 HC with cell surface They were ultimately assessed at baseline, 7 and 14 markers. Phenotyping Th cells: 1.use of cell surface days (moment_0, 7, 14). The viability and proliferation markers (CD183/Th1, CD 161/Th17, CD196/Th17.1); index of the Th17 subpopulations were thoroughly as- 2. intracellular cytokine staining (CD3+ CD4+ T cells with sessed. Multiparametric flow cytometry analysis was an IFN-γ+ IL-17-, IFN-γ- IL-17+, IFN-γ+IL-17+). The next performed using BD FACS ARIA III in order to identify the step was to determine the modification of secretory phenotypic profile of Th17 cells (Th17/Th17.1) and the profile of the cells in the presence of cladribine. CCR6 expression in all the stages of the experiment. Results. The lymphocyte purity after PBMC isolation Results. The cell viability and proliferation were opti- from whole blood had a median of 84,05%. Pearson mal throughout all the stages of the experiment correlations between the determined levels of above (p < 0.0001). cytokines secreted by isolated cells: in Th17.1 cells Significant results were found in MS groups between direct correlations Il-17/IFN γ(0.001) found also after 7 Th17 moment_0 and CLD-7/14days and Th17.1 mo- respectively 14 day of Cladribine exposure (0.004, ment_0 and CLD-7/14days (p < 0.0001) favouring higher 0.002). baseline CCR6 levels. We report a statistically significant Conclusions. The Th17.1 subpopulations of Th lym- result when comparing MS Th17.1 CLD-14days vs Th17.1 CLD+14 days (p = 0.040), favouring the latter, with high- phocytes is very rare in the periphery of MS patients but er CCR6 levels. When comparing HC vs MS Th17.1 CCR6 maintains its’ secretory profile after 7/14 days of cladrib- levels at both 7 and 14 CLD-, we found significant results ine exposure. Using intracellular cytokines (IFN-γ and for CCR6 at both 7 and 14 days (p = 0.011, p = 0.005), IL-17) allowed the selection of more cells than the rest favouring higher levels for HC. We found no statistically of cell phenotyping methods. significant results when comparing MS or HC Th17 (CLD +/- 7 or 14 days) populations. Romanian Journal of Neurology – Volume XIX, Supplement, 2020 15

Conclusions. The complexity of chemokine expres- munity is deficient and mixed diseases in which both sion and lymphocyte interaction is still in the early stag- types of mechanisms coexist. es of research. While CLD’s mechanism of action is cen- The concept of autoinflammatory diseases was con- tred on B lymphocytes, studying the immune response stantly revised during the past years, today being de- from a Th17 perspective is needed. The Th17.1 HC fined as clinical alterations characterized by an abnor- CCR6-positive cells had a higher survivability rate in cul- mal level of inflammation determined by a dysfunction tures. Our study indicates that perhaps under the effect of innate immunity. of CLD, Th17.1 CCR6 cells tend to proliferate, but the evaluation of CLD cell cultures reveals a mixed response of CCR6 from a Th17/Th17.1 perspective. Autoimmune encephalitis: Diagnosis, treatment Acknowledgement. This research was supported by and prognosis – an epilepsy monitoring unit 2017 Merck Grant for Eastern Europe Countries (No. perspective 6943/2018). I-F. BRATU, C. LENȚOIU, I. OANE, A. DĂNEASA, A. ROCEANU, D. MOROȘANU, O.A. BĂJENARU, I. MÎNDRUȚĂ Innate and adaptive immunity for clinicians – Department of Neurology, Emergency University Hospital, principles Bucharest, Romania Alina BOTEANU Introduction. Autoimmune encephalitis (AE) repre- Department of Rheumatology, “Ramon y Cajal” University sents an umbrella term for an expanding group of po- Hospital, Madrid, Spain tential reversible neurological diseases with different The autoinflammatory syndromes represent a heter- underlying pathophysiological mechanisms. Its manifes- ogeneous group of clinical syndromes produced by a tations can vary greatly, making its recognition trouble- dysfunction of innate immunity. They are caused by mu- some. Furthemore, AE is an increasingly recognized tations of genes which control the regulatory mecha- cause of seizures and epilepsy. nisms of nonspecific inflammation. Although patients The aim of this presentation is to pinpoint the curent with clinical manifestations suggestive for an autoin- aspects of diagnosis and management of patients with AE and the role of the epilepsy monitoring unit (EMU) in flammatory disease have been first described centuries this context. ago, their genetic cause was identified only in 1997 Methods. We present a case series of patients who when the link between the MEFV gene and Mediterra- were diagnosed with AE and managed in our Neurology nean fever was clearly proven. This gene was the first Department. among many others discovered thereafter which led to Results. The patients’ initial presentation was pre- development of the concept of autoinflammation in dominantly psychiatric. They were extensively assessed 1999. This concept is characterized by episodes of fever mostly for infectious encephalitis, acute psychosis and or systemic inflammation involving different organs or drug abuse. Consequently, they were referred to pyschi- systems without an underlying source of infection or atric or toxicology settings were only after failure of spe- other determined cause. The innate immunity is the cific treatment further testing was carried out. Brain first to intervene as a non-specific defence mechanism imaging, blood and CSF work-up eventually emphasized in contrast with adaptative immunity which is specific. an encephalitic process. As most of the patients exhibit- While the presence of antibodies and activated B or ed epileptic fits, part of the integrative diagnostic work- T lymphocytes is characteristic for autoimmune diseases, up included videoEEG monitoring. Non-specific EEG these markers are not found in the vast majority of alterations suggestive for an encephalitic process were autoinflammatory syndromes. The cells involved in found. Antibody panel and body imaging screening pin- innate immunity are the monocytes, the macrophages pointed autoantibodies indicative for either a sole auto- and the dendritic and NK cells. immune process or a paraneoplasic one. The patients Nowadays there is a consensus regarding the exist- were diagnosed with AE and were treated using immno- ence of a broad spectrum of dysfunctions of the im- modulatory drugs and/or plasmapheresis with subse- mune system including pure monogenic autoinflamma- quent improvement. tory diseases in which the innate immunity is altered, Conclusions. This series highlights the importance of pure autoimmune diseases in which the adaptative im- considering AE as potential cause of seizures and the 16 Romanian Journal of Neurology – Volume XIX, Supplement, 2020 role of the EMU in its diagnosis and management. Left left me? Alien hand syndrome – Case report Abrupt-onset psychiatric manifestations and, as in our series, subtle cognitive impairment might account for A.M. CHIRIAC1, C. LUCHIAN1, D. NACONECINII1, underdiagnosing AE. L. BOLOHAN1, D.I. CUCIUREANU1,2 1 Neurology 1, “Prof. Dr. N. Oblu” Emergency Clinical Hospital, Iasi, Romania Patent foramen ovale – a cause for acute ischemic 2 Neurology Department, “Gr.T. Popa” University of stroke in the young adult Medicine and Pharmacy, Iasi, Romania Bogdan CĂȘARU, Raluca BADEA, Dana ȘTEFAN, Introduction. Alien hand syndrome (AHS) is a un- Athena RIBIGAN, Florina ANTOCHI common neurological disorder characterized by invol- Neurology Department, Emergency University Hospital, untary and autonomous movements. The cause of AHS Bucharest, Romania varies from tumor, aneurysm to trauma, neurosurgical intervention and stroke. Acute ischemic stroke in young adults has long been Case presentation. We illustrate a case of a 68 years considered an uncommon condition, however, in the old patient with multiple vascular risk factor: diabetes last decades we have witnessed an increase in its inci- mellitus type 2 insulin dependent, grade II hyperten- dence. Taking into consideration also the high economic sion, chronic atrial fibrillation and hyperlipoproteinemia impact of this association, we must realize that we are type IIb. The patient presented to the hospital with facing a major health problem. There is a need of im- symptoms of a left-hand paresthesia and confusional proving our diagnostic methods in order to better un- state. derstand the magnitude of stroke in the young adults Management and results. Magnetic resonance and to help us prevent it. imaging of the brain showed a subaccute ischaemic cer- Paradoxical embolism through Patent foramen ovale ebral infarction in the splenium of the right corpus callo- (PFO) is considered one of the largely recognized etiolo- sum, the precuneus of the right cingulate gyrus, with gies for ischemic stroke. Approximately 1 of 4 persons the psychological exam confirming the “alien hand syn- still has this intracardiac shunt during adult life and that drome”. is the reason why there was a requirement for a more Conclusions. AHS remains a difficult diagnosis to accessible method for its detection. Contrast-enhanced make and manage given its low prevalence and requires transcranial Doppler (c-TCD) has proven its value in more research and a multidisciplinary approach. effectively diagnosing the presence of right-to-left cardiac shunting. Throughout 2019, patients, mostly young, were re- Autoimmune encephalitis in routine clinical ferred to our neurosonology laboratory after suffering a practice cerebral ischemic event without having an identified 1 2 3 cause, or if there were asymptomatic hyperintense L. COZMA , I. MITREA , D. MITREA , 4 2 1,2,5 T2/FLAIR lesions identified on cerebral magnetic reso- I. PARASCHIV-ORBAN , C. MITU , B.O. POPESCU nance imaging (MRI). C-TCD was performed with intra- 1 Department of Clinical Neurosciences, “Carol Davila” venous infusion of microbubbles and the number of University of Medicine and Pharmacy, Bucharest, Romania 2 Department of Neurology, Colentina Clinical Hospital, emboli signals was recorded. The decision for medical Bucharest treatment of PFO percutaneous closure was made by a 3 Neuroaxis – Neurology Clinic, Bucharest, Romania multidisciplinary team and follow-up with c-TCD was set 4 Neurohope, Bucharest, Romania for 6 months after the intervention. 5 Laboratory of Ultrastructural Pathology, “Victor Babes” C-TCD is a non-invasive valuable tool in the diagnosis National Institute of Pathology, Bucharest, Romania of PFO, offering a high accuracy at a low cost and at an increased comfort for the patient. Autoimmune encephalitis (AE) encompasses a wide spectrum of diseases, revolutionized after the discovery of NMDAR antibodies in 2007, with recent data suggesting a prevalence close to that of infectious encephalitis. We highlight the spectrum of various phenotypes of AE and the diagnostic challenges encountered in routine clinical practice. Romanian Journal of Neurology – Volume XIX, Supplement, 2020 17

Stiff-person syndrome and progressive encephalo- Sleep disturbances in AE can range from REM sleep myelitis with rigidity and myoclonus are in a spectrum behavior disorder in patients with antibodies against that starts with increased muscle tone, most often due VGKC (now classified as antibodies against LGI1 or to GAD antibodies, while glycine receptor antibodies CASPR2), hypersomnia and fragmented sleep in the anti move this spectrum towards CNS features. Subacute NMDA antibody syndrome, insomnia in patients with cerebellar degeneration is one of the most common AE Morvan syndrome or sleep disordered breathing in and is often paraneoplastic in nature. patients with IgLON5 antibodies. Antibodies against VGKC are still routinely tested There is a clear need to define the prevalence and despite recommendations from experts to replace this subtypes of sleep disturbances in AE patients, and to with exclusive LGI1/CASPR2 testing. Their phenotypical clarify the relationship between specific autoantibodies, spectrum includes both peripheral and central nervous sleep symptomatology, and outcomes. system features in the case of CASPR2 antibodies, while We retrospectively reviewed the data of 15 patients LGI1-encephalitis is limited to CNS symptoms, present- diagnosed with AE in our clinic between 2016 and 2020. ing most commonly as a limbic encephalitis. The latter All of the patients underwent CSF examination, MRI can be caused by a large number of antibodies and can scanning, standard EEG recording and an extended be a part of various phenotypes, most notable of which autoantibody screening upon admission. Sleep ques- is NMDAR-encephalitis. tionnaires, assessing daytime sleepiness, sleep disor- Diagnosis of AE most often proves to be very difficult dered breathing, parasomnias or the presence and rest- in routine clinical practice, where multiple questions less legs syndrome, were administered. Polysomnography arise: What clinical features should we pay attention to? was performed in patients with sleep complaints and/or Which antibodies to test, when to test them, by what a clinical indication. method and what does the result mean? What other paraclinical work-up should be done? When to start treatment? We try to address some of these issues and Hypersomnias of central origin answer with our own experience. Cristian FALUP-PECURARIU1,2, Ștefania DIACONU1,2 1 Department of Neurology, County Emergency Clinic Sleep disturbances in patients with autoimmune Hospital Brașov, România encephalitis 2 Faculty of Medicine, Transilvania University, Brașov, România L. CRĂCIUN1, L. COZMA1, C. MITU1, A. DANAU1, R. MIHAILESCU1, A. VLADILA1, A. TEODOSIU1, Among sleep disorders, central hypersomnias B.O. POPESCU1,2,3 require special attention due to their severity and nega- 1 Department of Neurology, Colentina Clinical Hospital, tive impact on patients’ quality of life. According to the Bucharest, Romania International Classification of Sleep Disorders, Third 2 Department of Clinical Neurosciences, “Carol Davila” Edition (ICSD-3), the entities considered to be part of University of Medicine and Pharmacy, Bucharest, Romania central hypersomnias include narcolepsy type 1 and 3 Laboratory of Ultrastructural Pathology, “Victor Babes” narcolepsy type 2, idiopathic hypersomnia, Kleine-Levin National Institute of Pathology, Bucharest, Romania syndrome and other symptomatic hypersomnias (e.g. Autoimmune encephalitis (AE) is increasingly recog- due to a medical disorder or due to medication/sub- nized as an important cause of subacute cognitive stance, hypersomnia associated with a psychiatric disor- decline, seizures, and encephalopathy, with rising prev- der). The key element for all these disorders is the pres- alence and a high potential for treatment responsive- ence of hypersomnolence. For a correct diagnosis, ness. As the understanding of the different clinical phe- careful clinical history, sleep diaries, objective investiga- notypes increased, so too did the appreciation of the tions of sleep (actigraphy, polysomnography, multiple neurological impairments that can persist in some of sleep latency test) or even genetic tests or cerebrospinal the AE patients. fluid examination are necessary. Symptomatic treat- Sleep disturbances are detected in a majority of pa- ment and behavioral modifications were shown to alle- tients systematically screened for sleep complaints and viate hypersomnolence in central hypersomnias, and may even be the presenting symptom in some patients there are also several stimulants known to have benefi- with AE. It is yet unknown if their presence or persis- cial effects, especially in narcolepsy. tence is linked to adverse neurological outcomes. 18 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

This lecture will focus on discussing the clinical pres- Rasmussen encephalitis – diagnostic and entation, pathogenesis, diagnostic criteria, differential treatment features diagnosis and management of main hypersomnias of central origin. Nicolae GRECU Department of Neurology, University Emergency Hospital, Restless legs syndrome Bucharest, Romania Cristian FALUP-PECURARIU1,2, Ștefania DIACONU1,2 Rasmussen encephalitis is a rare neurological disor- 1 Department of Neurology, County Emergency Clinic der, with an inflammatory and/or autoimmune patho- Hospital Brașov, România physiology, presenting with focal epileptic seizures and/ 2 Faculty of Medicine, Transilvania University Brașov, or progressive unilateral neurologic deficits, and a grad- România ually increasing, asymmetrical, cerebral atrophy. Restless legs syndrome (RLS) or Willis-Ekbom dis- With specific biomarkers lacking, diagnosis is ease is characterized by uncomfortable sensations in currently made based on the Bien criteria and by exclud- the lower limbs associated with an irresistible urge to ing other disorders which could mimic the clinical or move the legs. These sensations occur during rest, gen- imaging picture. erally in the evening or night, are partially or totally Therapy is based on medical management of epilep- relieved by movement, and are not better explained by tic seizures, with a potentially added benefit from im- any other medical condition. Since the first description mune therapies and immunosuppressants; surgical of RLS by Karl-Axel Ekbom in 1945, there were estab- treatment is probably the most effective in controlling lished several criteria for RLS diagnosis by the Interna- refractory seizures, with the caveat of potentially disa- tional Restless Legs Syndrome Study Group (IRLSSG) – in bling sequelae. 1995 and 2003, while the latest revision was published We will review some of the more important data in 2014. related to the clinical presentation, pathophysiology, Different epidemiological studies have shown that diagnosis, differential diagnosis, and therapy. Further- the RLS prevalence in the general population is estimated more, we will present a case series of Rasmussen to be 5-10%. Another condition often associated with encephalitis patients from the Neurology Department RLS is represented by periodic limb movements of sleep of the University Emergency Hospital of Bucharest, with (PLMS), which are repetitive involuntary movements of an emphasis on clinical features and treatment choices. the legs occuring during sleep. Both RLS and PLMS are associated with important sleep impairments. The pathophysiology of RLS is not completely under- Neurologic symptomatology onset of mixed stood. There are different factors involved, like brain cryoglobulinemia in occult C virus infection iron deficiency (especially in the substantia nigra and E.I. ISTRATE1, A.M. PARTOACA1, I.A. OLARU1, putamen), genetic factors, or abnormalities in regula- G.M. BONDOC1, L.A. NISTOREC1, A.M. DOBRI1, tion of the dopaminergic system. Secondary RLS occurs A. POPESCU1, M.M. MANEA1,2, S. TUTA1,2 in different diseases and conditions like uremia, celiac 1 The National Institute of Neurology and Neurovascular disease, diabetes mellitus, rheumatoid arthritis, preg- Diseases, Bucharest, Romania nancy. 2 “Carol Davila” University of Medicine and Pharmacy, Augmentation is a phenomenon characterized by Bucharest, Romania exacerbation and earlier onset of the symptoms during the day, and it may be induced by the medication in- Introduction. The diagnosis of mixed cryoglobuline- tended to alleviate RLS. mia is challenging because of the varied spectrum of Treatment options include non-pharmacologic and manifestations. It is characterized clinically by a triad pharmacological strategies (dopamine agonists, iron (purpura, arthralgias and Raynaud’s phenomenon) and supplimentation, α2 δ ligands, opioids). involvement of other organs. There is a strong associa- The presentation will focus on up-to-date information between hepatitis C viral infection and mixed cryo- tion regarding diagnosis, pathophysiology, investiga- globulinemia. tions, differential diagnosis and management of RLS in Methods. A series of 3 cases – A 74-year-old patient general population. with a history of rheumatoid arthritis presented for severe motor deficiency with an apparently acute onset. Romanian Journal of Neurology – Volume XIX, Supplement, 2020 19

