Altered Consciousness After Acute Lacunar Infarction of the Corona Radiata in Patients With Severe White Matter Change

With an increasing proportion of the elderly, dementia due to severe cerebral white matter change is frequently observed. Because these patients cannot express their symptoms effectively, the recognition of stroke can be delayed. In addition, clinical characteristics of their stroke might be different. We reported on three patients with severe leukoaraiosis, who exhibited altered consciousness after acute lacunar infarction in the corona radiata. This clinico-radiological discrepancy may have resulted from different susceptibility to ischemia in patients with severe white matter change.

Coexisting Carotid Atherosclerosis in Patients with Intracranial Small- or Large-Vessel Disease

BACKGROUND AND PURPOSE: The coexistence of carotid atherosclerosis in ischemic stroke patients with small-vessel disease (SVD) or intracranial large-vessel disease (ICLVD) was investigated using carotid duplex ultrasonography, and whether its coexistence affected the clinical prognosis was determined. METHODS: Ischemic stroke patients with SVD or ICLVD were enrolled (n=103). Risk factors, demographic data, and National Institutes of Health Stroke Scale (NIHSS) scores were obtained for all of the subjects. Early neurological progression was defined by an increase in NIHSS score during the first 7 days. Carotid ultrasonography was performed to measure the intima-media thickness (IMT) and carotid plaques. RESULTS: Among the 103 patients who were retrospectively enrolled in this study (56 with SVD and 47 with ICLVD), 66 (64.1%) had an atherosclerotic plaque and 23 (22.3%) had increased IMT. Increased IMT was observed more frequently in ICLVD than in SVD [15/47 (31.9%) vs. 8/56 (14.3%), p=0.032]. An atherosclerotic plaque was observed on subsequent carotid ultrasonographic examination in 28 (50%) of the 56 patients whose computed tomography angiography scans of the neck vessels were interpreted as normal. There was no association between presence of atherosclerotic change and early neurologic progression (p=0.94). CONCLUSIONS: A coexisting atherosclerotic plaque or increased IMT was observed in 71.8% of patients with SVD or ICLVD. Whether the coexistence of carotid atherosclerotic change with either of these conditions affects the clinical prognosis remains to be elucidated.

A Unique Ultrasonographic Finding of Carotid Thrombus in a Patient with Acute Cardiogenic Cerebral Infarction / 대한뇌졸중학회지

In patients with acute ischemic stroke, carotid duplex ultrasonography has been used to assess atherosclerotic lesions at the extracranial carotid artery. We reported a unique sonographic finding of carotid artery thrombus in a patient with acute cardioembolic stroke and atrial fibrillation. An 81-year-old woman with atrial fibrillation was presented with dysarthria and left side hemiparesis. She had undergone surgical thrombectomy and angioplasty for her right brachial artery occlusion four days before the stroke onset. Diffusion-weighted MRI revealed multiple territorial infarctions suggestive of acute cardio-embolic stroke. CT angiography showed an occlusion of the right common carotid artery. On B-mode ultrasonography, longitudinal intraluminal tortuous cylinderic oscillating thrombus was observed on the right distal common carotid artery to the proximal internal carotid artery. This case illustrates a unique ultrasonographic finding of acute cardiogenic thrombus in the extracranial carotid artery.

Headache Related to Secondary Hemochromatosis After Frequent Blood Transfusions

No abstract available.

Contralateral MCA Infarction Mimicking Post-stroke Seizure in a Patient With Previous Right MCA Infarct

No abstract available.

Abnormal Integrity of Corticocortical Tracts in Mild Cognitive Impairment: A Diffusion Tensor Imaging Study

Mild cognitive impairment (MCI) has been defined as a transitional state between normal aging and Alzheimer disease. Diffusion tensor imaging (DTI) can estimate the microstructural integrity of white matter tracts in MCI. We evaluated the microstructural changes in the white matter of MCI patients with DTI. We recruited 11 patients with MCI who met the working criteria of MCI and 11 elderly normal controls. The mean diffusivity (MD) and fractional anisotropy (FA) were measured in 26 regions of the brain with the regions of interest (ROIs) method. In the MCI patients, FA values were significantly decreased in the hippocampus, the posterior limb of the internal capsule, the splenium of corpus callosum, and in the superior and inferior longitudinal fasciculus compared to the control group. MD values were significantly increased in the hippocampus, the anterior and posterior limbs of the internal capsules, the splenium of the corpus callosum, the right frontal lobe, and in the superior and the inferior longitudinal fasciculus. Microstructural changes of several corticocortical tracts associated with cognition were identified in patients with MCI. FA and MD values of DTI may be used as novel biomarkers for the evaluation of neurodegenerative disorders.

