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Moyamoya disease initially manifesting as vascular parkinsonism
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Abstracts / Journal of the Neurological Sciences 357 (2015) e363–e423
disruption was associated with young age, non-smoker, and diabetes mellitus, and recanalized state of thrombolysis in cerebra infarction (TICI) 2b-3 (P b 0.05). However, BBB disruption was not association with poor prognosis (58.3% vs 68.2%). Conclusion: BBB disruption is not rare after mechanical thrombectomy, especially in patients with fully recanalization. BBB disruption shown on FLAIR may be benign. doi:10.1016/j.jns.2015.08.1452
1420 WFN15-1543 Stroke Thrombolysis with alteplase in acute ischaemic stroke at Dr. Fernan Henriquez Hospital of Temuco-Chile A. Soto, D. Pollak, A. Von Johnn, M. Grandjean, A. Riquelme, P. Garcia, C. Del Castillo, T. Castillo, D. Gonzalez, P. Jimenez. Medical specialties, Universidad de La Frontera, Temuco, Chile Background: Stroke is a leading cause of death and disability in Chile. Thrombolysis with alteplase is the reference treatment in acute ischaemic stroke. Since May 2012 thrombolysis is performed at the Hernan Henriquez Hospital. Objectives: To describe the experience of three years of intravenous alteplase in our center. Patients and methods: A series of consecutive cases of patients who received thrombolysis, between May 2012 and April 2015 at Dr. Hernan Henriquez Hospital of Temuco-Chile. Results: 53 patients were treated during the period. 86.8% of thrombolysis was performed under the system of neurology 24/7. The average age of patients was 68 years. 56.6% of patients were male (n = 30). Median time of arrival to the emergency department was 84 minutes (IQR 53-118). Median door-to-needle time was 87 minutes (IQR 62-114). Median NIHSS at admission was 12 points (IQR 8-16). Median time between the onset of symptoms to the start of thrombolysis was 174 minutes (IQR 150-210). Regarding the functional outcome measured by the Modified Rankin Scale (mRS) at discharge: 14 patients (26.4%) had a mRS of 0-1; 8 patients (15%) had a mRS of 2; 6 patients(11.3%) had a mRS of 3; 15 (28.3%) had a mRS of 4; 4 (7.6%) had a mRS of 5 and 6 (11.4%) died (mRS = 6). Conclusions: It is feasable to perform intravenous thrombolysis in public hospitals in all regions in Chile. The implementation of neurology shifts 24/7 in the Emergency Department, has developed the use of intravenous thrombolysis at our hospital.
doi:10.1016/j.jns.2015.08.1453
1422 WFN15-0551 Stroke The role of platelet count and mean platelet volume in clopidogrel resistance in ischemic stroke patients E. Xanmemmedov, E. Coban, B. Ciftci-Kavaklıoglu, E. Acar, F. Eren, N. Kale, A. Soysal. Neurology Department, Bakirkoy Training and Research Hospital for Psychiatry Neurology & Neurosurgery, Istanbul, Turkey Background: Clopidogrel resistance (CR) has been associated with increased recurrent stroke, morbidity and mortality rates in ischemic stroke patients. Objective: To explore whether platelet count and mean platelet volume (MPV) are indicators of platelet activation in ischemic stroke patients with CR.