The clinical examination revealed asymmetric tetrapa- as well as the clinical course, optimal treatment and resis and sensitivity disorder with a clinical picture sug- prognostic of cSAH. Unfortunately, given the low inci- gestive of mononeuritis multiplex . Another 63-year-old dence, the data are sparse. cSAH constitutes a challenge patient known with cardiac disease history presented not only because of the clinical presentation that is di- for horizontal diplopia with sudden onset. Clinically: verse and often atypical for a “classic” SAH, but also be- right abducens nerve palsy, tactile bilateral lower limb cause of the multitude of possible etiologies which en- hypoesthesia and purpura. The last patient, aged 60, tail different management approaches as well as with no pathological history, presents for oblique diplo- different prognosis. This presentation is based on a clin- pia and palpebral ptosis in the right eye. Clinical exami- ical case and aims to bring the current data on the pit- nation: right oculomotor nerve palsy, without parasym- falls in diagnosing and managing this extremely interest- pathetic involvement. ing pathology up to date. Results. The clinical and electrophysiological context, demonstrate peripheral nervous system involvement. Hepatitis C viral infection was detected and cryo- Sleep disturbance and epilepsy globulin testing was intensely positive. Other causes of Ioana MINDRUTA, Irina POPA mononeuritis multiplex and mononevritis of the cranial Neurology Department, University Emergency Hospital, nerves were excluded through imaging and laboratory Bucharest, Romania studies (compressive lesions, infectious causes, vascular, metabolic and other autoimmune systemic vasculitis). Sleep disturbance is a common occurrence in epilep- Conclusions. Although the association between cry- sy. It could be related to seizures but also to antiepilep- oglobulinemia and peripheral neuropathy is known in tic treatment. Sleep fragmentation is a common finding the literature, serum cryoglobulin levels are not routinely with variable causes in people with epilepsy. A polisom- dosed, reason why this pathology being frequently un- nography could show other sleep related comorbidities, derdiagnosed. the most common being sleep apnea. Neurocognitive deficits especially for memory are known to be preva- lent in people with epilepsy. The role of poor sleep and Pitfalls in the diagnosis and management of impact on memory processing and consolidation is well convexity subarachnoid hemorrhage recognized highlighting the importance of exploring C. LAZA1, M. PREOTESOIU1, sleep in cognitively impaired patients independent of L.N. NIȚU-DUMBRAVĂ1, R.A. BAZ2, G. BUTOI3, seizure control. Epileptic events are believed to be activated by sleep C. PASCU1, A. DOCU-AXELERAD1,4 and particularly nonrapid eye movement (NREM) sleep. 1 Neurology Department, “Sf. Andrei” Clinical County Reciprocally, epilepsy alters the sleep-waking cycle and Emergency Hospital, Constanta, Romania 2 Radioimaging Department, “Sf. Andrei” Clinical County sleep architecture. The sleep-epilepsy relationship dif- Emergency Hospital, Constanta, Romania fers according to the type of epilepsy or epileptic 3 Medimar Imagistic Services SRL, Constanta, Romania syndrome. Although sleep epilepsies are not considered 4 Neurology Department, School of General Medicine, to be entities in their own right, some epilepsies are “Ovidius” University, Constanta, Romania activated by sleep, and in others sleep deprivation leads to sensitization to seizures. Convexity or cortical subarachnoid hemorrhage (cSAH) is increasingly recognised as a separate clinical The association of blood pressure values with entity in the spectrum of cerebro-vascular diseases. It is ischemic stroke prognosis characterised by the presence of blood limited to the subarachnoid space overlying the hemispheric convexi- H. NICOLAE1,2, I. IONIȚĂ1, A.B. ARAMĂ2, ty, without extension into the basal cisterns, ventricular C. PANEA1,2 system or brain tissue. Although it is well known that 1 Neurology Department, Elias Emergency Hospital, approximately 15-20% of subarachnoid hemorrhages Bucharest, Romania (SAH) are nonaneurysmal, cSAH is emerging as a distinct 1 “Carol Davila” University of Medicine and Pharmacy, category, with an estimated share of 5-6% of the total Bucharest, Romania SAH. Over the past 10 years there have been several Introduction. Ischemic stroke is the most frequent studies that tried to clarify first and foremost the etiology, neurological disease in adults and the second cause for 20 Romanian Journal of Neurology – Volume XIX, Supplement, 2020 mortality and morbidity after cardiovascular disease. admitted in the Neurology Department of Elias Universi- High blood pressure is the most important modifiable ty Emergency Hospital from July 2014 to July 2019. We vascular risk factor for stroke. The aim of this study is to diagnosed the presence of neurocognitive disorder by analyse the influence of blood pressure values on the MMSE score. Pain was evaluated using Parkinson’s prognosis of patients with ischemic stroke. well-being map. For motor symptoms evaluation, we Materials and methods. We conducted a retrospec- used UPDRS III. We performed a statistical analysis of tive study that includes 344 patients admitted in the the data collected. Neurology department of Elias University Emergency Results. Out of the 51 patients with neurocognitive Hospital from February to August 2020, with the diagno- dysfunction, 45.1% had mild neurocognitive disorder, sis of ischemic stroke. We collected data from the medical 35.3% had a moderate form of major neurocognitive charts. We analysed blood pressure values at admission, disorder and 19.6% had a severe form of major neuro- at 24 hours and 48 hours after admission and at dis- cognitive disorder. Interestingly, 88% of the patients charge. The patients’ evolution was established by NIHSS with neurocognitive disorder experienced painful score progression, complications and length of hospital events. We found a statistically significant correlation stay. We carried a statistical analysis of the data collected. between the presence and intensity of painful episodes Results. We observed that the patients who had a and the MMSE score (p = 0.016) and also an association negative outcome had higher mean blood pressure val- with motor dysfunction. ues and a wider variation of blood pressure values. We Conclusions. The presence and the intensity of pain found a significant association between systolic blood related symptoms is correlated with the presence and pressure at 48 hours after admission and the neurologi- the severity of cognitive dysfunction in patients with cal evolution, as the mean systolic blood pressure values Parkinson’s disease. in the group with a negative outcome were with 15.08% Keywords: Parkinson`s disease, cognitive disorder, higher than the mean systolic blood pressure values in pain the group with a positive outcome (p = 0.002). Conclusions. Blood pressure values influence the prognosis of ischemic stroke; our results show that sys- Sleep study in the diagnosis of REM sleep tolic blood pressure at 48 hours after admission is statis- behavior disorder tically significant for the prognosis of ischemic stroke. Irina OANE, Andrei DANEASA, Flavius BRATU, Keywords: stroke, blood pressure, outcome Camelia LENTOIU, Ovidiu BAJENARU, Ioana MINDRUTA Epilepsy and Sleep Monitoring Unit, Neurology Clinic, The influence of neurocognitive dysfunction on University Emergency Hospital, Bucharest, Romania pain in patients with Parkinson’s disease Background. REM sleep behavior disorder (RBD) is a H. NICOLAE1,2, I. IONIȚĂ1, N.M. ROȘANU2, REM parasomnia in which patients act out their dreams. 1,2 C. PANEA Patients and method.We included patients that un- 1 Department of Neurology, Elias University Emergency derwent sleep studies in the Epilepsy and Sleep Unit at Hospital, Bucharest, Romania the University Emergency Hospital Bucharest. Polysom- 2 “Carol Davila” University of Medicine and Pharmacy, nographic recordings were performed using a particular, Bucharest, Romania extended EEG montage, 10-20 system; additionally, we Introduction. Parkinson`s disease is the second most monitored limb movements using four EMG motion frequent neurodegenerative disorder in the general sensors placed on each limb, electrooculogram to population, after Alzheimer`s disease. Neurocognitive record eye movements and determine REM stage, chin impairment is present from the onset, although it may EMG sensor to detect muscle tonus, thoracic belt, initially remain undetectable using commonly used neu- respiratory airflow and pulse oximetry to monitor the rocognitive tests. When evaluating non-motor symp- respiratory effort and EKG. toms, pain, together with fatigability, are very frequent. Results. Between 2014 and 2020 we explored over The purpose of this study is to determine the influence 200 patients using polysomnography and we were able of the cognitive dysfunction on pain related symptoms. to identify 30 patients with RBD. Most often patients Materials and methods. We conducted a retrospec- presented brisk upper limb movements, kicking using tive study on 134 patients with Parkinson’s disease the lower limbs, talk or smiled during the episodes. If Romanian Journal of Neurology – Volume XIX, Supplement, 2020 21 awakened, they could correlate their movements with Sleep in degenerative parkinsonism their dreams. These patients were diagnosed with multiple system atrophy, parkinson disease or RBD was idio- L. PERJU-DUMBRAVĂ, N. TOHĂNEAN, D. LASCU, pathic meaning that patients did not yet present with M. ȘTEȚCA additional symptoms of a neurodegenerative disorder. “Iuliu Hatieganu” University of Medicine and Pharmacy, Conclusion. Our experience is concordant with up to Cluj-Napoca, Romania date sleep studies in terms of diagnosis and evolution of Neurology Clinic I, Cluj County Emergency Clinical RBD. Hospital, Cluj-Napoca, Romania Introduction. Sleep disorders are non-motor symptoms of Parkinson’s syndromes, which is a recently Sleep disorder and headache – how do we introduced but much studied topic in literature. Some approach? sleep disorders have been shown to act as a biomarker, C. PANEA1,2, R. GURGU1, V. TIU1,2, S. PETRESCU1,2 facilitating early and differential diagnosis, especially in Elias University Emergency Hospital, Bucharest, Romania Parkinson’s disease (BP). “Carol Davila” University of Medicine and Pharmacy, The etiology of sleep disorders is multifactorial and Bucharest, Romania not entirely elucidated being attributed to the degeneration of the sleep center and the motor symptoms Introduction. Sleep disorders and headache are fre- themselves, but also to the dopaminergic medication. quent complaints in clinical practice and is not unusual The estimated prevalence is between 70-98%, hold- to coexist, whatever is dominant. They share anatomical ing a significant impact on the quality of everyday life. pathways, physiology and treatment in some cases, so is The most common sleep disorders are REM behavioral reasonable to approach them together sleep disorder, excessive daytime sleepiness, insomnia Objectives. To analyze the possible etiologies and and parasomnia. Sleep assessment is required based on the necessary steps to get them, underlaying mecha- the anamnestic data provided by both the patient and nisms and therapeutical options their relatives. Questionnaires such as “Parkinson’s Materials and methods. among patients addressed to sleep lab for sleep disorders we indentified those Disease Sleep Scale “ and “ The Scales for Outcomes in with headache also; we used headache and sleep dia- PD (SCOPA) “ can be particularly useful in quantification ries and severity scales, sleep, anxiety, depression and and follow-up of specific complaints. For diagnostic pur- QoL questionaires and standard neurological evaluation poses, however, the gold standard remains polysom- (clinical, EEG, vascular ultrasonography and brain MR nography with continuous recording during the nights. imaging); in selected cases we performed standard pol- Conclusion. The paper summarizes the main chang- ysomnography es regarding sleep in degenerative parkinsonism, em- Results. We identified 54 patients patients with phasizing the specific features of each entity. sleep disorders (insomnia, daytime sleepiness, circadian rhythm slepp disorders) and headache. In 22 (40,7%) cases we found sleep disorders and other 13 (24%) Oligoclonal bands in multiple sclerosis – undiagnosed primary headaches as main cause for pres- correlative interpretation entation. The other cases 19(35,18%) had various (psy- S. PETRESCU1,2, V. TIU1,2, M. MARTOIU1, chiatric, vascular, infectious) origins C. PANEA1,2 Conclusions: Although frequent and apparently easy 1 Department of Neurology, Elias University Emergency to approach, the association of sleep disorder an head- Hospital, Bucharest, Romania ache may hide conditions with aggravating potential, so 2 “Carol Davila” University of Medicine and Pharmacy, they must be addressed together by specialists with Bucharest, Romania comprehensive knowledge of neurology and sleep medicine Oligoclonal bands (OB) are present in more than 90% Keywords: sleep disorder, headache, diagnosis of patients with multiple sclerosis and their inclusion into the updated McDonald criteria has improved clinical diagnosis. OBs are considered now one of the diagnostic biomarkers of the disease, although these immunological 22 Romanian Journal of Neurology – Volume XIX, Supplement, 2020 abnormalities in cerebrospinal fluid (CSF) are also found (chi-square tests αand multiple regression analysis, in other neurological disorders. SPSS, v.23). Recent studies on biomarkers in multiple sclerosis Results. 95 patients were included (54 men, 74.1±11, found the presence of OB (both IgG and IgM) is correlat- mean (±SD) age) with mean length-of-stay 114±59 days. ed with a worse prognosis. Patients with right hemispheric (RH) lesions experi- No association between OB and magnetic resonance enced more severe dysphagia compared to left-sided imaging (MRI) features has been found (such as ana- (LH) lesions (p=0,009). Initial moderate-to-severe dys- tomical location of lesions or brain atrophy). phagia (76.8%) was reduced to 24.5% on discharge Different CSF biomarkers could help improve diag- (p<0.001). Dysphagia severity was significantly im- nostic accuracy, allow a personalized therapy of MS proved in both RH and LH patients but not in patients patients and provide valuable feedback regarding the with bilateral lesions. Improved dysphagia status on dis- course of the disease. charge was more likely in patients with unilateral lesions 2 Keywords: multiple sclerosis, oligoclonal bands, bio- (p = 0.037, R = 0.342). markers Conclusion. Stroke-specific factors exert an important influence on the outcome of dysphagia therapy delivered in RU subacute stroke patients. Further Dysphagia therapy in a stroke rehabilitation unit: research is required investigating how these factors What factors influence dysphagia severity on interact with SLT-led dysphagia therapy, and whether patient stratification would improve such care. discharge? C. Politi GHEMULET1, S. HAMDY2, G. NTAIOS3, E. KOROMPOKI4, G.I. MEREKOULIAS1, Lupus erythematosus – neurologic complications I. VLAXOMITROS1, E. MICHOU2,5 Athena Cristina Ribigan1,2, Raluca Badea1,2, 1 Olympion General Clinic and Rehabilitation Center, Daniela Stefan1,2, Cristina Davidoiu1, Patras, Greece Bogdan Casaru1, Florina Antochi1 2 Centre for Gastrointestinal Sciences, Faculty of Medical 1 and Human Sciences, University of Manchester, UK University Emergency Hospital, Bucharest, Romania 2 3 Internal Medicine School of Medicine, University of “Carol Davila” University of Medicine and Pharmacy, Thessaly, Larissa, Greece Bucharest, Romania 4 Department of Clinical Therapeutics, 1st Department of Introduction. Systemic lupus erythematosus (SLE) is Neurology, National and Kapodistrian University of characterized by numerous immunological abnormali- Athens, Greece 5 Department Speech Language Therapy, University of ties that lead to multiorgan involvement. The central Patras, Greece and/or peripheral nervous system are frequently affected in patients with SLE. It is estimated that 10-80% of Introduction. A proportion of stroke patients con- patients with SLE develop neurologic and psychiatric tinue to experience dysphagia both during the suba- symptoms. cute phase and after their admission to rehabilitation Materials and methods. In this paper the neurologi- units (RUs). Here, we investigated how stroke-and dys- cal complications of SLE will be presented and supported phagia-specific factors can influence the outcome of by two case presentations. First female patient of 64 rehabilitative dysphagia therapy. years old was transferred to our Neurology Department Methodology. Data from consecutively admitted for multiple oculomotor nerves palsies and motor weak- stroke patients to the dysphagia clinic of an RU in West- ness of the lower limbs with the absence of deep ten- ern Greece were examined retrospectively over a don reflexes. Serial cerebral magnetic resonance imag- 12-month period. Dysphagia scores – Dysphagia Sever- ing revealed cavernous sinus thrombosis that extended ity Rating Scale (DSRS) and Functional Oral Intake Scale despite anticoagulation. Nerve conduction studies (FOIS) – and stroke-specific measurements (NIHSS, showed sensorymotor axonal polyneuropathy. The sec- type of lesion, previous history of stroke and others) ond patient of the same age was transferred from the were collected on admission and discharge. Data for Cardiology Department, where she was admitted for the duration and intensity of dysphagia therapy were Libman-Sacks endocarditis, for abrupt onset of right also captured. Factors for positive changes in dysphagia hemiparesis and aphasia, 3 hours before. Cerebral com- status, cognitive and motor abilities were examined puted tomography with iv contrast revealed left middle Romanian Journal of Neurology – Volume XIX, Supplement, 2020 23 cerebral artery M1 segment occlusion. She also present- Neurologic manifestations of the ADA2 ed thrombocytopenia (61000/microliter). associated vasculopathy Results. The first patient was diagnosed with SLE and received treatment with cyclophosphamide with Elena Terecoasa, Cristina Ghita, improvement of the symptoms but one week later she Larisa Purcaru, Iulian Enache, Cristina Tiu presented severe anemia secondary to a large retroper- Department of Neurology, University Emergency Hospital, itoneal hematoma. The patient underwent surgery and Bucharest, Romania died few days later. The second patient underwent First described in 2014, deficiency of adenosine thrombectomy with complete remission of the symp- deaminase 2 (DADA2) is a monogenic autoinflammatory tomatology. disorder of children and less often adults, characterised Conclusion. We chose to present this paper in order by an early onset vasculopathy with skin rash associated to highlight the neurologic complications of SLE and the with systemic manifestations, nervous system involve- importance of an early diagnosis and treatment of this ment and mild immunodeficiency. This condition is sec- pathology. ondary to autosomal recessive mutations of CECR1 gene, mapped to chromosome 22q11.1, that encodes Plasmapheresis and double filtration the enzymatic protein adenosine deaminase 2 (ADA2). The pathogenetic mechanism of DADA2 is still plasmapheresis in severe neuroimune disorders unclear but abnormalities in adenosine breakdown are Corina Roman-Filip1,2 considered to play a key role. The diagnosis is estab- 1 Department of Neurology,County Emergency Hospital, lished through detection of reduced activity level of the Sibiu, Romania ADA2 and/or identification of bi-allelic mutations in the 2 “Lucian Blaga” University, Sibiu, Romania ADA2 gene. From the clinical point of view, this disease is charac- Therapeutic plasma exchange (TPE) is an extra-cor- terized by a wide spectrum of severity. Chronic or recur- poreal blood purification technique designed to remove rent systemic inflammation with fever, elevation of large molecular weight particles from plasma such as circulating autoantibodies, immune complexes, acute phase reactants and skin manifestations is the cytokines, monoclonal proteins, toxins and other in- typical clinical picture. While in some patients the dis- flammatory mediators. TPE is accepted by the American ease is mild and skin-limited, others present a severe, Society for Apheresis as first line treatment for some se- even lethal, disease with multi-organ involvement. Neu- vere neuroimmune disorders-Guilaine Barré syndrome rologic involvement is estimated to occur in 50–75% of (GBS), myasthenia gravis in severe crisis, chronic inflam- patients, the most frequent manifestations being matory demyelinating polyneuropathy and fulminant ischemic or hemorrhagic strokes. Meningitis, encephali- forms of Wilson disease. Plasmapheresis is accepted as tis and PNS involvement with mononeuritis multiplex, second line therapy in Lambert-Eaton myasthenic syn- cranial neuropathies, and polyneuropathy (sensory or drome, multiple sclerosis relapsing-remitting form, motor) have also been reported. acute disseminated encephalomyelitis (ADEM) and in Due to its rarity, the response to treatment of DADA2 neuromyelitis optica (NMO) unresponsive to high-dose is still anecdotal. The first-line treatment consists of corticosteroids. TNF-inhibitors which are effective in controlling inflam- Double filtration plasmapheresis (DFPP) is a newer mation and in preserving vascular integrity. Steroids can technique in which plasma is not entirely removed, only control the disease’s manifestations at high dosage. the antibodies, using special filters. High-dose intravenous immunoglobulins are an alternative treatment for these patients but are much more expensive. We report the experience with TPE and DFPP performed between 2012 and 2020 in a lot of patients with severe neuroimmune disorders that were admitted in our hospital. 24 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

Immunologic consequences of acute ischemic Common mistakes in neurocritical care stroke V. TIU1,2, S. PETRESCU1,2, V. MIHAI1, C. PANEA1,2 Cristina Tiu1,2, Cristina Ghiță2, Larisa Purcaru2, 1 Neurology Department, Elias University Emergency Iulian Enache2, Elena Terecoasă1,2 Hospital, Bucharest, Romania 2 1 ”Carol Davila” University of Medicine and Pharmacy, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Bucharest, Romania 2 University Emergency Hospital, Bucharest, Romania A brief review of the most common local practices in Acute stroke holds the second place after acute car- caring for the neurocritical patient, exploring the evi- diac ischemia regarding worldwide death causes. Signif- dence each of these therapeutic gestures is based on. icant progress has been achieved in recent years by The dos and don’ts of hyperosmolar therapy, proton using both chemical and mechanical revascularisation pump inhibitors overprescription, orotracheal intuba- techniques for acute ischemic stroke treatment. However, tion that overstays its welcome, microdosing statins, there is a constant need for complementary therapies in how training residents in acute stroke care lowered the order to improve quality of life and survival rates after annual furosemid consumption by almost a third and stroke. other hot topics will be brought under the spotlight. Inflammation is the key event that triggers immuno- While sorting guideline indications from folklore, the logic cascades within the central nervous system. The authors explore the medical and pharmaco-economic immune system acts through both pathways: innate and impact generated by common mistakes in day to day aquired. The innate immune system determines imme- practice. diate activation of non-specific leukocytic cells, granu- Keywords: neurointensive care, guidelines, errors locitic cells and innate lymphoid cells. These innate immune cells secrete cytokines and chemokines that recruit other innate cells, signal other pathways and ac- Diagnostic approach to central nervous system tivate secondary immunologic cascades. The adaptive lymphomas: A case series immune system is initiated within hours to days from D. Tulbă, L. Cozma, Z. Cofoian-Amet, the acute event. It uses cell mediated immunity (T cells) A. Florea, C. Lupu, R. Mihăilescu, D. Mitrea, and humoural mediated immunity (B cells). The anti- I. Mitrea, A. Vlădilă, C. Mitu, B.O. Popescu gen-specific response is characteristic for the adaptive Neurology Department, Colentina Clinical Hospital, immunity, as well as the ability to have immunological Bucharest, Romania memory. Current literature states that there is no certain cell Central nervous system lymphomas (CNSL) comprise population defined as main pathogenic effector in a diverse group of rare hematologic malignancies result- stroke. Neutrophils, followed by macrophages and natu- ing from monoclonal lymphocyte proliferation. They are ral killer cells are the first to migrate in the brain paren- divided into two subtypes, primary CNSL (that primarily chyma in the first hours up to days after the ischemic arise in the CNS) and secondary CNSL (metastatic). Con- event. B and T lymphocytes are later involved in the in- sidering their heterogeneous clinical presentation that flammatory event. Consequently, immediate immune ranges from paucisymptomatic to acute multifocal system approach should be attempted in the very early symptoms, particular imaging findings should raise a stages of an acute ischemic event in order to improve high index of suspicion. Provided that contiguity with a outcome. cerebrospinal fluid (CSF) space occurs, lumbar puncture The inflammatory cascade is responsible for molecu- might assist diagnosis. Nevertheless, histopathologic lar alterations in the blood brain barrier triggered by confimation is warranted. arterial vessel occlusion. Although the purpose of this We present ten patients aged 23 to 71 years old with mechanism is to restore homeostasis, inflammation can primary or secondary CNSL. Main clinical manifestations also alter the penumbral tissue. A better understanding were cerebellar signs, intracranial hypertension syn- of the intricate connections between ischemic stroke drome, limb motor deficits, cranial nerves palsies and and the immune system could help neurologists alter epileptic seizures. Most patients had bilateral parenchy- the effects of inflammation towards protection and mal involvement on MRI, one had leptomeningeal infil- away from tissue damage. tration and one had normal imaging. In two cases CSF Romanian Journal of Neurology – Volume XIX, Supplement, 2020 25 analysis identified atypical lymphoid cells and three had optic nerve ischemia. In particular, carriage of HLA- mild lymphocytic pleocytosis. DRB1*0401 and DRB1*0404 haplotypes are more prone Consistent with the literature, the immunocompe- to interact with a probable environmental infectious tent patients had late onset of primary CNSL, whereas agents or autoantigens and activate arterial wall den- the only one with HIV infection was diagnosed at age 30. dritic cells. Activated vascular dendritic cells are able to All primary CNSL in our group were diffuse large-B cell attract and activate T lymphocytes and macrophages lymphomas (DLBCL), one being confirmed at necropsy through production of specific chemokine and cytokine and one requiring two biopsies. Three patients had CNS and further initiate and maintain arterial inflammation involvement by primary extranodal DLBCL (mediastinal and granuloma formation. In the adventitia, activated and ovarian) and nodular sclerosis Hodgkin lymphoma, M1 macrophages primarily secrete proinflammatory cy- respectively. In one patient brain biopsy failed to pro- tokines like IL-1 and IL-6, while M1 macrophages in the bate the diagnosis of Bing-Neel syndrome. medial layer degrade the arterial matrix through secre- In conclusion, CNSL are “great imitators”, with heter- tion of matrix metalloproteinases and damage vascular ogeneous clinical presentations and imaging features. smooth muscle cells and endothelial cells. CD4+ T effec- Diagnostic approach is difficult and sometimes requires tor cell subtypes have been identified as key regulators sequential brain biopsies. in vasculitic lesions of GCA; type 17 helper T cells and type 1 helper T cells. Although a major immunologic Immunological features of giant cell arteritis role of B cells is the production of antibodies, B cells can also regulate T cell responses in auto-immunity through Sorin Tuță the secretion of both pro-inflammatory (TNF-α and IL-6) National Institute of Neurology and Neurovascular and anti-inflammatory (IL-10) cytokines. Beyond stand- Diseases, Bucharest, Romania ”Carol Davila” University of Medicine and Pharmacy, ard cortisone therapy the above immune mechanisms Bucharest, Romania are targeted by new therapeutic agents, including abat- acept and ustekinumab but also tocilizumab which has Giant cell arteritis (GCA) is the most common idio- shown clear benefit in both newly diagnosed and re- pathic systemic vasculitis in persons aged 50 years or lapsing patients with GCA. older, with increased risk of vertebral artery stroke and 26 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

The 18th National Congress of the Romanian Society of Neurology

POSTERS – ABSTRACTS (in alphabetical order of the first author)

Neuroimunologie / Chitinase 3-like-1 – a potential biomarker for Neuroimmunology benign multiple sclerosis Laura BARCUTEAN, Smaranda MAIER, Rodica BALASA Small discoveries can have great consequences – Neurology 1 Clinic, Emergency Clinical County Hospital; a peculiar case of neuro-Behçet Department of Neurology, University of Medicine, F. ANTONESCU1,2, F. IVANCIU1, E. MIHAI1, Pharmacy, “George Emil Palade” Science and Technology, N. ANGHEL1, S. TUȚĂ Tg. Mures, Romania 1National Institute of Neurology and Neurovascular Introduction. Chitinase 3-like-1(CHI3L1) is a serum Diseases, Bucharest, Romania protein secreted by the immune cells and its presence in 2 “Carol Davila” University of Medicine and Pharmacy, the inflammatory lesions suggest that it may be an es- Bucharest, Romania sential player in the astrocytic response in modulating Introduction. Behçet disease is a chronic, inflamma- the central nervous system inflammation. Benign multi- tory condition, characterized by oral and genital ulcera- ple sclerosis (B-MS) is a controversial diagnosis that has tive lesions, generally associated with systemic manifes- no definite consensus criteria. tations. We will be presenting the case of a patient in Material and method. We selected 20 MS patients which the changes on MRI were not suggestive, but a with an EDSS score ≤2.0, treated continuously with In- careful clinical examination was key to the diagnosis. terferon beta-1b (IFNβ1b) for at least 10 years and 20 Objective and methods. We will be presenting the healthy controls (HC). Venous blood samples were har- case of a patient admitted to our clinic with acute tran- vested from both groups and underwent serum CHI3L1 sient focal neurological symptoms, suggesting a tran- analysis. Both clinical and demographical data were as- sient ischemic attack, followed by progressive confu- sessed in the chosen B-MS lot, including evolution of sional state, cognitive impairment and fever. At first, we the disease before and after the treatment was started, suspected an infectious meningoencephalitis due to type of onset, cognitive and ambulatory assessment. changes on MRI, but the CSF examination disproved this Results. The mean age of B-MS patients was diagnosis. The patient also presented with pulmonary 47.75±7.07, and of HC was 39.8±9.42. The B-MS manifestations, as well as deep vein thrombosis on the patients had an average of 18.1 years of evolution, lower right limb which extended to inferior vena cava. A being under active IFNβ1b treatment for more than 14 careful clinical reexamination showed the presence of years, and with a median EDSS of 1.5. No statistical oral ulcerative lesions, a major criterion for diagnosis of significance was found when comparing the median Behçet disease. The initial immunosuppressive treat- level of CHI3L1 levels in B-MS lot with HC (p=0.085). ment was cortisone, to which we added azathioprine, Conclusion. A long disease evolution and a low disa- with a slowly favorable evolution with marked improve- bility score carries a good prognosis, but it is uncertain if ment of the clinical and imaging parameters. this follows the natural trend of the disease or we are Conclusions. Our case is particular in the way that faced with a homogenous lot of perfect IFNβ1b re- the first symptom was a stroke mimic, a phenomenon sponders. The lack of statistical significance in compar- also encountered in other types of autoimmune ening the CHI3L1 levels between B-MS patients and HC cephalopthies. Currently, there are no investigation indicates that the MS patients have a similar peripheral methods available which can confirm with certainty the diagnosis, this remains a diagnosis of exclusion in which immune reaction as normal population. the clinical findings (oral and genital ulcers, uveitis) remain paramount. Romanian Journal of Neurology – Volume XIX, Supplement, 2020 27

Methods. A 65-year-old patient, known with com- Is there any use for event-related auditory pensated essential hypertension, is admitted for sudden evoked potentials in multiple sclerosis? – A onset binocular diplopia. The neurological examination preliminary study revealed horizontal diplopia and convergent strabismus S.M. BULAI1, A. LEONTE1, D.A. SPÎNU1, E.B. IGNAT1,2 of the left eye (left abducens nerve palsy), bilateral abol- ¹Neurology Department, Clinical Hospital of ished corneal reflex (bilateral trigeminal nerve impair- Rehabilitation, Iasi, Romania ment), slight peripheral right facial palsy, otherwise nor- ²“Grigore T. Popa” University of Medicine and Pharmacy, mal clinical examination. Iasi, Romania Results. Cerebral MRI scan with contrast revealed Cognitive impairment affects patients suffering from enhancing lesions at the level of the intralabyrinthine multiple sclerosis and even though it was believed to be segment of the right facial nerve, the maxillary and characteristic to late stages of the disease, it is now mandibular branches of the bilateral trigeminal nerves known to be frequent, sometimes early, and an impor- and at the level of the retroclival meninges; without any tant cause of disability. Recent recommendations in- lesions of the cerebral parenchyma. CSF biochemistry clude cognitive screening of MS patients and annual and cytology analysis was normal. Bioumoral tests ex- re-assessment. For patients showing cognitive decline cluded other infectious diseases (TB, Borrelia burgdoferi, on minimal evaluation, there are other validated evalu- HIV, syphilis, hepatitis B or C infection). Angiotensin con- ation tools that can be used by clinicians for a more ex- vertase was negative. Other connective tissue diseases tensive assessment. were excluded, with the exception of SS antibodies (an- We present a preliminary report regarding our expe- tiLa antibodies, anti-Ro antibodies, positive ANA anti- rience in the Hospital of Rehabilitation in Iasi, following bodies) and the ultrasound imaging which revealed sug- a 3 year period of cognitive assessment of MS patients, gestive changes of SS in the parotid glands. One month using electrophysiological evaluation along with other after the onset of neurological symptoms, the patient clinical and imaging screening tools. As a neurophysio- developed xerostomia and dry eye syndrome, meeting logical indicator of cognitive function we used the P300 the diagnostic criteria. wave, a late component of the event related potential. It Conclusions. Neurological manifestations may is elicited by distinct (target) stimuli delivered among a precede the clinical onset of SS, therefore, in patients series of standard, non-target stimuli, thus depending with apparently isolated involvement of the cranial on the subject’s attention and working memory. nerves, a correct diagnosis of the underlying SS may of- We present the correlations emerged while also dis- ten be delayed. cussing the importance and utility of the selected tests.