Effect of TrkA and p75NTR on the Survival of Neurons in the Cultured Organotypic Hippocampal Slice

BACKGROUND: Nerve growth factor (NGF) promotes the survival and differentiation of vertebrate neurons, and their actions are mediated by two classes of cell surface receptors: tyrosine kinase A receptor (TrkA) and p75 neurotrophic receptor (p75NTR). We evaluated the role of NGF receptors in neuronal survival and the physical interactions between them. METHODS: Organotypic hippocampal slices were obtained from 5 to 7-day-old rat pups and were grown for 14 days in vitro. The expression of the TrkA and p75NTR was evaluated by the western blot and immunohistochemical methods. The neuroprotective effect of NGF on the blocking of antibody-induced neuronal cell death was tested by the application of NGF (0, 50 and 150 ng/ml) to the culture media in the presence of 200 ng/ml of blocking antibodies against TrkA and p75NTR. Functional interactions between the two receptors were examined using the immunoprecipitation method. RESULTS: TrkA and p75NTR were co-expressed in the principal neurons of the hippocampal slice culture, and the expression level was increased time dependently until 14 days of culture. The blocking antibody against each receptor induced neuronal damage in time and dose-dependent manners. NFG delayed or prevented the blocking antibody from inducing neuronal damage. Results from the immunoprecipitation experiment showed physical interactions between the two NGF receptors. CONCLUSIONS: Our results indicate that the co-expressed NGF receptors, TrkA and p75NTR, might have protective roles in the survival of neuronal cells through the cooperative interactions between them.

Diffusion Tensor Imaging in Acute Ischemic Stroke: Usefulness of Fractional Anisotropy

BACKGROUND: Progressing stroke (PS) variably develops from initially the same size and severity, and is most frequently observed in lacunar infarctions. We investigated fractional anisotrophy (FA), mean diffusivity (MD) and infarct volume by using diffusion tensor imaging during the acute phase of ischemic stroke to determine whether these parameters are useful in characterizing and predicting PS. METHODS: In this study, 55 consecutive patients admitted within 24 hours of the onset of their first ischemic stroke were included. NIH stroke scale (NIHSS) and Canadian Neurological scale (CNS) were performed upon admission, twice a day, and at discharge. Modified Rankin scale and Barthel index were also evaluated. PS was defined as a 2-point drop in NIHSS and a 1-point drop in CNS from admission to day 3. A correlation analysis was performed between clinical scale scores and imaging parameters, and the distribution of those values was compared between the two groups with and without PS. RESULTS: Significant correlations were observed between clinical scale scores and infarct volumes. The FA ratio in 14 patients with PS was lower than the patients without PS (p=0.004). Other characteristics including infarct volume and MD ratio were not different. The FA ratio remained as an independent predictor of PS (OR, 1.055; p=0.011). CONCLUSIONS: In acute ischemic stroke within the first 24 hours, only infarct volume was correlated with clinical status. However, patients with PS showed lower FA values, which accounts for rapid and severe vasogenic edema involving the disruption of the cell membrane and axonal fibers. Moreover, FA may be a predictor of PS.

