Correlation between Clinicoradiological Findings and Prognosis in Paramedian Pontine Infarction

BACKGROUND: To clarify the clinicoradiological correlation and prognosis of acute ischemic stroke involving para-median territory of pons. METHODS: We studied 37 patients with first-ever ischemic stroke involving paramedian terri-tory of pons and divided them based on the shape and level of lesion shown in their MRI. The clinical features, MRI findings, and prognosis were assessed. RESULTS: The paramedian infarctions extending to the basal surface were found in 28 patients (76%), and small infarctions separated from the basal surface were found in 9 patients (24%). In patients with infarction extending to the basal surface, 23 patients (82%) had progressive or fluctuating onset, whereas all patients with small infarction separated from the basal surface had non-progressive onset. In the group with upper pon-tine lesion (14 patients), dysarthria-clumsy hand syndrome was found in 4 patients, ataxic hemiparesis (AH) in 3, pure motor hemiparesis (PMH) in 2, and pure sensory stroke in 1. In the group with middle and lower pontine lesion (22 patients), PMH was found in 9, AH in 3, and sensory motor stroke in 2. The mean Modified Rankin Disability Scale scores on admission and after follow-up (mean 29 months) of the group with upper pontine lesion were 2.36 +/-0.50 and 1 . 0 0 +/-0.55, those with mid-lower pontine lesions, 3.48 +/-0.51 and 1.17 +/-0.49 (P0.05 respectively). CONCLUSIONS: Paramedian pontine infarction extending to the basal surface usually presents with progressive onset. Paramedian pontine infarction most often produces classic lacune syndrome of which PMH is the most common. In our study, patients with mid-lower paramedian pontine infarction had more severe initial neurological deficits than those with upper paramedian pontine infarction. However, a late outcome was found to be favorable in both groups.

A Pilot Study on Total Plasma Homocysteine Level of Patients with Cerebral Infarction

BACKGROUND: Hyperhomocysteinemia has been known to be associated with cerebrovascular disease. It is toxic to vascular endothelial cell and promotes arteriosclerotic detachment. There was no study of the homocysteine level in ischemic stroke patients in Korea except case report. Therefore we measured total plasma homocysteine level in ischemic stroke patients and evaluated association with other stroke risk factors. METHODS: We measured total plasma homocysteine level in 44 patients with ischemic stroke and 16 age-matched normal controls, and analyzed its relationship to other stroke risk factors. Total plasma homocysteine level was determined by using a radioenzymatic method. RESULTS: Total plasma homocysteine level was 12.12 5.11 micromol/L in patients and 9.40 1.93 micromol/L in controls. It was 13.03 5.78 micromol/L in lacunar infarction and 9.96 1.57 micromol/L in territory infarction. The total plasma homocysteine level of the patients with hypertension, DM, hyperlipidemia, heart disease, smoking, alcohol, previous stroke, carotid bruit was not different statistically from those without them. CONCLUSIONS: Total plasma homocysteine level was significantly higher in the ischemic stroke patients than that of controls. Lacunar infarction showed significantly higher level of total plasma homocysteine compared to territory infarction.

Three Cases of Work-Related Suprascapular Entrapment Neuropathy / 대한산업의학회지

OBJECTIVES: Entrapment of the suprascapular nerve is frequently overlooked in the differential diagnosis of shoulder pain. METHODS: Suprascapular entrapment neuropathy is a well-defined clinical entity and EMG and NCV is used to confirm a diagnosis. But the diagnosis is typically not considered until patients develop severe weakness secondary to atrophy of the spinous musculature that the nerve supplies. RESULTS: A narrow suprascapular notch has rarely been reported as a work-related factor of this entrapment neuropathy. Diagnosis of suprascapular entrapment neuropathy is based on the patients' clinical course, neurologic, radiologic, and electrophysiologic findings. One of the most helpful evaluations was the anteriorposterior projection with the X-ray tube angled 15-30 degree caudally. The suprascapular entrapment neuropathy is relatively uncommon entity of shoulder discomfort (pain, weakness, and atrophy). CONCLUSIONS: If the worker who used his shoulder joint repetitiously having the shoulder pain and muscle weakness, we must rule out the suprascapular entrapment neuropathy. And it is needed to evaluate the motions which cause suprascapular entrapment neuropathy as the ergonomic factor.