Clinical and paraclinical features of posterior An atypical case of multiple cranial neuropathies reversible encephalopathy syndrome (PRES) in in Sjögren’s syndrome systemic lupus erythematosus (SLE) 1 1 A.M. DOBRI1, G.M. MOCI1, L Nistorec1, I.A. OLARU1, Mustafa FILIS-ELIF , Corina GATU , 1,2 1,2 L. PINTE1, G.A. SÎRBU3, M.M. MANEA1,2, C. BAICUS, Simona PETRESCU , Cristina Aura PANEA S. TUȚĂ1,2 1 Neurology Department, Elias University Hospital, Bucharest, Romania 1 National Institute of Neurology and Neurovascular 2 “Carol Davila” University of Medicine and Pharmacy, Diseases, Bucharest, Romania Bucharest, Romania 2 “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Cerebral autoregulation is a homeostatic process 3 Diagnostic Center Medinst, Bucharest, Romania that regulates and maintains cerebral blood flow con- 4 Internal Medicine Department, Colentina Clinical stant across a range of blood pressures, with limits rang- Hospital, Bucharest, Romania ing from 50-150 mmHg cerebral perfusion pressure Objectives. Primary Sjögren’s syndrome (SS) is an (CPP) or 60-160 mmHg mean arterial pressure (MAP). autoimmune inflammatory disease, mainly affecting the This mechanism ensures an increase in resistance in the salivary and lacrimal glands, but may be complicated by small cerebral arteries as CPP or MAP increases. neurological manifestations, involvement of cranial Objectives. The symptoms of RPES syndrome evolve nerves being the rarest. rapidly, being characterized by headaches, altered con- 28 Romanian Journal of Neurology – Volume XIX, Supplement, 2020 sciousness, visual disturbances and seizures. Neuroim- with progressive gait instability, developing progressive aging reveals bilateral edema of the white matter in the weakness and pain in lower limbs, with marked im- posterior cerebral hemisphere, especially in the provement under administration of GCS shortly after parieto-occipital region. onset of symptoms. After two years the patient presented Methods. A 33-year-old woman, with history of SLE with recurrence of uncoordinated gait, lower limbs with hematological, articular and renal determinations, weakness, facial paresthesia, diplopia and dizziness. in treatment with corticosteroids and hydroxychloro- Neurological examination revealed Lhermitte’s sign, quine, was admitted for severe occipital headache with grade 4/5 paraparesis, palmomental reflex, exaggerated recent onset and high blood pressure. At the neurologi- deep tendon reflexes in lower limbs and bilateral Babinski cal examination, she had temporal and spatial disorien- sign. Investigations including routine bloodwork, auto- tation, bradypsychia, bradylalia, blinked inconsistently immune-bloodwork, infectious markers, Borrelia burg- at visual threats in both visual hemifields, weakly reac- dorferi antibodies, anti-aquaporin-4 antibodies, angio- tive bilateral miosis, oculomotor disorder with bilateral tensin converting enzyme, chest x-ray, ECG, abduction limitation, plantar cutaneous reflex in exten- electromyoneurography revealed no abnormality. Cere- sion bilaterally. Biologically, she had mild leukocytosis brospinal fluid examination showed absence of oligo- with neutrophilia and minimal lymphopenia, bicytopenia, clonal bands. Brain MRI scan showed a bulky pons with moderate inflammatory syndrome, significant nitrogen mildly hypointense lesions on T1-weighted images, be- retention syndrome, high D-dimers. ing hyperintense on T2 and FLAIR image, with gadolini- Results. Native MRI examination revealed diffuse um contrast enhancement giving a typical ‘peppering of bilateral lesions with hyperintensity on T2 and Flair, pre- pons’ appearance. MRI scan of the spinal cord also dominantly at the level of the structures irrigated by the revealed hyperintense T2-weighted lesions in the cervi- posterior circulation (bilateral occipital and cerebellar), co-dorsal region. After intravenous corticotherapy con- with superficial and deep topography. tinued by 4-month-long oral GCS treatment, regression Conclusions. The occurrence of PRES syndrome of symptoms occured and at 6-month follow-up, MRI associated with SLE was mainly caused by hypertension imaging showed resolution of lesions. induced by renal failure and the antihypertension treat- Conclusions. After excluding pathological conditions ment was the most important to reverse the RPES that may result in similar clinical and radiological fea- lesion. tures and taking into consideration the success of GCS Keywords: posterior reversible encephalopathy syn- therapy, the case was interpreted as CLIPPERS-syndrome (PRES), systemic lupus erythematosus (SLE) drome. The core of early diagnosis and adecvate management is emphasising the importance to consider CLIPPERS in young patients with progressive gait impair- CLIPPERS syndrome: A rare cause of gait ment accompanied by other brainstem signs, therefore impairment – case report leading to a good prognosis as making this yet not fully discovered entity curable. E. FINNA1, S. MAIER1,2, Z. BAJKÓ1,2, A. MOȚĂȚĂIANU1,2, R. BĂLAȘA1,2 1 Neurology I Department, Emergency Clinical County Natalizumab and persistent leukocytosis Hospital, Targu-Mures, Romania treatment considerations in a group of patients 2 Discipline of Neurology, UMFST, Targu-Mures, Romania with relapsing-remitting multiple sclerosis Introduction. Chronic lymphocytic inflammation C. GROSU1,2, M. STOICA1, A. PLESCA1, with pontine perivascular enhancement responsive to O. UNGUREANU1 steroids (CLIPPERS)-syndrome is an inflammatory dis- 1 Clinical Rehabilitation Hospital, Iasi, Romania ease of CNS with distinct clinical and radiological fea- 2 “Gr. T. Popa” University of Medicine and Pharmacy, Iasi, tures, representing a rare cause of uncoordinated gait Romania amongst other specific CNS symptoms. An important aspect of the diagnosis is significant clinical and radio- Natalizumab (Tysabri) is a recombinant humanized logical responsiveness to glucocorticosteroid (GCS)-based α4-integrin antibody on the surface leukocytes, availa- immunosuppression. ble in Romania since 2006, approved for the treatment Case report. A 45-year-old male patient with history of multiple sclerosis very active recurrent remiss form, of electric shock, with no prior medical history, presented proving its effectiveness by decreasing the number of Romanian Journal of Neurology – Volume XIX, Supplement, 2020 29 relapses and slowing the progression of disability. The Results and discussions. Between 2007 and 2019 literature considers the occurrence of leukocytosis in there were 13 patients discharged from the Neurology patients treated with Natalizumab as a haematological Department of Elias University Hospital with a diagnosis adverse effect, but there are also studies that conclude of Miller Fisher syndrome. Complete results of the elec- that it may be a biomarker of therapeutic efficacy. trodiagnostic testing were available for only 9 patients. We analyzed a group of 19 patients, registered in the The assessed patients were 25 to 65 years old. Sex distri- Neurology Clinic, the Clinical Hospital of Recovery Iasi, bution was 5 males and 4 females. In total, the electro- diagnosed with recurrent remiss multiple sclerosis that diagnostic testing included 58 motor nerves (including are being treated with Natalizumab for at least 1 year. evaluation of minimum latency of the F wave in 49 The average age of the study group was 36.7 years, 4 motor nerves) and 59 sensitive nerves. Only one patient men and 15 women. The values of leukocytes, lympho- had normal electrodiagnostic testing. In order of fre- cytes, neutrophils and were analyzed of ESR for each quency, we observed the following changes of electrodi- patient, for 1 year, monthly. Thus, the mean value of agnostic parameters: reduced SNAP amplitude (21 sen- leukocytes was 9107 leukocytes / mm 3, of which 34% sitive nerves in 6 patients), increased peak distal were increased. Also 19% of the values neutrophils and sensitive latencies (15 sensitive nerves in 6 patients), 69.7% of lymphocyte values were increased, ESR show- reduced SCVs (5 sensitive nerves in 4 patients), reduced ing increased by 7.5%. We mention that no patient pre- distal CMAP amplitude (6 motor nerves in 3 patients), sented a burst during the period analyzed. increased distal motor latency outside usual entrap- Large observational studies with standardized data ment sites (3 motor nerves in one patient), reduced seg- collected from real experience are needed to provide mentary MCVs (4 motor nerves in one patient), possible additional information about the Natalizumab profile, conduction blocks (2 motor nerves in one patient) and to improve intake decisions and optimization of treat- increased minimum F wave latency (2 motor nerves in ment management. one patient). All changes described above (except Keywords: Natalizumab, leukocytosis, multiple scle- reduced SNAP amplitude and reduced SVCs in sensitive rosis nerves) were minimal and the electrophysiological criteria for acute demyelinating poliradiculoneuritis were not fulfilled. Electrophysiologic abnormalities in patients with Conclusion. The main electrophysiological changes Miller-Fisher syndrome in Miller-Fisher syndrome are usually found in sensitive nerves and are frequetly severe, but unspecific, for de- R. GURGU1, V. MIHAI1, F. MUSTAFA1, myelinating disorder. M. MOLDOVAN1, I. CODITA1, C. PANEA1,2 Keywords: Miller Fisher syndrome, electrophysiology 1 Neurology Department, Elias University Emergency Hospital, Bucharest, Romania 2 “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Diagnostic difficulties in atypical demyelinating lesion with pseudotumoral form. Case report Background. Miller-Fisher syndrome is a rare type of Raluca-Andreea IGNAT1, Diana ELISEI1, acute poliradiculoneuritis, with a typical clinical picture Liviu PENDEFUNDA1, Anca SAVA1,2, including ophtalmoparesis, ataxia and areflexia. It can 3 also associate other clinical signs indicating involvement Gabriela Florenta DUMITRESCU 1 of other cranial nerves (facial paresis, swallowing diffi- Neurology Departament II, “Prof. Dr. Nicolae Oblu” culties, etc) as well as sensory disturbances in the limbs. Emergency Clinical Hospital, Iasi, Romania 2 Morphofunctional Science Department I, “Grigore T. Objectives. Characterization of electrophysiological Popa” University of Medicine and Pharmacy, Iasi changes in patients with Miller Fisher syndrome. 3 Anatomical Pathology Departament, “Prof. Dr. Nicolae Materials and method. We identified all patients Oblu” Emergency Clinical Hospital, Iasi, Romania discharged between 2007-2019 from the Neurology Department of Elias University Hospital with a diagnosis Multiple sclerosis is the most common chronic disa- of acute poliradiculoneuritis - Miller Fisher variant. For bilitating disease of the central nervous system in young all identified patients, we collected demographical data adults. It is characterized by the presence of multiple and the results of the nerve conduction studies per- inflammatory demyelinating lesions, disseminated in formed during the admission. the CNS. 30 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

The pseudotumoral form of multiple sclerosis is con- patients is statistically 3 to 6 times higher in both sexes, sidered a rare variant of the disease. The frequency is compared to the general population. Treating patients uncertain, but a prevalence of 3 cases per million inhab- with MS and epilepsy may be challenging. itants per year has been estimated, being described Case report. We present the case of a 41 years old more frequently in women, in the second and third woman, with personal history of meningitis, diagnosed decade of life. The definition of pseudotumoral form is with generalized tonic-clonic epilepsy at the age of 35, based on image explorations. However, the lesions have treated with Levetiracetam and Lamotrigine and diag- not yet been given an exact description (1). nosed at the age of 39, on clinical (sensory and motor There may be difficulties in establishing the diagnosis. symptoms) and imagistic criteria (MRI), with relapsing The differential diagnosis should include tumors, remitting MS. Glatiramer acetate was added, knowing abscesses and acute disseminated encephalomyelitis that beta interferons could induce seizures. Two relapses when the lesions are multiple. were treated with intravenous methyprednisolone, but Clinical evolution, cerebrospinal fluid analysis, new every administration induced severe generalized advanced MRI techniques, and response to steroid tonic-clonic seizures, treated with emergency treat- treatment could guide the clinician to diagnosis (2). ment. Headache and several hours of language distur- Due to their rarity, clinical behavior and exact lesion bances (speaking in foreign languages) suggesting a management are partially known to clinicians. temporal status epilepticus followed the seizures. We present the case of a 24 year old patient, whith- Conclusions. MS treatment should be changed, due out any special medical history, who presents in the to disease activity and methylprednisolone intolerance neurology department for vertigo aggravated by head but in accordance with the patient’s status. Terifluno- mobilization, static and dynamic balance disorders. MRI mide and Cladribine were taken into account and plas- examination that detects multiple demyelinating lesions ma exchange for relapses. White and grey matter MS (subtentorial and supratentorial, some with pseudotu- lesions can increase epileptogenesis. Language dysfunc- moral cystic appearance with maximum diameter ranging tions may occur due to demyelinating lesions, but also from 12 to 24 mm) raises differential diagnostic prob- as epileptic ictal or postictal manifestations. Limited lit- lems; additional clinical and paraclinical examinations, erature data regarding the association of epilepsy and including brain biopsy, guide the etiologic diagnosis and MS, drug interactions for the two diseases and methyl- therapeutic behaviour. prednisolone intolerance need a special consideration Keywords: demielinizing, pseudotumoral in the treatment decision.

References 1. Mauri-Fábrega L et al. Pseudotumoral Forms of Multi- Rare infratentorial demyelinating lesion ple Sclerosis: Report of 14 Cases and Review of the associated with mediastinal mass Literature. Eur Neurol. 2014;72:72-78. 2. Totaro R et al. Tumefactive demyelinating lesions: I. IONIȚĂ1, G. VULPE1, A. DRUȚĂ2, A.C. PANEA1 spectrum of disease, diagnosis and Treatment. Curr 1 Elias University Emergency Hospital, Bucharest, Romania Neurobio. 2016;7(1):21-26. 2 Rahova Clinic, Bucharest, Romania

Introduction. Infratentorial lesions can have a wide Patient associating multiple sclerosis, epilepsy range of aspects on brain imagery, often not very specif- and intolerance to methylprednisolone – a ic for a certain diagnosis, therefore making the case difficult therapeutic approach rather challenging for the medical team. Case presentation. It is the case of a 50 year old hy- 1 1,2 D.M. ILIE , G. MIHĂILESCU pertensive, obese, non-smoker female without other 1 Colentina Clinical Hospital, Neurology Department, significant comorbidities, who presents in the neurology Bucharest, Romania unit for vertigo and imbalance. Upon clinical evaluation 2 “Carol Davila” University of Medicine and Pharmacy, we found a discrete left palpebral ptosis, diminished left Bucharest, Romania pupillary reflex, torsional nystagmus at lateral view, axial Introduction. Multiple sclerosis (MS) can associate and left arm and leg ataxia and absence of plantar reflex epileptic seizures, most of them with focal onset, but it on the left side. The MRI shows a large, infratentorial can also be associated with epilepsy as a prior disease. lesion of demyelinating aspect, affecting the brainstem Even if under diagnosed the incidence of epilepsy in MS and the cerebellum, mostly on the left side. She under- Romanian Journal of Neurology – Volume XIX, Supplement, 2020 31 went a full body CT (thorax, abdomen and pelvis) to in- disorders: accentuation of the motor deficit (tetrapa- vestigate a possible paraneoplastic syndrome; the result reza with the predominance of paraparesis), astazo- was a mass in the superior mediastinum, compressing abasis, balance disorders, repeated falls, persistent the thyroid and the aortic arch. As for the laboratory dizziness. findings, mild pleocytosis in the cerebrospinal fluid was The treatment of pathologies associated with the noted and high values of angiotensin-converting en- specific treatment of MS, has led to a stagnation of evo- zyme. Therefore, a first question is raised – which is the lution. aetiology of the brain mass and of the mediastinal Conclusions. Combining multiple sclerosis with oth- mass? An excisional biopsy is performed in order to an- er systemic disorders, complicates the clinical picture, swer the question. can lead to diagnostic confusion and unexpected aggra- Conclusion. The case explores the presence of two vation of symptoms. different masses, a brain mass and a mediastinal mass Early diagnosis and proper treatment are the key to and the possible correlation between them, considering success in such situations. as well the high levels of angiotensin-converting enzyme and the role it might play. Natalizumab-induced peripheral immune profile changes correlated with the clinical activity of the Morbid associations in a case of multiple disease sclerosis Smaranda MAIER1,2, Mihaela SIMU3,4, 1,2 Emilia FURDU LUNGUȚ , Laura BĂRCUȚEAN1, Zoltan BAJKO1, 3 4 Iustinian PORFIR FURDU , Silviu LUNGUȚ Anca MOȚĂȚĂIANU1, Adina HUȚANU5, 1 Neurology, CF2 Hospital, Bucharest, Romania Septimiu VOIDĂZAN6, Rodica BĂLAȘA1,2 2 “Titu Maiorescu” University, Bucharest, Romania 1 Neurology, “G.E. Palade” UMFST, Tg. Mures, Romania 3 Radiology, CF2 Hospital, Bucharest, Romania 2 Mures County Clinical Emergency Hospital, Tg. Mures, 4 “Carol Davila” University of Medicine and Pharmacy, Romania Bucharest, Romania 3 “Victor Babes” University of Medicine and Pharmacy, , Introduction. Multiple sclerosis is a chronic disease, Timisoara, Romania 4 Department of Neurology, “Pius Brinzeu” County which is characterized clinically by episodes with focal Emergency Clinical Hospital, Timisoara, Romania deficits of the optic nerves, brain and spinal cord, which 5 Laboratory Medicine, CCAMF, “G.E. Palade” UMFST, are remeasured to varying degrees, presenting recur- Tg. Mures, Romania rences over the years and usually progressively. 6 Epidemiology, “G.E. Palade” UMFST, Tg. Mures, Romania Characteristic, demyelinating lesions may vary in diameter, mainly affecting the white matter of the brain Introduction. Natalizumab (NAT) was the first and spinal cord, and do not extend beyond the entrance disease-modifying treatment used for the treatment of areas of the cranial or spinal nerves. multiple sclerosis with a targeted mechanism of action There are situations in which demyelinating disease to block the penetration of activated T-cell lymphocytes is associated with other conditions, which complicates through the blood-brain barrier. both its clinical manifestations and its evolution over The aim of this study is to characterize the effects of time. NAT on the production of cytokines in the periphery and Case presentation.We present the case of a 43-year- to find correlations between changes in serum levels of old male patient with recurrent remissive MS at the age cytokines, induced by NAT, and disease activity. of 30, who was treated with Betaferon until 2016, when Materials and methods. The study included 60 he discontinued it on his own initiative. patients with multiple sclerosis registered in the region- In 2011, he was also diagnosed with HTAE, dyslipi- al centers of Timisoara and Targu Mures and a number demia, spinal cord compression syndrome; In 2012 she of 33 healthy controls. Demographic and disease-related suffered a lower myocardial infarction followed by triple data of patients were obtained by medical history and stent coronary angioplasty. medical records. Using the Bio-plex Pro Human Th17 In this context, the demyelinating disease was mani- Cytokine Panel kit, serum levels of 15 cytokines were as- fested with frequent outbreaks, then it became second- sessed simultaneously at both the beginning and the ary progressive with major aggravation of neurological end of the study. 32 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

Results. A significant decrease in IL-17, IL-33 and signs on SWI). EEG showed no epileptiform changes IL-31 serum levels was observed after approximately 6 during DFBS and CSF biochemical test was normal. The months of NAT treatment in naïve patients. The number TPO antibody titer was increased (245 IU / ml) and the of relapses during the study correlated positively with anti-VGKC antibodies strongly positive (897 pmol / l). the initial serum levels of IL-17 and negatively with Other causes of infectious / autoimmune encephalopa- IL-33. Patients who did not have relapses during the thies / alterations in the context of nonketotic hypergly- study had lower baseline serum levels of IL-17 com- cemia were excluded. Following immunomodulatory, pared with those with relapses. Patients in whom the the evolution was favorable. EDSS score increased during the study had lower base- Conclusions. HE patients should be monitored for line serum levels of IL-33 and IL-17 compared to those in anti-VGKC antibodies in the presence of FBDS. whom the EDSS score decreased. Causal lesions in patients with FBDS appear in the Conclusions. The results of our study demonstrate basal ganglia and do not affect the EEG pattern, suggest- once again that the mechanism of action of NAT is not as ing that FBDS may be associated with these lesions. simple as it was created, NAT treatment causes changes in the inflammatory mechanism in the periphery. IL-17 can be used both as a biomarker of disease activity and Executive disfunction and its correlation with progression in patients treated with NAT. quality of life at patients with multipe sclerosis Maria M. MARTOIU1, Simona PETRESCU1,2, Cristina A. PANEA1,2 Neuronal surface autoantibodies anti-VGKC 1 complex in thyroid antibody-positive and Neurology Department, Elias Emergency University Hospital, Bucharest, Romania negative limbic encephalitis – case report 2 “Carol Davila” University of Medicine and Pharmacy, M.M. MANEA1,2, G.M. MOCI1, A.M. DOBRI1, Bucharest, Romania 3 1 1 1,2 G.A. SÎRBU , L. NISTOREC , I.A. OLARU , S. TUȚĂ Introduction. Motor disability, cognitive dysfunction 1 National Institute of Neurology and Neurovascular and neuropsychiatric symptoms are common in multi- Diseases, Bucharest, Romania ple sclerosis (MS). The common cognitive symptoms 2 “Carol Davila” University of Medicine and Pharmacy, include deficits in executive functioning, attention, Bucharest, Romania information processing and long-term memory. These 3 Medinst Diagnostic Center, Bucharest, Romania deficits affect the quality of life of the patient. Introduction. Thyroid peroxidase (TPO) antibodies Aim. The paper aims to analyze the degree of execu- present in Hashimoto’s encephalopathy (HE) may be tive disfunction and to identify the relationship between elevated in other cases of autoimmune encephalitis, it and the quality of life for patients with multiple sclerosis. often in combination with antibodies to specific anti- Methods. 97 patients diagnosed with MS have been gens. A large proportion of HEs are actually encephalitis clinically evaluated using Expanded Disability Status with voltage-gated potassium channel antibodies Scale (EDSS). We applied cognitive tests: MMSE (Mini (VGKCs), targeting the extracellular domains of leu- Mental State Examination), MoCA (Montreal Cognitive cine-inactivated glioma 1 (LGI1) and contactin-associated Assessment) and executive function test: Trail Making protein-like 2 (CASPR2). Dystonic facio-brachial epileptic Test Part A and B (TMT). Quality of life was measured by seizures (FBDS) reported a high incidence in encephalitis the self-reporting scale: EuroQol 5-Dimension, with with anti-VGKCs / LGI1 antibodies. EQ-5D-index and EQ-Visual Analogue Scale (EQ-VAS). Methods. A 71-year-old patient diagnosed 3 months Statistical correlations were performed. prior with focal seizures presented to our clinic with in- Results. Over 50% of patients have mild executive creased seizure frequency. The neurologic examination disfunction with score values between average and defi- revealed temporo-spatial disorientation, behavioral, cient on TMT Part A and B examination. Executive func- mnesic symptoms and faciobrachial dystonic seizures, tion test TMT Part A and B corelated statistically signifi- without other pathological findings. cant with EDSS score (pA = 0,002 < 0.01 and pB=0,0004 < Results. The cerebral MRI scan revealed a pseudofo- 0,001), and self-reported scale EQ-5D correlates statistical area with hyperintense signal in T2, FLAIR, DWI cally significant with all applied cognitive scale including B1000 and T1 images, at the level of the right striatal executive function test TMT Part A and B (p< 0,001). nuclei, without contrast enhancement or any hemorrhagic Romanian Journal of Neurology – Volume XIX, Supplement, 2020 33

Conclusions. The quality of life in patients with mul- Conclusions. Cognitive impairment and depression tiple sclerosis is greatly influenced by cognitive impair- have an increased prevalence among patients with MS. ment, especially by executive disfunction. Patients with EDSS correlates with cognitive dysfunction and depres- executive dysfunction were more likely to have a higher sion. The level of education of patients can contribute to degree of physical disability. a better cooperation and treatment compliance, thus Keywords: multiple sclerosis, executive dysfunction, with a favorable prognosis. Natalizumab demonstrated quality of life a decrease in annual recurrence rate our results were not statistically significant.