The Effect and the Mechanism of Action of High Frequency Electrical Stimulation of Subthalamic Nucleus on Status Epilepticus Induced by Lithium-Pilocarpine of Rat / 대한간질학회지

OBJECTIVES: Deep brain stimulation (DBS) of subthalamic nuclei (STN) is one of the current modalities of refractory epilepsy, but its exact mechanism and route of action have not been elucidated yet. We investigated the effect of STN stimulation on the development and propagation of seizures in the rats with lithium-pilocarpine induced status epilepticus in its functional anatomy. METHODS: Both pilocarpine injection and high frequency stimulation on STN (HFSSTN) were provided to rats (STN group, n=12), but pilocarpine injection with no stimulation was done on the sham group (n=8). The latency to first discrete ictal discharges and the latency to status epilepticus (SE) were analyzed and the electrical stimulation lasted for 30, 60, 90, 120 minutes after its first discrete spikes. After stimulation, the rats were immediately decapitated for immunohistochemistry and histologic examination. RESULTS: Both the latency to first discrete ictal discharges and the latency to the onset of SE were delayed in the STN group than in the sham group. The latency to the first SE was also more delayed in the STN group (42.7+/-7.9 min) than in the sham group (p<0.05). Remarkably, there was marked Fos immunoreactivity (FIR) on the reticular thalamic nuclei in the STN group, but not in the sham group. CONCLUSIONS: Increased FIR in the reticular thalamic nuclei during HFSSTN suggested that the facilitation of the inhibitory thalamic output prevented generalized motor seizure behavior. We assume that HFSSTN has a pivotal role in the suppression or progression to SE, but cannot prevent seizure onset.

Changes of Regional Cerebral Blood Flow in Left Anterior Thalamic Infarction: Analysis of 99mTc-Ethyl Cysteinate Dimer (ECD) SPECT by using Statistical Parametric Mapping

BACKGROUND: The thalamus has multiple connections with areas of the cerebral cortex involved in arousal and cognition. Thalamic damage has been reported to be associated with variable neuropsychological dysfunctions and dementia. This study investigates the changes of regional cerebral blood flow (rCBF) by using SPM analysis of 99mTc-ECD SPECT and examining the neuropsychological abnormalities of 4 patients with anterior thalamic infarctions. METHODS: Four patients with left anterior thalamic infarctions and eleven normal controls were evaluated. K-MMSE and the Seoul Neuropsychological Screening Battery were performed within 2 days after stroke. The normalized SPECT data of 4 patients were compared to those of 11 controls for the detection of areas with decreased rCBF by SPM analysis. RESULTS: All 4 patients showed anterograde amnesia in their verbal memory, which was not improved by recognition. Dysexecutive features were occasionally present, such as decreased word fluency and impaired Stroop test results. SPM analysis revealed decreased rCBF in the left supramarginal gyrus, the superior temporal gyrus, the middle and inferior frontal gyrus, the medial dorsal and anterior nucleus of the left thalamus. CONCLUSIONS: The changes of rCBF in patients with left anterior thalamic infarctions may be due to the remote suppression on metabolism by the interruption of the cortico-subcortial circuit, which connects the anterior thalamic nucleus and various cortical areas. The executive dysfunction and dysnomia may be caused by the left dorsolateral frontal dysfunction of the thalamocortical circuit. Anterograde amnesia with storage deficit may be caused by the disruption of mamillothalamic tract.

Analysis of SPECT in Two Sub-types of Subcortical Ischemic Vascular Dementia

BACKGROUND: The brain imaging criteria for subcortical ischemic vascular dementia (SIVD), as proposed by Eurkinjuntti, incorporates the two familiar entities, "the lacunar state" and "Binswanger's disease". However, it has not been proven whether these two subtypes of SIVD have common pathophysiological features. This study investigated the changes of the regional cerebral blood flow (rCBF) in the two subsets of SIVD. METHODS: 12 SIVD patients with predominant white matter lesions, 13 patients with predominant multiple lacunar infarctions and 17 controls were evaluated. The general cognitive function and the severity of dementia were measured by using the K-MMSE and the clinical dementia rating scale. The patients simultaneously met both the NINDS-AIREN criteria for probable or possible vascular dementia (VaD) and the Eurkinjuntti's brain imaging criteria for SIVD. 99mTc-ethyl cysteinate dimmer (ECD)-SPECT was performed to measure the rCBF, and statistical parametric mapping (SPM) was applied to the objective analysis of the SPECT data. RESULTS: SPM analysis of the SPECT images revealed that decreased rCBF in the bilateral thalami, anterior cingulated gyri, superior temporal gyri, caudate heads and left parahippocampal gyrus was significant in the patients with SVaD compared to the controls (uncorrected P=0.001). This pattern of rCBF reduction was the same in both the SIVD patients with predominant white matter lesions and with predominant lacunar infarctions. CONCLUSIONS: Our study suggests that the two subsets of SIVD proposed by Eurkinjuntti may have a common functional abnormality, and the Eurkinjuntti's criteria offers a solution for researchers to identify the more homogeneous group of VaD patients.

