The Role of Neurologists in Pain Management – Based on the Survey Conducted by the Korean Neurological Association in 2020

Background@#Pain is one of the most common chief complaints in neurological field. Authors try to inform the current situation of pain medicine in neurological practice and present an effective method for pain-related education during neurology residency and for practicing neurologists. @*Methods@#A survey was conducted from November 16 to November 27, 2020 for members of the Korean Neurological Association, and the results were analyzed. @*Results@#About two-thirds of neurologists replied that more than 25% of their patients were suffered from diverse pain including headache, spine pain or neuropathic pain. Despite many patients are visiting to neurologist for pain treatment, most neurologists are aware that they have not received sufficient practical pain education in the past and present. Therefore, they want more educational opportunities in pain medicine including interventional pain management and physical and pharmacologic therapies for more effective treatment. @*Conclusions@#More follow-up studies on pain treatment and education should be conducted. It is also essential that the members of the society continue to interest and participate in the change of the pain education program.

The Role of Neurologists in Pain Management – Based on the Survey Conducted by the Korean Neurological Association in 2020

Background@#Pain is one of the most common chief complaints in neurological field. Authors try to inform the current situation of pain medicine in neurological practice and present an effective method for pain-related education during neurology residency and for practicing neurologists. @*Methods@#A survey was conducted from November 16 to November 27, 2020 for members of the Korean Neurological Association, and the results were analyzed. @*Results@#About two-thirds of neurologists replied that more than 25% of their patients were suffered from diverse pain including headache, spine pain or neuropathic pain. Despite many patients are visiting to neurologist for pain treatment, most neurologists are aware that they have not received sufficient practical pain education in the past and present. Therefore, they want more educational opportunities in pain medicine including interventional pain management and physical and pharmacologic therapies for more effective treatment. @*Conclusions@#More follow-up studies on pain treatment and education should be conducted. It is also essential that the members of the society continue to interest and participate in the change of the pain education program.

Chronic Inflammatory Demyelinating Polyneuropathy Combined With Limited Cutaneous Systemic Sclerosis

Chronic inflammatory demyelinating polyneuropathy (CIDP) has been rarely reported in systemic sclerosis (SSc). We describe the clinical, electrophysiological, and pathologic findings in a 73-year-old female with established limited cutaneous SSc who later developed CIDP. The patient had progressive limb weakness, sensory loss, and slow nerve conduction velocities. Sural nerve biopsy showed evidence of demyelination and remyelination. This case demonstrates that chronic demyelinating polyneuropathy can be an unusual manifestation of SSc, presumably resulting from an immune-mediated process.

A Case of Tuberculous Cerebellitis Detected by MRI Presenting Typical Meningitis

No abstract available.

Fibromyalgia Syndrome

Fibromyalgia is a chronic pain syndrome of unknown etiology that is characterized by diffuse musculoskeletal pain, fatigue, sleep disturbance, memory disturbance, and exaggerated tenderness over particular paired locations. Fibromyalgia is found in 2% to 4% of the general population and more common in women, with symptoms usually appearing between 20 and 55 years of age. The diagnostic criteria for fibromyalgia syndrome established in 1990 by the American College of Rheumatology (ACR), includes widespread pain for at least 3 months and point tenderness upon the application of a 4 kg weight at 11 or more of the 18 characteristic tender points. The 2010 ACR preliminary diagnostic criteria have been developed, which are strongly correlated with the 1990 ACR criteria and provide an alternative approach to diagnosis. Patients with fibromyalgia syndrome have lower pain thresholds and experience an altered temporal summation to pain stimuli. The sensitization of pain perception occurs in the dorsal horn of patients with fibromyalgia. However, it is unknown whether sensitization is due to increased pain fiber facilitation, or decreased inhibition. Pregabalin is approved by the United States Food and Drug Administration for the management of fibromyalgia patients. Tricyclic antidepressants, cardiovascular exercise, cognitive behavioral therapy and patient education are also effective in reducing the pain experienced by fibromyalgia patients. This article provides an overview of fibromyalgia syndrome, which is currently thought to be partly responsible for chronic diffuse pain.

Acute Peripheral Neuropathy, as One of Early Manifestations in Crohn's Disease

Acute neuropathic complications rarely develop in patients with inflammatory bowel disease. A case of acute peripheral neuropathy that developed only 4 weeks after a diagnosis of Crohn's disease (CD) is reported herein. Peripheral neuropathy can be a rare extraintestinal manifestation of CD. Early recognition and proper management of the neurologic complications are crucial for preventing the associated morbidity.

