Delayed Migration of Tapered Open-Cell Design Carotid Stent: A Case Report / 신경중재치료의학

We present a case of delayed migration of an open-cell design carotid stent, which is a rare complication following carotid artery stenting (CAS). A 65-year-old patient with carotid artery stenosis underwent CAS with an open-cell stent, initially achieving successful deployment. However, 4 months later, the stent migrated and resulted in restenosis. The patient underwent balloon angioplasty and received an additional stent, leading to improved blood flow. The rarity of stent migration, particularly in the absence of risk factors, highlights the need for clinicians to be vigilant and consider early imaging follow-up for patients at risk of this complication after CAS.

Impact of Left Atrial or Left Atrial Appendage Thrombus on Stroke Outcome: A Matched Control Analysis / 대한뇌졸중학회지

Background@#and Purpose Left atrial or left atrial appendage (LA/LAA) thrombi are frequently observed during cardioembolic evaluation in patients with ischemic stroke. This study aimed to investigate stroke outcomes in patients with LA/LAA thrombus. @*Methods@#This retrospective study included patients admitted to a single tertiary center in Korea between January 2012 and December 2020. Patients with nonvalvular atrial fibrillation who underwent transesophageal echocardiography or multi-detector coronary computed tomography were included in the study. Poor outcome was defined as modified Rankin Scale score >3 at 90 days. The inverse probability of treatment weighting analysis was performed. @*Results@#Of the 631 patients included in this study, 68 (10.7%) had LA/LAA thrombi. Patients were likely to have a poor outcome when an LA/LAA thrombus was detected (42.6% vs. 17.4%, P<0.001). Inverse probability of treatment weighting analysis yielded a higher probability of poor outcomes in patients with LA/LAA thrombus than in those without LA/LAA thrombus (P<0.001). Patients with LA/LAA thrombus were more likely to have relevant arterial occlusion on angiography (36.3% vs. 22.4%, P=0.047) and a longer hospital stay (8 vs. 7 days, P<0.001) than those without LA/LAA thrombus. However, there was no difference in early neurological deterioration during hospitalization or major adverse cardiovascular events within 3 months between the two groups. @*Conclusions@#Patients with ischemic stroke who had an LA/LAA thrombus were at risk of a worse functional outcome after 3 months, which was associated with relevant arterial occlusion and prolonged hospital stay.

The Relationship of Methylenetetrahydrofolate Reductase(MTHFR) C677T, Thymidylate Synthase(TS) Gene Polymorphism and Epilepsy / 대한간질학회지

PURPOSE: Thymidylate synthase (TS) gene encodes a tightly regulated enzyme that catalyzes the conversion of deoxyuridylate to thymidylate, and contains a tandem repeat polymorphism, of which a triple repeat is associated with increased expression of TS. TS is a key enzyme in the folate metabolism and compete with methylenetetrahydrofolate reductase (MTHFR) for limiting supplies of folate required for the remethylation of homocysteine. We studied to clarify the association between MTHFR C677T and TS polymorphism and prognosis in epilepsy. METHODS: 119 patients with antiepileptic drug more than one year were included. We investigated the MTHFR C677T and TS polymorphism using PCR, and analyzed the association between plasma homocysteine, folate levels, clinical profiles (especially seizure frequencies) and polymorphism. RESULTS: In seizure frequencies during one year, TT type in MTHFR and 3R3R type in TS polymorphism had higher frequencies than any other types without statistical significance. In plasma homocysteine levels, TT type had significantly higher homocsyteine levels than any other types, but 3R3R type had higher homocsyteine levels than any other types without statistical significance. Combined analysis of MTHFR C677T and TS polymorphism revealed that plasma homocysteine levels (18.22+/-8.32 micromol/l; p=0.039) and seizure frequencies (6.38+/-7.35/year; p=0.04) in patients with TT/3R3R were significantly higher than any other groups. A significant correlation between plasma homocysteine levels and seizure frequencies also was shown in multivariate linear regression analysis (B=0.160, Std error=0.069, adjusted R2=0.039, p=0.021). CONCLUSION: Epileptic patients with hyperhomocysteinemia, especially when combined with mutant allele for MTHFR and TS genes, have higher seizure frequencies. Therefore, our results suggest that the genotyping for the MTHFR and TS polymorphism may become a useful indicator in determining prognosis of epilepsy.