A Case of Spontaneous Intracranial Hypotension presented as Bilateral Abducens Nerve Palsy without Postural Headache

No abstract available.

Reliability and Validity of the Korean Version of Revised form of Hasegawa Dementia Scale (K-HDS)

BACKGROUND: The revised version of the Hasegawa Dementia Scale (HDS-R) is a useful dementia screening tool with a test for frontal lobe function and is relatively less influenced by education level and linguistic ability. We developed a Korean version of HDS-R (K-HDS) by translating the HDS-R to screen dementia patients in the Korean elderly. METHODS: The basic structure of the HDS-R was preserved but some questions were modified for lingual and cultural difference. It was administrated along with the Korean version of the MMSE, Korean Dementia Screening Questionnaire, Short form Samsung Dementia Questionnaire and Clinical Dementia Rating (CDR) scales, to 151 patients (55 Alzheimer's disease, 73 vascular dementia, 23 others) with mild to moderate dementia and to 225 elderly control subjects. To screen dementia, the optimal cut-off score was estimated by receiver operating characteristic (ROC) curve analysis. By comparing the Area Under the Curve, the diagnostic efficiency of K-HDS was compared with that of K-MMSE. RESULTS: The K-HDS had good internal consistency (Crohnbach's alpha coefficient=0.66), inter-rater reliability (r=0.95), and test-retest reliability (r=0.92). K-HDS was well correlated with the K-MMSE (r=0.84) and CDR (r=-0.67), which confirms the validity of this test. The optimal cut-off score was different according to educational level. In patients with an educational level less than 10 years, the cut-off score was 20 with the sensitivity of 87.0% and the specificity of 83%. With an educational level of 10 years or more, the cut-off score was 22 with the sensitivity of 93.0% and the specificity of 89.6%. The overall diagnostic efficiency of K-HDS was superior to that of K-MMSE especially in patients with an educational level of less than 10 years. CONCLUSIONS: The K-HDS is a reliable, valid and useful tool to screen dementia in the Korean elderly.

Correlation between Multifocal Hypointense Cerebral Lesions on Gradient-echo MRI and White Matter Changes in Patients with Stroke

BACKGROUND: The multifocal hypointense cerebral lesions (MHCLs) on gradient echo (GE)-MRI and white matter changes on T2WI have been thought to be indicative of microangiopathy. The purpose of this study is to elucidate the relationship between MHCLs and white matter (WM) changes and the clinical significance of WM changes in stroke patients. METHODS: We retrospectively reviewed MRI and clinical data of 115 patients with stroke (56 female and 59 male). Periventricular and deep white matter hyperintensity (PVHI and DWMHI) were measured by semiquantative rating scale proposed by Mantyla. The round, hypointense signal, less than 7 mm in diameter on GE-MRI were counted as MHCLs. The association between risk factors of stroke and MHCLs on GE-MRI and sum of the white matter change scores and total number of MHCLs were analyzed, respectively. RESULTS: MHCLs on GE-MRI were significantly associated with old age (p<0.05) and hypertension (p<0.001) among risk factors of stroke. The distribution of MHCLs in subcortical area is associated with hypertension (p<0.05) and total number of MHCLs was significantly associated with sum of the white matter change scores (p<0.05). CONCLUSIONS: MHCLs on GE-MRI were significantly associated with severity of WM changes. Severe WM change may be an indicator of advanced small artery disease of the brain with an increased risk factor for bleeding. This should be taken into consideration when treating patients with stroke.