Methods: Medical records of ischdemic stroke patients on clopidogrel therapy who have been screened for CR were studied retrospectively. Platelet count was performed within routine complete blood count (CBC) at two hours of blood withdrawal. CR was measured with an impedance aggregometer. Results: Platelet count was significantly higher in patients with CR compared to those without CR (p =0.005; p Conclusion: A platelet count of 254 or higher has been demonstrated to be associated with a substantially increased risk of developing clopidogrel resistance. Our data suggest that platelet count should be considered while determining the optimal dosage of clopidogrel therapy to prevent recurrent stroke. doi:10.1016/j.jns.2015.08.1454
1423 WFN15-0913 Stroke Cytokine responses in patients with acute ischemic stroke or transient ischemic attack during hospitalization and intensive treadmill training A. Strømmen, T. Christensen, K. Jensen. Neurology, Copenhagen University Hospital - Nordsjællands Hospital - Hillerød, Hillerød, Denmark Background: Cytokines are produced locally following tissue damage during acute cerebral ischemia with e.g. interleukin (IL) 6 shown to be significantly higher shortly after symptom onset. Some cytokines are also produced by skeletal muscle cells during physical activity. Little is however known about cytokine responses in patients with acute cerebral ischemia during physical activity. Objective: The purpose of our study was to compare cytokine responses during hospitalization in patients with 1) transient ischemic attack (TIA), 2) patients with acute ischemic stroke and 3) patients with acute ischemic stroke during intensive treadmill training. Additionally, the cytokine responses were compared with physical activity measured with accelerometry. Methods: 16 TIA patients (group 1) and 15 and 20 acute ischemic stroke patients with motor disability (groups 2 and 3) admitted to our acute stroke unit were included within 72 hours of ictus. All patients wore 5 accelerometers continuously for up to 7 days of hospitalization. Patients from group 3 trained 2 × 30 minutes daily on a weight bearing treadmill for the first 5 days of admission. Blood samples were taken daily for all patients and up to 20 additional blood samples were taken during 2 training sessions in group 3. Blood samples were analyzed for IL-6, 10, 17A, 17B, 21, 23 and 33 using flow cytometry. Results and conclusion: All samples have been analyzed and we are currently in the process of preparing our manuscript. All results from the 51 patients will thus be presented at the XXII World Congress of Neurology. doi:10.1016/j.jns.2015.08.1455
1424 WFN15-0876 Stroke Moyamoya disease initially manifesting as vascular parkinsonism T.H. Leea, S.M. Sungb, H.J. Chob. aDepartment of Diagnostic Radiology, Pusan National University Hospital, Busan, Korea; bDepartment of Neurology, Pusan National University Hospital, Busan, Korea Moyamoya disease is a cerebrovascular disorder characterized by progressive stenosis of the distal internal carotid artery, which can
Abstracts / Journal of the Neurological Sciences 357 (2015) e363–e423
attribute to the wide range of clinical presentations. The majority of affected patients present with transient or fixed symptoms of cerebral ischemia such as hemiparesis, dysarthria and aphasia. However, vascular parkinsonism (VP) has been described as extremely rare clinical manifestation. We report a patient presenting with clinical symptom of VP as the initial manifestation of moyamoya disease. A 55-year-old woman presented with slowly progressive gait disturbance during a period of 2 years. She had no remarkable past history except for hypertension. On neurological examination, bradykinesia in all extremities, but more prominent on the left side, was noted with no resting tremor and rigidity. She showed smallstepped gait with pivotal turning, initiation failure and postural instability. Deep tendon reflexes were asymmetrically brisker on the left. T2-weighted and FLAIR images of the brain demonstrated diffuse hyperintensity involving cortical and subcortical areas of the bilateral frontal lobes. MRA and digital subtraction angiography of the brain revealed steno-occlusion at the terminal ends of the bilateral internal carotid arteries with the development of collateral vascular network. To our knowledge, this is the first case presenting with clinical symptoms of VP as the initial manifestation of moyamoya disease. Our case allows us to supplement clinical symptoms of VP to the initial manifestation of moyamoya disease, resulted from chronic ischemia to cortical and subcortical areas of the brain.