A Case of Epilepsia Partialis Continua after Gamma Knife Radiosurgery / 대한간질학회지

The gamma knife radiosurgery (GKS) is a safe and effective neurosurgical approach in the treatment of arteriovenous malformation (AVM). Seizures after GKS are rarely reported, but epilepsia partialis continua (EPC) has not been reported yet. We report a patient with EPC accompanied with cerebral edema after GKS in AVM. A 50-year-old man was admitted for EPC, dysarthria and monoparesis 20 days after GKS due to AVM. Brain MRI showed increased cerebral edema around AVM in the left premotor area. Symptoms were relieved by IV dexamethasone and antiepileptic drugs (AEDs). 15 weeks later, EPC recurred and aphasia and right hemiplegia were rapidly aggravated. The follow up brain MRI showed markedly increased cerebral edema compared with previous MRI. EPC was well controlled by AEDs, but aphasia and hemiplegia were not responsive to IV dexamethasone until trying oral prednisolon. We think that cerebral edema induced by EPC, as a complication of GKR, might aggravate hemiparesis.

An Adolescent Ischemic Stroke Patient with Hyperhomocysteinemia, MTHFR 677TT and CBS 1080TT genotypes

Hyperhomocysteinemia is an independent risk factor for cerebrovascular disease. Hyperhomocysteinemia can be caused by the defect of the remethylation pathway including the 5, 10-methylenetetrahydrofolate reductase (MTHFR) gene or the transsulfuration pathway including the cystathionine beta-synthase (CBS) gene of homocysteine metabolism. The major cause of severe hyperhomocysteinemia is CBS gene mutation. A 16-year-old male was admitted with vertigo. Brain MRI showed right cerebellar infarction. The plasma homocysteine level was 175 mocro mol/L. According to a genetic evaluation, the patient had the MTHFR 677TT and CBS 1080TT genotypes.

Association between Migraine with Aura and both Homocysteine and MTHFR C677T Polymorphism

BACKGROUND: The pathophysiology of migraine is not yet fully understood. Homocysteine acts as an excitatory amino acid in vivo and may influence the threshold of migraine. The previous studies have revealed strong association between the homozygous C677T mutation in the methylenetetrahydrofolate reductase (MTHFR) gene and hyperhomocysteinemia. In this study, we examined the association between both homocysteine and MTHFR C677T polymorphism and headache, such as migraine and tension headache. METHODS: We enrolled 148 headache patients (75 tension headache, 34 migraine with aura [MWA], and 39 migraine without aura [MOA]) and 121 normal controls; checked their fasting homocysteine levels and analyzed for the MTHFR C677T polymorphism. For the multivariate analysis, we used logistic regression to adjust for age and sex. RESULTS: Plasma homocysteine levels were significantly higher in patients with MWA than those in controls (adjusted odds ratio (AOR), 1.12; 95% confidence intervals (CI), 1.02~1.23). The AOR and 95% CI of the MTHFR 677TT genotype was significantly higher in patients with total migraine (AOR, 3.32; 95% CI, 1.30~9.55; p< 0.05) and with MWA (AOR, 4.70; 95% CI, 1.44~15.29; p<0.01) than the controls. However, the AOR was not significant in patients with tension headache (AOR, 0.93; 95% CI, 0.37~2.32) and with MOA (AOR, 2.77; 95% CI, 0.78~9.74). CONCLUSIONS: Our findings suggest that both elevated homocysteine level and the homozygous C677T mutation in the MTHFR gene are associated with migraine with aura.

A Case of Acute Myelogenous Leukemia Presenting as Polyradiculomyelopathy and Peripheral Facial Paralysis

It is uncommon for acute myelogenous leukemia to present a symptom referrable to a tumor mass. A rare case of spinal epidural granulocytic sarcoma preceding the diagnosis of acute myelogenous leukemia is described. Also, reports of acute myelogenous leukemia associated with facial palsy have been extremely rare. We report a patient who had facial nerve paralysis and polyradiculomyelopathy due to granulocytic sarcoma as the presenting symptoms of acute myeloid leukemia.

Moyamoya Disease Initially Presenting Visual Field Defect

Progressive narrowing of distal carotid arteries and the development of compensatory fine networks are the characteristic findings of moyamoya disease. Cerebral infarction in moyamoya disease is due to a decreased blood flow and shows an uneven distribution in the distal bed of the anterior and middle cerebral arteries. The progression of disease in the posterior circulation follows that in the anterior circulation. Posterior circulation symptoms due to cerebral infarction usually occur in the advanced stage of the disease and follow the anterior circulation symptoms. We encountered an unusual case of moyamoya disease which initially presented with a transient visual field defect. One month later our patient developed blindness and her cerebral angiography showed advanced moyamoya disease.

