Objectives: To present a case of co-occurrence of neurobrucellosis and cerebral venous sinus thrombosis. Methods: Case report. Clinical presentation: We presented 49-year-old Caucasian domicile female-farmer with a history of headache, weakness, and vomiting for a period of three months. Also, she had significant papilledema. We diagnosed rare co-morbidity of neurobrucellosis (confirmed after ELISA-test in serum samples and CSF analysis of pleocytosis/increase in protein/decrease in glucose level) in the setting of cerebral venous thrombosis developed in left sigmoid/left transverse sinus (confirmed after MRV of brain). Favorable outcome was achieved by applying protracted polymicrobial antibiotic therapy and heparin. Discussion: It may be challenging to diagnose neurobrucellosis, especially in patients with atypical presentation and abortive clinical forms. The co-morbidity of neurobrucellosis and cerebral venous sinus thrombosis is uncommon. However, it provides a possibility of brucella-colonization in cerebral venous sinuses as a potential hidden link between them. Conclusion: Patients with severe and persistent headache, as well as other neurological symptoms/signs should be considered for neurobrucellosis in endemic, but also in brucella non-endemic regions due to migrations. According to literature survey, this co-occurrence of neurobrucellosis and cerebral venous sinus thrombosis is third one reported from Europe.

Introduction: Transcranial sonography (TCS) is a relatively new ultrasound modality which could display echogenicity of human brain tissue through the intact skull. TCS may be useful in differentiation of idiopathic Parkinson’s disease (PD) from other parkinsonian disorders. Therefore, we studied different ultrasound markers by TCS in individuals with Parkinson’s disease. Patients and Methods: We performed TCS in 44 patients with PD and 22 patients with other parkinsonian disorders. Echogenic sizes of the substantia nigra (SN) and the lentiform nuclei (LN), as well as the width of the third ventricle and the frontal horns of the lateral ventricle, were measured. We also analyzed the echogenicity of the brainstem raphe (BR). Results: An unilateral hyperechogenic SN was observed in 31 (70%) patients with PD and only in 2 patients (9%) with other parkinsonian disorders (P<0.0001). Hyperechogenicity of the LN was no observed in patients with PD; however, it was present in 7 (32%) patients with other parkinsonian disorders (P=0.0002). Diameter of third ventricle (8.6+/-2.2 mm vs. 6.9+/-1.7mm, P=0.001), right (18.5+/-2.6 mm vs. 16.5+/-2.3 mm, P=0.003) and left frontal horn of lateral ventricle (19.0+/-3.7 mm vs. 16.2+/-2.6 mm, P=0.0006) was significantly wider in patients with other parkinsonian disorders compared with patients with PD. There was no difference in presence of hypoechogenic or interrupted BR in patients with PD and patients with other parkinsonian disorders (39% vs. 27%, P=0.4). Conclusion: TCS is a promising diagnostic technique and can be very helpful in differentiating between idiopathic Parkinson’s disease and other parkinsonian disorders.

Introduction: Basic cognitive functions such as: alertness, working memory, long term memory and perception, as well as higher levels of cognitive functions like: speech and language, decision-making and executive functions are affected by aging processes. Relations between the receptive vocabulary and cognitive functioning, and the manifestation of differences between populations of elderly people based on the primary disease is in the focus of this study. Aim: To examine receptive vocabulary and cognition of elderly people with: verified stroke, dementia, verified stroke and dementia, and without the manifested brain disease. Material and Methods: The sample consisted of 120 participants older than 65 years, living in an institution. A total of 26 variables was analyzed and classified into three groups: case history/anamnestic, receptive vocabulary assessment, and cognitive assessments. The interview with social workers, nurses and caregivers, as well as medical files were used to determine the anamnestic data. A Montreal Cognitive Assessment Scale (MoCA) was used for the assessment of cognition. In order to estimate the receptive vocabulary, Peabody Picture Vocabulary Test was used. Results: Mean raw score of receptive vocabulary is 161.58 (+–21:58 points). The best results for cognitive assessment subjects achieved on subscales of orientation, naming, serial subtraction, and delayed recall. Discriminative analysis showed the significant difference in the development of receptive vocabulary and cognitive functioning in relation to the primary disease of elderly people. The biggest difference was between subjects without manifested brain disease (centroid = 1.900) and subjects with dementia (centroid = -1754). Conclusion: There is a significant difference between elderly with stroke; dementia; stroke and dementia, and elderly people without manifested disease of the brain in the domain of receptive vocabulary and cognitive functioning. Variables of serial subtraction, standardized test results of receptive vocabulary, delayed recall, abstraction, orientation and vigilance successfully discriminate studied groups.

