Clinical Reasoning: A 23-Year-Old Man with Intermittent Impaired Awareness

No abstract available.

Sleepwalking Triggered by Hypoglycemia

Sleepwalking is a rare parasomnia in the elderly. We report two cases of the patients who presented complex motor behaviors during sleep triggered by hypoglycemia. A 76-year-old male patient with diabetes mellitus presented to the sleep clinic for recurrent sleepwalking with amnesia. Night polysomnogram showed REM sleep without atonia with sleep talking and distal arm movements. While taking clonazepam, he had a few more episodes of sleepwalking. The last episode finally revealed severe hypoglycemia when he was found very far from his house. The second patient, a 67-year-old male showed four episodes of nocturnal confusion and sleepwalking lasting 20 minutes during sleep. His blood glucose and HbA1c were low. After decrease of the dose of oral hypoglycemic agent, no more recurrent sleepwalking occurred. Our cases showed hypoglycemia can induce sleepwalking in the older adults, rather than decreased mentality. Metabolic workup should perform for evaluation of sleepwalking, especially in the elderly.

The Effect of Ropinirole on the Quality of Life in Patients with Restless Legs Syndrome in Korea: An 8-Week, Multicenter, Prospective Study

BACKGROUND AND PURPOSE: Dopamine agonists are first-line drugs for treating the symptoms of restless legs syndrome (RLS). However, few studies have investigated the effect of dopamine agonists on the quality of life (QoL) in RLS patients. We conducted a study to determine whether ropinirole exerts positive effects on the QoL in RLS patients and to analyze the underlying factors. METHODS: Primary RLS patients from eight medical centers were recruited in the study. They were evaluated in the baseline phase using various questionnaires including the Korean versions of the International Restless Legs Scale (K-IRLS), RLS QoL questionnaire (K-RLSQoL), and the Short Form 36 Health Survey (SF-36). After taking ropinirole for 8 weeks the same questionnaires were again completed as a re-evaluation. We analyzed the statistical difference using a paired t-test, a Pearson's correlation, and a stepwise multiple regression in order to identify the factors associated with the QoL change. RESULTS: A total of 107 subjects, including 65 (60.7%) females, completed this study. They were aged 51.68+/-14.80 years (mean+/-SD) and had a symptom duration of 8.8+/-9.0 months. After treatment with ropinirole, there were significant improvements on the K-RLSQoL, SF-36, and K-IRLS. The Pearson's correlation analysis showed that the improvement of QoL in RLS patients was significantly correlated with the severity of RLS (r=0.236, p<0.014) at baseline. CONCLUSIONS: The results from this study suggest that treatment with ropinirole can improve the QoL in RLS patients. The improvement in the QoL is more related with the improvement of RLS symptoms.

Pseudo-Vestibular Neuronitis Caused by Medial Vestibular Nucleus Infarction

No abstract available.

Type 1 Chiari Malformation Presenting With Medullary Infarction and Syncope

No abstract available.

Cortical Localization of Scalp Electrodes on Three-Dimensional Brain Surface Using Frameless Stereotactic Image Guidance System

BACKGROUND: The purpose of this study was to localize the cortical regions reflected by overlying scalp electrodes. METHODS: We enrolled 10 patients with epilepsy (5 males, mean age 29.7 years old). Thin slice coronal T1 weighted MR images were obtained and then scalp EEG electrodes were placed based on an international 10-20 system. Cortical locations of scalp electrodes were determined using a real-time frameless stereotactic image guidance system, Brainsight(R). RESULTS: The locations of 19 scalp electrodes were marked on the 3D rendered cortical surface of one representative patient's MRI; Fp1 (Fp2) on the anterior pole of the middle frontal gyrus, Fz on the mid-point of the interhemispheric fissure in the frontal lobe, F3 (F4) on the mid-portion of the middle frontal gyrus, F7 (F8) on the pars triangularis of the inferior frontal gyrus, Cz on the interhemispheric fissure where a lateral precentral gyrus starts, C3 (C4) scattered around postcentral gyrus, T3 (T4) on the middle temporal gyrus, P3 (P4) on the angular gyrus, Pz on the mid-point of the interhemispheric fissure in the parietal lobe, T5 (T6) on the posterior part of the inferior temporal gyrus, and O1 (O2) on the occipital pole. CONCLUSIONS: The locations of scalp electrodes were well correlated with conventional concepts of their cortical locations. The individual differences of the scalp electrode locations may be due to the different sizes and morphologies of the brains in each of the patients. Real time cortical localization of scalp electrodes using the Frameless Stereotactic Image Guidance System may provide useful information for more accurate localization of focal cerebral activity in partial epilepsy patients.