Cognitive impairment and depression in multiple sclerosis pacients undergoing Natalizumab Multiple sclerosis Balo like form wit a good treatment in a romanian population: The role of response to plasmapheresis education, physical disability and relapse rate B. MOSCU1, C. ROMAN-FILIP1,2, M. HANEA1 A. MOLDOVAN1, S. MAIER1,2, A. MOTATAIANU1,2, 1 Department of Neurology, Emergency County Hospital, Z. BAJKO1,2, L. BARCUTEAN1,2, R. BALASA1,2 Sibiu, Romania 2 1 Neurology I, Emergency Clinical County Hospital, “Lucian Blaga” University, Sibiu, Romania Tg. Mures, Romania Balo concentric sclerosis (BCS) is considered a vari- 2 Neurology, UMFST, Tg. Mures, Romania ant of multiple sclerosis. It occurs predominantly in Background. Recently, studies have described cogni- young adults, it is a rare and relatively acute condition. tive impairment as having major effect on the disability Attacks can progress quickly for weeks or months with- of patients with multiple sclerosis (MS). Depression is a out remission, leading to death or severe disability. frequent part of the clinical presentation of patients Most cases have a more benign, self-limiting course, with MS and influences their quality of life, compromis- with spontaneous remission. The progression of the ing cognitive function, leading to suicide attempts and disease is monophasic, with a rare frequency of recur- reducing treatment compliance. Monoclonal antibody rences. MRI is essential in establishing the diagnosis, it Natalizumab has been shown to improve these parame- can highlight lesions in the cerebral hemispheres, optic ters at 1 and 2 years of treatment. chiasm, brainstem, cerebellum and spinal cord. Inten- Objective.The purpose of this study is to identify pa- sive immunosuppression treatment may be indicated in tients with MS who are treated with Natalizumab and patients with more aggressive form. have cognitive impairment and depression, to monitor We present the case of a 30 year old patient, who the evolution of neurocognitive and depression aspects, presented during the year of 2016 a right sided pares- to identify the main factors, while assessing the impact thetic syndrome and in January 2019 an episode of of MS on quality of life. retrobulbar optic neuritis of the right eye. Material and methods. A prospective case-control Cerebral MRI (February 2019) highlights 2 non-spe- study was performed aiming to analyze patients (n = 28, cific frontal subcortical punctual lesions. 8M / 20F) diagnosed with MS according to McDonald’s In 18.10. 2019 he has a sudden motor deficit of the criteria from the records of the Neurology I Department right upper and lower limb. of Târgu-Mureș County Emergency Clinical Hospital who Cerebral MRI (18.10.2019) shows a concentric active are following Natalizumab treatment. Control subjects demyelinating nodular lesion in the left semioval center. (n = 100, 42M / 59F) were recruited to analyze cognition Under treatment with methylprednisolone, symptom and depression between the two groups. EDSS (Expanded relief was achieved. Disability Status Scale), Beck depression inventory In 15.11.2019 the patient returns, for an aggravated (BDI-II) and Symbol Digit Modality Test (SDMT) were ap- motor deficit at the level of the upper and lower right limb. plied. Cerebral MRI (15.11.2019) shows an active concentric Results. We found a positive association between nodular demyelinating lesion in the left semioval center, EDSS and BDI-II - p 0.010, as well as EDSS and SDMT - increasing in size, with oedema in the adjacent white p 0.048; statistically significant correlation was found matter. between education and BDI-II (p 0.001) and SDMT The symptomatology improved after the administra- (p 0.0040); the relapse rate was not playing a significant tion of methylprednisolone 5 days and 5 sessions of role in cognitive deterioration or depression. plasmapheresis performed at 2 days interval. 34 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

The link between neuroinflammation and Association between systemic lupus neurodegeneration in amyotrophic lateral erythematosus and neuromyelitis optica sclerosis I.M. OLARU1, M. SPOIALĂ1, M.L. HOHAN1, Anca MOȚĂȚĂIANU D. ALEXA1,3, E. REZUS2,3 Neurology, „George Emil Palade“ UMFST, Tg. Mures, 1 Neurology Department, Clinical Rehabilitation Hospital, Romania Iasi, Romania 2 Rheumatology Department, Clinical Rehabilitation Amyotrophic lateral sclerosis (ALS) is a neurodegen- Hospital, Iasi, Romania erative multifactorial disease of the central nervous 3 “Grigore T. Popa” University of Medicine and Pharmacy, system (CNS), characterized by selective destruction of Iasi, Romania motoneurons in the spinal cord, brain stem and primary motor cortex. Introduction. Systemic lupus erythematosus (SLE) is Neuroinflammation is now accepted as a key modu- an autoimmune disease that can affect any component lator factor of disease progression in ALS. Innate and of the central or peripheral nervous system, and its adaptive immunity have an complex interrelationship in manifestations can range from headaches, mood disor- neurodegenerative process in ALS. As a part of innate ders, to stroke, optic neuropathy or myelopathy. Lupus immune system, CD4+T (TCD4+) cells under the influ- mielopathy may have as pathogenic mechanism the ence of transcription factors and of cytokines differenti- inflammation mediated by anti-aquaporin-4 (AQ-4) ated into T effector cells (Teff). This Teffs cells have antibodies and is associated with neuromyelitis optica different immunological functions: Th1 and Th17 have (NMO) or non-AQP4-mediated inflammation or vascular an proinflammatory role, Th2 has an antiinflammatory occlusion associated with antiphospholipid antibodies. effect, while regulatory T cells (Treg) are involved in im- Case study. We present the case of a 37-year-old mune suppresion. Th1 and Th17 are the most frequent patient, known with SLE with neurological and immuno- TCD4+ cells infiltrating the CNS in ALS and by secreting logical manifestations, who suddenly presents in proinflammatory cytokines influences the function of December 2019 cervical pain with irradiation in the microglia and switch the phenotype and function, from right upper limb accompanied by motor deficit and an protective type (M2) to a neurodegenerative (M1). paresthesias in the lower limbs and right upper limb. Treg are potent immune modulators wich supress the The examination of cervico-dorsal MRI with contrast neuroinflammation by inhibiting the proliferaration of substance showed extensive longitudinal transverse Th1 and Th17, by down-regulation of proinflammatory myelitis, and biologically AQ-4 were in high titer. Subse- cytokines (IL-17, Il-6, IL-21, IL-22, TNF-α) and by secreting quent development under immunosuppressive therapy antiinflamatory types of cytokines (IL4, IL10, IL13). was slightly favorable with amelioration of motor deficit Recent data from experiments in animal models and and sensitivity disorder. in ALS patients have shown that the main effectors of Discussion. The association between SLE and NMO neuroinflammation (reactive microglial and astrocytes) may involve a common immune mechanism and an actively can display, in a time dependent and context increased susceptibility to antibody-mediated autoim- dependent manner, both neuroprotective and neurode- mune diseases. In patients diagnosed with SLE it is nec- generative properties, depending on the stage of essary to establish the pathogenic mechanism of disease progression and cytokine secretion. This data myelopathy. The presence of AQ-4 implies an increased demonstrated the pivotal role of T cells and microglia in risk of relapse, and for this purpose aggressive long- disease progression, mediating the neuroinflammatory term immunosuppressive therapy is used. processes of ALS. Conclusions. In the case of lupus myelopathy, the Understanding of the biological processes of the detection of the presence of AQ-4 antibodies requires neuroinflammation in ALS will increase our understand- repeated tests, especially during relapses, being absent ing of motoneuron degeneration and the ability to target during remission periods. new perspective for treatment intervention in this dev- Keywords: systemic lupus erythematosus (SLE), optic astating disease. neuromyelitis (NMO), anti-aquaporin-4 antibodies (AQ-4) Acknowledgment. This work was supported by funding number 293/5/14.01.2020 from University of Medicine, Pharmacy, Science and Technology George Emil Palade Tg. Mureș. Romanian Journal of Neurology – Volume XIX, Supplement, 2020 35

level of HbA1c, glycaemia, or triglycerides at admission Morbidity and mortality risk factors in type 2 and mortality. diabetes mellitus patients with acute ischemic Keywords: stroke, type 2 diabetes, mortality stroke-immunological mechanisms L. POPA1, S. PETRESCU1,2, C. PANEA1,2 1 Neurology Department, Elias University Hospital of TULBURĂRI ALE SOMNULUI / Emergency, Bucharest, Romania SLEEP DISORDERS 2 “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Sleep quality in patients with minor stroke Background and aims. Type 2 diabetes mellitus 1 1 1 2 (T2DM) is a well-established risk factor for ischemic R. GURGU , V. MIHAI , F. MUSTAFA , O. DRUGA , 1,3 stroke. We aimed to assess the impact of T2DM on mor- C. PANEA 1 bidity and mortality in patients with acute ischemic Neurology Department, Elias University Emergency stroke, as well as associated factors that could lead to a Hospital, Bucharest, Romania 2 Geriatrics Department, Elias University Emergency bad prognosis. Hospital, Bucharest, Romania Methods. We conducted a study on 194 patients 3 “Carol Davila” University of Medicine and Pharmacy, with T2DM and acute ischemic stroke. The information Bucharest, Romania was collected retrospectively, using patient electronic charts and analyzed using SPSS v20 – through logistic Background. Sleep disorders are frequent in patients regression, Chi-square and Pearson bivariate correlation with acute stroke and are associated with a poor out- test. come, on short- and medium-term. On the other hand, We used clinical, etiological and imagistic scales for recent studies show that persons with a poor quality of categorizing the severity and subtypes of ischemic sleep develop cardiovascular diseases (coronary is- stroke (modified Rankin Score-mRS, TOAST Classifica- chemic disease and/or stroke) more frequently than tion, Oxford Stroke Classification). We used glycosylated persons with a good quality of sleep. hemoglobin (HbA1c) level, glycaemia level at admission Objectives. Analysis of quality of sleep before the and triglycerides level as indicators for the metabolic acute clinical event in acute stroke patients. control of diabetes. Materials and method. We identified patients dis- Results. The considered indicators of poor metabolic charged in March 2020 from the Neurology Department control - HbA1c (either for a threshold of 8%, or for of Elias University Emergency Hospital with a diagnosis 10%), triglycerides level (>200mg/dl) and glycaemia of acute stroke (ischemic/haemorrhagic) who also un- levels at admission (either for a threshold of 180 mg/dl, derwent neurocognitive testing and were also adminis- or for 210 mg/dl) - were not associated with a worse tered the self-assessment quality of sleep scale PSQI outcome. (Pittsburgh Sleep Quality Index) on admission. For all We noticed a lower risk of death in men (p = 0.015, patients identified, we collected demographic data, OR = 3.425, CI 95% (1.26, 9.2)). Patients older than 60yo concomitant disease data, PSQI score (total score and appear to have a worse outcome (mRS > 3) (p = 0.035, subcomponents scores) on admission. OR = 3.823, CI 95%(1.1; 13.25)). Results and discussions. We identified 14 patients We observed an increased risk of mortality in (9 males and 4 females), with ages between 48 and 82 patients that presented atrial fibrillation (p < 0.001, years, without major cognitive impairment (MMSE OR = 9.67, CI 95% (3.34;27.97)), cardioembolic stroke >=26) and without other significant neurological disabil- (p < 0.001, OR = 8.83, CI 95% (3.06;25.48)), cardiac fail- ities who also completed the sleep quality questionnaire ure (p = 0.006, OR = 4.01, CI 95% (1.5;10.73)) and health- administered at admission. The PSQI scores (N = 14) were care associated infections (p < 0.001, OR = 11.308, CI between 3 and 17 (mean total PSQI score 7.71). 50 per- 95% (4.16;30.69)). cent of all patients reported a poor quality of sleep (to- Conclusions. Immune dysfunction in T2DM predis- tal PSQI score >=6) in the 4 weeks preceding the acute poses patients to health-care associated infections, also vascular event. Patients with a poor quality of sleep linked to higher morbidity and mortality. T2DM also were younger than patients with a good quality of sleep leads to increased mortality due to chronic cardiac com- (mean age 62 years old vs. 68.57 years old) and were plications. There was no direct causal link between high more frequently associated with atherothrombotic is- 36 Romanian Journal of Neurology – Volume XIX, Supplement, 2020 chemic stroke. There were no significant differences We performed a total of 4 TPE sessions, being able to between the two groups regarding type or location of replace 4 plasma volumes. Between sessions, a number acute stroke or regarding the presence of other vascular of seric parameters were followed: calcium, magnesi- risk factors. um, fibrinogen, total proteins, potassium, platelets, he- Conclusions. The proportion of patients with acute matocrit. In our case, there were no significant changes. stroke in this small case series that report poor quality The neurological exam after the last TPE session, of sleep before the vascular event is similar to the pro- revealed motor deficit improvement up to grade 4/5 portion of patients presented in literature that report tetraparesis, no respiratory symptoms, no urinary reten- sleep disorders after the occurrence of acute stroke. tion. Sleep disorders could represent risk factors for acute Conclusions. TPE can be considered as a first-line stroke, and not just complications. treatment for AMAN. Performing TPE as soon as possi- Keywords: quality of sleep, stroke, vascular risk factors ble can save further axonal damage and increases the chances for a good outcome, but it requires specific equipment and trained staff. VARIA

Therapeutic plasma exchange in acute motor Probable early-onset Alzheimer’s disease – case axonal neuropathy (AMAN) – case report presentation 1 Sebastian ANDONE1, Adina STOIAN1,2, Ramona-Andreea ANDREI , 1 Anca MOȚĂȚĂIANU1,3, Zoltan BAJKO1,3, Raluca Andreea MOLDOVAN , 1,2 Smaranda MAIER1,3, Laura BĂRCUȚEAN3, Cristina-Aura PANEA Rodica BĂLAȘA1,3 1 Neurology Department, Elias University Hospital, Bucharest, Romania 1 Department of Neurology, Emergency Clinical County 2 “Carol Davila” University of Medicine and Pharmacy, Hospital, Targu Mures, Romania Bucharest, Romania 2 Discipline of Pathophysiology, “George Emil Palade” University of Medicine, Pharmacy, Science and Introduction. Alzheimer’s disease is a neurocogni- Technology, Targu Mures, Romania tive disorder with insidious onset and gradual progres- 3 Discipline of Neurology, “George Emil Palade” University of Medicine, Pharmacy, Science and Technology, Targu sion of impairment in one or more cognitive domains, Mures, Romania without extended plateaus, excluding other etiologies. Onset age is usually after the age of 65 years old, but Guillain-Barré syndrome (GBS) is an acute disease some patients may preset with early-onset forms in the with immune-mediated mechanisms and represents a fourth or fifth decade of life. neurological emergency. Acute motor axonal neuropa- Case presentation. We present a 52-years old, male thy (AMAN) is a rare GBS subtype with poor outcome patient without a significant medical family history, and is treated with intravenous immunoglobulins and occasional ethanol consumption in moderate quanti- therapeutic plasma exchange (TPE). ties, with cardiovascular risk factors, with memory and We present the case of a 27-year-old male patient behavioral impairment. The symptoms were noticed by that had a mild upper respiratory tract infection 1 week the patient and the family 5 months ago, and had a pro- before the onset of the neurological symptoms. The on- gressive evolution since. set of the disease was 2 days prior to his admission, the patient developing paresthesia in his lower, with as- Management and results. The clinical, neurological cending character towards his upper limbs, followed by and psychological evaluation showed that the patient progressive motor deficit. At admission, the patient had had partial temporal-spatial disorientation, a depressive already a moderate respiratory dysfunction. The neuro- mood, a diminished spontaneous speech with difficulty logical exam at admission showed grade 2/5 MRC tetra- in finding words and names, attention deficits, difficulty paresis, abolished deep tendon reflexes, without any in retaining new information and processing mathemat- pyramidal signs, and later developed urinary retention. ical calculation, and biography errors. Cognitive tests: Nerve conduction studies were performed showing letter verbal fluency = 2 words/minute; semantic group low amplitude of compound muscle action potential verbal fluency = 3 words/minute; MMSE= 18/30 points, (CMAP) which is characteristic for axonal loss. Clock test = 5/10 points. Romanian Journal of Neurology – Volume XIX, Supplement, 2020 37

Lab results showed elevated levels of glycemia, There were 4 deaths, mean Rankin score for the rest mixed dyslipidemia, while the cerebrospinal fluid analy- of the discharged patients was 2,8, while 8 patients sis showed low levels of β-amyloid 42, β-amyloid remained with moderate or severe disability (mRS > 2). 42/β-amyloid 40 < 0.1 and intermediate levels of tau We noticed underlying or associated conditions in 11 protein. patients (cardiovascular, haematological, respiratory Brain tomography and magnetic resonance showed systems), and for 1 case we recorded minor trauma as a few small vascular-degenerative lesions and uncharac- trigger factor (parachute jump). teristic diffuse cerebral and cerebellum atrophy. Conclusion. Carotid artery dissection, generally con- Conclusions. From the patient history, clinical exam- sidered to have a benign clinical outcome, may prove ination, paraclinical and imagistic investigation, we con- itself a severely debilitating condition for young pa- clude the diagnosis of a major neurocognitive disorder tients, while we are still figuring out the complexity of of neurodegenerative etiology, probable Alzheimer’s predisposing factors. disease. The case’s particularity is the early-onset of the Keywords: stroke, carotid artery dissection disease without a family history of neurocognitive disorders. Keywords: Alzheimer’s disease, young onset Infective endocarditis and stroke – case series A. BĂNICĂ1, S. PETRESCU1,3, A. RACHIERU2, A. POPESCU2,3, C. PANEA1,3 Case series depicting carotid artery dissection – 1 outcomes, particularities Neurology Department, Elias Emergency Hospital, Bucharest, Romania A. BĂNICĂ1, S. PETRESCU1,2, C. PANEA1,2 2 Cardiology Department, Elias Emergency Hospital, 1 Neurology Department, Elias Emergency Hospital, Bucharest, Romania Bucharest, Romania 3 “Carol Davila” University of Medicine and Pharmacy, 2 “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania Bucharest, Romania Background. Infective endocarditis is a disorder of Introduction. Carotid artery dissection is a signifi- the cardiac valves with systemic repercussions and cant cause of ischemic stroke in young and middle-aged which mimics multiple pathologies, creating diagnostic patients. It is generally considered to be provoked by difficulties. The neurologic complications are the most minor trauma or to occur spontaneously, most likely frequent extracardiac manifestation of the disease, with due to genetic disorders. the highest mortality rate. Objectives, method and results.We studied the cases Objective. Upon facing a clinical stroke-like onset, of 18 patients diagnosed with carotid artery dissection brain imaging raises the suspicion of possible cardioem- in our clinic over a 5-year period, presenting with vari- bolic etiology. Specialized investigations confirm the pri- ous underlying or associated conditions. mary diagnosis of left-sided infective endocarditis, with Men were twice more affected than women, with a cerebral embolization. similar mean age, most patients not undergoing previ- Method and results. We studied the cases of 9 pa- ous treatment. tients diagnosed with infective endocarditis in our clinic NIHS score upon admission was under 8 points for 6 during 2016-2019. Mean age of the patients was over patients, whereas 7 patients scored over 16 points. 80 years, 6 of them were previously independent or had Mean hospitalization duration was 13 days, only 7 pa- slight disability and most patients had significant valvu- tients needing under 7 days of medical care. lopathies or valvular prosthesis of the left heart. Initial imaging studies consisted of Doppler examina- Clinical examination upon admission revealed al- tion of the cervical and cerebral arteries (raising diag- tered state of consciousness or focal neurologic deficits, nostic suspicion), completed by cerebral angiography in with a NIHS score > 16 for 6 patients. Cerebral CT scans 7 patients or CTA (9 patients)/MRA (2 patients). showed multiple ischemic strokes in different vascular Regarding therapy, 2 patients received intravenous territories, some with haemorrhagic transformation, thrombolysis with rtPA; all patients received aspirin, 3 of and in some cases, concomitant multifocal haemorrhag- which also received clopidogrel, while for 10 patients ic lesions, raising suspicion of infective endocarditis. low molecular weight heparin was associated, and other Progressive deterioration of clinical and biologic 3 patients also received unfractionated heparin. state (obtundation, progression of neurologic deficits, 38 Romanian Journal of Neurology – Volume XIX, Supplement, 2020 fever, inflammatory syndrome) requires cardiologic Posterior reversible encefalopathy syndrome: A evaluation with transthoracic echocardiography, com- neurological and radiological challenge pleted by transesophageal echocardiography for 4 patients, which visualises vegetations attached to the A.M. BORUZ1, A. VELICU2, S. DUMITRACHE1 mitral and/or aortic valve. 1 National Institute of Neurology and Neurovascular Blood culture samples confirm the infection with Diseases, Bucharest, Romania Staphylococcus aureus in 5 cases. Despite adequate 2 University Emergency Hospital, Bucharest, Romania· antibiotic treatment, clinical evolution is fatal, resulting Introduction. Posterior reversible encefalopathy in 8 deaths (3 of which occurred within 7 days of admis- syndrome (PRES) is a neurological condition caused by sion). neurotoxic status secundary to the dysfunction of pos- Conclusions. Staphylococcus aureus infective endo- terior self-regulation in response to high blood pressure carditis associating neurologic complications has the (BP). Typically PRES is caused by damage to the blood- highest mortality rate. However, prompt adequate anti- brain barrier by hyperperfusion causing vasogenic ede- biotic therapy is frequently delayed faced with the neu- ma most commonly located in posterior territories (pa- rologic diagnostic trap. rieto-occipital), atypically these lesions can occur in the Keywords: endocarditis, stroke, mortality basal ganglia, frontal lobe brainstem and cerebellum. Case presentation. We present an atypical case of PRES of a 40-year-old male, known with severe kidney Diagnostic problems in inflammatory myopathies disease and hypertension, who presents for intense Lenuţa BÎRSANU, Raluca ASAFTEI, headache, neck stiffness and emetic syndrome, Dan Iulian CUCIUREANU BP = 240 / 120 mmHg and normal neurological examina- “Prof. Dr. N. Oblu” Emergency Clinical Hospital, Iasi, tion. Biologically there is uremic syndrome (creatinine 6 Romania mg/dl and urea 104 mg/dl), without large variations of electrolytes. Initial imaging: head CT reveals ponto-mes- Inflammatory myopathies are a group of conditions encephalic and left cerebellar hypoattenuation as well characterized by muscle weakness, elevated CK levels, as cerebellar cortical hemoragic foci raising the suspi- and inflammatory infiltrate on muscle biopsy. cion of stroke in the vertebro-basilar territory, but a pos- Inflammatory myopathies can be classified into 4 sible PRES, vasculitis, hypoglycemic crisis, cerebral glio- groups: idiopathic myopathies- whose aetiology is un- matosis, hypoxic-ischemic encephalopathy or cerebral known; myositis associated with connective tissue dis- venous thrombosis can not be excluded. ease (CTD) and autoimune disease; myositis associated It is decided to perform a rapid head MRI-DWI se- with neoplasm; myositis in infections. The group of idio- quence that excludes ischemic lesions and after the rest pathic inflammatory myopathies includes: dermatomy- of the MRI sequences plus angio-MRI that reveals con- ositis, polymyositis, myositis with inclusion bodies and fluent signal changes of supra / infratentorial with con- necrotizing autoimmune myopathy. fluent appearance, without diffusion restriction, in the Overlap syndrome refers to dermatomyositis, poly- context of higher blood pressure values at the time of myositis and necrotizing myopathy in association with presentation we raise the suspicion of PRES. Given the other connective tissue disorders: systemic lupus ery- creatinine values, no contrast could be administrated. thematosus, sleroderma, rheumatoid arthritis and Conclusions. Corroborating imaging, clinical and Sjogren syndrome. severe hypertension its raises the suspicion of PRES con- The annual incidence of inflammatory myopathies is firmed by clinical improvement after administration of about 1:100,000. antihypertensives and control MRI performed at one In the following we discuss two clinical cases of pa- month. tients with polymyositis and myositis with inclusion bodies. Keywords: myopathies, inflamation Romanian Journal of Neurology – Volume XIX, Supplement, 2020 39