doi:10.1016/j.jns.2015.08.1456
1425 WFN15-0881 Stroke Emergent stent-assisted recanalization for wake-up stroke S.M. Sunga, T.H. Leeb, H.J. Choa. aDepartment of Neurology, Pusan National University Hospital, Busan, Korea; bDepartment of Diagnostic Radiology, Pusan National University Hospital, Busan, Korea Background & Purpose: Patients who suffer an acute ischemic stroke during sleep and present with symptoms on awakening are ineligible for standard intravenous thrombolysis due to uncertainty in symptom onset times. Some patients may, however, benefit from emergent stent-assisted recanalization. Therefore, this study aimed to evaluate the feasibility and safety of emergent stent-assisted recanalization in wake-up stroke (WUS) patients. Methods: Ten WUS patients with internal carotid (ICA) or middle cerebral artery (MCA) occlusions were evaluated in this study. Stent-assisted recanalization was measured using the Thrombolysis in Cerebral Infarction (TICI) score. Safety and functional outcome were assessed by the occurrence of symptomatic intracranial hemorrhage (ICH) and the National Institute of Health Stroke Scale (NIHSS) at admission and at 7 days after recanalization. The modified Rankin Scale (mRS) was also checked at 90 days after recanalization. Results: The mean NIHSS score on admission was 17.8 ± 4.5. Occlusion sites were proximal ICA in 3, supraclinoid ICA in 1 patient, and M1 of the MCA in 6 patients. Successful recanalization (TICI 2b: 4 patients, TICI 3: 3 patients) was achieved in 70% of patients. At 7 days after recanalization, 2 patients had no change, 1 patient had aggravated symptoms, and 7 patients showed improved NIHSS scores (mean 9.4), and at 90 days a mRS score of ≤2 was achieved in 2 patients (20%) with no occurrence of symptomatic ICH in any patients. Conclusions: This case series demonstrates the feasibility of emergent stent-assisted recanalization for successful recanalization and improvement on NIHSS in WUS patients. doi:10.1016/j.jns.2015.08.1457
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1426 WFN15-0715 Stroke Non-hdl-cholesterol in ischemic stroke patients populations A. Szczepanska-Szereja, E. Belniaka, A. Buryb, P. Nowakc. aDepartment of Neurology, Medical University of Lublin, Lublin, Poland; bDepartment of Neurology, Wojewódzki Szpital Specjalistyczny, Rzeszów, Poland; c Centrum Opieki Medycznej w Jarosławiu, Oddział Neurologiczny z Pododdziałem Udarowym, Jarosław, Poland Background: The Adult Treatment Panel III and International Atherosclerosis Society guidelines established non-high-density lipoprotein cholesterol (non-HDL-C) as a secondary and alternate to LDL-C treatment target in cardiovascular diseases treatment. The association of non-HDL-C with ischemic stroke (IS) is not well established. Objective: We evaluated non-HDL-C in IS patients and its relation to stroke aetiology and statin pre-treatment. Patients and methods: We analyzed data from 1 476 patients with IS hospitalized in 10 centres. Stroke risk factors, statin pre-treatment, fasting lipid profile (blood samples were collected within 36 hours of IS onset), modified TOAST classification were evaluated. Results: We didn’t find deflections in mean values of Total-C193,9 ± 49,2 mg/dl, HDL-C– 50,4 ± 16,2 and Triglicerydes-133,0 ± 79,0 mg/dl comparing to general guidelines. Both mean values of LDL-C – 118,5 ± 42,3 mg/dl and non-HDL-C – 143,5 ± 47,1 mg/dl were higher than recommended values for high risk population. Among all IS patients 619 had optimal non-HDL-C (b130 mg/dl), 360 elevated non-HDL-C (130 -159 mg/dl) and 476 high non-HDL-C (≥160 mg/dl). Elevated and high levels of non-HDL-C were associated with lacunar stroke (p b 0,01). There were no gender differences in non-HDL-C levels observed. Non-HDL-C levels negatively correlated with age (p b 0,001). Statin pre-treatment was associated with significantly lower mean values of non-HDL-C (p b 0,001). Conclusion: In IS risk evaluation non-HDL-C seems to have the same prognostic value as LDL-C, especially in case of lacunar stroke risk and should be investigated among standard lipid panels in clinical practice of primary and secondary stroke prevention. doi:10.1016/j.jns.2015.08.1458
1428 WFN15-0740 Stroke Lacunar infarct presenting with pure arm weakness S. Tasdemira, H. Yasarb, S. Alayc. aDepartment of Neurology, Beytepe Military Hospital, ANKARA, Turkey; bDepartment of Neurology, Mevki Military Hospital, ANKARA, Turkey; cDepartment of Neurology, Gulhane Military Medical Academy, ANKARA, Turkey Background: Lacunar infarcts are small deep infarcts that result from occlusion of a penetrating artery. Patients usually present with a classical lacunar syndrome (pure motor hemiparesis, pure sensory syndrome, sensorimotor stroke, ataxic hemiparesis or dysarthria-clumsy hand). Pure motor hemiparesis can be presented with affected face, arm, leg equally . Objective: Monoparesis is rare in pure motor paresis. We present a pure motor monoparesis of the upper limb caused by lacunar infarct. Patient and report: A 53 year old male patient presented with weakness of lifting left arm. The weakness started three weeks ago. First he was admitted to department of physical therapy and rehabilitation. There was no cure after the therapy, so he was admitted to our clinic. On the neurological examination there was weakness abduction on the left arm, weakness flexion and extension on left forearm. Deep tendon reflexes were increased on left upper limb.
