Why do headaches occur?
Many reasons can cause a headache. Headaches not based to another reason are called primary headaches, the most common types of which are stress and migraine type aches. Headaches with another reason are called secondary headaches and these can be caused by a number of reasons such as sinusitis, hunger, infections, vascular and metabolism diseases and intracranial tumors.

When should a patient apply to a physician?
If headaches are periodical or continuous, experienced for the first time or very intense, new and different, gradually increasing, has started after the age of 50, developed after head trauma, emerge with exercise or sexual activity or do not respond to treatment, professional medical help should be sought immediately.

Which tests are needed?
Headaches can occur in intervals or on a continuous basis. There is no test to indicate primary headaches. The first step of diagnosis is defining the problem. It mostly depends on giving correct answers to the questions asked by your physician. Various tests can be conducted in order to distinguish different headaches from each other.

Where and how should you apply?
2 residents provide service under the supervision of an academic staff member in the Outpatient Clinic of Headache in Hacettepe Adult Hospital Neurology Department on Thursdays. Examinations are given both in the outpatient clinic and also by academic staff with appointments on other days. Patient should apply to the emergency department in case of severe headache.

Major area of subject associated with behavioral neurology is dementia. Dementia, which generally starts with advanced age and indicated the symptoms of forgetfulness, behavioral disorders, delusion, poor self-care and hygiene as well as decreased interest in the surrounding environment is also commonly known as “Alzheimer’s disease”. It should be remembered that not every case of forgetfulness is dementia and every case of dementia does not mean Alzheimer’s disease as well. People can experience the symptoms of interest such as forgetting names, addresses and numbers due to many reasons such as stress, fatigue and depression. Such examples usually do not last for long and recovery from forgetfulness is spontaneous after the underlying reason is eliminated. However, the help of a neurologist should be sought if forgetfulness is affecting your daily and business life and it is continuously increasing. “Behavioral neurology” determine whether these symptoms mean dementia and, if so, plan the treatment.

It is a test method which amplified the electrical activity of brain and either print these in paper or on computer media. It is safely used for even pregnant patients.

The test is required for epilepsy diagnosis, epilepsy classification, monitoring the efficiency of epilepsy treatment as well as any kind of alteration in consciousness, which could result from toxic factors.

There 3 32-chanelled (two of which are able to conduct video screening) and 1 10-channelled EEG (with this portable device, screening can be carried out at emergency service and intensive care departments) at the department of Neurology at Hacettepe Adult University, A Floor EEG laboratories, which mainly offer service for outpatients.

5 technicians (Chief technician Ertuğrul Kaplan and his team) work at the EEG laboratory. There is also an Adult Video-EEG Monitorisation Unit located in Ward 31 with 2 beds for inpatient care. This unit comprises of a 64-channelled device capable of conducting polysomnography recording and a 128-channelled device capable of conducting invasive EEG recording. EEGs are evaluated by 1 professor and 1 associate professor specialized in this issue.

Types of Screening
20-30 minutes of routine recording in scope of outpatient care clinic: the patient must come to the screening with a full stomach. The patient lies with his/her eyes closed and screening is conducted for 20-30 minutes. During the screening, a technician requests from the patient to perform deep breathing and to open and close their eyes simultaneously. Photic(light) stimulation is applied at differing frequencies through the end of the screening.

The patient is requested not to sleep during the night in accordance with physician's instructions and 1-3 hours of EEG screening is carried out. The patient is supposed to sleep during the screening. If the screening is carried out on 32-channelled EEG, additional electrodes such as EKG, T1 and T2 are also applied.

In both types of screenings stated above, the electrode stickers are chyle or commercially available ready-to-use stickers. The patient is taken to the hair washing room following the screening, where he/she is provided with hot water, shampoo and a clean towel.

Based upon the physicians demand who is dealing with the epilepsy patients, the patients are transferred to adult video-EEG monitorization unit together with their hospital attendants for video-EEG monitorization. The objective here is to simultaneously record the video images of the attack and the EEG. Here, the electrodes are placed onto the head with a material called collodion, which ensures firm adhesion to the head. Continuous EEG image is recorded while the patient carries out his/her normal daily activities in front of a video camera. The test is needed when the area of the brain which constitutes the source of seizure should be determined,

Collodion sticker is cleaned by the nurse following the screening with acetone. Patients are advised to bring a cream shampoo with them. In addition to that, women are adviced to come for inpatient treatment with pajamas instead of a bedgown.