Protective Effects of the Green Tea Polyphenol(-)-epigallocatechin Gallate Against Ischemia Reperfusion Injury Induced by Middle Cerebral Artery Occlusion in Rats

BACKGROUND: EGCG(epigallocatechin gallate), a major green tea extract, is a potent free radical scavenger which has been shown to reduce free radical-induced lipid peroxidation. The purpose of this study was to examine whether EGCG reduces focal ischemia/reperfusion-induced brain injury in rats. METHODS: Male Wistar rats were anesthetized with ketamine and xylazine and subjected to 120 min of temporary middle cerebral artery occlusion by an intraluminal nylon suture coated with poly-L-lysine. The drug (EGCG, n=8) or vehicle (normal saline, n=8) was administered iv.(as a 50 mg/kg bolus) immediately after the onset of middle cerebral artery occlusion. Neurologic status was evaluated 2 hours after occlusion and 24 hours after. Twenty-four hours after ischemia, the brain was perfusion-fixated and the infarct volume was determined. RESULTS: EGCG significantly improved the neurological status at 24 hours after middle cerebral artery occlusion.(p<0.05), and reduced total infarct volumes (p<0.01). CONCLUSIONS: These results demonstrate the neuroprotective effect of EGCG in a rat model of transient focal cerebral ischemia.

The Selective Cyclooxygenase-2 Inhibitor Rofecoxib Reduces Chronic Cerebral Hypoperfusion-induced Apoptosis in the Rat Hippocampus

BACKGROUND: Chronic cerebral hypoperfusion induced by permanent occlusion of bilateral common carotid arteries (2VO) in rats caused cognitive deficits and neuronal damage. Cyclooxygenase-2 (COX-2) inhibitor was reported to attenuate both post-ischemic prostaglandin accumulation and neuronal damage. We studied the expression of mRNA of COX-2 in the hippocampus during hypoperfusion and the effectiveness of selective cyclooxygenase-2 inhibitor, rofecoxib, in preventing the neuronal damage of this model. METHODS: Bilateral common carotid arteries of the rat were ligated with silk sutures. The expression of mRNA for COX-1 and COX-2 were detected by the RT-PCR. The first group of animals (n=6) was treated with rofecoxib (10 mg/kg, i.p.) 7 days after operation and the following 7 days. The second group of animals (n=6) was treated with diclofenac sodium (9mg/kg, i.p.) and the third group of animals (n=5) was treated with vehicle (DMSO). TdT-mediated dUTP nick end labeling (TUNEL) technique was performed to estimate delayed cell death. RESULTS: Bilateral carotid artery occlusion (2VO) was shown to induce apoptotic morphology and DNA strand break in hippocampal neurons from 7 days with a peak at 14, 28 days. mRNA of COX-2 appeared in the frontal cortex (14, 28 days) and hippocampus (14, 28, 63 days). Treatment with rofecoxib significantly (p<0.05) attenuated the number of TUNEL-labeled cells in the hippocampus, whereas the cells of the diclofenac treated group were not protected. CONCLUSIONS: We concluded that COX-2 might contribute to cell death of pyramidal cells of the hippocampus of hypoperfusion and selective COX-2 inhibitor, rofecoxib, could prevent the neuronal damage.

The Different Patterns of Behavioral Derangements in Subcortical Vascular Dementia and Alzheimer's Disease: Evaluated by the Korean Version of the Neuropsychiatric Inventory

BACKGROUND: The neuropsychiatric derangements in dementing patients are common and troublesome in their managements. The purpose of this study is to compare the behavioral changes in patients with subcortical vascular dementia (SVaD) and to those in patients with Alzheimer's disease (AD) by using the Korean version of the neuropsychiatric inventory (K-NPI). METHODS: The K-NPI was administrated to the close caregivers of 19 patients with AD (who met the criteria of the NINCDS-ADRDA for probable AD) and 14 patients with SvaD (who met the criteria of the NINDS-AIREN criteria for probable or possible VaD). Groups were matched for age, education and dementia severity. We evaluated the prevalence, the composite score (frequency X severity) of each behavioral domain in K-NPI between two groups. RESULTS: The most common behavioral disturbances were anxiety (63%) in AD and apathy/indifference (93%) in SVaD. Patients with SVaD had significantly greater total K-NPI scores than patients with AD and exhibited apathy/indifference, agitation/aggression and anxiety more frequently. Composite score of apathy/indifference over 4.7 point discriminates between AD and SVaD with accuracy of 75.8%. CONCLUSIONS: The K-NPI provides behavioral profiles that differentiate patients with SVaD from patients with AD. Patients with SVaD are more behaviorally disturbed. Clinicians need to pay more attention to the behavioral disturbances when managing the patients with SVaD.