Background: Fatigue is usually defined as a subjective lack of physical and/or mental energy necessary for doing everyday activities. Fatigue is a subjective condition, and there is not a valid definition of fatigue after a stroke at the moment. Aim: The analysis of frequency of fatigue syndrome in 200 patients after an ischemic stroke and its effect on cognitive functioning and quality of life after an ischemic stroke was conducted. The measuring instruments for the assessment of fatigue used were the Chalder Fatigue Scale, for cognitive functioning the Mini-Mental State Examination, and for the quality of life SF-36, scale for measuring quality of life. Neurological and neuropsychological testings of the participants were conducted three months after an ischemic stroke – first testing, six months after an ischemic stroke – second testing, and twelve months after an ischemic stroke – third testing. Results: Fatigue syndrome was noted in 68% of the patients three months after an ischemic stroke, in 71% in testing after six months, and 70% after twelve months. The mean values of MMSE score in the patients with and without fatigue syndrome was between 28 and 29 in all testings, which indicates that they had normal cognitive functioning. The significance of differences in the MMSE score in the patients with and without fatigue syndrome in the first, second and third testing was tested using HI-squared test and the results showed that there were no statistically significant differences (p>0.005). In comparison of quality of life between the patients with and without fatigue the results showed that the patients without fatigue syndrome had significantly better quality of life in comparison with the patients with fatigue syndrome in the field of mental and physical health (p< 0.0001). Conclusion: Fatigue syndrome after an ischemic stroke has a significant frequency (68-71%) and duration. Fatigue syndrome does not affect cognitive functioning of patients after an ischemic stroke but it leads to impaired quality of life of patients in all areas.

Introduction: Psychological stress and changes in hypothalamic-pituitary-adrenal (HPA) axis in period after diagnosis of “de novo” Parkinson disease (PD) could be a big problem for patients. Materials and Methods: We measured psychological stress and changes in hypothalamic-pituitary-adrenal axis (HPA) in thirty patients (15:15) with “de novo” Parkinson’s disease, average age 64.17 ± 13.19 (28-82) years (Department of Neurology, University Clinical Center Tuzla). We used Impact of events scale (with 15 questions) to evaluate psychological stress. Normal level of morning cortisol was 201-681 nmol/l, and morning adrenocorticotropic hormone (ACTH) up to 50 pg/ml. Results: Almost 55% patients suffered from mild or serious psychological stress according to IES testing (Horowitz et al.). Non-iatrogenic changes in HPA axis were noticed at 30% patients. The differences between female and male patients regarding to the age (p=0.561), value of cortisol (p=0.745), value of ACTH (p=0.886) and IES testing (p=0.318) were not noticed. The value of cortisol was the predictor of value of ACTH (r=0.427). Conclusion: Psychological stress and changes in hypothalamic-pituitary-adrenal axis are present in patients with “de novo” PD. There is significant relation between values of cortisol and ACTH. Psychological stress is frequent problem for “de novo” PD patients.

Background: There have been only a small number of studies that have evaluated the outcome of post-stroke delirium. Objectives: To evaluate the effects of gender, age, stroke localization, delirium severity, previous illnesses, associated medical complications on delirium outcome as well as, to determine effects of delirium on cognitive functioning one year after stroke. Patients and Methods: Comprehensive neuropsychological assessments were performed within the first week of stroke onset, at hospital discharge, and followed-up for 3, 6 and 12 months after stroke. We used diagnostic tools such as Glazgow Coma Scale, Delirium Rating Scale, National Institutes of Health Stroke Scale and Mini-Mental State. Results: Patients who developed post-stroke delirium had significantly more complications (p = 0.0005). Direct logistic regression was performed to assess the impact of several factors on the likelihood that patients will die. The strongest predictor of outcome was age, mean age ≥ 65 years with a odds ratio (OR) 4.9. Cox’s regression survival was conducted to assess the impact of multiple factors on survival. The accompanying medical complications were the strongest predictor of respondents poore outcome with Hazard-risk 3.3. Cognitive assessments including Mini Mental State score have showen that post-stroke delirium patients had significant cognitive impairment, three (p = 0.0005), six months (p = 0.0005) and one year (p = 0.0005) after stroke, compared to patients without delirium. Conclusion: Patient gender, age, localization of stroke, severity of delirium, chronic diseases and emerging complications significantly affect the outcome of post- stroke delirium. Delirium significantly reduced cognitive functioning of after stroke patients.