A pathology that should not be overlooked in Personalized treatment of the patient with patients with subarachnoid haemorrhage – ischemic stroke and severe systemic spontaneous intracranial carotid artery dissection atherosclerosis I-F. BRATU1, A.C. RIBIGAN1, R.S. BADEA1, C. LAZA1, Constantin BUNEA, O. IOGHEN, D. DUMITRASCU, O. RUSU1, B. DOROBAT2, A. DIMITRIADE2, F.A. ANTOCHI A. CARP2, O.A. BAJENARU1, F.A. ANTOCHI1 Department of Neurology, University Emergency Hospital, 1 Department of Neurology, University Emergency Bucharest, Romania Hospital, Bucharest, Romania 2 Department of Interventional Neuroradiology, University Introduction. Personalized treatment of secondary Emergency Hospital, Bucharest, Romania prevention of ischemic stroke by revascularization procedures (carotid endarterectomy / percutaneous angio- Introduction. Intracranial carotid artery dissection plasty with carotid stent) is indicated for symptomatic (ICAD) represents an uncommon cause of subarachnoid segmental stenosis, hemodynamically significant haemorrhage (SAH), the mortality in patients with this (> 70%) located at the carotid level in the extracranial association being approximately 50%. This case was segment. Patients candidates for revascularization ther- chosen to be reported as to its particularities of pres- apy should be evaluated to detect other sites of system- entation. ic atherosclerosis and associated cardiovascular diseas- Case presentation.We present the case of a 66-year- es in order to prevent peri- or post-procedural old female with medical history of arterial hypertension complications. and right lenticular haemorrhagic stroke a few years Case presentation. We present the case of a 75-year back, who was transferred to the Neurology Depart- old man, smoker (50 packs of cigarettes), with stage II of ment for subsequent management of a recent SAH hypertension , with non-insulin-dependent diabetes (Hunt-Hess grade 2). The patient had been admitted to mellitus, who presented an ischemic stroke in the terri- our hospital for intense occipital headache, dizziness, tory of the left middle cerebral artery. Doppler ultra- emesis and sleepiness of abrupt onset. The neurosurgi- sound evaluation of cervical vessels showed moderate cal examination established the presence of nuchal segmental stenosis (~ 60%) in left ICA (clinically sympto- rigidity and right oculomotor nerve palsy. A cerebral matic) and severe segmental stenosis (~ 90%) in right computed tomography (CCT) scan was performed and it ICA (clinically asymptomatic). revealed the presence of a peribulbar, prepontine, The patient performed cerebral angiography “4 ves- interpeduncular cisterns as well as forth and lateral ven- sels”, which showed a segmental stenosis of ~ 50% in tricles hyperdensity (suggestive for SAH), diffuse cere- the left ICA origin, as well as a contralateral stenosis of bral oedema and hydrocephalus. The 4-vessel digital 90% in the extracranial segment. Regarding the pres- subtraction angiography excluded a vascular malforma- ence of cardiovascular risk factors, a coronary angiogra- tion or an aneurysm and showed complete occlusion of phy was requested, although there are no clinical symp- the left common carotid artery and multiple hemody- toms of affecting the coronary territory. This highlighted namically significant stenoses (including of the con- the occlusion of the right coronary artery and the sub- tralateral internal carotid artery (ICA)). The patient occlusive stenosis of the circumflex artery (ACx), for received symptomatic treatment and was transferred to which it was decided to mount 2 pharmacologically ac- our department. Cerebral and cervical region MRI scan tive DES stents. After 6 months, the patient was reeval- was performed and revealed a right intracranial ICA dis- uated neurologically and the stationary appearance of section. Successive CCT scans established the resorp- the degree of bilateral carotid stenosis was underlined, tion of the SAH with the CCT scan taken at one month as well as the stable appearance of atheroma plaques, showing the absence of the SAH. The patient received with the absence of microembolism in the cerebral cir- antiplatelet therapy. culation when monitoring TCD. It was decided to contin- Conclusions. This case report pinpoints the impor- ue the maximal drug therapy and periodic neurological tance of taking into consideration ICAD as a potential and imaging reassessment. cause of SAH. Conclusions. The case presented above shows the importance of performing coronary angiography before taking a personalized decision of secondary prevention of ischemic stroke in patients with severe systemic ath- 40 Romanian Journal of Neurology – Volume XIX, Supplement, 2020 erosclerosis. Another particularity of the case is that the Posttraumatic right sided direct carotid-cavernous patient suffered an ischemic stroke in the distribution fistula with bilateral carotid artery dissection – territory of the left ICA, which had a moderate carotid case report segmental stenosis extra-cranial and in the asymptomatic territory had a severe carotid segmental stenosis, A. CIOBAN1, A. MOȚĂȚĂIANU1, Z. BAJKO1,2, for which it will be considered personalized revasculari- L. MĂRGINEAN3, R. BĂLAȘA1,2 zation decision as primary prevention. 1 Neurology Clinic 1, County Emergency Clinical Hospital, Targu-Mures, Romania 2 Neurology Department, “G.E. Palade“ University of A case report of Alzheimer disease associated Medicine, Pharmacy, Science and Technology, with cerebral amyloid angiopathy Targu-Mures, Romania 3 Interventional Radiology Department, County Emergency Dr. Bogdan CĂȘARU, Dr. Raluca BADEA, Clinical Hospital, Targu-Mures, Romania Dr. Florina ANTOCHI Carotid artery dissection may arise as a complication Department of Neurology, University Emergency Hospital, of blunt head or cervical trauma, especially after car Bucharest, Romania accidents. High flow carotid cavernous fistula is a direct The accumulation of beta amyloid peptide within connection between the cavernous sinus and the intra- the blood vessels of the brain, which is the hallmark of cavernous carotid artery and occur most often after a the cerebral amyloid angiopathy, can occur as a sporadic traumatic injury. event or it can be associated with Alzheimer disease. We report the case of a 21-year-old male who suf- However, even in the sporadic cases the vascular amy- fered a polytrauma caused by a car accident. The pa- loid deposits are biochemically similar to the senile tient sustained a bilateral hip dislocation, a trochanteric plaques described in Alzheimer disease. While most of femoral right fracture and a right knee injury. He was the patients remain asymptomatic, this pathological admitted in the Orthopedic Clinic for specialized treat- process has been recognized to increase the risk of ment and after four days he presented bruit, headache, intracerebral haemorrhage. diplopia, pulsatile proptosis and chemosis of the right Hereby we would like to present the case of a eye associated with ocular pain. Neurologic examina- 70-year-old man with a medical history of arterial tion showed abducens nerve palsy. The cerebral angiog- hypertension, who was prompted to have a cerebral raphy demonstrated a right sided direct carotid-cavern- magnetic resonance imaging (MRI) after complaining of ous fistula with venous drainage through ipsilateral memory problems, especially short-term memory defi- superior ophthalmic vein, facial vein, superior and infe- cits. Given the fact that the MRI result described multi- rior petrosal sinus with a complete flow steal from the ple areas of lobar microbleeds and cortico-meningeal right internal carotid artery. Furthermore, the cerebral hemosiderin deposits, the suspicion of Alzheimer’s angiography revealed the dissection of both carotid disease was raised. This was confirmed by the lumbar arteries with the vascular supply to the right cerebral puncture which revealed low beta42-amyloid level with hemisphere from the left carotid artery through anteri- high tau and phosphorylated-tau protein level in the or communicating artery. cerebro-spinal fluid. The aim of the present report is to communicate this Incidental findings of microbleeds and hemosidero- rare posttraumatic association between direct carotid sis on MRI suggestive of cerebral amyloid angiopathy cavernous fistula and bilateral carotid artery dissection should prompt us to look further for the presence of and to examine the proper management and the suita- cognitive impairment and eventually for the diagnosis ble treatments. of Alzheimer disease. Romanian Journal of Neurology – Volume XIX, Supplement, 2020 41

The pharyngeal-cervical-brachial variant (PCB) of tern. The seroimmunological study of antiglycolipid Guillain-Barré syndrome (GBS) associated to a antibodies conducted by enzyme immunoassay (ELISA) were negative (anti-GT1a, GT1b, GQ1b, GD1a, GD1b, cytomegalovirus infection in an GD2, GD3, GM1, GM2, GM3, GM4 and anti-sulfatides immunocompetent patient – case report antibodies), also the serologic tests (HVB, HVC, HIV, R. CIOCAN, O.C. DAN syphilis, Lyme, Campylobacter, Mycoplasma), excepting Neurology Department, Nord Franche-Comté Hospital, CMV, with both IgG and IgM elevated. Our conclusion France was a seronegative PCB following a CMV infection. Neurological improvement was observed after intra- Introduction.The pharyngeal-cervical-brachial (PCB) venous gamma globulin and follow-up examinations variant of Guillain-Barré syndrome is defined by rapidly showed a continuous clinical amelioration with no more progressive oropharyngeal and cervicobrachial weak- need of the nasogastric intubation folowed by normal ness associated with areflexia in the upper limbs. The refeeding. neurologic signs are preceded by signs of upper respira- Conclusions. When one sees acute onset bulbar pal- tory tract infection in 56-76% of the patients. The most sy and limb muscle weakness, the possibility of PCB common pathogens are Campylobacter jejuni, Haemo- should be considered, thus compelling the need for se- philus influenzae, Mycoplasma pneumoniae and cyto- rum anti-ganglioside antibody measurement. CMV can megalovirus. The onset is typically acute, beginning with also induce the production of anti-GT1a antibody, there- neurologic symptoms approximately 8–10 days follow- by resulting in PCB. This case suggests the need for all ing the antecedent illness. The disease then progresses ganglioside antibodies to be tested in suspected variant until a clinical nadir is reached approximately a week Guillain-Barré syndromes. after the initial neurologic symptoms. Serum antigangli- Keywords: Guillain-Barré syndrome, cytomegalovi- oside antibodies are positive in 85% of patients. rus, anti-ganglioside antibody Case report. A 56 years old woman with a history of polytrauma was hospitalized for cervicalgia followed by dysphagia to both solids and liquids associated with Therapeutic challenge in hyperacute progressive weakness first of the neck and then in the simultaneous cardiocerebral infarction – case upper limbs with numbness in the fingers and then hands. A progressive deterioration occurs in the pa- report tient’s neurological status: worsening dysphagia with R. CIOCAN, O.C. DAN dysphonia and dysarthria, bilateral facial nerve palsy, Neurology Department, Nord Franche-Comté Hospital, numbness in the face, weakness in the upper limb. France Three weeks before admission, she presented an episode of viral rhinopharyngitis. At admission, neurologi- Introduction. Both acute ischemic stroke and acute cal examination showed bilateral facial nerve palsy, myocardial infarction are medical emergency condi- bilateral hypoesthesia and numbness in the maxillary tions, which require timely diagnosis and management. and mandibular divisions of the trigeminal nerve, severe Simultaneous acute ischemic stroke and acute myocar- dysphagia with left absent pharyngeal reflex, dysphonia, dial infarction is described as “hyperacute simultaneous left tongue weakness, loss of deep tendon reflexes in cardiocerebral infarction” and concerns patients with lower limbs, mild proximal limb muscles fatigability and simultaneous cardiocerebral infarction who arrived at bilateral paresthesias of both hands. The patient need the hospital within 4.5 h of the thrombolytic therapeutic to have a nasogastric intubation pour feeding. window. Complementary tests highlighted albumino-cytolog- Case report. We present a case of a 80-year-old ical dissociation in the cerebrospinal fluid with no de- woman, who suffered from an acute ischaemic stroke tected PCR DNA for CMV, Epstein-Bar and herpes virus. (AIS) and ST-elevation myocardial infarction (STEMI) Neuroimaging tests (brain, cervical and thoracolumbar concurrently. She was admitted at emergency depart- MRI scans) showed no morphological changes or signal ment due to acute onset of right-sided body weakness alterations in the brain, brainstem, spinal cord or cauda with slurred speech and clinical findings suggestive of a equina in T-1, T-2 or FLAIR weighted sequences. The stroke with National Institute of Health Stroke Scale electromyogram of the upper limb (deltoid, biceps and (NIHSS) of 11. MRI revealed acute ischaemic stroke in extensor digitorum muscles) revealed a neurogenic pat- the left middle cerebral artery (MCA) territory with 42 Romanian Journal of Neurology – Volume XIX, Supplement, 2020 proximal thrombus in M1 segment and ECG showed endocrinopathy, monoclonal gammopathy and skin atrial fibrillation and acute inferolateral ST-elevation. changes. Both clinical suspicion and diagnosis of POEMS The first decision was to proceed with thrombolysis. syndrome can be challenging. Intravenous recombinant tissue plasminogen activator Case presentation. We report on a patient present- (rtPA) was administered with standard dose of 0.9 mg/kg ing with a neuropathic syndrome and generalized ade- at 2 h 50 min after onset with the improvement in NIHSS nopathy secondary to monoclonal gammopathy and score to 5 after 1 hour post-thrombolysis. A second ECG also outline considerations that can impact diagnostic made after the thrombolysis and the kinetics of cardiac decision-making. Clinical examination, serum protein troponins were indicating one more time the acute electrophoresis followed by bone-marrow aspiration STEMI. Upon multidisciplinary collegial discussion (neu- and PET-CT were performed. rologists, cardiologists, neuroradiologists) and due to A 64 years old male patient with a positive history of the occlusion at proximal M1 segment of the left-middle progressive, generalized adenopathy for one year was cerebral artery we decided to perform mechanical addressed to our center for lower limb paresthesia. He thrombectomy after intravenous thrombolytic. In sec- was diagnosed with monoclonal gammopathy, light ond time, the emergency coronary angiography was chain Kappa subtype. He developed sclerotic bone le- performed and revealed acute occlusion at bifurcation sions and enlarged liver and spleen. He associated capil- of the circumflex artery and the first lateral artery. Per- lary permeabilization syndrome with generalized ede- cutaneous coronary intervention (PCI) with drug eluting ma and pleurisy. The endocrine evaluation revealed stent placement was performed. The patient’s neuro- hypothyroidism. Moreover, the patient associated scle- logical evolution was favorable with the progressive rodermic-like skin changes. POEMS syndrome is there- regression of the deficit, NIHSS to 1. The CT-scan 24 fore established and the characteristics of paraproteine- hours later was not complicated by hemorrhagic trans- mic neuropathy are discussed. formation. Conclusions. Failure to recognize the patient’s signs Conclusions. Due to the rarity of the condition, the and symptoms as attributable to POEMS syndrome is management of these patients with a concurrent AIS unsurprising given the rarity of the entity. Furthermore, and STEMI is very challenging and there is no ideal it can also mimic other disorders. Without treatment recommendation. Decision to treat AIS should be indi- progress is rapid, mandating early diagnosis. vidualized based on the risk and benefit of the treat- Keywords: POEMS syndrome, polyneuropathy, mon- ment. Balanced management should be a trade-off oclonal gammopathy, organomegaly, endocrinopathy between early rescuing the brain or the heart. Mechan- ical thrombectomy should be performed as soon as possible after symptom onset. High age alone should not be Stroke and hypercortisolism – a bidirectional considered as a contraindication for mechanical relationship thrombectomy. Re-organization of stroke care systems is needed to provide rapid access to endovascular ther- V. CONSTANTINESCU, G. CONSTANTINESCU, apy equitably to all eligible patients. D.I. CUCIUREANU Keywords: hyperacute simultaneous cardiocerebral “Gr.T. Popa” University of Medicine and Pharmacy, Iasi, infarction, stroke, STEMI, thrombolysis, thrombectomy Romania

Background. Neurovascular events may trigger POEMS syndrome – a challenging diagnosis hypothalamic-pituitary-adrenal axis activation deter- mining an adrenal glucocorticoid stress response. Post- 1,2 2 D.I. CUCIUREANU , L. CUCOS , stroke cortisol concentration may reflect the severity as 1 V. CONSTANTINESCU well as predict outcomes. Prolonged exposure to corti- 1 Neurology Department, “Gr.T. Popa” University of sol can also lead to several metabolic complications Medicine and Pharmacy, Iasi, Romania such as diabetes or hypertension, raising the risk of car- 2 Neurology 1, “Prof. Dr. N. Oblu” Emergency Clinical diovascular events. Cyclic hypercortisolism is a rare dis- Hospital, Iasi, Romania order characterized by episodes of cortisol excess, fol- Background. POEMS represents a rare paraneoplas- lowed by periods of normal secretion. It can occur tic syndrome caused by a clone of aberrant plasma cells. regularly or irregularly with intercyclic phases ranging It is the acronym for polyneuropathy, organomegaly, from days to years. Romanian Journal of Neurology – Volume XIX, Supplement, 2020 43

Case presentation.A 52-year old female patient was Clinically, the temporal superficial arteries are thick- referred to our clinic for neurological evaluation after er, with no pulse. On neurologic examination, the pa- right middle cerebral artery ischemic stroke. For about tient have: bilateral neurosensory hearing loss, no deep 20 years she was diagnosed with cyclic Cushing. She had tendon reflexes of the lower limbs, Babinski sign present developed secondary hypertension, diabetes mellitus, bilateral. Cranial computed tomography is negative. The depression and osteoporosis. A postero-lateral pituitary inflammation markers are positive (reactive protein C, microadenoma was identified but technical difficulties erythrocyte sedimentation rate 46 mm/h, fibrinogen made surgery impossible. Left adrenalectomy was per- 460 mg/dl). Head, neck and transcranial Doppler ultra- formed for a macronodular aspect at the age of 39. Prior sound findings are: 20-25% right carotid artery stenosis, hospitalization to our center, she presented a myocardial occlusion of the left vertebral artery, hypointense thick- infarction, ventricular fibrillation and a concomitant ening of the right vertebral artery wall, superficial tem- ischemic stroke. She did not present any clinical signs poral arteries with compression sign positive, significant typical of Cushing’s with the exception of distal muscu- segmental stenosis, hypoechoic halo sign suggestive for lar atrophy. Biologically, there was mild hypercorti- arteritis. The symptoms improved after therapy with solism. methylprednisolone. Conclusion. Excessive cortisol can be deleterious to The patient refused temporal artery biopsy, but the cerebrovascular structures, not only inducing acute vas- diagnosis is sustained by clinical and ultrasound find- cular events but also complicating the outcome. Several ings, the inflammatory syndrome and therapeutic re- studies identified elevated cortisol levels post-stroke. sponse. Keywords: ischemic stroke, hypercortisolism, diabe- Conclusions. GCA, misdiagnosed or untreated, can tes, hypertension lead to serious complications like vertebrobasilar transient ischemic attacks even in patients with no visual disturbances. Repetitive vertebro-basilar transient ischemic attacks secondary to giant cell arteritis – Case report Subacute axonal polyneuropathy after bariatric surgery R. COTOI1, Z. BAJKO1,2, S. MAIER1,2, A. MOȚĂȚĂIANU1,2, A. STOIAN1,2, L. BĂRCUȚEAN1,2, I.A. DRĂGHICI1, A. ALEXANDRESCU1, R. BĂLAȘA1,2 A. MOȚĂȚĂIANU1,2, Z. BAJKO1,2, S. MAIER1,2, 1 Emergency Clinical County Hospital, Targu Mures, A. STOIAN1,2, L. BĂRCUȚEAN2, R. BĂLAȘA1,2 Romania 1 Neurology 1 Clinic, Emergency Clinical County Hospital, 2 “G.E. Palade“ University of Medicine Pharmacy Science Targu Mures, Romania and Technology, Targu Mures, Romania 2 “G.E. Palade“ University of Medicine Pharmacy Science and Technology, Targu Mures, Romania Introduction. Giant cell arteritis (GCA) is a chronic inflammation of the medium and large vessels, which Introduction. Nutrition-related neuropathies are can lead to multiple complications. The main symptoms defined by a progressive loss of function in the peripher- are: headache, visual disturbances, laterocervical and al nerves, that result from either vitamin or mineral facial pain. deficiency, related to acquired factors such as malab- Objective. The aim of this paper is to emphasize how sorption due to bariatric surgery. The most common important is a correct diagnosis in a patient with crani- type of pathological reaction is a length-dependent ax- ocervical algic symptoms. onal degeneration. The aim of this presentation is to Case report. We present a case of a 74-years old highlight the major neurological complications that male,hypertensive, diabetic, with occipital headache and might occur after bariatric surgery. right shoulder pain which radiates to the laterocervical Case presentation. We present the case of a 33-year- area. At the consultations made prior to hospitalization, old female, who underwent gastric sleeve surgery in the symptoms were interpreted in the context of a cervical October 2019 with favorable postoperative evolution spinal syndrome, migraine, vertebrobasilar insufficiency and a total weight loss of 30 kilograms. The onset of syndrome. After six months, the symptoms got worse de- symptoms occurred two months after surgery, the pa- spite antalgic treatment and the patient experienced brief tient describing a slow progressive distal upper and low- episodes of vertigo, nausea and balance disturbances. er limb muscle weakness, accompanied by paresthesia. 44 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