Abstracts / Journal of the Neurological Sciences 357 (2015) e363–e423
disruption was associated with young age, non-smoker, and diabetes mellitus, and recanalized state of thrombolysis in cerebra infarction (TICI) 2b-3 (P b 0.05). However, BBB disruption was not association with poor prognosis (58.3% vs 68.2%). Conclusion: BBB disruption is not rare after mechanical thrombectomy, especially in patients with fully recanalization. BBB disruption shown on FLAIR may be benign. doi:10.1016/j.jns.2015.08.1452
1420 WFN15-1543 Stroke Thrombolysis with alteplase in acute ischaemic stroke at Dr. Fernan Henriquez Hospital of Temuco-Chile A. Soto, D. Pollak, A. Von Johnn, M. Grandjean, A. Riquelme, P. Garcia, C. Del Castillo, T. Castillo, D. Gonzalez, P. Jimenez. Medical specialties, Universidad de La Frontera, Temuco, Chile Background: Stroke is a leading cause of death and disability in Chile. Thrombolysis with alteplase is the reference treatment in acute ischaemic stroke. Since May 2012 thrombolysis is performed at the Hernan Henriquez Hospital. Objectives: To describe the experience of three years of intravenous alteplase in our center. Patients and methods: A series of consecutive cases of patients who received thrombolysis, between May 2012 and April 2015 at Dr. Hernan Henriquez Hospital of Temuco-Chile. Results: 53 patients were treated during the period. 86.8% of thrombolysis was performed under the system of neurology 24/7. The average age of patients was 68 years. 56.6% of patients were male (n = 30). Median time of arrival to the emergency department was 84 minutes (IQR 53-118). Median door-to-needle time was 87 minutes (IQR 62-114). Median NIHSS at admission was 12 points (IQR 8-16). Median time between the onset of symptoms to the start of thrombolysis was 174 minutes (IQR 150-210). Regarding the functional outcome measured by the Modified Rankin Scale (mRS) at discharge: 14 patients (26.4%) had a mRS of 0-1; 8 patients (15%) had a mRS of 2; 6 patients(11.3%) had a mRS of 3; 15 (28.3%) had a mRS of 4; 4 (7.6%) had a mRS of 5 and 6 (11.4%) died (mRS = 6). Conclusions: It is feasable to perform intravenous thrombolysis in public hospitals in all regions in Chile. The implementation of neurology shifts 24/7 in the Emergency Department, has developed the use of intravenous thrombolysis at our hospital.
doi:10.1016/j.jns.2015.08.1453
1422 WFN15-0551 Stroke The role of platelet count and mean platelet volume in clopidogrel resistance in ischemic stroke patients E. Xanmemmedov, E. Coban, B. Ciftci-Kavaklıoglu, E. Acar, F. Eren, N. Kale, A. Soysal. Neurology Department, Bakirkoy Training and Research Hospital for Psychiatry Neurology & Neurosurgery, Istanbul, Turkey Background: Clopidogrel resistance (CR) has been associated with increased recurrent stroke, morbidity and mortality rates in ischemic stroke patients. Objective: To explore whether platelet count and mean platelet volume (MPV) are indicators of platelet activation in ischemic stroke patients with CR.