A Case of Marchiafava-Bignami Disease with Reversible Brain MRI Findings of Corpus Callosal Lesions

Marchiafava-Bignami disease(MBD), characterized by the primary degeneration of the corpus callosum, is a rare complication of chronic alcoholism. Recently, a few cases of MBD with reversible neuro-imaging abnormalities were reported. A 58-year-old, chronic alcoholic man was admitted with mental change, dysarthria, and a seizure attack. A T2-weighted Brain magnetic resonance imaging demonstrated high signal intensities in the body and splenium of the corpus callosum, multiple white matter, and cortical gray matter. Treatment with a multiple vitamin complex resulted in a near complete recovery of neurological manifestation. A brain MRI obtained four weeks after admission revealed a dramatic resolution of previous imaging abnormalities. We report a case of Marchiafava-Bignami disease with reversible neuro-imaging abnormalities.

Cheiro-oral Syndrome with INO following Brainstem Infarction

Brainstem lesions may produce a cheiro-oral syndrome infrequently. The cheiro-oral syndrome in pontine lesion is due to involvement of ventral trigeminothalamic tract and the medial part of the medial lemniscus. The cheiro-oral syndrome rarely associates with internuclear ophthalmoplegia. A 58-year-old hypertensive man complained of dizziness, diplopia, and dysesthesia in the right hand and ipsilateral perioral region. On neurologic examination, there was left internuclear ophthalmoplegia. Others were unremarkable. Brain MRI demonstrated a small round lesion in the paramedian tegmentum of the left upper pons and lower midbrain, which involved ventral trigeminothalamic tract, medial part of medial lemniscus and medial longitudinal fasciculus. We report a case of brainstem infarction with a rare combination of cheiro-oral syndrome and internuclear ophthalmoplegia.

A Case of Pupil-Sparing Oculomotor Nerve Palsy due to Midbrain Infarction in Diabetic Patient

BACKGROUND: In general, vasculopathic oculomotor nerve palsy with pupil-sparing implied a lesion in the subarachnoid space or the cavernous sinus; however, it has been reported that similar findings can be produced by fascicular lesion. CASE: A 48-year-old woman with diabetes mellitus complained of diplopia and right ptosis. Examination revealed a complete oculomotor nerve palsy of the right eye with sparing of the pupil. The MRI revealed a infarction in the fascicular portion of the oculomotor nerve. CONCLUSION: It is emphasized that the intraaxial lesion should be ruled out using the sophisticated study in patients with pupil-sparing vasculopathic oculomotor nerve palsy.

Silent Brain Infarcts in First-ever Ischemic Stroke Patients: MRI Findings and Stroke Risk Factors

BACKGROUND AND OBJECTS: It is common to find cerebral infarction without a history of stroke on neuroimaging. This study was to determine the frequency, MRI characteristics of these lesions, and the risk factors related with silent brain infarcts in patients with first-ever ischemic stroke. METHOD: Sixty seven patients with acute ischemic stroke, who hospitalized in our hospital from April 1992 to May 1994, were reviewed. Brain MRI was performed in all patients. We evaluated frequency, site, size, and anatomic location of silent infarcts and compared the risk factors of the patients with silent infarcts with that of the ones without silent infarcts. RESULTS AND CONCLUSIONS: The prevalence of silent infarct was 58.2% ( (39/67). The predilection sites were in the right hemisphere and subcortical area (basal ganglia, thalamus), and their sizes were less than 1 cm mostly. The significant risk factor of silent infarcts was hypertension(P<0.01), and the other risk factors, such as age, sex, DM, and EKG abnormality, were not remarkable.

A Case of Partial Seizure Following Enfluran Anesthesia

Although clectroencephalographic and clinical evidence of seizure activities during enfluran anesthesia have been documented in man, the incidence of post operative electro clinical partial seizure activity following enfluran anesthesia is rare phenomenon. We report a patient who developed post operative partial seizure with secondary generalized tonic clonic seizure that may have been related to the administration of enfluran.