It is important to mention that the substitutive vitamin STIR C3 posterior columns lesion. The laboratory tests B complex treatment has been initiated after the onset indicated positive HLA B51 and also positive cerebrospi- of symptoms and before she was admitted into our clinic nal fluid oligoclonal bands. The diagnoses of multiple The most suggestive laboratory findings are: vitamin B1 sclerosis, neuro-Behçet disease and glial neoplasm were 86.3 µg/l (28-85), vitamin B6 97.83 µg/l (8.7-27.2), vita- taken into consideration. min B9 2.12 ng/ml (3-17), 25-hidroxi-vitamin D 6.7 µg/l Conclusions. Although cases of tumefactive multiple (30-100), seric copper, selenium and vitamin B12-nor- sclerosis with brainstem involvement are rare, they mal levels. Lumbar puncture was perfomed describing pose a challenge in term of diagnosis and treatment. mild protein elevation 455.7 mg/l (155-400) and normal This statement is also valid in our case as, for the time level of glucose in CSF. MRI of cervical spine described being, further investigations (3T MRI exam, proton MR no abnormalities. The electroneurography/electromy- spectroscopy, rheumathology evaluation) are needed to ography revealed the diagnosis: subacute axonal poly- establish an accurate overview of the pacient’s state neuropathy. and a correct subsequent therapeutical approach. Conclusions. We concluded that this is a case of nutritional subacute axonal polyneuropathy occured as a complication of the bariatric surgery the patient suffered. Clinical implications of anatomical variations of We observed serum deficite of vitamin B9, coupled with circle of Willis identified in an autopsy study the suspicion of a serum deficite of the B12 vitamin. The A.M. DUMITRESCU1, D.I. CUCIUREANU2, A. SAVA1 latter was addresed with a tardy administration of vita- 1 min B12 – all before getting admitted into our clinic. Department of Anatomy and Embriology, “Gr.T. Popa” University of Medicine and Pharmacy, Iasi, Romania Keywords: bariatric surgery, subacute axonal poly- 2 Department of Neurology, “Gr.T. Popa” University of neuropathy, vitamins Medicine and Pharmacy, Iasi, Romania

Introduction. Autopsy or imaging studies that have The challenging diagnosis of a tumefactive been conducted so far showed that a normal circle of brainstem lesion – a case report Willis (CW) occurs in less than half of the population. Our aim was to identify the clinical importance of the Diana DUMITRASCU1, R. BADEA1, A. RIBIGAN1, anatomical variations of CW in certain forms of cere- F. ANTOCHI1, O. BAJENARU1,2 bro-vascular diseases. 1 University Emergency Hospital, Bucharest, Romania Materials and methods. The study analyses all the 2 “Carol Davila“ University of Medicine and Pharmacy, autopsies that have been performed over a period of 30 Bucharest, Romania months, in “Prof. Dr. N. Oblu” Emergency Clinical Hospi- Background. Tumefactive multiple sclerosis is a rare tal, Iași, Romania. The demographic data of the de- form of multiple sclerosis. This type of multiple sclerosis ceased, the macroscopic appearance of the CW and the with brainstem involvement is sometimes indistinguish- causes of death were taken from the Necropsy Register able from neuro-Behçet disease, glial neoplasm, lym- of the Laboratory of Pathology of the same hospital. phoma or abcesses. Results. Out of 96 available human circles of Willis, Case presentation. We report on a 24-year-old male 28 cases (29.17%) were classified as „anatomical vari- who was admitted for difficulty in swallowing liquids, ants”. The average age of the group was 61.78 years. blurred vision in the right visual field, loss of coordina- The Male:Female ratio was 1.1. 60.71% of patients with tion and involuntary movements affecting the left arm anatomical variants of CW had cerebro-vascular disease and leg, symptoms that progressed during a 4 year peri- as the cause of death, among which 32.14% died from od as repeated episodes with complete or partial remis- ischemic stroke and 21.42% from hemorrhagic strokes. sion, that lasted for one to 3-4 days. Clinical examination In 10.71% of all performed autopsies, the cause of death revealed multiple brainstem signs. The brain MRI exam was an aneurysm of the anterior communicating artery. performed revealed numerous T2-FLAIR hyperintense 39.29% of autopsies revealed some other causes of and T1 hipointense disseminated supratentorial white death: acute myocardial infarction (17.85%), pneumo- matter lesions and a 2.3 cm round shaped hyperintense nia with pleurisy (7.14%), multiple vertebral and liver T2-FLAIR, DWI, Gd+ brainstem lesion with perilesional metastases from lung cancer (7.14%), metabolic en- edema involving the left side of the pons and the mid- cephalopathy (3.57%) and tuberculous meningitis with brain. The cervical medular MRI showed a hyperintense intracerebral tuberculomas (3.57%). Romanian Journal of Neurology – Volume XIX, Supplement, 2020 45

Conclusions. The anatomical variants of CW may be resources to exclude all the rare causes, we are faced a risk factor for stroke, especially the ischemic ones, in with a wide range of diagnostic possibilities. cases with comorbidities (hypertension, cerebral ather- Case presentation. A 60 year old patient with mild osclerosis or diabetes). hypertension was admitted in the Neurology Depart- ment at the County Emergency Hospital in Cluj-Napoca accusing sudden onset lower back pain after physical A case of late-onset chorea exertion. The neurological examination revealed a painful trunk anteflexion and a right extrapyramidal syn- C. DUMITRESCU, O. ARAMA, N. IONITA, drome. He received treatment with a dopaminergic G. MIHAILESCU, S.M. NICA agonist and had a favorable evolution. However after a Colentina Clinical Hospital, Bucharest, Romania short while the parameters changed. The patient was no Introduction. Chorea is an abnormal involuntary longer able to suppress the trunk anteflexion, did not movement that is characterized by brief, abrupt, irregu- tolerate levodopa treatment and did not have the spe- lar, unpredictable, non-stereotyped movements. There cific evolution of Parkinson’s disease over time. A diagnostic reassessment was mandatory in this case and we are numerous causes of late-onset chorea, including also included an exhaustive research of all the medical drugs, medications, cerebrovascular disease, genetic literature published about similar cases diagnosed with and sporadic neurodegenerations, immune disorders camptocormia. and metabolic disorders. Conclusion. The pathology is quite common but fair- Case report. We report the case of a 75-year old ly new without having a well-developed diagnostic woman who was admitted to our clinic for generalised guide. We only found systematic analyzes that try to in- involuntary movements, balance problems and rec- tegrate the symptomatology of patients as efficiently as curent falls. About 2 years ago, she first noticed the in- possible. voluntary movements that aggravated progressively. Particularities. The disease had a sudden onset with She had no family history of movement disorders. symptoms mainly in the lumbar spine. Also it was quite Neurological examination showed generalised cho- similar to Parkinson’s disease at first and could only be rea, with orofacial involvement and asymmetric involve- excluded by the disease evolution. ment of the limbs. Laboratory evaluation, including complete blood cell count, peripheral blood smear, routine chemistry, thy- The utility of semiology in etiological disclosure. roid and parathyroid function, coagulation profile, tu- Incomplete Villaret’s syndrome. Case review mor markers, autoimmune studies, was normal. A brain MRI was performed and showed only diffuse brain atrophy. I. GEORGESCU1, M. ȚARNĂ1, L.A. GOGU1, Genetic testing for HD revealed 35+/-1 CAG repeats D.A. PÂRVU2, R.D. MIHĂILESCU1, B.O. POPESCU1,3 on one allele and 15+/-1 repeats on the other. 1 Neurology Department, Colentina Clinical Hospital, Discussion. Late onset HD patients present more fre- Bucharest, Romania 2 quently with gait and balance problems and with no Affidea Hiperdia Colentina Clinic, Bucharest, Romania 3 Neurology Department, “Carol Davila” University of family history of movement disorders. Repeat size is sig- Medicine and Pharmacy, Bucharest, Romania nificantly lower in the late-onset compared to common-onset. Villaret’s syndrome consists of ipsilateral paralysis of the last four cranial nerves (sometimes also the 7th cranial nerve) and the cervical sympathetic fibers. It is Camptocormia – a challenging diagnosis caused by a lesion in the posterior retroparotid space. We present the case of a 37 year old woman, with a G. FRUNZĂ, M. BACIU, D.F. MUREȘANU history of bilateral polychondritis, who came in for Department of Clinical Neurosciences, “Iuliu Hatieganu“ mixed dysphagia, dysarthria and sensation of swollen University of Medicine and Pharmacy, Cluj-Napoca, tongue, with relatively acute onset two days prior. She Romania County Emergency Hospital, Cluj- Napoca, Romania was also complaining of intense constrictive unilateral left headache, worsening in the evenings. In addition, Introduction. Camptocormia may be present in a she mentioned facial asymmetry (dropped left oral com- variety of pathologies but when there are insufficient missure and left lagophtalmia) that lasted for 2 days, ca. 46 Romanian Journal of Neurology – Volume XIX, Supplement, 2020 one month before. Neurological examination: mixed Conclusions. We observe a significant increase in dysphagia, loss of gag reflex on the left side, dysphonia, total number of patients treated with alteplase adminis- dysarthria, left deviation of the tongue in protrusion tration and an important improvement of key procedural and no other significant abnormalities. Biological tests: times. Only 55.5% of patients were able to benefit from minimal inflammatory syndrome. Differential diagnosis: echocardiography during their admission. Screening of bulbar stroke, vertebral artery dissection, retropharyn- dysphagia, taking into account interventional treat- geal or retroparotidian tumor, glomus jugulare tumor, ment, calculating NIHSS, monitoring ECG and smoking infectious, inflammatory, granulomatous, carcinoma- cessation should be extended to all stroke patients. Un- tous or vasculitic lesion. Brain CT – angiography was fortunately, there are still unjustified delays in pre-hos- normal. Brain MRI showed left retropharyngeal tumor, pital phase and also a shortage in interventional therapy with diffuse contrast, involving the left internal carotid specialists. artery and partially the left internal jugular vein, with left mastoiditis. Corticosteroids and antibiotics were initiated, with minimal benefit on dysphagia and with The many faces of infective endocarditis complete remission of headache. She was referred to an Cristina GHIȚĂ1, Anca NICULESCU1, otolaryngologist for biopsy. Elena TERECOASĂ1,2, Cristina TIU1,2 This particular case emphasizes the importance of 1 Department of Neurology, University Emergency clinical neurologic examination in diagnostic process. Hospital, Bucharest, Romania 2 “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania RWD 2019: Alteplase administration in Neurology Department of Colentina Clinical Hospital Background. Neurologic complications in infective endocarditis (IE) are frequently encountered and directly I. GEORGESCU1, R.D. MIHĂILESCU1, A.M. VLADILA1, influence the short- and long-term outcome. Acute D.G. LUCA1, E. ROSIANU1, I.E. DAVIDESCU1,2, ischemic or hemorrhagic stroke, subarachnoid hemor- B.O. POPESCU1,2 rhage, mycotic aneurisms, spondylodiscitis, encepha- 1 Neurology Department, Colentina Clinical Hospital, lopathy, meningitis and brain abscesses are the most Bucharest, Romania common neurologic entities that may arise during the 2 Neurology Department, “Carol Davila” University of course of this disease. Medicine and Pharmacy, Bucharest, Romania Case report. We present the case of a 74 year old patient who was initially admitted in our department Objectives. We present the evolution of thrombolytic due to confusion, fever and aphasia. Cerebral MRI showed therapy in stroke, in the Neurology Department of multiple bilateral milimmetric lesions with restricted Colentina Clinical Hospital, in 2019. diffusion suggestive for acute ischemic strokes of cardi- Materials and methods. Retrospective analysis of oembolic ethiology. He was at that time diagnosed with internal data, National Register and Res.Q data regard- infective endocarditis of unknown etiology, based on a ing total number of patients, key procedural times, highly suggestive image of mitral valve vegetation, scales, tests and investigations, treatment results and severe mitral valve regurgitation and 3 sets of negative discharge recommendation. We compared this data blood cultures. He was administered antibiotic treat- with that reported in previous years, national reported ment and had a favourable outcome with complete results and international recommendations. remission of symptoms. 4 months later he was admitted Results. Total number of patients and addressability again in our department with left sided hemiparesis, for intravenous thrombolysis were higher than previous confusion and fever and was diagnosed with acute right years, 90 patients in 2019 (as opposed to 38 patients in parietal hemorrhagic stroke and subarachnoid hemor- 2018 and 18 patients in 2017), covering a 120 km area. rhage. Taking into consideration the positive blood cul- Average door-to-needle time was 40 minutes (best one tures with Staphylococcus aureus, a myxomatous being 5 minutes). NIHSS dropped from an average of 13 degeneration of the mitral valve found on transthoracic to 5.2 points. There were 16.6% deaths reported and echocardiography, as well as the Janeway lesions ob- 15.5% hemorrhagic transformations (none of them served on both hands, the vascular manifestations (right being cause of death). Also, there were 2 thrombolysed parietal hemorrhagic stroke, subarachnoid hemorrhage) patients with stroke mimics, without adverse reactions. and the immune complications (glomerulonephritis) the Romanian Journal of Neurology – Volume XIX, Supplement, 2020 47 diagnosis of recurrent IE was established. Beside the and anticoagulant agents, with no neurological deficit. aforementioned complications, the patient also devel- Six months later Doppler control showed a total recanal- oped spondylodiscitis during hospitalization. After re- ization of the cervical arteries, the patient being asymp- ceiving prolonged specific antibiotic therapy, the symptomatic. toms remitted entirely and the patient was referred to Conclusion. CAD is a major cause of cerebrovascular the Department of Cardiac Surgery. diseases in young people and most of them can be safe- Conclusion. The heterogenic symptoms of onset of ly and conservatively managed, with generally good IE should not be disregarded, as early initiation of proper clinical and imagistic outcomes. antibiotic therapy greatly improves its outcome. IE must always be considered in patients with ischemic or hemorrhagic stroke of unclear etiology, especially if they Rapid progressive dementia syndrome. Diagnosis have specific brain imaging findings and significant heart by anatomopatologic post-mortem examination valve disease. Raluca-Andreea IGNAT1, Diana HALIT1, Ion ROTARU1, Anca SAVA2,3, 2 Spontaneous multiple cervical artery dissection in Gabriela Florenta DUMITRESCU 1 a young patient during marathon Neurology Departament II, “Prof. Dr. Nicolae Oblu” Emergency Clinical Hospital, Iasi, Romania A. IAROVOI2, Z. BAJKO1,2, L. TOMA2, 2 Anatomical Pathology, “Prof. Dr. Nicolae Oblu” A. MOȚĂȚĂIANU1,2, S. MAIER1,2, A. STOIAN1,2, Emergency Clinical Hospital, Iasi, Romania L. BĂRCUȚEAN1, R. BĂLAȘA1,2 3 Morphofunctional Science Department I, “Gr.T. Popa” University of Medicine and Pharmacy, Iasi, Romania 1 “G.E. Palade“ University of Medicine Pharmacy Science and Technology, Targu Mures, Romania It is argued that most dementias develop slowly. A 2 Neurology 1 Clinic, Emergency Clinical County Hospital, careful anamnesis usually detects dementia secondary Targu Mures, Romania to drugs or depression, and lab tests help eliminate met- Cervical artery dissection (CAD) is a relatively unusual abolic disorders that can cause dementia. Most slow entity within cerebrovascular events, but represents progressive dementias are secondary to Alzheimer’s dis- approximately 20% of ischemic strokes in patients ease (AD). between 30 to 45 years old. Management options in- Rapidly progressive dementia (RPD) is a neurological clude thrombolysis, antiplatelet or anticoagulation ther- condition that develops subacute, within weeks or apy, and endovascular or surgical intervention. months, or less frequently within a few days. We present a case of a 38-year-old male smoker who It is important to have an organized and systematic presented left neck pain, amaurosis fugax and motor approach to differential diagnosis, especially in identify- aphasia during a marathon after rapid flexion and exten- ing DPRs that are treatable and potentially reversible. sion of the head. Symptoms disappeared after 20 min. DPR prototype are considered by some clinicians, In the emergency room, the neurological examination prion diseases, such as Jakob-Creutzfeldt disease (1). showed no neurological deficit. CT-brain was interpret- The most commonly used clinical criteria do not ed as no acute intracranial abnormality. CT-angiography allow the early diagnosis of CJD and use auxiliary tests revealed left internal carotid artery dissection from its with a sensitivity and specificity considered by some cli- origin to cavernous segment with subocclusive stenosis. nicians to be difficult to use in current practice (2). Doppler ultrasound demonstrated left internal carotid We present the case of a 70-year-old patient who artery dissection with severe stenosis and also a dissec- addresses the neurology service for mental confusion, tion of right vertebral artery in V1-V2 segments. The pa- temporal-spatial disorientation, with sudden onset of tient was admitted to the hospital and started treatment the condition. A neoplastic, vascular disease (through with heparin and aspirin. He was evaluated by interven- repeated imaging scans), an infectious disease, a toxic/ tional radiology which recommended conservative metabolic cause (through laboratory tests), and an medical management. On the 13th day of hospitaliza- autoimmune encephalitis with positive auto-antibodies tion, before discharge, Doppler revaluation showed left (antibody panel testing) are excluded. The neurological internal carotid and right vertebral arteries occlusion evolution is initially stationary, later with neurological secondary to the fold dissection. He was discharged aggravation, with the alteration of the conscious state, home on the 14th day of hospitalization on antiplatelet with the installation of a right motor focal epileptic sta- 48 Romanian Journal of Neurology – Volume XIX, Supplement, 2020 tus, later with death. The positive 14-3-3 protein and Hemodynamic instability represents a complication the post-mortem anatomopathological result are deter- of CAS that should always be taken into account. It is minant for our etiological diagnosis. produced by the excessive carotid sinus baroceptor Keywords: prion, dementia, rapid progressive stimulation during stent mounting. Thus, monitoring the blood presssure and heart rate during and after the References procedure is of utmost importance for prevention and 1. Geschwind MD. Rapidly Progressive Dementia. Con- rapid correction. tinuum (Minneap Minn). 2016;22(2):510-537. 2. Geschwind MD. Prion Diseases. Continuum (Minneap Minn). 2015;21(6 Neuroinfectious Disease):1612-38. Tolosa-Hunt syndrome in a patient with hypersensitivity reaction to systemic corticosteroids A clinical case of hemodynamic stroke during carotid artery stenting Octavian IOGHEN, Patricia IOAN, Raluca BADEA, Florina ANTOCHI, Ovidiu BAJENARU Octavian IOGHEN, Patricia IOAN, Raluca BADEA, 1 Department of Neurology, University Emergency Constantin BUNEA, Diana DUMITRASCU, Hospital, Bucharest, Romania Alida CIOCAN, Florina ANTOCHI, Ovidiu BAJENARU 2 “Carol Davila“ University of Medicine and Pharmacy, 1 Department of Neurology, University Emergency Bucharest, Romania Hospital, Bucharest, Romania 2 “Carol Davila“ University of Medicine and Pharmacy, Tolosa-Hunt syndrome is an inflammatory idiopathic Bucharest, Romania disease. It consists of cavernous sinus noncaseating granulomas formation. The diagnosis is made by the Carotid artery stenting (CAS) represents a revascu- presence of the typical clinical picture- periorbital pain larization procedure for symptomatic and hemodynam- and unilateral paresis of the oculomotor, trochlear or ically significant carotid stenosis. It comes with the ad- abducens nerves- and by the detection of the granu- vantage of being minimally invasive, but it can lead to lomatous inflammation, either using cerebral imaging various peri- and post-procedural complications. or histopathological examination. Other diseases that We present the case of a 76-year-old patient with can affect the cavernous sinus should be excluded. generalised atheromatosis. Within the last 4 months, he We present the clinical case of an otherwise healthy suffered 2 ischemic strokes in the left internal carotid 50-year-old female patient. She presented to the hospi- artery teritory, with mixed aphasia and mild right hemi- tal with severe left periorbital pain and diplopia. Neuro- paresis as post-stroke neurologic sequelae. „Four-ves- logical examination revealed left exophtalmos, impaired sel” cerebral angiography was performed and a suboclu- left visual acuity, diplopia caused by trochlear and abdu- sive segmental stenosis was observed at the internal cens paresis, left periorbital hypoesthesia. Cerebral MRI carotid artery origin. An autoexpandable stent was revealed T2 hyperintense gadolinophilc material in the mounted, followed by balloon dilatation. A significant cavernous sinus, which extends to the superior orbital stenosis of the M1 segment of the left middle cerebral fissure, orbital apex and optic canal, surrounding the artery was observed. During the procedure, hemody- optic nerve. Biopsy was performed and the histopatho- namic depression with severe bradycardia and hypoten- logical examination reveled nonspecific granulomatous sion occured, which improved after atropine adminis- inflammation. Subsequent paraclinical tests excluded tration. Subsequently, the patient presented confusion, other cavernous sinus syndrome causes. Treatment with right homonymous hemianopia and worsening of the oral metilprednisolone was initiated, which led to the right arm motor deficit. A subsequent cerebral imaging rapid alleviation of the periorbital pain. Nevertheless, revealed the formation of a left temporo-parieto-occip- the medication was discontinued due to a hypersensi- ital ischemic stroke. Considering the hemodynamic tivity reaction. As an alternative, the patient was started depression episode, there is a high chance that the on an immunosupresive treatment, such as azathio- respective episode together with the alteration of the prine. At 6-month follow-up, the brain MRI revealed a collateral circulation by the MCA stenosis caused the reduction of the inflammatory lesion. stroke. Subsequently, hemorrhagic transformation was In conclusion, Tolosa-Hunt syndrome is a rare dis- identified, without worsening in the neurological condi- ease that should be taken into account when painful tion of the patient. ophtalmoplegia is found. Even though systemic cortico- Romanian Journal of Neurology – Volume XIX, Supplement, 2020 49 therapy is the prefered treatment, immunosupression differential diagnosis is further discussed here compre- might as well be used in case of corticoid intolerance. hensively. Management of glioblastoma requires a functional multidisciplinary team despite the unfavourable outcome, with a poor survival rate. Our case is also Differential diagnosis and unusually long survival remarkable in that the survival rate of over 4 years in a patient with recurrent glioblastoma greatly surpasses the median overall reported rate. A. LEFTER1, C. LUPU1, I. GOBEJ2, A. BASTIAN3,4, V. IONESCU5, L. DUMITRESCU1,4,6, Intracerebral calcifications – Fahr disease or Fahr B.O. POPESCU1,4,7 syndrome? 1 Department of Neurology, Colentina Clinical Hospital, Bucharest, Romania L.D. MAKO1, N. ASAFTI1, A.C. BELDEAN1, 2 Department of Neurosurgery, Colentina Clinical Hospital, A.V. BESNEAG1,2 Bucharest, Romania 1 Neuroloy II Clinic, Municipal Hospital, Cluj-Napoca, 3 Department of Anatomic Pathology, Colentina Clinical Romania Hospital, Bucharest, Romania 2 Department of Neurosciences, “Iuliu Hatieganu” 4 “Carol Davila” University of Medicine and Pharmacy, University of Medicine and Pharmacy, Cluj-Napoca, Bucharest, Romania Romania 5 Department of Radiology, Monza Metropolitan Hospital, Bucharest, Romania Introduction.Fahr disease or Fahr syndrome are char- 6 Department of Neurology, Research Division, Colentina acterized by intracerebral calcifications in the basal gan- Clinical Hospital, Bucharest, Romania glia, which according to their location can determine a 7 Laboratory of Molecular Medicine, “Victor Babeș” various symptoms: parkinsonism, involuntary move- National Institute of Pathology, Bucharest, Romania ments, cognitive dysfunction and rarely seizures. The eti- Introduction. Glioblastoma is the most common pri- ology of Fahr disease is genetic, whereas Fahr syndrome mary malignancy of the central nervous system. It is occurs secondary to disturbances in calcium metabolism. highly aggressive and bears a poor prognosis despite Case presentation. 81 year old male presents in the multimodal treatment, with a mean overall survival rate Neurology department for dizzines and balance issues. of about 12 to 15 months. His family also reports moments of compulsive eating, Case report. We report the case of a 46-year old emesis and loss of consciousness with generalized tonic woman who presented at 42 years with headache and aspect. Our patient is diabetic and hypertensive, both focal seizures over the course of 2 weeks, which prompted pathologies controlled with oral medication. The neuro- admission to an infectious disease ward on suspicion of logical examination revealed an asymmetric parkinson- infectious encephalitis. Brain magnetic resonance imag- ism, postural tremor in the upper limbs, diminished os- ing (MRI) showed a right frontal mass with heterogene- teotendinous reflexes in the lower limbs, independent ous enhancement, vasogenic oedema and bilateral walk with small steps and mild cognitive dysfunction. fronto-insular grey matter changes potentially sugges- In order to establish the aethioogical diagnosis we tive for paraneoplastic encephalitis. The patient under- collected blood samples for hormonal investigations, re- went virtually complete surgical resection of the right sults which showed primary hypoparathiroidism: PTH frontal mass and histopathological evaluation revealed level extremely low, hypocalcemia, phosphate and mag- glioblastoma grade IV WHO. Radiotherapy and chemo- nesium within normal range. An endocrinology consult therapy with temozolomide were indicated and fol- confirmed the diagnosis. An electroencephalography lowed. Over the next 8 months she had a recurrence showed no pathological graph elements which could which was completely excised. At age 46 she had a left suggest epileptiform discharges. Head CT showed in- frontal relapse, which was surgically removed, yet 4 tracerebral calcifications in the basal ganglia (caudate months later she presented with aphasia, dysphagia nucleus), thalamus, cerebellous bilateral, subcortical in and status epilepticus, and brain MRI revealed a left con- the white matter of the occipital lobe and centrum se- trast-enhancing temporo-parietal relapse, which was inop- miovale bilaterally, with a symmetrical aspect. erable. The family declined continuing chemotherapy. The patient was diagnosed with Fahr syndrome, sec- Thus, palliative care measures were further indicated. ondary to primary hipoparathyroidism and recieved Conclusions. This case initially implied a diagnostic substitutive treatment with calcium, vitamin D and anti- challenge prior to histopathological assessment and the convulsivant (Levetiracetam). 50 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

