Reversible Burst-suppression Pattern of Acute Hyperammonemic Encephalopathy

Acute hyperammonemic encephalopathy is generally associated with severe liver disease, manifesting with neuropsychiatric symptoms including confusion, lethargy, seizure, coma, and even death. Electroencephalogram (EEG) is a proven diagnostic, prognostic, and therapeutic tool in patients with acute and chronic encephalopathies. EEG changes in acute hyperammonemic encephalopathy are associated with background slowing in theta to delta ranges, accompanied by presence of triphasic waves. We reported a patient with acute hyperammonemic encephalopathy showing an unusual burst-suppression pattern, which was reversible with proper treatment.

Etiology-Related Outcome of Endovascular Therapy in Posterior Circulation Stroke Compared to Anterior Circulation Stroke / 대한뇌졸중학회지

Background@#and Purpose We investigated the impact of stroke etiology on the endovascular treatment (EVT) procedure and clinical outcome of posterior circulation stroke (PCS) patients with EVT compared to anterior circulation stroke (ACS) patients. @*Methods@#We retrospectively analyzed ischemic stroke patients who underwent EVT between January 2012 and December 2020. Enrolled ACS and PCS patients were compared according to etiologies (intracranial arterial steno-occlusion [ICAS-O], artery-to-artery embolic occlusion [AT-O], and cardioembolic occlusion [CA-O]). EVT procedure and favorable clinical outcomes at 3 months (modified Rankin Scale 0–2) were compared between the ACS and PCS groups for each etiology. @*Results@#We included 419 patients (ACS, 346; PCS, 73) including 88 ICAS-O (ACS, 67; PCS, 21), 66 AT-O (ACS, 50; PCS, 16), and 265 CA-O (ACS, 229; PCS, 36) patients in the study. The onset-to-recanalization time was longer in the PCS group than in the ACS group (median 628.0 minutes vs. 421.0 minutes, P=0.01). In CA-O patients, the door-to-puncture time was longer, whereas the puncture-to-recanalization time was shorter in the PCS group than in the ACS group. The proportions of successful recanalization and favorable clinical outcomes were similar between the ACS and PCS groups for all three etiologies. Low baseline National Institutes of Health Stroke Scale (NIHSS) scores and absence of intracerebral hemorrhage at follow-up imaging were associated with favorable clinical outcomes in both groups, whereas successful recanalization (odds ratio, 11.74; 95% confidence interval, 2.60 to 52.94; P=0.001) was only associated in the ACS group. @*Conclusions@#The proportions of successful recanalization and favorable clinical outcomes were similar among all three etiologies between PCS and ACS patients who underwent EVT. Initial baseline NIHSS score and absence of hemorrhagic transformation were related to favorable outcomes in the PCS and ACS groups, whereas successful recanalization was related to favorable outcomes only in the ACS group.

Long-Term Changes in Post-Stroke Depression, Emotional Incontinence, and Anger / 대한뇌졸중학회지

Background@#and Purpose Long-term changes in post-stroke depression (PSD), post-stroke emotional incontinence (PSEI), and post-stroke anger (PSA) have rarely been studied. @*Methods@#This is a sub-study of EMOTION, a randomized, placebo-controlled trial, that examined the efficacy of escitalopram on PSD, PSEI, and PSA in patients with stroke. We interviewed patients at the long-term period (LTP) using predefined questionnaires: Montgomery-Åsberg depression rating scale (MADRS) for PSD, modified Kim’s criteria for PSEI, and Spielberger trait anger scale for PSA. Additionally, the ENRICHD Social Support Instrument (ESSI) for the social support state and the modified Rankin Scale (mRS) were measured. We investigated the changes in and factors behind PSD, PSEI, and PSA at LTP. @*Results@#A total of 222 patients were included, and the median follow-up duration was 59.5 months (interquartile range, 50 to 70). Compared to the data at 6 months post-stroke, the prevalence of PSEI (11.7% at 6 months, 6.3% at LTP; P=0.05) and mean anger score (21.62, 16.24; P<0.01) decreased, while the prevalence of PSD (35.6%, 44.6%; P=0.03) and mean MADRS (6.16, 8.67; P<0.01) increased at LTP. ESSI was associated with PSD and PSA, but not with PSEI. The effect of the baseline National Institutes of Health Stroke Scale score on PSD decreased over time. The effect of low social support on PSD was greater than that of mRS at LTP. @*Conclusions@#The prevalence and degree of PSD significantly increased, while those of PSEI and PSA decreased at LTP. PSD in this stage appeared to be more closely associated with a lack of social support than patients' physical disabilities.