Objectives: To determine the incidence of brain edema after ischaemic stroke and its impact on the outcome of patients in the acute phase of ischaemic stroke. Patients and Methods: We retrospectively analyzed 114 patients. Ischaemic stroke and brain edema are verified by computed tomography. The severity of stroke was determined by National Institutes of Health Stroke Scale. Laboratory findings were made during the first four days of hospitalization, and complications were verified by clinical examination and additional tests. Results: In 9 (7.9%) patients developed brain edema. Pneumonia was the most common complication (12.3%). Brain edema had a higher incidence in women, patients with hypertension and elevated serum creatinine values, and patients who are suffering from diabetes. There was no significant correlation between brain edema and survival in patients after acute ischaemic stroke. Patients with brain edema had a significantly higher degree of neurological deficit as at admission, and at discharge (p = 0.04, p = 0.004). Conclusion: The cerebral edema is common after acute ischaemic stroke and no effect on survival in the acute phase. The existence of brain edema in acute ischaemic stroke significantly influence the degree of neurological deficit.

Introduction: Homocysteine is process-product of methionine demethylation. It has proatherogenic, prothrombotic, prooxidative, proapoptotic, osteoporotic, neurotoxic, neuroinflamatory, and neurodegenerative effects. Hyperhomocysteinemia correlates with C667T MTHFR mutation, decrease of folic acid and vitamin B, as well as prolonged use of certain medications. Materials and Methods: We measured levels of homocysteine in thirty patients (15::15) with “de novo” Parkinson’s disease, with average age 64.17 ± 13.19 (28-82) years (Department of Neurology, University Clinical Center Tuzla). Normal level of homocysteine for women was 3.36-20.44 micromole/l and 5.9-16 micromole/l for men. We followed the effects of medicament approach (folic acid) every six months for next five years. Results: 20% of patients with “de novo” Parkinson’s disease exhibited hyperhomocysteinemia. An average level of homocysteine was 13.85 ± 5.82 micromole/l. Differences due to age and homocysteine levels, regardless of sex, were not concluded. For the next five years intake of folic acid (periodically, 1-2 months, 5 mg per day, orally) was effective to normalized levels of homocysteine in all. Conclusion: Hyperhomocysteinemia is present in every fifth patient with “de novo” Parkinson’s disease. Folic acid is medication of choice in treatment of hyperhomocysteinemia coexisting with Parkinson’s disease.

Aim. To demonstrate our experiences of thrombolytic therapy in acute ischemic stroke. Subjects and Methods. Patients with ischemic stroke treated with rt-PA, admitted at the Department of Neurology, Tuzla, Bosnia and Herzegovina, in the period between April 1, 2008, and December 31, 2012, were included. Results. Between April 2008 and December 2012, intravenous rt-PA was given to 87 patients with acute ischemic stroke, which represents 3.2% of patients with acute ischemic stroke admitted to our department in that period. Hypertension was the leading stroke risk factor. The mean NIHSS score before thrombolysis was 12 (range 4–21). Large artery arteriosclerosis was the most common stroke etiology. The mean door-to-needle time was 72 minutes and onset-to-needle time 152 minutes. Half of patients (44/87) had a significant improvement within the first 24 hours. Parenchymal hemorrhage occurred in 5 patients (6%) and was fatal in two cases. At 3-month follow-up, 45% of patients (39/87) had good outcome (mRS 0 or 1). Sixteen patients were dead at 3 months, and mean baseline stroke severity was significantly higher in patients who died (NIHSS 16.5 versus 11, ). Conclusion. The number of patients with acute ischemic stroke treated using rt-PA in the Department of Neurology, Tuzla, is lower than in developed countries. Thrombolytic therapy is safe and leads to favorable outcome in half of the patients.