The Development and Validation of Korean Dementia Screening Questionnaire (KDSQ)

BACKGROUND: Dementia Screening Questionnaire is sensitive to detect early dementia patients and is not influenced by age and educational level. We conducted a case-control study to assess the validity and reliability of the Korean Dementia Screening Questionnaire (KDSQ) for the diagnosis of early dementia. METHODS: We developed KDSQ in a semi-structured manner with the questionnaire of 15 items about cognitive dysfunctions and 5 items of ischemic and depression scales respectively to evaluate the possibility of vascular dementia and degree of depression. It was adminis-trated to informants of 72 dementia patients (39 Alzheimer's disease, 33 vascular dementia) with Clinical Dementia Rating (CDR) scales of 0.5, or 1.0 and to those of 66 hospital control subjects. Test-retest data for the KDSQ were obtained from informants within a time interval of 20.82 days. RESULTS: The KDSQ was not influenced by education level, age, or sex. KDSQ score correlated with the K-MMSE (r=-0.75) and Short form Samsung Dementia Questionnaire (r=0.80). The area under the receiver operating characteristic curve for the KDSQ was 88.9% (S.E.=0.028). KDSQ depression score was correlated with Geriatric Depression Scale (r=0.34). With respect to a diag-nosis of dementia, the KDSQ (cut-off point 6) had a sensitivity of 79% and a specificity of 80%. The KDSQ was found to have a high test-retest reliability (r=0.81) CONCLUSIONS: The KDSQ has high validity and reliability for the diagnosis of early dementias. It may be a useful tool to screen early stage of dementias.

A Case of Digoxin-induced Catatonic Stupor

We experienced a rare clinical manifestation of a digoxin induced catatonic stupor without other features of digoxin toxicity. This case suggests that the neurological manifestation of digoxin toxicity can occur without the usual side effects. Also, a serum digoxin level should be checked in any elderly patient presenting with abnormal cerebral func-tions, irrespective of whether or not the dose of digoxin has been changed. (J Korean Neurol Assoc 19(4):438~439, 2001)

Apolipoprotein E4 Genotype in Patient with IschemicCerebrovascular Disease in Korea: A Preliminary Study

BACKGROUND: The apolipoprotein E (APOE) epsilon4 allele is over-represented in Alzheimer's disease, atherosclerosis, and ischemic heart disease. We investigated whether specific APOE polymorphism is a risk factor for ischemic cerebrovas-cular disease in the Korean population. METHODS: We compared 98 patients with ischemic cerebrovascular disease with 209 controls similar in age and dwelling areas. APOE genotypes were determined by restriction fragment-length poly-morphism analysis. The association of the APOE with: stroke subtypes, white matter hyperintensities, lipid profiles, and potential vascular risk factors, including: age, sex, hypertension, diabetes mellitus, lipid disorders, smoking habit, cardiac diseases, presence of past history and family history of ischemic cerebrovascular diseases, was examined. RESULTS: Overall, patients with ischemic cerebrovascular disease had no difference in APOE allele frequency with controls (p>0.05). Also, neither stroke subtypes nor white matter high signal intensities were associated with APOE polymorphism (p>0.05). APOE epsilon4 carriers exhibited more frequent personal stroke histories compared with non-epsilon4 subjects (p<0.01). CONCLUSIONS: Our data suggests that the APOE epsilon4 is not associated with ischemic cerebrovascular disease in the Korean population. However, an association between APOE epsilon4 and personal history supports the possibility that the APOE is a susceptibility locus for the risk of ischemic cerebrovascular diseases. (J Korean Neurol Assoc 19(1):19~23, 2001