Cerebral Thromboangiitis Obliterans: Report of 3 cases

Thromboangiitis obliterans (Buerger's disease) is an inflammatory, thromboccluisive vasclar disease that usually involves small and medium sized arteries and veins of the distal extremities of young male smokers. Involvement of cerebral blood vessels in Buerger's disease is rare, but clinical and Pathological demonstration has ionally been found. We describe three patients with cerebral infarction who had amputated their distal extremities due to thromboangiitis obliterans. - they had . No clinical, laboratory, a,ngiographic evidence of vasculitis, source of emboli, and atherosclerotic risk factors except heavy smoking.

Effect of Snake Venom: Arginine-esterase on the Fibrinolytic Activity

BACKGROUND AND PURPOSE: Arginine esterase(Ancrod), a thrombin-like enzyme, purified from the venoms of Agkistrodon halys, has known to cleave fibrinopeptide A from the fibrinogen and lead to circulation of soluble noncross-linked "ancrodfibrin', which stimulates endogenous T-PA release.Many authors have suggested clinical applicability of this enzyme,but clinical studies on its fibrinolytic action has been insufficient.Thus we studied the influence of this enzyme on fibrinolytic activity in cerebral infarction. METHOD: We observed the change of euglobulin fibrinolytic activity, t-PA antigen, t-PA activity, fibrinopeptide A, fibrinogen, FDP and D-dimer, during 12 hours after a bolus intravenous administration of 0.25 unit of the arginine esterase to the 9 patients with cerebral infarction. RESULT:There was no change of the euglobulin fibrinolytic activity, fibrinopeptide A and t-PA Ag but there was significant increase in both t-PA activity and FDP, D-dimer and significant decrease in fibrinogen. CONCLUSION: Our result suggest that arginine esterase converts fibrinogen to a fibrin polymer which has a increased susceptibility to lysis by plasmirl This enzyme seems to amplify T-PA activity through the consequent increase in FT)P, because there is no increase in the euglobulin fibrinolytic activity, fibr'mopeptide A and t-PA Ag suggesting direct T-PA release. Arginine esterase, having action of effective defibrinogenation and safe fibrinolysis,could be used for the thrombus related disease.

Magnetic Resonance Angiography: Its Role in Early Thrombolytic Theraphy: Preliminary study

In early thrombolytic therapy for acute focal ischemic stroke, the start of treatment within therapeutic time window is one of the most important thing. Recently, new imaging modalities such as SPECT, transcranial doppler, diffusion/ perfusion-weighted MRI, and MR anglography have been implicated to avoid time consumption and delayed therapy. Of these, MR angiography is nomnvasi and rapid technique to visualize large and medium-sized arteries. We explored the usefulness of MR angiography in early thrombolytic therapy. Arterial occlusion of three patients with severe ischemic stroke were demonstrated on MR anglography and wluch were treated with Urokmase (10, 000-20, 000 units/kg) by intravenous infusion within 2-4 hours after symptom onset. Recanalization and brain lesion was assessed by repeated MR angiography and MRI or CT 24 hours later. Clinical improvement was observed in two patients 5-24 hours after initiation of treatment. In one patient hemorrhagic infarction without clinical deterioration was detected by follow-up computed tomography. Recanalization was documented on repeated MR angiography of three patients. MR angiography can document occlusion of stroke-related vasculature without delay of thrombolytic therapy and repeated MR anglography can reveal whether recanalization has occurred.

Seasonal Variation of Fibrinolytic Activity

BACKGROUND AND PURPOSE: Among the many factors having influence on seasonal incidence of thrombotic disease, we studied the seasonal variation of fibrinolytic activity, which might be thought to have influence on seasonal incidence of thrombotic disease. SUBJECT AND METHOD: Seasonal plasma tissue type plasminogen activator (t-PA) and euglobulin fibrinolytic activity (EFA) were measured in 18 male and 22 female normal volunteers during a year. RESULT: The level of t-PA was higher in winter than in spring (p<0.05), but was not significantly different in the other couples of four seasons. The level of EFA was higher in winter than in summer and in autumn (p<0.01), and was slightly higher in winter than in spring without significance. The level of EFA was higher in spring than in summer (p<0.05). There was no correlation between the level of t-PA and that of EFA in any of the seasons. CONCLUSION: The fibrinolytic activity is higher at lower temperature than at higher temperature. Thus, it seems that a rise in fibrinolytic activity in cold weather counters certain changes which make a thrombotic event.