Long-Term Changes in Post-Stroke Depression, Emotional Incontinence, and Anger / 대한뇌졸중학회지

Background@#and Purpose Long-term changes in post-stroke depression (PSD), post-stroke emotional incontinence (PSEI), and post-stroke anger (PSA) have rarely been studied. @*Methods@#This is a sub-study of EMOTION, a randomized, placebo-controlled trial, that examined the efficacy of escitalopram on PSD, PSEI, and PSA in patients with stroke. We interviewed patients at the long-term period (LTP) using predefined questionnaires: Montgomery-Åsberg depression rating scale (MADRS) for PSD, modified Kim’s criteria for PSEI, and Spielberger trait anger scale for PSA. Additionally, the ENRICHD Social Support Instrument (ESSI) for the social support state and the modified Rankin Scale (mRS) were measured. We investigated the changes in and factors behind PSD, PSEI, and PSA at LTP. @*Results@#A total of 222 patients were included, and the median follow-up duration was 59.5 months (interquartile range, 50 to 70). Compared to the data at 6 months post-stroke, the prevalence of PSEI (11.7% at 6 months, 6.3% at LTP; P=0.05) and mean anger score (21.62, 16.24; P<0.01) decreased, while the prevalence of PSD (35.6%, 44.6%; P=0.03) and mean MADRS (6.16, 8.67; P<0.01) increased at LTP. ESSI was associated with PSD and PSA, but not with PSEI. The effect of the baseline National Institutes of Health Stroke Scale score on PSD decreased over time. The effect of low social support on PSD was greater than that of mRS at LTP. @*Conclusions@#The prevalence and degree of PSD significantly increased, while those of PSEI and PSA decreased at LTP. PSD in this stage appeared to be more closely associated with a lack of social support than patients' physical disabilities.

Safety and Effectiveness of Percutaneous Low-Dose Thrombin Injection for Femoral Puncture Site Pseudoaneurysms in Neurointervention: Single-Center Experience / 신경중재치료의학

Purpose@#We present ultrasound-guided percutaneous low-dose thrombin (200–250 IU) injection for the treatment of iatrogenic femoral pseudoaneurysms. Second, we compared patient and procedure factors between subcutaneous hematoma and pseudoaneurysm groups. @*Materials and Methods@#From April 2012 to May 2018, 8425 patients underwent neurointervention. Among these patients, 18 had small subcutaneous hematomas and 6 had pseudoaneurysms. Pseudoaneurysms in the neck and entire sac were visualized, and low-dose thrombins were injected while visualizing a “whirlpool” hyperechoic core in the pseudoaneurysm sac. Subcutaneous hematomas were treated with simple compression. We compared the following parameters between the subcutaneous hematoma group and pseudoaneurysm group: sex, age, body mass index (BMI), type of procedure, heparin usage, sheath size, procedure time, and number of previous neurointervention procedures with the Mann-Whitney U test. @*Results@#Most of the pseudoaneurysms were successfully occluded with 200 IU of thrombin (n=5). Only 1 pseudoaneurysm required a slightly higher thrombin concentration (250 IU, n=1). During the short-term follow-up, no residual sac was observed and no surgical repair was necessary. Pain in the groin region was alleviated. During the 1-month follow-up, no evidence of pseudoaneurysm recurrence nor subcutaneous hematoma was noted. Patient factors (sex, age, and BMI) and procedure factors (heparin usage, sheath size, procedure time, number of previous procedures) were not statistically different between the subcutaneous hematoma and pseudoaneurysm groups. @*Conclusion@#Ultrasound-guided percutaneous low-dose thrombin injection (200–250 IU) is safe, effective, and less invasive for treating iatrogenic femoral pseudoaneurysm in neurointervention.