It is well known that thrombolysis with intravenous recombinant tissue plasminogen activator (rt-PA) is the first evidence-based treatment for acute ischemic stroke. In the European Union (EU), rt-PA was approved in 2002 and has been used widely since then. Bosnia and Herzegovina is one of the few European countries not yet part of the EU, and approval for rt-PA in acute ischemic stroke was granted in 2007 under the same conditions as in other European countries. We presented our results with the use of intravenous thrombolytic therapy in patients with acute ischemic stroke in Tuzla Canton, Bosnia and Herzegovina. Between April 2008 and December 2011, intravenous rt-PA was administered to 72 patients with acute ischemic stroke, which represents 3·5% of patients with acute ischemic stroke admitted to the Department of Neurology Tuzla in that period (2067 patients). Baseline characteristics of the patients treated with thrombolytic therapy are provided in Table 1. Figure 1 illustrates the three-month outcome of our patients treated with thrombolytic therapy in comparison with the results of the neighboring countries: Sestre milosrdnice University Hospital Zagreb, Croatia (1) and Institute of Neurology Belgrade, Serbia (2). We wish to emphasize that these are only the results from our department, not at the national level. Bosnia and Herzegovina is one of the few countries in Europe that does not have an official National Stroke register, primarily because of the political situation. Therefore, our participation in multicenter studies is limited. With this article we want to demonstrate that we are working in line with the established protocols and show that our results are approximate to the results of other countries, despite the aforementioned shortcomings. These are small steps for world’s neurology but big ones for neurology in Bosnia and Herzegovina.

The aim of the study was to analyze stroke in young adults in Tuzla Canton, Bosnia and Herzegovina. From January 2001 to December 2005, 3864 patients with first-ever stroke were admitted at the Department of Neurology Tuzla. A retrospective analysis of risk factors, stroke types, severity and one month outcome in all young adults (18-45 years of age) with first-ever stroke was carried out. Out of total, there were 154 (4%) young adults with stroke. Mean age was 38.8 +/- 5.7 years and 47% were women. The leading risk factors were smoking (56%) and hypertension (45%). Subarachnoid hemorrhage (SAH) was more frequent in young adults compared with older patients (> 45 years of age) (22% vs. 3.5%, p < 0.0001), intracerebral hemorrhage (ICH) was similar in both groups (16.9% vs. 15.8%, p = 0.7), but ischemic stroke (IS) was predominant stroke type in the older group (61% vs. 74%, p = 0.0004). Young adults had more frequent lacunar stroke (26.6% vs. 16.1%, p = 0.01) and stroke due to other etiology (8.5% vs. 1.8%, p = 0.0004) than stroke patients over 45 years of age. Stroke severity at admission was lower in young adults than in older patients (p < 0.0001), as well as mortality at one month (11% vs. 30%, p < 0.0001). Favorable outcome (modified Rankin Scale < or = 2) had 71% of young adults compared with only 53% of patients in the older group (p = 0.0003). Stroke in young adults in Tuzla Canton is rare. Risk factors profile, stroke types, severity and outcome at one month in young adults are different from those in older patients.

The aim of this study was to determine whether volume and localization of intracerebral hematoma affects the six-month prognosis of patients with intracerebral hemorrhage (ICH). Patients and Methods. The study included 75 patients with ICH of both sex and all age groups. ICH, based on CT scan findings, was divided in the following groups: lobar, subcortical, infratentorial, intraventricular haemorrhage and multiple hematomas. Volume of intracerebral hematoma was calculated according to formula V = 0.5 × a × b × c. Intracerebral hematomas, according to the volume, are divided in three groups (0–29 mL, 30–60 mL, and >60 mL). Results. The highest mortality rate was recorded in the group with multiple hematomas (41%), while the lowest in infratentorial (12.8%). The best six-month survival was in patients with a volume up to 29 mL, 30 of them (64%) survived. The highest mortality rate was recorded in patients with the hematoma volume >60 mL (85%). Kaplan-Meier's analysis showed that there was statistical significance between the size of the hematoma and the six-month survival (P < 0.0001). More than half of patients (61.1%) who survived 6 months after ICH were functionally independent (Rankin scale ≤2). Conclusion The volume of hematoma significantly affects six-month prognosis in patients with intracerebral hemorrhage, while localization does not.