Distinctivness of the case. Late diagnosis, episodes The evolution of a 32-year old female patient of loss of consciousness with generalized tonic aspect with recurrent remissive multiple sclerosis after reaching a normal calcemia, EEG without patho- noncompliant to the treatment – a case logical graph elements. presentation C. MARGARIT, I. GANDABESCU, O.A. BAJENARU Confusional state and somnolence in a 52-year University Emergency Hospital, Bucharest, Romania old male with hairy cell leukemia and quick worsening of consciousness – a clinical case Introduction. Multiple sclerosis (MS) is the most common immune-mediated inflammatory demyelinat- C. MARGARIT, I. GANDABESCU, O.A. BAJENARU ing disease of the central nervous system that predomi- University Emergency Hospital, Bucharest, Romania nantly affects young adults. Case report. This is the case of a 32-year old female Introduction. Hairy cell leukemia (HCL) is an uncom- patient diagnosed with recurrent remissive multiple mon lymphoid neoplasm characterized by the reduction sclerosis in 2013, hospitalized for motor deficit worsen- in the production of normal red blood cells, platelets ing in the lower limbs. In 2010 she had an episode of and monocytes. Among its complications there are ane- optic neuritis. She enrolled in the National Programme mia, bleeding and infection. for Multiple Sclerosis, received treatment with interfer- Case report. This is the case of a 52-year old male on beta-1a and then with Natalizumab. As the patient patient diagnosed with HCL four months ago (undergo- says, she suddenly stopped the treatment two years ing chemotherapy), secondary anemia, diabetes, hyper- ago. She was proposed for Ocrelizumab therapy but did tension, sepsis in recent history, hospitalized for confu- not take it. EDSS was first 3,5p, then 4,5p two years ago sion and somnolence in the last day. A week ago he had when she stopped the treatment. When she came to fever that passed without autoadministered medica- hospital, she has right central facial palsy, horizontal tion. At clinical examination the patient is somnolent, nystagmus at left gaze and when looking up, spastic confused, central left facial palsy, left hemiparesis tetraparesis predominantly crural and in the left limbs, 4/5MRC. dysmetria, exaggerated osteotendinous reflexes, bilat- The head computed tomography shows no recent or eral achillean clonus, moderate-severe dysarthria – sequelar lesions. Lumbar puncture cannot be performed EDSS = 8.5 p. as the ophthalmologic examination describes bilateral The head and spine MRI shows in T2 hypersignal/ papillary edema. Biologically there is pancytopenia, fluid-attenuated inversion recovery (FLAIR) and T1 mild anemia, spontaneous high INR, hyposodemia, hy- hyposignal over 40 ovalar supra- and infratentorial bilat- popotassemia, negative tumoral markers. Electrocardio- eral lesions in the middle cerebellar peduncles, pons, gram shows sinus rhythm. The patient’s situation wors- midbrain, subcortical, periventricular, fronto-temporo- ens very fast, becoming very somnolent and with very parietal bilateral, intramedullary C2-T2, T6-T8, T10-T11, low cooperation. At many times repeated ophthalmo- with over 10 enhanced-gadolinium lesions. The patient logic exam the aspect remains the same. The electroen- received treatment for the exacerbation with favorable cephalography and echocardiography are normal. The evolution. MRI head scan describes right temporo-insular and cap- Conclusions.This case represents a red flag for pa- sulo-lenticular ischemic stroke. The patient has fever. tients with multiple sclerosis to take the treatment, Hemoculture sets and urine culture results are negative, without (sudden) discontinuation in order to prevent a no inflammatory syndrome, with hepatic cytolysis and rapid evolution of the pathology and its accompanied renal deficiency. The patient’s situation continues to psycho-social consequences. The patient now has pro- worsen, unjustified by the MRI scan and he is trans- gressed to secondary progressive MS, immobilized in ferred in the intensive care unit, where he died soon after. bed, with a chronic urinary catheter. Conclusions. This case was challenging concerning the diagnostic. Cumulating all the information and taking into consideration the history of sepsis, the patient most probably had sepsis again determined by HCL, the highest risk of infection in these patients occuring in the first years after the diagnostic was established. Romanian Journal of Neurology – Volume XIX, Supplement, 2020 51

head computed tomography there are two small seque- The case of a 63-year old patient with aphasia lar hypodensities in the left occipital region and right and a temporal ischemic hipodensity on CT scan parietal region. During the hospitalization the somno- C. MARGARIT, I. GANDABESCU, O.A. BAJENARU lence progressively becomes more intense. Biologically University Emergency Hospital, Bucharest, Romania there is an inflammatory syndrome and hyperglycemia with high value of glycosylate hemoglobin. Electrocardi- We are presenting the case of a 63-year old female ography, electroencephalography, ophthalmologic patient, smoker, with diabetes, dyslipidemia, hyperten- exam, chest radiography and Holter examination/24 h sion, overweighted hospitalized for predominant ex- results are normal. pressive aphasia noticed suddenly in the morning of the Transthoracic echography shows nodular, hypere- day of coming to hospital. chogenic forms attached to the posterior mitral and The head computed tomography (CT) examination aortic valves. Hemoculture sets were negative. Trans- shows a recent ischemic hypodensity in the left tempo- esophageal echography shows small subvalvular aortic ral lobe. The patient receives antiplatelet therapy under forms, nonsuggestive for vegetations. Head MRI shows which the patient’s situation evolves rapidly very well, multiple regions with restriction of diffusion in cerebral with the almost complete remission of symptomatology, peduncles, pons, right thalamus, occipital bilateral, right from having alexia, being unable to read to having diffi- cerebellum peduncle, suggestive for multiple embolic culties in reading the first letter of the word. Taking into strokes. New hemoculture sets are positive for Entero- consideration that the hypodensity aspect on CT scan coccus spp. The patient received antibiotic therapy with was atypical, round-ovoid shaped, inhomogeneous, favorable outcome. without respecting a specific vascular territory it is Conclusions. What is striking at this case is the ex- decided to make an MRI head scan. This describes in the cessive atypical somnolence, which is evolving. Besides, left temporo-parietal region in T2 hypersignal / Fluid-At- the normal temperature, the transesophageal echogra- tenuated Inversion Recovery (FLAIR) and T1 hyposignal phy not suggestive for vegetations, the first hemocul- a cortico-subcortical zone with associated left temporal tures sets that were negative, the Holter examination hematic effusion, suggestive for hemorrhagic venous result made it difficult to establish a diagnostic. The infarction. The anticoagulant treatment is started. The head MRI and the result of the last hemoculture sets evolution is favorable and when leaving the patient’s helped us conclude that the patient suffered multiple neurologic examination is normal. Thrombophilic anti- vertebro-basilar cardioembolic strokes through septic bodies were taken with the results in progress. dissemination. Conclusions. It is extremely important to investigate in detail every clue that raises a question mark in a patient. The particularity in this case is the unusual im- Etiopathogenic and therapeutic considerations age on CT scan together with the symptomatology and based on a clinical case of paroxysmal cerebellar rapidly favorable evolution of the patient. ataxia Maria M. MARTOIU1, Carmen RAGAN1, Atypical excessive somnolence in a 62-year old Cristina A. PANEA1,2 female with left hemiparesis – a clinical case 1 Neurology Department, Elias University Hospital, Bucharest, Romania C. MARGARIT, I. GANDABESCU, O.A. BAJENARU 2 “Carol Davila” University of Medicine and Pharmacy, University Emergency Hospital, Bucharest, Romania Bucharest, Romania

Introduction. Somnolence is a vague, nonspecific Introduction. Episodic ataxia known as paroxysmal symptom with a variable etiology. In some cases it can cerebellar ataxia is a heterogeneous group of disorders become a problem in diagnosing. that are characterized by recurrent episodes of ataxia Case report. This is the case of a 62-year old female and incoordination, lasting minutes to hours. patient, known with hypertension and chronic alcohol- Objective. We present the case of a young patient ism, hospitalized for left hemiparesis and mild somno- with a form of paroxysmal cerebellar ataxia including lence since one day. At clinical examination the patient clinical features of episodic ataxic type 2 (EA2), which is somnolent, with left ataxic hemiparesis 4/5MRC, dys- posed diagnosis difficulties, and was responsive to arthry, normal temperature, accusing intense vertigo. At Acetazolamide and Levetiracetam. 52 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

Case report. 23 years old male with recurrent epi- Case report. We present the case of a 35-year-old sodes of dysarthria, nystagmus, incoordination and patient who suddenly presents with balance disorders, walking disorder, with variable duration – minutes to nausea and vomiting, reporting a similar episode in his- hours, with frequency and intensity that had increased tory. A cranial CT scan is performed that does not show over the last few months. acute heterodense lesions, an angio CT scans that do The onset of the symptoms was around the age of not show thrombosis or aneurysms in the arteries affe- seven, when the episodes were classified as epileptic rent or efferent to the Willis polygon, homogeneous seizures, especially as treatment with valproate con- opacified cerebral venous sinuses and carotid Doppler trolled the symptomatology at that time. ultrasound that didn’t show any modifications. The pati- Family anamnesis revealed fetal distress at birth, de- ent returns to the Neurology Clinic for reassessment. layed motor and cognitiv development. The Doppler ultrasound is repeated in left lateral rotati- The neurologic exam between episodes revealed a onal position of the cephalic extremity that highlights right cerebellar syndrome, nystagmus and mild dysar- the disappearance of blood flow in the right vertebral tria. The brain MRI showed mild atrophy of the cerebel- artery, raising the suspicion of mechanical compression at V3 or V4 level. Angiography CT is performed at the lar vermis. The EEG revealed bihemispheric epileptiform level of the cervical vessels in the lateral rotation positi- discharges. The EMG and ionogram during episodes on of the cephalic extremity, highlighting a stenosis of were normal. 90% at the level of the C2 segmental vertebral artery. Acetazolamide was associated to Levetiracetam The patient received treatment with Plavix, Sortis, therapy. Enap, Metoprolol, Metoclopramide, Betaserc, vitamin Conclusions. The non-progressive course of the dis- B1, vitamin B6 and the patient presented a favorable ease, the cerebral MRI and the other paraclinical exams evolution with regression of symptoms. did not bring arguments for infantile encephalopathy or Conclusions. The case was interpreted as an acute a hereditary metabolic disorder. central vestibular syndrome that arose as a result of Although the EEG revealed epileptiform discharges, rotational occlusion of the right vertebral artery. This the clinical episodes aspect and duration were not typi- case highlights a rare cause of cerebral ischemia in cal for epileptic seizures. young patients. It is important to monitor these patients Taking into account the paroxysmal aspect of the to reduce the appearance of symptoms due to circulatory symptomatology it was taking into discussion an episod- dysfunction. ic ataxia type 2, a channelopathy of the calcium channel. Genetic testing was not possible. Keywords: paroxysmal cerebellar ataxia, channelop- The attention deficit in Parkinson’s disease athies H. NICOLAE1,2, I. IONIȚĂ1, I. BARBU-RĂDULESCU2, C. PANEA1,2 1 A rare cause of ischemic stroke in vertebro-basilar Neurology Department, Elias University Hospital, Bucharest, Romania territory: Rotational vertebral artery occlusion 2 “Carol Davila” University of Medicine and Pharmacy, (Bow-Hunter’s syndrome) Bucharest, Romania 1 1,2 1,2 O. MOSORA , A. MOȚĂȚĂIANU , Z. BAJKO , Introduction. Parkinson’s disease is the second most 1,2 1,2 1 S. MAIER , A. STOIAN , L. BĂRCUȚEAN , frequent neurodegenerative disorder in the world, after 1,2 R. BĂLAȘA Alzheimer’s disease, with cognitive impairment present 1 Neurology I Clinic, Emergency Clinical County Hospital, from the beginning of the disease. Out of the six cogni- Targu Mures, Romania tive domains in DSM-5, the study we conducted analyz- 2 Discipline of Neurology, “G.E. Palade“ University of ed the presence of the attention deficit in patients with Medicine, Pharmacy, Science and Technology, Targu Parkinson’s disease. Mures, Romania Material and methods. We conducted a study on Introduction. Bow Hunter’s syndrome is a rare vas- 130 patients with Parkinson’s disease in evidence at the cular pathology that can be manifested by transient department of Neurology of Elias University Emergency ischemia as a result of compression on the vertebral Hospital. We identified the presence of attention and artery at the time of rotation of the head. memory deficit through both subjective methods – Romanian Journal of Neurology – Volume XIX, Supplement, 2020 53

Parkinson’s well-being map – and objective methods – any MRI specific lesions afterwards. Yet, she developed MMSE score. We evaluated sleep quality through a severe upper tracheal stenosis with stridor and con- Parkinson’s disease sleep scale. We performed a statisti- stant dyspnea for which a tracheal dilation was per- cal analysis on the data collected. formed. Two weeks later, new repetitive focal motor Results. We identified a deficit of attention in 66 pa- seizures appeared and the stridor with inspiratory dysp- tients, 32 did not have neurocognitive disorder, 24 had nea recurred. The patient had constant reduced oxygen mild cognitive impairment and 10 had a moderate form pressure levels and was referred for to the ENT depart- of major neurocognitive disorder. The attention deficit ment. existed in 50.76% of the patients with Parkinson’s dis- Conclusions. The peculiarity of the case relies in the ease, affecting almost equally patients with and without fact that anti-GABA-A receptor encephalitis patients neurocognitive disorder. An association was found be- have an increased risk of recurrent seizures, but addi- tween sleep and the frequency of attention and memo- tional factors such as hypoxia can further alter the func- ry deficit symptoms. The attention deficit existed either tion of the GABAergic system and serve as a serious ep- alone, or associated with memory loss. ileptogenic factor especially in such patients. Conclusions. The attention deficit is important in patients with Parkinson’s disease, affecting both patients with and without neurocognitive impairment. There is a Real world data – Teriflunomide experience in correlation between the frequency of attention deficit Colentina Clinical Hospital MS Center symptoms and sleep disturbances. 1 1 1,2 Keywords: Parkinson`s disease, attention deficit I. ODAJIU , D. SANDU , I. DAVIDESCU 1 2nd Neurology Department, Colentina Clinical Hospital, Bucharest, Romania 2 Increased risk of hypoxia-induced seizure “Carol Davila“ University of Medicine and Pharmacy, recurrence in a young patient with autoimmune Bucharest, Romania encephalitis and severe secondary tracheal Background and aims. Teriflunomide, an immuno- stenosis modulatory disease modifying therapy (DMT) adminis- I. ODAJIU1, L. CRĂCIUN1, I. DAVIDESCU1,2 tered in relapsing-remitting multiple sclerosis, is the single 1 2nd Neurology Department, Colentina Clinical Hospital, oral drug currently available in Romania since 2017. Our Bucharest, Romania aim was to present the real world data regarding pati- 2 “Carol Davila“ University of Medicine and Pharmacy, ents undergoing treatment with Teriflunomide in Colen- Bucharest, Romania tina Clinical Hospital. Methods. Non-interventional retrospective study. Background and aims. Anti-GABA-A receptor en- Data gathered and processed in Microsoft Excel. cephalitis is an immune-mediated inflammatory conditi- Results. Out of 820 patients in the Multiple Sclerosis on of the brain, with a rapidly progressive course mani- Program in our center, 16.46% (135) administer Teriflu- festing with refractory seizures, status epilepticus and/ nomide 14 mg once daily. The majority of them are wo- or epilepsia partialis continua. Tracheal stenosis can determine variable degrees of hypoxia, therefore ser- men (65.93%) from urban areas (79.25%) with a median ving as an epileptogenic trigger. Our aim was to present age of 41.26 years (80% range between 35 and 59). The the case of a patient with anti-GABA-A receptor median EDSS score was 2.7 and disease evolution time encephalitis that developed recurrent seizures following of 7.8 years, values comparable to other studies. Naïve a severe secondary tracheal stenosis. patients (42.22%) in contrast to patients who switched Case report. We present the case of a 22-years old from other DMTs to Teriflunomide (57,78%) had a short- female patient, with no remarkable personal of family er disease duration of 5.5 years versus 9.43 and a better medical history, who developed anti-GABA-A receptor EDSS score of 2.0 versus 3.0. The majority of patients encephalitis manifested initially by convulsive status switched from Interferon ß1-a (66%) followed by Glati- epilepticus with a prolonged course of protective oro- ramer acetate (26%) and for 12 patients it was the sec- tracheal intubation. She underwent treatment with ond or even third switch, the primary determinant methylprednisolon pulse-therapy, plasma exchange and being lack of tolerance regarding injectables. As regards intravenous immunoglobulins along with antiepiletic Teriflunomide’s efficacy, there were registered no re- medication, with a remarkable clinical outcome without lapses or EDSS progression since treatment initiation. 54 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

Adverse events, namely hair loss or thinning, occurred months, then after multiple attempts at ventilatory in 8.88% cases (12 patients). withdrawal, it shows effective spontaneous breathing Conclusions. The real world data gathered in our and succeeds in suppressing the tracheostomy cannula. center proves that Teriflunomide appears to be one of After about five months, the patient is discharged with the best tolerated DMTs with a satisfactory safety and endoscopic percutaneous gastrostomy and tetraplegic. effectiveness profile in carefully selected patients which Conclusions. The acute axonal form of Guillain-Barré ensures a stable disease course. syndrome is an important, rapidly evolving pathology that can occur after a respiratory infection. Establishing treatment on time increases the prognosis of recovery. Good outcome of an acute severe sensory-motor axonal neuropathy after infection with AH1N1 R.B. OLARIU-ARITON1, A. MOȚĂȚĂIANU1,2, “Thunderclap” headache in pituitary apoplexy Z. BAJKO1,2, S. MAIER1,2, A. STOIAN1,2, with aseptic meningitis clinical case L. BĂRCUȚEAN2, R. BĂLAȘA1,2 Cristina PATRASCU, Vlad GHIMPU, 1 Neurology I Clinic, Emergency Clinical County Hospital, Stefan DUMITRACHE Targu Mures, Romania National Institute of Neurology and Neurovascular 2 “G.E. Palade“ University of Medicine, Pharmacy, Science Diseases, Bucharest, Romania and Technology, Targu Mures, Romania Introduction. “Thunderclap” is a headache of maxi- Introduction. Axonal acute sensory-motor polyradic- mum intensity, which may suggest a varied neurological uloneuropathy is a variant of Guillain-Barré syndrome, pathology, such as SAH, cerebral venous thrombosis, the defining characteristics being represented by elec- reversible cerebral vasoconstriction syndrome, menin- trically inexcitable motor nerves, signs of extended den- goencephalitis or pituitary apoplexy. ervation and also by a possible complete recovery. The Case report. T.C.A, female, 19 years old, without most common cause of this pathology is a respiratory medical history, smoker, postpartum, without medica- infection. tion at home, is admitted for persistent, intense head- Case report. We present the case of a 56-year-old ache, reaching the maximum threshold quickly, nausea patient who, after a respiratory tract infection with in- fluenza AH1N1 virus a month before hospitalization, and vomiting, symptoms that suddenly started, which suddenly presents, in the morning, paresthesias in the did not respond to any NSAIDs. distal lower and upper limbs, later, the patient develops Neurological examination reveals stiff neck. Labora- motor deficit at this ascending level. Less than 24 hours tory tests show mild microcytic hypochromic anemia, after appearance, the patient becomes tetraplegic, with mild leukocytosis with neutrophilia. Native brain CT is severe acute respiratory failure, requiring orotracheal normal. Lumbar puncture shows increased cellularity intubation and mechanical ventilation. Four plasma- (lymphocytes and neutrophils), but with proteins and pheresis sessions were performed with a stationary evo- glucose within normal limits, negative Pandy reaction, lution in the Neurology Department of the Sfântu Gheo- IgG and oligoclonal bands normal and negative cultures. rghe County Emergency Hospital, later she was The suspicion of encephalitis is raised so that an EEG is transferred to the Neurology I Clinic within Mures Coun- performed, but with normal results and brain MRI with ty Emergency Clinical Hospital for the treatment with contrast and angio-MRI, made to exclude venous throm- intravenous immunoglobulins. bosis as a differential diagnosis, given the postpartum The electroneuromyographic examination performed status, reveals constitutional stenosis in the transverse on the median, ulnar, bilateral common peroneal nerves and sigmoid sinuses and a non-secreting hemorrhagic does not show motor / sensory response, at supramaxi- pituitary microadenoma (normal hormonal profile) mal stimulation the motor and sensory nerves are inexcit- without any characteristics of encephalitis. able, in the vast lateral and right deltoid muscles show Conclusions. Following the investigations, subarach- acute neurogenic pathway with active denervation. noid hemorrhage (cerebral CT and LP), venous throm- Examination of cerebrospinal fluid reveals albumino- bosis (cerebral MRI and venous angio-MRI), as well as cytological dissociation. meningoencephalitis (MRI and EEG) were excluded. The During hospitalization, the patient required ad- particularity of the case is the onset of pituitary mi- vanced life support, mechanical ventilation for four croadenoma bleeding with “thunderclap” headache Romanian Journal of Neurology – Volume XIX, Supplement, 2020 55 accompanied by meningism, and lumbar puncture with Progressive multifocal leukoencephalopathy after the appearance of aseptic meningitis. non-Hodgkin’s lymphoma treatment – Case Keywords: “thunderclap” headache, meningism, pi- presentation tuitary apoplexy, aseptic meningitis C.M. PETREA2, A. ALEXANDRESCU2, A. MOȚĂTĂIANU1,2, A. STOIAN1,2, S. MAIER1,2, Atypical imaging after pontine ischemic stroke L. BĂRCUȚEAN1, Z. BAJKO1,2, R. BĂLAȘA1,2 1 A.M. PARTOACA, E.I. IOACHIM, A. SIRBU, “G.E. Palade” University of Medicine, Pharmacy, Science A. POPESCU and Technology, Targu Mures, Romania 2 Neurology I Clinic, Emergency Clinical County Hospital, National Institute of Neurology and Neurovascular Targu Mures, Romania Diseases, Bucharest, Romania Introduction. Progressive multifocal leukoencepha- Introduction. Wallerian degeneration is the process lopathy (PML) is a rare demyelinating disease of the cen- of degeneration and disintegration of axons and their tral nervous system and results from the reactivation of accompanying myelin sheaths secondary to axonal prox- a latent JC polyomavirus. It is frequently diagnosed in imal lesions or neurons that can affect both the periph- HIV-positive patients, but recently, the attention has eral and central nervous system. In the case of brain been focused on the association between immunosup- injuries, this process frequently affects the cortico-spi- pressive therapy and PML. nal tract but also the optic tract, the fibers of the corpus Objective. The purpose of this presentation is to callosum, the fornix and the pontocerebellar tracts. The raise the suspicion of PML when a patient meets the investigation that can objectify these changes, in case of anamnestic, clinical, imaging and laboratory criteria. damage to a large number of fibers, is MRI. Case presentation. We would like to present the Case report. The authors present the case of a case of a 27-year-old patient diagnosed with T-cell 60-year-old patient with cardiovascular risk factors and lymphoblastic lymphoma, treated with polychemiother- medical history of vertebro-basilar ischemic stroke apy and autologous stem cell transplantation. After one treated with thrombolytic therapy (with favorable evo- year, he presents in the emergency department accus- lution, Rankin score = 0 points), who presented to our ing dizziness, nausea, vomiting and vision disorders. At clinic for neurological reassessment. We illustrate the the neurological examination were detected: diplopia in imaging changes at a distance of 12 months after cere- the lateral gaze to the left, limitation of abduction of the bral ischemia. left eyeball, non-systematic positive Romberg test, gait Brain MRI shows a right paramedian pontine lacunar ataxia. Serum biochemistry revealed a hepatic cytolysis lession and T2/FLAIR hypersignal with relatively sym- syndrome, anti-HIV serological tests, VDRL, HBs antigen, metrical T1 hyposignal, at the level of the middle cere- anti-HCV antibodies were negative and cerebral CT/An- bellar peduncles in the context of Wallerian degenera- gioCT examinations were normal. Cerebral MRI exami- tion. nation revealed pontine and left cerebellar white matter Conclusions. The distribution of Wallerian degenera- hyperintense lesions on T2/FLAIR and the CSF biochem- tion depends on the relation of the brain lesion to the ical examination revealed an increased proteinuria of efferent axonal tracts. The most common pattern seen 1,949.6 mg/dl, with albuminocytological dissociation. in the brain is degeneration of the corticospinal tract in With the suspicion of PML, serum samples were collect- the context of lesions of the precentral gyrus. The pecu- ed for JC virus antibodies, which were positive. Isolation liarity of the case is the highlighting of this process at of viral DNA from the CSF was not possible, so we can the level of the middle cerebellar peduncles, by degen- only very likely suspect PML. eration of the ponto-cerebellar tracts, a less common Conclusions. This case draws attention to neurologi- location. cal symptoms during or after immunosuppressive treatment and aims to include PML in the differential diagnosis series. Early diagnosis also implies a better therapeutic attitude. Keywords: progressive multifocal leukoencephalopathy, immunosuppressive therapy, JC virus 56 Romanian Journal of Neurology – Volume XIX, Supplement, 2020