Structural Brain Abnormalities in Juvenile Myoclonic Epilepsy Patients: Volumetry and Voxel-Based Morphometry

OBJECTIVE: We aimed to find structural brain abnormalities in juvenile myoclonic epilepsy (JME) patients. MATERIALS AND METHODS: The volumes of the cerebrum, hippocampus and frontal lobe and the area of the corpus callosum's subdivisions were all semi-automatically measured, and then optimized voxel-based morphometry (VBM) was performed in 19 JME patients and 19 age/gender matched normal controls. RESULTS: The rostrum and rostral body of the corpus callosum and the left hippocampus were significantly smaller than those of the normal controls, whereas the volume of the JME's left frontal lobe was significantly larger than that of the controls. The area of the rostral body had a significant positive correlation with the age of seizure onset (r = 0.56, p = 0.012), and the volume of the right frontal lobe had a significant negative correlation with the duration of disease (r = -0.51, p = 0.025). On the VBM, the gray matter concentration of the prefrontal lobe (bilateral gyri rectus, anterior orbital gyri, left anterior middle frontal gyrus and right anterior superior frontal gyrus) was decreased in the JME group (corrected p < 0.05). CONCLUSION: The JME patients showed complex structural abnormalities in the corpus callosum, frontal lobe and hippocampus, and also a decreased gray matter concentration of the prefrontal region, which all suggests there is an abnormal neural network in the JME brain.

The Effect of Topiramate and Lamotrigine on Cerebral Glucose Metabolism in Idiopathic Generalized Epilepsy Patients / 대한간질학회지

BACKGROUND: To investigate the effects of topiramate (TPM) or lamotrigine (LTG) on cerebral glucose metabolism, we performed 18F-fluorodeoxy glucose positron emission tomography (FDG-PET) before and after medication in patients with drug naive idiopathic generalized epilepsy. METHODS: Thiry-three patients with newly diagnosed as idiopathic generalized epilepsy (IGE) or IGE without antiepileptic drugs after diagnosis were included. Pre- and post-antiepileptic drug FDG-PET were performed (before and after TPM or LTG administration) in 33 subjects treated with TPM or LTG who had been seizure free for at least 8 weeks. Sixteen of patients received TPM (M/F=8/8, aged 29.2+/-12.3 years) and 17 LTG (M/F=8/9, 26.8+/-9.3 years). For statistical paramateric (SPM) analysis, all PET images were spatially normalized to the standard PET template and then smoothed using a 12-mm full width at half-maximum Gaussian kernel. The paired t-test was used to compare pre- and post-medication FDG-PET images. RESULTS: SPM analysis of post- and pre-medication FDG-PETs showed TPM reduced glucose metabolism markedly in the thalamus, corpus callosum, and white matters, whereas LTG decreased glucose metabolism in cortico-striato-entorhinal areas with a false discovery rate corrected p<0.05. No brain region showed post-medication hypermetabolism in either group. CONCLUSION: Our study demonstrates that both TPM and LTG affect the cerebral glucose metabolism in drug naive idiopathic generalized epilepsy patients.

The Statistical Parametric Mapping Analysis between Pre- and Post-Operative FDG-PET Images in Patients with Mesial Temporal Lobe Epilepsy / 대한간질학회지

