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.

OBJECTIVE The aim of this study was to determine the prevalence of symmetry, asymmetry and hypoplasia of the intracranial internal carotid artery (ICA), and the possible presence of other variants of the ICA by magnetic resonance angiography (MRA). SUBJECTS AND METHODS This prospective-retrospective study included 1000 subjects who underwent consecutively MRA of the cerebral arteries. 3D-time of flight angiograms were performed according to the standard protocol. We measured the diameter of the ICA and the diameter of the A1 segment of the anterior cerebral artery (ACA). The symmetry, asymmetry and hypoplasia of the ICA, as well hypoplasia of the A1 segment of the ACA were analysed using the vascular asymmetry coefficient. RESULTS The right and left ICA were symmetrical in 93.9% examinees, and asymmetrical in 6%, while ICA hypoplasia was found in only one patient (0.1%). Other variants of the ICA were not found. There was no significant difference in the prevalence of individual variations between male and female patients, and no significant frequency difference was found between anatomical variations in terms of the right and left ICA. In 38.3% patients with asymmetrical ICAs, aplasia or hypoplasia of the A1 segment of the ACA was found on the side of the ICA with a reduced diameter. CONCLUSION Congenital hypoplasia of ICAs is a very rare abnormality, while asymmetry of ICAs is more common. After evaluating severe asymmetry of intracranial ICAs by MRA, MRA of the neck is recommended, especially in patients with a complete anterior part of the circle of Willis.

INTRODUCTION Cerebral ischemic small-vessel disease (SVD), causing lacunar infarcts and white matter hyperintensities on brain magnetic resonance imaging (MRI), is a progressive disease associated with an increased risk of stroke, dementia and death. Increased arterial stiffness has been associated with ischemic stroke and cerebral SVD independently of common vascular risk factors. OBJECTIVE The aim of the study was to analyze arterial stiffness in our patients with symptomatic SVD. METHODS In a cross-sectional study design we included 30 patients with clinical and MRI evidence of cerebral SVD and 30 age-, gender- and risk factor-matched control subjects with no neurological diseases. Patients were evaluated at the Ultrasound Laboratory at the Neurology Clinic, Clinical Center of Serbia in Belgrade, during a three-month period (from September 1st to December 1st 2012). Baseline demographic and vascular risk factors were recorded. All patients underwent standard carotid ultrasound scans with measuring of intima-media thickness (IMT) and analysis of atheromatous plaques. Internal carotid artery stiffness was evaluated with the use of e-tracking option as beta stiffness index (BSI) value. RESULTS There were no differences between study groups in regard to degree of carotid stenosis and type of carotid plaques (p > 0.05). Patients in SVD group had significantly higher mean IMT (p = 0.0093) and mean BSI (p < 0.0001) than subjects in the control group. No significant correlation was detected between IMT and BSI in SVD group (r = 0.168; p = 0.376). Brain lesions severity correlated with BSI (r = 0.733; p < 0.0001). CONCLUSION Arterial stiffness is increased in symptomatic patients with SVD, independently of vascular risk factors and IMT.

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.