A Case of Postural Orthostatic Tachycardia Syndrome Associated with Migraine and Fibromyalgia

Postural orthostatic tachycardia syndrome (POTS) refers to the presence of orthostatic intolerance with a heart rate (HR) increment of 30 beats per minute (bpm) or an absolute HR of 120 bpm or more. There are sporadic reports of the autonomic nervous system dysfunction in migraine and fibromyalgia. We report a case of POTS associated with migraine and fibromyalgia. The patient was managed with multidisciplinary therapies involving medication, education, and exercise which resulted in symptomatic improvement. We also review the literature on the association between POTS, migraine, and fibromyalgia.

Cervical Myelopathy Resulting From Non-Rheumatoid Atlantoaxial Subluxation

Degenerative pannus arising from the atlanto-axial articulation is a rare entity, which is associated with chronic atlanto-axial instability in degenerative arthropathies. Due to cervical instability and the mass effect on the spinal cord, it can produce severe neck pain and compressive myelopathy. We report a case of cervical myelopathy resulting from non-rheumatoid atlanto-axial subluxation. The posterior stabilization provided excellent neurological improvement and pannus regression. Early recognition of this condition is important as the clinical condition will deteriorate without surgical interventions.

Moraxella Meningoencephalitis: Case Report and Review of the Literature

Moraxella is an aerobic, Gram-negative coccobacillus, which is rarely associated with serious and invasive infections. Because of its rarity, the clinical significance and appropriate therapy for infections due to Moraxella are not well understood. We report a case of meningoencephalitis caused by Moraxella. The patient presented with fever and confusion and was successfully treated with beta-lactam and aminoglycoside antibiotics. We also review 8 previously published cases of Moraxella meningitis or meningoencephalitis.

Piriformis Syndrome Following Transarterial Embolization of Bilateral Uterine Arteriovenous Malformation

Piriformis syndrome is a rare entrapment neuropathy in which the sciatic nerve is compromised by the piriformis muscle or other local structures. We report a case of sciatic and gluteal nerve lesions with infarction of the piriformis muscle following internal iliac artery embolization of the bilateral uterine vascular malformation. The surgical intervention revealed anatomical variation of the right sciatic nerve. To our knowledge, this is the first case of piriformis syndrome following endovascular treatment of uterine vascular malformation in Korea.

Platelet Function Assay for Clopidogrel and Ticlopidine in Patients With Ischemic Stroke

BACKGROUND: The rapid platelet function assay (RPFA) has recently been developed and used to monitor the antiplatelet effects on the P2Y12 ADP receptor. We describe the platelet response to clopidogrel and ticlopidine using the RPFA and identify the clinical factor related to laboratory resistance in patients with ischemic stroke. METHODS: Of the 172 outpatients with ischemic stroke or transient ischemic attack (TIA) enrolled in this study, 86 were taking clopidogrel (75 mg/day) and 86 were taking ticlopidine (500 mg/day). Demographic data, vascular risk factors, stroke subtypes, and the results of blood tests were recorded. Inhibition is described as the percentage change from baseline aggregation, and is calculated from the P2Y12 reaction unit (PRU) and the base PRU on the RPFA. Those patients who displayed ineffective aggregation-inhibition (inhibition <20%) on the RPFA were defined as nonresponders. RESULTS: The response of platelet aggregation-inhibition to clopidogrel and ticlopidine exhibited a variable distribution (PRU; coefficient of variability, 0.477). Ineffective platelet inhibition was detected in 25.6% of the clopidogrel group and 3.5% of the ticlopidine group (p<0.001). In addition to clopidogrel, TIA and diabetes exhibited significantly higher ineffective platelet inhibition in a univariate analysis. In the multivariate analysis, clopidogrel and TIA remained significant, and diabetes fell to borderline significance (p=0.061). CONCLUSIONS: The response to clopidogrel and ticlopidine can vary between patients. Platelet inhibition is lower for clopidogrel than for ticlopidine on the platelet function test in patients with ischemic stroke. The clinical impact of these results remains uncertain; further investigations are needed.

Pneumocephalus in Patients With Orthostatic Headache

Cerebrospinal fluid (CSF) leak or shunt overdrainage is a well-known cause of orthostatic headaches and low CSF pressures. We report two cases of orthostatic headache with pneumocephalus on brain imaging. The orthostatic headache developed after drainage of spinal operation site and epidural block. Brain MRI revealed characteristic findings of CSF hypovolemia including pachymeningeal enhancement and mild subdural fluid collections. Air was also observed in the ventricular or subarachnoid space in both patients, which might enter the subarachnoid or ventricular space during a procedure via the pressure gradient or an injection.

A Case of Apogeotropic Positional Nystagmus Associated With Anti-GD1b IgG Antibody

The binding of anti-GD1b IgG antibody to the cerebellar granular area or spinocerebellar Ia fibers in the peripheral nerves may cause the prominent cerebellar ataxia, mild quadriparesis and sensory dominant neuropathy. A 31-year woman presented with severe cerebellar ataxia and prominent apogeotropic positional nystagmus/vertigo. Increased anti-GD1b antibody IgG in her serum was noted. 18F-flurodeoxyglucose positron emission tomography (FDG-PET) showed decreased uptake in cerebellum. It is the first case of central positional nystagmus with anti-GD1b IgG antibody.