BACKGROUND: To investigate postoperative changes in the cerebral glucose metabolism of patients with mesial temporal lobe epilepsy (MTLE), statistical parametric mapping (SPM) analysis was performed on pre- and post-operative 18F-fluorodeoxy glucose positron emission tomographic (FDG-PET) images. METHODS: We included 28 patients with MTLE who had under-gone surgery and had been seizure free postoperatively (16 had left MTLE and 12 right MTLE). All patients showed hippocampal sclerosis by pathology or brain MRI. FDG-PET images of the 12 right TLE patients were reversed to lateralize the epileptogenic zone to the left side in all patients. RESULTS: Application of the paired t-test in SPM to pre- and postoperative FDG-PETs showed that the postoperative glucose metabolism decreased in the caudate nucleus, pulvinar of thalamus, fusiform gyrus, lingual gyrus, and in the posterior region of the insular cortex in the hemisphere ipsilateral to resection, whereas postoperative glucose metabolism increased in the anterior region of the insular cortex, temporal stem white matter, midbrain, inferior precentral gyrus, anterior cingulate gyrus, and supramarginal gyrus in the hemisphere ipsilateral to resection. No significant postsurgical changes of cerebral glucose metabolism occurred in the contralateral hemisphere. Subtraction between pre- and postoperative FDG-PET images in individual patients produced similar findings to the SPM results. CONCLUSION: This study suggests that brain regions showing a postoperative increase in glucose metabolism appear to represent the propagation pathways of ictal and interictal epileptic discharges in MTLE while a postoperative decrease in glucose metabolism may be related to a permanent loss of afferents from resected anterior-mesial temporal structures.

Dipole Source Localization and Low Resolution Electromagnetic Tomography(LORETA) of Interictal Spikes in Mesial and Lateral Temporal Lobe Epilepsy / 대한간질학회지

PURPOSE: To investigate the usefulness of dipole source localization (DSL) and low resolution electromagnetic tomography (LORETA) in localizing epileptic focus, we performed DSL and LORETA of interictal spikes in patients with mesial and lateral temporal lobe epilepsy (TLE). METHOD: We analyzed representative interictal spikes in 17 patients with TLE (9:mesial TLE; 8:lateral TLE). We used ASA3 (Advanced Neuro Technology, Netherlands) for DSL, voltage topography (VT) and LORETA of interictal spikes. RESULT: Most interictal spikes for analysis have their maximum amplitudes at electrode F7, 8 or T7, 8 except one patient with lateral TLE (P7). In mesial TLE, VT showed a maximum negative electrical field in ipsilateral fronto-temporal region. DSL showed dipole sources in ipsilateral anterior mesial temporal lobe (33.3%, 3/9), temporal pole (44.5%, 4/9), orbitofrontal (11.1%, 1/9) and anterior inferior frontal (11.1%, 1/9) regions. LORETA showed maximum current density in ipsilateral fronto-temporal or anterior-mid temporal areas with lateral temporal maximum. In lateral TLE, dipole sources were in ipsilateral temporal pole (62.5%, 5/8), thalamus (12.5%, 1/8) and in posterosuperior temporal area (2/8, 25%). VT of spikes at F7 or F8 showed similar results as those of mesial TLE while that of spikes at T7, T8 and P7 had a tendency of electrical fields more extending to the mid- and posterior temporal regions. LORETA showed more diffuse current distribution in whole temporal lobe (anterior to posterior) with lateral temporal maximum. CONCLUSION: The patterns of DSL and LORETA were somewhat helpful to differentiate mesial from lateral TLE. LORETA usually showed more diffuse activity beyond the epileptic focus.

The Effect of Resection Extent Upon Postoperative Outcome of Seizures and Memory in Anterior Temporal Lobectomy with Amygdalohippocampectomy / 대한간질학회지

PURPOSE: To investigate the relationship of the resection extent of hippocampus and temporal neocortex with the postsurgical outcome in patients with mesial temporal lobe epilepsy (TLE). METHODS: Sixty-eight patients with TLE underwent brain MRI pre- and post-operatively. They were divided into two groups by seizure outcomes:seizure free group (SF, N=54) and non-seizure free group (NSF, N=14). Patients were classified further according to the post-surgical memory changes:MD group (with postsurgical memory decline, N=15) and NMD group (without postsurgical memory decline, N=16). The hippocampal resection was estimated by subtracting the length of post-surgical hippocampus from the pre-surgical length. The resection of temporal neocortex was measured by comparing the resection lengths on superior, middle, inferior and basal temporal gyri shown on three dimensional brain MRI. RESULTS: The mean extent of hippocampal resection was significantly larger in SF than in NSF (33.2+/-7.5 mm vs. 24.8+/-7.4 mm p=0.001) while that between MD and NMD was not significantly different. The resection extent of temporal neocortex was not significantly different between SF and NSF as well as between MD and NMD, but the resection extent of basal temporal gyrus of left TLE was significantly larger in MD than in NMD. CONCLUSIONS: The hippocampal resection was significantly greater in SF. The overall resection extent of the temporal neocortex did not correlate to the surgical outcomes of seizures or memory although that of the basal temporal gyrus of the left TLE was larger in MD.