To conduct video-EEG monitorization with intracranial electrodes, video-EEG monitorization with electrodes sticked on scalp must have been carried out and the situation of the patient must have been discussed at the epilepsy surgery meeting. Electrodes are placed in the head with an operation. Through the recording of crisis via video-EEG monitorization, the exact part of the brain causing the damage is tried to be detected. In addition to that, by means of stimulation works, the relationship between speaking and motor fields and the epileptogenic fields is analysed.

EEG screening during the operation as well as EEG screening during WADA test can also be carried out in our hospital. These tests are applied to the patients selected by the physicians responsible from the Unit.

How to arrange an appointment? When are the results received?
Appointments are generally daily arranged for routine outpatient EEGs. For EEGs with sleep deprivation, it is generally possible to arrange an appointment for the next day. For long digital outpatient EEGs, an appointment for screening might be arranged within a few days. For inpatient treatment at the monitorization unit, the doctor must first examine the patient and include the patient in the waiting list for inpatient treatment. Inpatient treatment might take 6-8 weeks to commence.

The day after the screening, the reports are given to the patient in the afternoon. Monitorization reports are finalized within 1-2 weeks after the patient's discharge.

 

What is ENMG?
EMG (Electromyography) is a method of investigation in which the electrical features of muscles, nerves and nerve roots are analysed and their health status is examined.

How is ENMG conducted?
EMG investigation consists of two parts: 1) Measurement of the conduction of nerves, 2) Examination of muscles. One or both of these methods might be applied based on the projected diagnosis. The measurement of nerve conductions is carried out by the doctor or a technician assigned by the doctor, whereas the muscles are only analysed by the doctor. The duration of the investigation ranges between 15 minutes and 1,5 hours based on the planned transaction.

Measurement of nerve conduction: Some nerves in the arm, thigh or other part of the body selected by the doctor are stimulated by means of an electrode placed on the skin. Though the applied electric flow is high-voltage (around 100 watt), it is applied for less than one thousandth of a second and causes no harm. It creates an uncomfortable feeling at the point where it is applied, but this is generally not felt as a pain. The electrical activity generated on the nerve through this stimulator radiates throughout the nerve.The activity on the nerve is recorded by means of a separate electrode. With the help of this recording, the pace of conduction of the nerve and the duration of the reaction created by the stimulator are measured. In one ENMG investigation, around 5-10 nerves are measured in this way.

Examination of the muscles: An electrode with the shape of a needle is placed on a muscle on the arm, thigh or another part of the body and then the electrical activity in the muscle is examined. The electrode usedlooks like injection needles in terms of its size and look. These electrodes are for single use and a new needle is used for each patient, the needle is then discharged (In some single fiber ENMGs, electrodes are not for single use and might be re-used after sterilization). The pain felt during the placement of electrode needle onto the muscle is similar to the pain felt during the injection of medicine into the muscle; however, since no medicine injection is carried out during ENMG, the pain is much weaker. The examination of each single muscle takes about a few minutes. During this time, the needle is kept within the muscle. The direction and position of the needle might be changed a few times in order to obtain records from different parts of the muscle. These transaction generally cause no pain or creates a reasonable pain at an endurable level. The number of muscles to be analysed during an ENMG differs in accordance with the projected diagnosis; 1-10 muscles are analysed generally.

Evoked Potentials: These are the methods developed to analyse the motor and sensual conduction lines in the central neural system. Visual Evoked Potentials (VEP) is used for the analysis of visual line; Somatosensory Evoked Potentials (SEP) is used for the analysis of sensual lines in the spinal cord and the brain; Brainstem Auditory Evoked Potentials (BAEP) is used for the analysis of auditory lines in the brainstem.
Motor evoked potentials is a method used to analyse the motor lines beginning from the brain and reaching to the muscles. It is carried out by means of transcordial magnetic stimulation, which is painless and harmless. In addition to this, by means of this method, a lot of research and examination might be carried out on the working physiology of brain cortex.

Intraoperative neuromonitoring: These are the electrophysiological transactions carried out during the operations about the neural system by using the appropriate and necessary techniques out of all the techniques used at ENMG unit in order to minimize or prevent any damage to the neural system.