Diffusion-Weighted MRI in Recurrent Wernicke's Encephalopathy: a Remarkable Cerebellar Lesion

We report unusual MRI findings (including those from diffusion-weighted imaging (DWI)) in a patient with recurrent Wernicke's encephalopathy with a remarkable cerebellar lesion. DWI showed high signal intensities in the superior portion of the cerebellar hemisphere and vermis area. After thiamine administration, clinical symptoms improved and the lesions with high signal intensities disappeared on follow-up DWI.

Representational Neglect in Left Anterior Cerebral Artery Infarction

We report a patient with a left anterior cerebral artery (ACA) infarct showing representational neglect. Representational neglect is some form of neglect to areas of imagined space. We believe that the description of our case gives further information about neglect syndrome and the functional asymmetry of the cerebral hemispheres because these observations are rare.

A Case mimicking Neuroleptic Malignant Syndrome associated with Levodopa Withdrawal in Parkinson's Disease

No abstract available.

A Case of Pseudotumor Cerebri Associated with Aplastic Anemia

A 39-year-old woman with aplastic anemia suffered from progressive visual disturbance and headache. Funduscopic examination revealed pronounced bilateral papilledema. Lumbar puncture disclosed an elevated opening CSF pressure with normal biochemical and cellular findings. Brain MRI was normal. After transfusion of blood products, papilledema and her symptoms were improved. We conclude that the development of pseudotumor cerebri is related to aplastic anemia resulting from bone marrow failure.

A Case of Hypothyroid Myopathy due to Hashimoto's Thyroiditis

A 59-year-old man was admitted because of progressive proximal muscle weakness over 4 months. Serum creatine kinase was markedly increased and electromyography revealed myopathic pattern. Muscle biopsy showed nonspecific myopathic changes. No inflammatory change was shown. Thyroid function tests revealed very low thyroxine and low triiodo-L-thyronine, whereas thyroid-stimulating hormone was greatly increased as well as serum anti-thyroglobulin and microsome antibodies. The patient had hypothyroid myopathy due to Hashimoto's thyroiditis, which improved with L-thyroxine replacement.

Clinical Manifestations of Intracranial Complication Associated With Paranasal Sinus Infection

BACKGROUND: Intracranial complications of paranasal sinus infection are rare and may be misdiagnosed during an initial evaluation because they often show subtle symptoms, which include elusive physical and neurological findings and imaging. The late recognition of these conditions and the delayed treatment can increase morbidity and mortality rates. We aimed to characterize the typical clinical features of intracranial complications associated with sinusitis. METHODS: Twelve patients who visited the Eulji Medical Center from 1994 to 2000, with sinogenic suppurative intracranial lesions were reviewed. Medical records and radiological studies were reviewed retrospectively. RESULTS: There were 12 cases with 15 sinogenic intracranial complications. The ratio of males to female was 2 : 1. The ages of patients ranged from 16 to 81 (average: 46.7). Four cases had meningitis, four had focal cerebritis, three had cavernous sinus throm-bophlebitis, two had subdural empyema, and two had epidural abscess or empyema. The primary lesions of paranasal sinusitis were located at the sphenoid in three, ethmoid sinus in two, frontal sinus in one and the multiple sinus in six. The outcome revealed complete recovery in six cases, mild neurologic sequelae in three cases, death in two cases and recurrence in one case. CONCLUSIONS: The type of intracranial complication and origin of paranasal sinusitis may be changing. Cases in which such complications are suspected, in order for an early diagnosis, a MRI should be considered. The successful management of intracranial complications consists of timely antibiotics therapy combined with surgical drainage of the loculated infection. (J Korean Neurol Assoc 19(5):457~463, 2001)

Binswanger's Disease Associated with Alzheimer's Pathology: An Autopsy Case

Binswanger's disease (BD) is an illness of hypertensive elderly patients characterised clinically by disorders of memory, mood and cognition; focal motor signs; and less often, a pseudobulbar syndrome with deterioration of gait and sphincter control. The illness is usually slowly progressive. The important pathological features of BD are widespread degeneration in the deep white matter with diffuse, patchy axonal and myelin loss, and gliosis. The more diffuse lesions in the centrum semiovale have been related to myelin rarefaction that spares the U-fibers. The MRI appearance of BD is multiple confluent white matter lesions of various sizes, many of which are quite small and concentrated around the basal ganglia and periventricular areas. We report an autopsy case of Binswanger's disease associated with Alzheimer's pathology.