Effect of Topiramate on Cerebral Glucose Metabolism / 대한간질학회지

PURPOSE: To investigate the effects of topiramate on cerebral glucose metabolism, we performed 18F-fluorodeoxy glucose positron emission tomography (FDG-PET) in patients with new-onset epilepsy. METHODS: Thirteen patients with new-onset epilepsy or without medication after epilepsy diagnosis were included. Pre- and post-drug FDG-PET were performed (before and after topiramate administration) in all subjects (M/F=9/4, 28.2+/-11.4 years). For SPM analysis, paired pre- and linearly transformed post-drug FDG-PETs were spatially normalized into a standard PET template, provided in SPM-99, using a 12-parameter affine and a non-linear transformation. Spatially normalized images were then smoothed by convolution using an isotopic Gaussian kernel with a 14 mm full width at half maximum. The paired t-test was used to compare pre- and post-drug PET images. RESULTS: Mean dose of topiramate at the time of post-drug FDG-PET scanning was 163+/-71 mg. Mean duration of topiramate administration was 169+/-54 days. Responses to topiramate medication were seizure free in 7, reduced seizures in 3, and no changes in 3 patients. Reported adverse events were headache in 2 patients. SPM analysis between post-drug and pre-drug FDG-PET images showed post-drug hypometabolism in the white matters of both parietal and right temporal lobes, and corpus callosum, both thalami, right cingulate gyrus, left midbrain, both superior frontal gyri, left middle frontal gyrus, right inferior- and left superior parietal lobules, and left inferior temporal gyrus (corrected p<0.05). No brain region showed post-drug hypermetabolism. CONCLUSION: Topiramate reduced glucose metabolism more in the corpus callosum, thalamus and white matters, and less in the cerebral cortex.

Abnormal Cerebral Glucose Metabolism in Patients with Narcolepsy

BACKGROUND: The purpose of this study was to investigate the differences of cerebral glucose metabolism between narcoleptic patients and normal controls. METHODS: We enrolled 24 patients with narcolepsy who underwent night polysomnography and multiple sleep latency tests to confirm the narcolepsy. 18F-fluorodeoxy glucose positron emission tomography scan was performed in all narcoleptic patients and 24 normal age-sex matched controls. To compare the cerebral glucose metabolism between the two groups, statistical parametric mapping (SPM99) was used. RESULTS: Patients with narcolepsy showed significant decreases of cerebral glucose metabolism in the bilateral rectal and subcallosal gyri, right superior frontal gyrus, right medial frontal gyrus, bilateral precuneus, right inferior parietal lobule, and left supramarginal gyrus of the parietal lobe at the uncorrected P<0.001. The bilateral posterior hypothalami and mediodorsal thalamic nuclei showed glucose hypometabolism at the level of corrected P<0.05 with small volume correction. CONCLUSIONS: This study showed cerebral glucose hypometabolism of hypothalamus-thalamus-orbitofrontal pathways in narcoleptic brains. The distribution of abnormal glucose metabolism is concordant to the cerebral pathways of the hypocretin system.

Diffuse Signal Changes in Corpus Callosum after Decompression Surgery of Hydrocephalus

Wide spread MR signal changes in the corpus callosum can occur after shunt operation in patients with hydrocephalus. Although the mechanism of these signal changes remains unclear, neural compression caused by active hydrocephalus and changes of conditions after shunt operation may contribute to the development of these changes. We present a patient who underwent successful ventriculo-peritoneal shunt operation for hydrocephalus and had diffuse signal changes in the corpus callosum in MR images taken 2 years after the surgery.

Cavernous Angioma Coexisting with Venous Angioma in the Posterior Fossa

Venous angioma and cavernous angioma have its own distinctive characteristics in the pathological, radiological, and clinical points of view. However, the chances of coexistence of two disease entities as the neuroimaging techniques developed, and highlight the possibility made us suspect that they might share the same pathogenesis. When they coexist, the clinical symptoms are almost always caused by cavernous angioma. Here, we report 2 cases of cavernous angioma coexisting with a venous angioma in the posterior fossa presenting acute brainstem dysfunction.