What kind of preparation is needed before the ENMG investigation?
You don't need to be hungry before the investigation. The arms must be opened up to the elbow and the legs must be opened up to the knee during the investigation. Sometimes, you may be requested to take off all of your clothes except for your underwear. Therefore, it is advised that you come to the investigation with loose clothes which are easy to take off. You shouldn't put on any cream on your skin since the ekectrical conductivity of your skin is important. Also, your skin must be free of dust, oil and dirt. For similar reasons, you will be required to remove any dressing or bondage on the relevant parts of your body during the investigation. In some cases, the transactions of the patient before you may last longer than expected, then you may have to wait for about half an hour longer than your appointment time. Since the investigation also lasts for about an hour, you are advised to plan to spend about 1,5 hour at the ENMG laboratory.

Movement disorders cover a wide range of illnesses from slow to unintentional movements resulting from the disorder seen in the systems in the brain controlling the movements. The most common of these disorders is the Parkinson disease, which consists of slow motions and tremor. The most common disease resulting from unintentional movements is the familial tremor disorder called benign tremor disroder (essential tremor), which is generally observed at the elderly. Disorders characterized by unintentional contractions affecting different parts of the body are defined as dystonia, korea, athetosis and myoclonus and there are different treatment methods for each of these disorders. Tic disorders, whose features are different, are analysed in cooperation with the department of Psychiatry in addition to this specialized sub-branch of Neurology due to the behavioral change. In addition to this, balance and coordination problems resulting from cerebellum disorders and named as "ataxia" are classified within the category of movement disorders. Our unit serves as a reference center for the diagnosis and treatment of all the above-mentioned movement disorders as well as those which are observed less. For some of these disorders which are familial, the recognized and known genetic causes are analysed. In some cases, detailed electrophysiological diagnostic analyses are carried out by means of special methods. Unintentional contractions in the face, neck, arms and thighs known as dytonia and similar hemifacial spasms are treated directly via Botulismus toxin injections or with EMG. Also, in some cases where no response to medical treatment is obtained, special functional surgical treatment approaches are used in cooperation with the Department of Neurology.

Neumuscular disorders cover the illnesses of muscles, nerves controlling the movements of the muscles and the points where these nerve stem from in the spinal cord. The most common muscle disorders among these are the "muscular dystrophia"; myasthenia and ALS (amyotrophic lateral sclerosis or motor neural disorders). Our department conducts studies with regard to diagnosis and treatment of these disorders. Muscle and nerve biopsies required for the diagnosis of some of these disorders can be carried out at the "Neuromuscular Disorders Laboratory" at our department. This laboratory is one of the two grand laboratories under the department of neurology in our country. Muscle and nerve biopsies are carried out by the specialized academic personnel; the results are then processed at the laboratory and examined again by the same staff.

Things you should know about muscle biopsy
You need to arrange an appointment with the relevant academic personnel for muscle biopsy. You need to bring the document including detailed information on your illness as well as your EMG report when you come to arrange an appointment. You will also need to bring a box of sticking plaster when you come for the biopsy on the date and hour allocated for you. You DON'T need to be hungry for the biopsy.

• • Muscle biopsies are generally conducted on the left arm; and less frequently, on the left thigh.

• • During the operation, by means of a cut of 4 cm, a part of the muscle is taken out from the arm or the thigh. Since the cut is very small, it does not cause incapability.

• • Muscle biopsy is carried out after the point of cut is locally anesthetized. If you have had any allergic reaction to local anaesthesia before, please inform your doctor.

• • Since bleeding might occur during the operation, you need to inform your doctor if you take any medication (such as aspirin or coumadin) that prevents blood clogging.

The point of cut is stitched up after the part of muscle is taken out. The stitches under the skin will be absorbed by itself. One single stitch is placed upon the skin, which is removed a week later. The biopsy lasts 30 minutes. You need to rest your arm or thigh where the biopsy is conducted on the day of the operation. You may go back to your normal activities on the following day. You need to keep the point of cut dry until the stitch is removed. There is no need for medical dressing. The stitch will be removed by our unit a week later. The result of the biopsy is given on the same day.

Things you should know about nerve biopsy
You need to arrange an appointment with the relevant academic personnel for nerve biopsy. You need to bring the document including detailed information on your illness as well as your EMG report when you come to arrange an appointment. You will also need to bring a box of sticking plaster when you come for the biopsy on the date and hour allocated for you. You DON'T need to be hungry for the biopsy.

• • Nerve biopsies are conducted on the left thigh, which must be shaved up to the knee on the day of the operation.

• • A part of the nerve is taken out through a cut of 4 cm on the thigh. The nerve taken out is a completely sensual nerve, which means it carries sense from the skin and does not reach the muscles. Therefore, it is easy to take it out.