Cerebral Infarction Associated with Marijuana

Whereas stroke that is associated with the use of various street drugs has been frequently noted, cerebral infarction related to marijuana has been rarely reported. We experienced a 36 year-old male who developed sudden onset of dizziness and gait disturbance after marijuana smoking. On admission, neurological examination revealed right cerebellar dysfunction with prominent falling tendency to right side during tandem gait. Brain MRI showed high signal intensity on T2-weighted image on right posterior inferior cerebellar arterial (PICA) territory suggesting acute infarction. He had no risk factors for stroke except tobacco smoking and denied the use of other street drugs. Serologic work-up for coagulopathy and cardiologic evaluation were unremarkable. On cerebral angiogram, narrowing of proximal part of left PICA and diffusely spastic arterial changes of whole posterior circulation were revealed. On the basis of the physiologic effect of marijuana, we could infer that the probable mechanism of the stroke was intracerebral vasoconstriction or hemodymic change.

Safety and Effect of Continuous Intravenous Urokinase Therapy in Acute Ischemic Stroke ( Open Clinical Trial )

BACKGROUND: Early thrombolysis with intra-arterial urokinase(UK) or intravenous(IV) t-PA may be beneficial for patients with acute ischemic stroke, but this therapy is unavailable in some circumstances and cannot be applied in the cases of late admission. Thus, continuous IV UK infusion has been applied empirically in many hospitals of our country. However, the therapeutic efficacy of this therapy is not known yet. In this study, we investigated the safety and the clinical effect of continuous IV UK infusion. METHOD: 68 patients with acute supratentorial ischemic stroke within 3 days of onset received 6 x 105units of UK daily by continuous infusion for 5 days without loading dose. We estimated European stroke scale (ESS) and Barthel index score (BIS) prior to therapy, on day 1, 3 and 7 after the start of UK, and on the day of discharge. RESULTS: The ESS and BIS were improved in most patients after the therapy. There are no differences in therapeutic effects among the various stroke subtypes and the starting times of therapy after onset. Out of 10 TIA patients, 9 patients did not undergo further TIA and only one patient had complete infarction during UK infusion. Complications were noted in 7(10.3%) patients. But these complications were all minimal. CONCLUSION: As this study was just an open clinical trial, we could not conclude about definite efficacy of continuous IV UK infusion in acute ischemic stroke. However, this therapy might be at least acceptable safe regimen and deserves to be performed in multicenter double-blind controlled trials to clarify the efficacy.

A Case of Myelopathy due to Spinal Dural Arteriovenous Fistula Supplied by Branches of the Internal Iliac Arteries

Spinal dural arteriovenous fistulas are rare abnormal connections of artery and vein within the dura, at the level of the intervertebral foramen. A 57-year-old male developed weakness in both lower extremities and sphincteric dysfunction, which had stepwisely, progressive and fluctuating course since 6 months ago. He showed areflexia in both ankle & right knee. T-spine MRI showed high signal intensity with ill defined margin in T2WI and intensely enhanced by con-trast agent through lower thoracic and lumbosacral spinal cord. Selective spinal angiography revealed a dural arteriove-nous fistula with a nidus at thoracolumbar vertebral level, supplied by the internal iliac artery and enlarged medullary veins. Superselective angiographic embolization was done. Clinically, his symptoms has been ameliorated. We report a rare case of thoracic myelopathy due to spinal dural arteriovenous fistulas exclusively supplied by the branches of internal iliac artery.

Bilateral Paramedian Thalamic Infarction: Mimicking Wernicke Encephalopathy

A 48-year-old man was admitted due to sudden disorientation and dysarthria. He has been drinking almost everyday for the past 25 years. At the time of the admission, he was alert but confused. Neurologic examination revealed disorientation to time, memory disturbances, decreased amount of speech, dysarthria, limitation of extraocular movement, ataxia of left limbs, and unsteady gait. He was treated with thiamine under the impression of Wernick's encephalopathy. Ataxia of limbs and unsteady gait improved but limitation of extraocular movement and disturbed higher cortical function remained. MRI of the brain taken 24 hours after the onset showed asymmetrical bilateral paramedian thalamic high signal lesions on 72-weighted images. We report here a case of bilateral paramedian thalamic infarction clinically mimicking Wernicke's encephalopathy.