Endovascular Treatment in Patients with Cerebral Artery Occlusion of Three Different Etiologies / 대한뇌졸중학회지

Background@#and Purpose The outcome of endovascular treatment (EVT) may differ depending on the etiology of arterial occlusion. This study aimed to assess the differences in EVT outcomes in patients with intracranial arterial steno-occlusion (ICAS-O), artery-to-artery embolism (AT-O), and cardiac embolism (CA-O). @*Methods@#We retrospectively analyzed 330 patients with ischemic stroke who underwent EVT between January 2012 and August 2017. Patients were classified according to the etiology. The clinical data, EVT-related factors, and clinical outcomes were compared. The modified Rankin Scale (mRS) score at 3 months, determined using ordinal logistic regression (shift analysis), was the primary outcome. @*Results@#CA-O (n=149) was the most common etiology, followed by ICAS-O (n=63) and AT-O (n=49). Age, initial National Institutes of Health Stroke Scale (NIHSS) score, and rate of hemorrhagic transformation were significantly higher in patients with CA-O compared to AT-O and ICAS-O. The time from onset-to-recanalization was the shortest in the CA-O (356.0 minutes) groups, followed by the AT-O (847.0 minutes) and ICAS-O (944.0 minutes) groups. The rates of successful recanalization, mRS distribution, and favorable outcomes at 3 months (mRS 0–2; CA-O, 36.9%, AT-O, 53.1%; and ICAS-O, 41.3%) did not differ among the three groups. Baseline NIHSS score (odds ratio, 0.87; 95% confidence interval, 0.83 to 0.91) could independently predict a favorable shift in mRS distribution. @*Conclusions@#The functional outcomes of ICAS-O and AT-O were similar to those of CA-O, despite the delay in symptom onset-to-recanalization, suggesting that the therapeutic time window may be extended in these patients.

Cigarette Smoking Preferentially Affects Intracranial Vessels in Young Males: A Propensity-Score Matching Analysis / 신경중재치료의학

PURPOSE: Cigarette smoking (CS) is one of the major risk factors of cerebral atherosclerotic disease, however, its level of contribution to extracranial and intracranial atherosclerotic stenosis (ECAS and ICAS) was not fully revealed yet. The purpose of our study was to assess the association of CS to cerebral atherosclerosis along with other risk factors. MATERIALS AND METHODS: All consecutive patients who were angiographically confirmed with severe symptomatic cerebral atherosclerotic disease between January 2002 and December 2012 were included in this study. Multivariate logistic regression analyses were performed to identify risk factors for ECAS and ICAS. Thereafter, CS group were compared to non-CS group in the entire study population and in a propensity-score matched population with two different age-subgroups. RESULTS: Of 1709 enrolled patients, 794 (46.5%) had extracranial (EC) lesions and the other 915 (53.5%) had intracranial (IC) lesions. CS group had more EC lesions (55.8% vs. 35.3%, P<0.001) whereas young age group (<50 years) had more IC lesion (84.5% vs. 47.6%, P<0.001). In multivariate analysis, seven variables including CS, male, old age, coronary heart disease, higher erythrocyte sedimentation rate, multiple lesions, and anterior lesion were independently associated with ECAS. In the propensity-score matched CS group had significant more EC lesion compared to non-CS group (65.7% vs. 47.9%) only in the old age subgroup. CONCLUSION: In contrast to a significant association between CS and severe symptomatic ECAS shown in old population, young patients did not show this association and showed relatively higher preference of ICAS.

Low-dose Prasugrel in Patients with Resistance to Clopidogrel for the Treatment of Cerebral Aneurysms: Follow-up of over 6 Months / 신경중재치료의학

No abstract available.

Symptomatic Relief of Idiopathic Infratentorial Superficial Siderosis with Maintaining Supine Position

Superficial siderosis results from the deposition of hemosiderin in subpial layers of the central nervous system following hemorrhage in subarachnoid spaces. Infratentorial superficial siderosis (ISS) presents with unique clinical features including progressive hearing loss, ataxia, and myelopathy, and the most common cause of idiopathic ISS is dural abnormality. Here we report a case of idiopathic ISS with radiological findings of spontaneous intracranial hypotension, whose clinical symptoms of ISS including cerebellar dysfunction improved after supine position was maintained for 2 months.