Methods: Medical records of ischdemic stroke patients on clopidogrel therapy who have been screened for CR were studied retrospectively. Platelet count was performed within routine complete blood count (CBC) at two hours of blood withdrawal. CR was measured with an impedance aggregometer. Results: Platelet count was significantly higher in patients with CR compared to those without CR (p =0.005; p Conclusion: A platelet count of 254 or higher has been demonstrated to be associated with a substantially increased risk of developing clopidogrel resistance. Our data suggest that platelet count should be considered while determining the optimal dosage of clopidogrel therapy to prevent recurrent stroke. doi:10.1016/j.jns.2015.08.1454
1423 WFN15-0913 Stroke Cytokine responses in patients with acute ischemic stroke or transient ischemic attack during hospitalization and intensive treadmill training A. Strømmen, T. Christensen, K. Jensen. Neurology, Copenhagen University Hospital - Nordsjællands Hospital - Hillerød, Hillerød, Denmark Background: Cytokines are produced locally following tissue damage during acute cerebral ischemia with e.g. interleukin (IL) 6 shown to be significantly higher shortly after symptom onset. Some cytokines are also produced by skeletal muscle cells during physical activity. Little is however known about cytokine responses in patients with acute cerebral ischemia during physical activity. Objective: The purpose of our study was to compare cytokine responses during hospitalization in patients with 1) transient ischemic attack (TIA), 2) patients with acute ischemic stroke and 3) patients with acute ischemic stroke during intensive treadmill training. Additionally, the cytokine responses were compared with physical activity measured with accelerometry. Methods: 16 TIA patients (group 1) and 15 and 20 acute ischemic stroke patients with motor disability (groups 2 and 3) admitted to our acute stroke unit were included within 72 hours of ictus. All patients wore 5 accelerometers continuously for up to 7 days of hospitalization. Patients from group 3 trained 2 × 30 minutes daily on a weight bearing treadmill for the first 5 days of admission. Blood samples were taken daily for all patients and up to 20 additional blood samples were taken during 2 training sessions in group 3. Blood samples were analyzed for IL-6, 10, 17A, 17B, 21, 23 and 33 using flow cytometry. Results and conclusion: All samples have been analyzed and we are currently in the process of preparing our manuscript. All results from the 51 patients will thus be presented at the XXII World Congress of Neurology. doi:10.1016/j.jns.2015.08.1455
1424 WFN15-0876 Stroke Moyamoya disease initially manifesting as vascular parkinsonism T.H. Leea, S.M. Sungb, H.J. Chob. aDepartment of Diagnostic Radiology, Pusan National University Hospital, Busan, Korea; bDepartment of Neurology, Pusan National University Hospital, Busan, Korea Moyamoya disease is a cerebrovascular disorder characterized by progressive stenosis of the distal internal carotid artery, which can
Abstracts / Journal of the Neurological Sciences 357 (2015) e363–e423
attribute to the wide range of clinical presentations. The majority of affected patients present with transient or fixed symptoms of cerebral ischemia such as hemiparesis, dysarthria and aphasia. However, vascular parkinsonism (VP) has been described as extremely rare clinical manifestation. We report a patient presenting with clinical symptom of VP as the initial manifestation of moyamoya disease. A 55-year-old woman presented with slowly progressive gait disturbance during a period of 2 years. She had no remarkable past history except for hypertension. On neurological examination, bradykinesia in all extremities, but more prominent on the left side, was noted with no resting tremor and rigidity. She showed smallstepped gait with pivotal turning, initiation failure and postural instability. Deep tendon reflexes were asymmetrically brisker on the left. T2-weighted and FLAIR images of the brain demonstrated diffuse hyperintensity involving cortical and subcortical areas of the bilateral frontal lobes. MRA and digital subtraction angiography of the brain revealed steno-occlusion at the terminal ends of the bilateral internal carotid arteries with the development of collateral vascular network. To our knowledge, this is the first case presenting with clinical symptoms of VP as the initial manifestation of moyamoya disease. Our case allows us to supplement clinical symptoms of VP to the initial manifestation of moyamoya disease, resulted from chronic ischemia to cortical and subcortical areas of the brain.