• • Nervebiopsy is carried out after the point of cut is locally anesthetized. If you have had any allergic reaction to local anaesthesia before, please inform your doctor.

• • Since bleeding might occur during the operation, you need to inform your doctor if you take any medication (such as aspirin or coumadin) that prevents blood clogging.

• • The point of cut is stitched up after the part of nerve is taken out. The stitches under the skin will be absorbed by itself. One single stitch is placed upon the skin, which is removed 10 days later. The biopsy lasts 30-40 minutes. You need to rest your thigh where the biopsy is conducted on the day of the operation. You may go back to your normal activities on the following day. You need to keep the point of cut dry until the stitch is removed. There is no need for medical dressing. The stitch will be removed by our unit a week later. The result of the biopsy is given on the same day.

Following the biopsy, hypokinesia at the back of your foot including the ankle as well as a sense of pricking or pain at the field of biopsy lasting for about a week, and in some rare cases for about a year, might be experienced.

What is multiple sclerosis?
Multiple sclerosis is a disease occurring in the central neural system consisting of brain and spinal cord. This disease results from the damage to the tissue called "myelin" which covers the nerves and functions as a case. Though the cause of the disease is not known, it is considered that the immune system in the body causes the disorder.

What are the symptoms?
The symptoms vary according to the affected point of the neural system; which is why different symptoms might be observed in different people. Weakness, formication, balance problems, visual disorders, speech disorders, lack of strength are among the most common symptoms.

How should the treatment and its follow-up be?
Though there s no known treatment for the disease, new treatments which lessens the frequency and seriousness of the crises and slows down the increase of impairment are discovered. In addition to these treatments, there are also other treatments which amends the symptoms of the patients (for instance; muscle stiffness, fatigue, bladder and intestine problems, pain). In addition to all these treatments, the rehabilitation of the patient requires a team consisting of doctors specialized on multiple sclerosis. Multiple Sclerosis Unit at Department of Neurology of Hacettepe University Adult Hospital is composed of an experienced group of experts specialized on the diagnosis, regular follow-up and treatment of patients with multiple sclerosis.

What is Neuro-Ophtalmology, which diseases does it deal with?
Neuro-Ophtalmology is a branch of science dealing with the common disorders of ocular and neural systems. The visibility of a substance is possible through the perception of the image in the eye and then in the visual cortex located at the back of the brain. When there is a problem in these optic tracts, the symptoms might occur suddenly and as an advanced visual loss. The fundamental symptom in diseases about eye movements is diplopia (double vision) and the problem might be about the ciliary muscle, nerves or about the control center at the brain. Patients with complaints including temporary visual loss or diplopia, hallucination, eyelid ptosis, difference in the size of eyeballs are also dealth with at the Neuro-Ophtalmology Unit.

Where should the patients with such compaints apply?
Patients with such complaints may directly apply to the Department of Neurology Unit of Neuro-Ophtalmology or may also apply to ophtalmic optician. They may then be transferred to the unit of Neuro-Ophtalmology after the causes regarding the eyes are distinguished. The Neuro-Ophtalmology Unit provides an appointment-based outpatient clinic service for one day in a week at Hacettepe University Adult Hospital A Floor, the Neurology Polyclinic with one research assistant from the Departments of Neurology and Eye Diseases as well as with 3 experts coming to the hospital from other hospitals for training. Patients are also accepted on other days of the week through appointment.

The loss of motor, sensual, cognitive or other functions resulting from atherosclerosis in the brain or cerebral hemorrhage is called "stroke". This is an advance unit where "all types of" stroke cases are diagnosed and treated on an inpatient or outpatient clinic level. The Stroke unit where the inpatient follow-up and treatment of patients are carried out under the guidance of the academic personnel provide service between 13:30 and 17:00 on Fridays.

The Neuro-Intensive Care Unit within the Department of Neurology offers "intensive care service" at the highest levels in terms of personnel and technology for long years. The unit especially provides special service for the cases including acute stroke; subarachnoid bleeding; vasospasm; extubation, encephalitis and mechanic ventilation for neuromuscular respiratory insufficiency.

It is an advanced ultrasonography laboratory where all routine and research tests of ultrasound can be conducted. Ultrasound studies for stenosis in neck and brain vessels, holes and spaces in the heart, Parkinson’s disease and functions of cerebral (brain) vessels are directly conducted by academic staff. Patients are admitted to the laboratory from external centers and outpatient clinics “only” between 13:30-17:00 on Mondays.