Low-Dose Prasugrel in Patients with Resistance to Clopidogrel for the Treatment of Cerebral Aneurysms / 신경중재치료의학

Thromboembolism is one of the major complications of stent assisted coiling in treatment of cerebral aneurysm. Clopidogrel resistance is so common and prasugrel is more effective in its rapid and potent effect. We investigated changes in the value of P2Y12 resistance unit (PRU) when prasugrel was administered to patients with clopidogrel resistance. One hundred mg of aspirin and 75 mg of clopidogrel were administered for 5 days before the procedure, and PRU were examined. The resistance to clopidogrel was defined as the inhibition of PRU was less than 20%. PRU was re-examined after loading 20 mg of prasugrel. We treated 98 consecutive patients between January 2018 and July 2018, and 24 patients (24.5%) had resistance to clopidogrel. Nineteen patients were female. The mean PRU value at admission was 238.5±36.9 and the percentage inhibition value was 4.8±6.3%. After the use of prasugrel, the mean PRU and percentage inhibition values were measured as 124.9±49.9 and 48.0±19.24, respectively. All patients except one patient had a PRU inhibition value as a responder. There was no hemorrhage or thromboembolic complication during mean 1.5 months follow-up after embolization procedure. In conclusion, in patients resistant to clopidogrel, the low dose prasugrel seems to be effective in keeping the percentage inhibition value of PRU within the normal range in treatment of cerebral aneurysm. Further study will be needed to determine the optimal dose of prasugrel to enhance prevention effect of thromboembolism and to reduce hemorrhagic complications during stent assisted coiling.

Treatment of Propriospinal Myoclonus at Sleep Onset

No abstract available.

Sleep Disturbances and Predictive Factors in Caregivers of Patients with Mild Cognitive Impairment and Dementia

BACKGROUND AND PURPOSE: We examined the characteristics of sleep disturbances and sleep patterns in the caregivers of patients with amnestic mild cognitive impairment (aMCI) and dementia. METHODS: We prospectively studied 132 patients (60 with aMCI and 72 with dementia) and their caregivers, and 52 noncaregiver controls. All caregivers and controls completed several sleep questionnaires, including the Pittsburgh Sleep Quality Index (PSQI). The patients were administered neuropsychological tests and the neuropsychiatric inventory to evaluate their behavioral and neuropsychiatric symptoms of dementia (BPSD). RESULTS: The PSQI global score was 6.25+/-3.88 (mean+/-SD) for the dementia caregivers and 5.47+/-3.53 for the aMCI caregivers. The Insomnia Severity Index (ISI) and short form of the Geriatric Depression Scale (GDS-S) predicted higher PSQI global scores in aMCI caregivers, and higher scores for the ISI, Epworth Sleepiness Scale (ESS), and GDS-S in dementia caregivers. BPSD, including not only agitation, depression, and appetite change in dementia patients, but also depression, apathy, and disinhibition in aMCI patients, was related to impaired sleep quality of caregivers, but nighttime behavior was not. Age and gender were not risk factors for disturbed sleep quality. CONCLUSIONS: Dementia and aMCI caregivers exhibit impaired quality of sleep versus non-caregivers. ISI, GDS-S, and ESS scores are strong indicators of poor sleep in dementia caregivers. In addition, some BPSD and parts of the neuropsychological tests may be predictive factors of sleep disturbance in dementia caregivers.

Superior Rectus-Levator Palpebrae Complex Myositis Presenting as Isolated Painless Ptosis

No abstract available.

Bilateral Striopallidodentate Calcinosis in Chromosome 22q11.2 Deletion Syndrome

Symptomatic bilateral striopallidodentate calcinosis is required to identify the underlying causes. Disorder of calcium metabolism, such as hypoparathyroidism is the most common cause. We report a patient with hypoparathyroidism induced intracranial calcification who presented seizure and psychotic symptoms in adult and finally diagnosed as a choromosome 22q11.2 deletion syndrome.