doi:10.1016/j.jns.2015.08.1456
1425 WFN15-0881 Stroke Emergent stent-assisted recanalization for wake-up stroke S.M. Sunga, T.H. Leeb, H.J. Choa. aDepartment of Neurology, Pusan National University Hospital, Busan, Korea; bDepartment of Diagnostic Radiology, Pusan National University Hospital, Busan, Korea Background & Purpose: Patients who suffer an acute ischemic stroke during sleep and present with symptoms on awakening are ineligible for standard intravenous thrombolysis due to uncertainty in symptom onset times. Some patients may, however, benefit from emergent stent-assisted recanalization. Therefore, this study aimed to evaluate the feasibility and safety of emergent stent-assisted recanalization in wake-up stroke (WUS) patients. Methods: Ten WUS patients with internal carotid (ICA) or middle cerebral artery (MCA) occlusions were evaluated in this study. Stent-assisted recanalization was measured using the Thrombolysis in Cerebral Infarction (TICI) score. Safety and functional outcome were assessed by the occurrence of symptomatic intracranial hemorrhage (ICH) and the National Institute of Health Stroke Scale (NIHSS) at admission and at 7 days after recanalization. The modified Rankin Scale (mRS) was also checked at 90 days after recanalization. Results: The mean NIHSS score on admission was 17.8 ± 4.5. Occlusion sites were proximal ICA in 3, supraclinoid ICA in 1 patient, and M1 of the MCA in 6 patients. Successful recanalization (TICI 2b: 4 patients, TICI 3: 3 patients) was achieved in 70% of patients. At 7 days after recanalization, 2 patients had no change, 1 patient had aggravated symptoms, and 7 patients showed improved NIHSS scores (mean 9.4), and at 90 days a mRS score of ≤2 was achieved in 2 patients (20%) with no occurrence of symptomatic ICH in any patients. Conclusions: This case series demonstrates the feasibility of emergent stent-assisted recanalization for successful recanalization and improvement on NIHSS in WUS patients. doi:10.1016/j.jns.2015.08.1457
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1426 WFN15-0715 Stroke Non-hdl-cholesterol in ischemic stroke patients populations A. Szczepanska-Szereja, E. Belniaka, A. Buryb, P. Nowakc. aDepartment of Neurology, Medical University of Lublin, Lublin, Poland; bDepartment of Neurology, Wojewódzki Szpital Specjalistyczny, Rzeszów, Poland; c Centrum Opieki Medycznej w Jarosławiu, Oddział Neurologiczny z Pododdziałem Udarowym, Jarosław, Poland Background: The Adult Treatment Panel III and International Atherosclerosis Society guidelines established non-high-density lipoprotein cholesterol (non-HDL-C) as a secondary and alternate to LDL-C treatment target in cardiovascular diseases treatment. The association of non-HDL-C with ischemic stroke (IS) is not well established. Objective: We evaluated non-HDL-C in IS patients and its relation to stroke aetiology and statin pre-treatment. Patients and methods: We analyzed data from 1 476 patients with IS hospitalized in 10 centres. Stroke risk factors, statin pre-treatment, fasting lipid profile (blood samples were collected within 36 hours of IS onset), modified TOAST classification were evaluated. Results: We didn’t find deflections in mean values of Total-C193,9 ± 49,2 mg/dl, HDL-C– 50,4 ± 16,2 and Triglicerydes-133,0 ± 79,0 mg/dl comparing to general guidelines. Both mean values of LDL-C – 118,5 ± 42,3 mg/dl and non-HDL-C – 143,5 ± 47,1 mg/dl were higher than recommended values for high risk population. Among all IS patients 619 had optimal non-HDL-C (b130 mg/dl), 360 elevated non-HDL-C (130 -159 mg/dl) and 476 high non-HDL-C (≥160 mg/dl). Elevated and high levels of non-HDL-C were associated with lacunar stroke (p b 0,01). There were no gender differences in non-HDL-C levels observed. Non-HDL-C levels negatively correlated with age (p b 0,001). Statin pre-treatment was associated with significantly lower mean values of non-HDL-C (p b 0,001). Conclusion: In IS risk evaluation non-HDL-C seems to have the same prognostic value as LDL-C, especially in case of lacunar stroke risk and should be investigated among standard lipid panels in clinical practice of primary and secondary stroke prevention. doi:10.1016/j.jns.2015.08.1458
1428 WFN15-0740 Stroke Lacunar infarct presenting with pure arm weakness S. Tasdemira, H. Yasarb, S. Alayc. aDepartment of Neurology, Beytepe Military Hospital, ANKARA, Turkey; bDepartment of Neurology, Mevki Military Hospital, ANKARA, Turkey; cDepartment of Neurology, Gulhane Military Medical Academy, ANKARA, Turkey Background: Lacunar infarcts are small deep infarcts that result from occlusion of a penetrating artery. Patients usually present with a classical lacunar syndrome (pure motor hemiparesis, pure sensory syndrome, sensorimotor stroke, ataxic hemiparesis or dysarthria-clumsy hand). Pure motor hemiparesis can be presented with affected face, arm, leg equally . Objective: Monoparesis is rare in pure motor paresis. We present a pure motor monoparesis of the upper limb caused by lacunar infarct. Patient and report: A 53 year old male patient presented with weakness of lifting left arm. The weakness started three weeks ago. First he was admitted to department of physical therapy and rehabilitation. There was no cure after the therapy, so he was admitted to our clinic. On the neurological examination there was weakness abduction on the left arm, weakness flexion and extension on left forearm. Deep tendon reflexes were increased on left upper limb.