Amyloid angiopathy and concomitant atrial PRES, psychotic disorder and eclampsia in a fibrillation – challenges regarding long-term woman with twin pregnancy and major treatment thrombophilia C. POSTOLE, A.M. NICULESCU, N. GRECU, C. TIU L. PRODAN1,2, C. ROMAN-FILIP1,2, A. TANASE1 Neurology Department, University Emergency Hospital, 1 Department of Neurology, Emergency County Hospital, Bucharest, Romania Sibiu, Romania 2 “Lucian Blaga” University, Sibiu, Romania Background. Cerebral amyloid angiopathy is a degenerative condition with an increased risk of intrac- Background. Posterior reversible encephalopathy erebral hemorrhages, most commonly encountered in syndrome (PRES) is a rare clinical and neuro-radiological the elderly. A major problem is the antithrombotic condition, often associated with hypertensive encepha- treatment in this setting in this age group, as these lopathy, preeclampsia-eclampsia, immunosuppressive patients frequently have associated disorders with an agents. increased risk of stroke. Objective. This is the case of a patient with twin Case report. An 85-year-old patient, with a history of pregnancy, known with major thrombophilia, compli- atrial fibrillation (for which she received apixaban 2.5 cated with preeclampsia-eclampsia and PRES. mg bid), hypertension, hypercholesterolemia, and dia- Case report. The 33 years old pregnant woman, betes mellitus, was admitted for facial asymmetry and known with major thrombophilia treated with Clexane, moderate dysarthria. who presented at 35 weeks twin pregnancy lower Non-contrast-enhanced cerebral CT scan showed a extremity swelling and discrete global headache. Her small hyperdensity of 91 Hounsfield units (HU) located blood pressure was 196/138 mmHg. The patient pre- in the left frontal cortex. Cerebral MRI showed multiple sents a first generalised tonic-clonic seizure, then a sec- cortical and subarachnoid hypointense T2* lesions, ond generalized tonic-clonic seizure. An emergency suggestive of cerebral amyloid angiopathy (CAA). cesarean section was performed using general anesthe- She subsequently developed facial motor seizures sia. with secondary generalization, with good response to Postoperative neurological examination revealed: therapy with levetiracetam. Cognitive evaluation spatial and temporal disorientation, heteroaggressivity showed a severe impairment. Serum analysis was signif- and self-defense at minor stimulation, prosopagnosia icant for reduced B12 vitamin levels. and an episode of absence preceded by psychomotor Final treatment recommendation, taking into con- agitation. Pregnancy succeeded with two alive fetuses sideration the increased risk for cardioembolic events, with dynamics in normal limits. was the continuation of the patient’s ongoing therapy as The MRI examination initially reveals multiple areas this provides a superior safety profile compared to oth- with hypersignal T2 and FLAIR, hyposignal T1 with sub- er drugs. cortical distribution and cortical extension, located at Conclusions. Conventional cerebral CT examination the temporo-occipital level and the parietal lobe, with cannot precisely determine the etiology of lesions less complete resolution of the lesions in dynamics. than 100HU. MRI, with the aid of the Boston criteria, The patient was evaluated periodically, neurological- can aid the diagnosis of CAA. While CAA can also mani- ly and psychiatricly with favorable evolution. She has fest as dementia it is advisable to perform a complete not presented anymore epileptic seizures, false recogni- standard evaluation for other treatable causes of cogni- tions, visual hallucinations. Her blood pressure was nor- tive impairment. Oral anticoagulation reduces the glob- mal and also the brain MRI control. al risk of cerebrovascular events in patients with CAA Conclusions. This is the case of a patient known with and atrial fibrillation. major thrombophilia, twin pregnancy, who presented eclampsia and PRES. She presents prosopagnosia, delir- ium and hallucinatory syndrome, drug controlled and clinical remission associated with remission of neuroimaging signs. Romanian Journal of Neurology – Volume XIX, Supplement, 2020 57

and the involvement of cognitive impairment was not Sturge-Weber syndrome and hemiplegic migraine properly studied. Depression is an underdiagnosed – case report comorbidity associated with ALS. L. PURCARU1, I. TUDOR1, E. TERECOASA1,2, Material and method. 33 patients with the diagnosis N. GRECU1, C. TIU1,2 of amyotrophic lateral sclerosis, who attended the Neu- 1 Departament of Neurology, University Emergency rology I Department of Mures County Clinical Emergen- Hospital, Bucharest cy Hospital, were included. All participants underwent 2 “Carol Davila“ University of Medicine and Pharmacy, a neurological evaluation and were evaluated using Bucharest Beck Depression Inventory and ALS-FRSr scale. BDI-I is Introduction. Sturge-Weber syndrome is a sporadic often denounced for overestimating depression in disa- neurocutaneous disorder which associates epileptic sei- bled persons because of its somatic items, but we crea- zures and migraine, the latter in about 28% of patients. ted a sub-score of vegetative symptoms measured wi- Case presentation. A 28-years-old female, with type thin the BDI-I. Five questions were selected to describe II Sturge-Weber syndrome and epilepsy (treated with vegetative symptoms: loss of interest in sex, sleep dis- levetiracetam, with lowered doses during pregnancy), turbance, fatigue, appetite and weight loss. developed right hemicrania and left hemiparesis 2 days Results. 36% of patients were diagnosed with depre- after a caesarean section; she also developed recurrent ssive disorder according to BDI-I. The total score of the seizures with left hemifacial onset and secondary gene- vegetative symptoms is correlated with depression ralization. Her medical history was also significant for (p = 0.001, OR 35.20, CI 95% 3.6-344.18), as well as par- two other episodes of right-sided hemicranias associa- ticular items: appetite and weight loss (p = 0.028, OR ting left hemiparesis, which lasted for about 7 days. A 10.0, CI 95% 0.96-103.77) and libido loss (p = 0.002, OR cerebral MRI, excluded a cerebral venous thrombosis, 13.3, CI 95% 2.08-84.98). Also, we found significant but was consistent with her prior diagnosis, showing positive correlation between the BDI-I score and respi- volume asymmetry between the cerebral hemispheres, ratory impairment ((p = 0.008, OR 14.28, CI 95% 1.41- with no leptomeningeal angiomatosis. Her clinical evo- 144.37). Patients affected by salivary dysfunction lution was good, with remission of neurologic deficits in (p = 0.001, OR 4.000, CI 95% 2.106-7.598) and speech 10 days. Taking into consideration her history, the disturbance (p = 0.03, OR 0.147, CI 95% 0.023-0.942) diagnosis of associated sporadic hemiplegic migraine have more severe symptoms of depression. Increased was taken into consideration. depressive symptoms were associated with disease pro- Conclusions. The absence of leptomeningeal angio- gression, and a positive correlation is established matosis as well as the absence of significant cortical p = 0.001, R = 0.558. structures modifications and EEG alterations raises the Conclusions. Our results suggest that there are signi- issue of the etiology of the migraine and epileptic seizu- ficant correlations between depression and physical res in this case. Hemiplegic migraine can trigger epileptic function, vegetative symptoms and progression rate. seizures, both during the attack as well as intercritical. Depression may occur in patients with ALS, but is not an inevitable consequence of the progression of this disease.

Depression in ALS patients with a minumum one year since diagnosis in a Romanian population: Parkinsonism – a complex approach Interraction of physical function, vegetative P. ROȘU1, B. AZAMFIREI1, A.V. BLESNEAG1,2 symptoms and progresion rate 1 Neurology II Clinic, County Emergency Hospital, C. RADU1, S. MAIER1,2, Z. BAJKO1,2, Cluj-Napoca, Romania A. MOŢĂŢĂIANU1,2, R. BĂLAŞA1,2 2 Neuroscience Department, „Iuliu Hatieganu” University of Medicine and Pharmacy, Cluj-Napoca, Romania 1 Neurology I Department, Emergency Clinical County Hospital, Targu-Mures, Romania Introduction. Parkinsonism is frequently enclosed in 2 Discipline of Neurology, „G.E. Palade“ University of Parkinson’s disease, but many other signs and symp- Medicine Pharmacy Science and Technology, Targu Mures, toms of the clinical picture are falsely interpreted or Romania overlooked. Introduction. Until recently, amyotrophic lateral Case presentation. A 79 year old female patient, sclerosis was perceived as a pure motor neuron disease diagnosed with Parkinson’s disease for 5 years, is admit- 58 Romanian Journal of Neurology – Volume XIX, Supplement, 2020 ted to our clinic for postural instability, frequent falls, in all this time. Now she was admitted in our Neurology worsening gait, confusion and apathy. Initially the department for palpebral ptosis dysphagia, frequent patient had a favorable outcome under treatment with cough, that she developed about 2 weeks ago. In the Levodopa+Carbidopa, however gradually she presented last 3 days the symptoms started to get worse. Her med- cognitive and motor function decline. The neurological ical evolution gets worse and she develops acute res- exam reveals temporo-spatial disorientation, asymmet- piratory failure that requires the use of endotracheal rical hypertonic-hypokinetic syndrome, bradylalia, intubation and mechanical ventilation. She undergoes eupraxia, insomnia and the psychiatric evaluation four sessions of plasmapheresis with a slow improve- exposed visual and auditory hallucinations, especially ment of medical condition. There had been performed during the night accompanied by psychomotor agita- multiple electrocardiograms that demonstrated that the tion. Cerebral MRI showed symmetrical cortico-subcor- patient had paroxysmal atrial fibrillation with a CHA2DS- tical atrophy. The detailed heteroanamnestic data re- 2VASc score of 4 that needed oral anticoagulation. vealed that the cognitive decline and the postural Therefore we revised the case reports in the interna- instability had an earlier onset than the motor dysfunc- tional literature and chose to use Apixaban as the NOAC. tion. This fact alongside the presence of the hallucina- Under treatment with Apixaban there was no signs of tions lead to the final diagnosis of Lewy Body dementia. exacerbation. Conclusion. The patient exhibiting parkinsonism Conclusions. There are multifactorial mechanisms im- requires a multidisciplinary approach and monitoriza- plicated in the exacerbation of myasthenia gravis, this tion. The differential diagnosis of the Parkinson-plus fact reflects the complex dynamics of the neuromuscular syndromes should not be overlooked. junction system. The use of NOAC in patients with myas- Particularities. The early onset of the cognitive dis- thenia gravis that have atrial fibrillation is for the moment function, the poor response to treatment and the pres- at the beginning and that is why patients that take oral ence of hallucinations lead to the final diagnosis of Lewy anticoagulants should be very carefully monitored. Body dementia, confirmed solely post-mortem. Keywords: myasthenia gravis, NOAC, neuromuscular junction, atrial fibrillation

Can we safely use non-vitamin K antagonist oral anticoagulants in patients with myasthenia Levodopa-Carbidopa Intestinal Gel impact on gravis? Case report long term QoL and safety in advanced Parkinson V. SAPIRA1,2, A. TELEHUZ3, A. NECHIFOR2, disease patients: Romanian results from GLORIA A. MOCANU1, I.M. COJOCARU4, L. CHIPER1, registry M. LUNGU1,2 J. SZASZ1,2, M. SIMU3,4, L. PERJU-DUMBRAVA5, 1 “Sf. Ap. Andrei” Emergency Clinical County Hospital, L. BERGMANN6, D. POPESCU7, O.A. BAJENARU8,9 Galati, Romania 1 Department of Neurology, Emergency Clinical County 2 “Dunarea de Jos” University, Galati, Romania Hospital Mures, 3 Emergency County Hospital, Slobozia, Romania 2 “George Emil Palade” University of Medicine, Pharmacy, 4 Colentina Clinical Hospital, Bucharest, Romania Science and Technology, Targu-Mures, Romania 3 Department of Neurology, Clinical Emergency County Introduction. There are several factors that influence Hospital, cholinergic transmission, among them medication, tem- 4 “Victor Babes” University of Medicine and Pharmacy, perature and emotional state play a key role. There are Timisoara, Romania some classes of medications that can provoke exacerba- 5 “Iuliu Hatieganu” University of Medicine and Pharmacy, tions, therefore, carefully obtaining a medication history Cluj-Napoca, Romania is of vital importance. In the literature there is little or no 6 AbbVie, Inc., North Chicago, USA data whatsoever that concerns the use of non-vitamin K 7 AbbVie SRL, Bucharest, Romania 8 antagonist oral anticoagulants (NOAC) in patients with Department of Neurology, University Emergency Hospital, myasthenia gravis. What NOAC should we chose? Is there 9 “Carol Davila” University of Medicine and Pharmacy, a difference between different types of NOAC? Bucharest, Romania Case report. We present the case of a 70 year old woman that has been diagnosed with myasthenia gravis Background. Levodopa-Carbidopa Intestinal Gel 9 months ago. She was on pyridostigmine 240 mg/daily (LCIG) treatment aims to reduce motor fluctuations by Romanian Journal of Neurology – Volume XIX, Supplement, 2020 59 providing stable plasma levodopa concentrations in ad- thrombolysis and endovascular mechanical thrombec- vanced Parkinson’s disease (APD) patients. tomy. The EKG performed at admission and the 24 hours Objective. GLORIA registry evaluated LCIG efficacy, EKG monitoring showed sinus rhythm. The carotid safety and effect on quality of life (QoL). We present the Doppler ultrasonography did not reveal stenoses or ath- results for the enrolled Romanian patients. eromas. No significant changes were found at transtho- Methods. GLORIA was an international, multicenter, racic echocardiography. Follow up cerebral MRI revealed observational registry. In Romania, 39 APD patients an acute ischemic stroke in the same territory, despite were enrolled and followed for up to 24 months. Changes antithrombotic treatment. On further evaluation, tran- in complications of therapy and activities of daily living scranial Doppler monitoring for emboli detection (ADL) were evaluated by Unified Parkinson’s Disease showed the presence of one microembolic signal. Trans- Rating Scale (UPDRS). QoL was assessed by the esophageal echocardiography revealed a hypoechogen- Disease-specific 8-item Parkinson’s Disease Question- ic formation in the left atrial appendage, attached to the naire (PDQ-8) and the EuroQoL-5 Dimensions question- lateral wall of the left atrium, mobile, with irregular naire (EQ-5D). Adverse Drug Reactions (ADRs) were margins (0.9/0.4 cm). The hypotheses of an intracardiac collected from baseline up to 28 days after the end of thrombus or myxoma were placed. We also performed the follow-up. a cardiac MRI, with an aspect more likely suggestive of a Results. Over 24-month LCIG treatment period there thrombus. was a significant and clinically relevant improvement in Results. We initiated anticoagulant treatment. “Off” time, “On” time with dyskinesia, and ADL. PDQ-8 Follow up transesophageal echocardiography after 1 total score decreased significantly up to 12 months post month showed a minimal decrease in the size of the left LCIG therapy initiation and maintained numerically low- atrial appendage formation. At this moment, there is a er than baseline up to study end. EQ-5D usual activities high probability of the formation being a thrombus, but item score improved significantly up to 18 months and we can not certainly exclude a myxoma. remained numerically lower than baseline up to 24 Conclusion. Although left atrial appendage thrombi months. During the permanent tube phase was report- and myxomas are rare causes of stroke, they should not ed at least 1 ADR for 62.9% of the patients. In 1 patient be overlooked in young patients with no other apparent the ADR (polyneuropathy) led to LCIG discontinuation. cause of the stroke. The most frequently reported ADRs were decrease of body weight and polyneuropathy. Conclusions. LCIG treatment showed sustained im- What does a half swollen tongue hide? provements in ADL and QoL in APD patients and con- 1 1 1,3 firmed the established safety profile. I. TUDOR , L.I. PURCARU , E.O. TERECOASA , R.A. RADU2, B. DOROBAT2, C. TIU1,3 1 Department of Neurology, University Emergency A hypoechogenic left atrial appendage formation Hospital, Bucharest, Romania 2 Department of Interventional Radiology, University – cause of ischemic stroke in a young patient Emergency Hospital, Bucharest, Romania Daniela STEFAN1, Bogdan CASARU1, 3 “Carol Davila” University of Medicine and Pharmacy, Athena RIBIGAN1,2, Ovidiu BAJENARU1,2 Bucharest, Romania 1 Neurology Department, University Emergency Hospital, Introduction. We present the case of a 44 years old Bucharest, Romania female patient, without any other associated pathology, 2 “Carol Davila” University of Medicine and Pharmacy, except for a cervical trauma 10 years before, admitted in Bucharest, Romania our department for paresthesias with tingling on the Background and aims. Although cardioembolic right side of the tongue and mild dysarthria. strokes account for an important proportion of ischemic Case presentation. At the moment of admission the strokes, left atrial appendage thrombi and myxomas are neurological examination was normal. The patient af- rare causes of embolism. firmed a feeling of swollen tongue and minimal dysar- Methods. We present the case of a 51-year-old man, thria. Next day, the neurological examination revealed known with intellectual disability, who was admitted for tongue deviated to the right side in protrusion. Diagno- an acute ischemic stroke in the territory of the left inter- sis: right hypoglossal nerve palsy. Brain magnetic reso- nal carotid artery, for which he undergone intravenous nance imaging revealed a 10/5 mm mass with marked 60 Romanian Journal of Neurology – Volume XIX, Supplement, 2020 contrast enhancement located anterior to the right in- himself to the Neurology Department for progressive ternal carotid artery, imprinting the right hypoglossal loss of vision for approximately 18 months. The previous nerve channel and a T2/FLAIR hyperintensity of the ophthalmology consultations revealed an optic atrophy right half of the tongue. Cerebral angiography revealed with mild progression. 2 sacciform aneurysms of the right internal carotid ar- The neurological examination showed low visual tery mirrorly located (most likely secondary to a acuity in both eyes, right areactive mydriasis, abolished post-traumatic dissection), and a small caliber of the ar- right photomotor reflex, convergence paralysis of the tery, suggestive of vasospasm. A second angiography, right eye, normal oculomotricity, diminished deep ten- performed with the purpose of placing a stent graft, don reflexes of the left lower limb, absent left plantar showed the presence of a single aneurysm of reduced reflex. The laboratory tests showed mild leukocytosis, size compared with the first examination and a loop positive qualitative VDRL test, positive TPHA test, quan- made by the right internal carotid artery. During the titative VDRL test 1/32 0/2, negative ELISA IgM test, procedure the patient developed severe vasospasm, so negative HIV test. Magnetic-resonance angiography the procedure was stopped, without placing the stent. examination of the head and neck vessels showed few The electrophysiological examination was normal and nonspecific white matter lesions. Electroneurography the dysarthria and the swollen tongue meanwhile re- was normal. CSF examination showed positive TPHA mitted. She was discharged with the recommendation test, positive qualitative and quantitative VDRL test. of antiplatelet treatment with Aspirin. Mental status examination was normal. Conclusions. The hypoglossal nerve palsy was caused After the dermatology consultation treatment was by ischemic nerve compression due to an internal carot- started with benzylpenicillin 7,200,000 IU, administered id artery aneurysm. IM in 3 doses at 1 week interval. Familial investigation showed that patient’s wife was also positive for syphilis, but asymptomatic. Blindness – a diagnostic challenge in neurology Ocular syphilis, a type of neurosyphilis, must always be taken into consideration when diagnosing young I.M. VĂDAN1,2, I. PĂCURAR1, A.V. BLESNEAG1,2 apparently healthy individuals that present for progres- 1 County Emergency Hospital, Cluj-Napoca, Romania sive loss of vision, even though it is acknowledged to be 2 Neuroscience Department, “Iuliu Hatieganu“ University of Medicine and Pharmacy, Cluj-Napoca, Romania more common in HIV positive patients.

A 49-year-old patient with a smoking history and a traumatic amputation of the right lower leg presents ANNUAL SUBSCRIPTION FEES 2020 Annual subscription fees for 2020 are now available at: https://abonamente.medica.ro/ SUBMITTING A MANUSCRIPT Authors are strongly encouraged to review the entire “Instructions for authors” document to ensure that the manuscript is properly prepared and formatted, available at: https://RJN.com.ro/instructions-for-authors/ IMPORTANT: According to CMR accreditation No. 12000/23.01.2020, after subscribing the Romanian Journal of Neurology you will receive a Certificate with 10 EMC credits (4 issues per subscription yearly). The Certificate (the original art-work in ready-to-print form) will be sent, along with the first issue of the Journal to which you subscribed, at the subscriber’s e-mail address. HOW TO RECEIVE THE PRINTED JOURNALS? By ordinary mail: – All mailing costs will be supported entirely by the publisher! Useful: If you are a member of the Romanian Society of Neurology or a subscriber, but you haven’t received our journal, please call the Publishing House, at 0742 155 511.

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