Pain Control and Sedation in Neuro Intensive Critical Unit

Neurocritical patients who can self-report pain use the 0-10 numerical rating scale (NRS, verbal or visual form). However, critically ill patients whose nervous systems cannot express pain use the behavioral pain scale (BPS) and the critical care pain observation tool (CPOT) behavioral pain assessment tools. These tools reveal pain-related changes in movement, facial expression, posture, and physiological indicators such as heart rate, blood pressure, and respiratory rate. In pain control, it is first essential to reduce unnecessary painkillers through non-drug therapy and maximize the effect of the administered analgesics. For nonneuropathic pain, narcotic analgesics such as fentanyl, hydromorphone, morphine, and remifentanil are administered intravenously. Gabapentin, pregabalin, and carbamazepine are recommended along with narcotic analgesics for neuropathic pain control. In addition, nonnarcotic analgesics for multi-modal analgesia are used to reduce the use of narcotic analgesics or the side effects of narcotic analgesics. In the intensive care unit (ICU), the sedation-agitation scale (SAS) and the Richmond agitation-sedation scale (RASS) are used to determine the depth of sedation to be maintained during shallow or deep sedation, considering the condition of the critically ill patient. When selecting sedatives for critically ill patients, preferentially consider nonbenzodiazepines such as propofol or dexmedetomidine rather than benzodiazepines such as midazolam or lorazepam. In addition, patients use painkillers or sedatives for over a week, and neurological changes or physiological dependence may occur. Therefore, clinicians should evaluate the critically ill patient’s condition, and sedatives and painkillers should be reduced or discontinued.

Practical Drug Treatment Recommendations on the Drug Refractory Epilepsy Patients: 2021 Clinical Guideline Subcommittee for Epilepsy in the Korean Neurological Association

One third of the overall epilepsy population are estimated to be a drug refractory epilepsy (DRE), defined as the patients who failed to control seizure reduction, even tried two or more appropriate antiepileptic drugs (AEDs) trials. Those people need additional AEDs trials or other treatment options (resective surgery, neuromoulation, etc.). Here, we, clinical guideline committee of the Korean Neurological Association (KNA) introduce the recommendations of AEDs treatments including not only old and new AEDs currently available in Korea but also AEDs planned to be launched in the new future for DRE patients with literature review to help efficient decision of the clinician. The authors reviewed literatures and assessed efficacy and tolerability on 12 currently available and four newly introduced/or planned AEDs applied to DRE patients, published from November 2015 to July 2021. Brivaracetam, eslicarbazepine, canabidiol and cenobamate are the four AEDs that are newly introduced or planned to be launched soon. The reviewed articles are publications after November 2015, 2018 American Association of Neurology guideline, new AEDs which were introduced or planned to be launched as of 2021. All AEDs are classified based on the therapeutic rating scheme, generating recommendations. Overall 173 papers have been reviewed and analyzed for recommendation rationales. KNA introduce additional add-on treatment or conversional monotherapy guidelines on the drug refractory focal and generalized epilepsy. We hope these guidelines or recommendations to help clinical decision for the treatment of drug refractory epilepsy patients

Korean Neurological Terminology

Experts have communicated and developed field of study through scientific terminology. However, medical terminologies are no longer used only by experts. As technology advances and society becomes more complex, the public encounter medical terminology more often. Therefore, medical experts need to revise the medical terms in simple and easy way to facilitate communication with the public. Korean Neurological Association has been make an efforts to manage the Korean terminologies in field of neurology. In this paper, we summarized principles of the use in Korean neurological terminologies, and frequently misused terms.

Renal Cholesterol Embolism during Warfarin Treatment

Cholesterol embolization syndrome (CES) usually occurs after endovascular procedures, it may also occurs after using anticoagulants and thrombolytics. We report a case of 66-year-old man with sudden elevation of creatinine after using warfarin due to cortical infarction. Histologic examinations revealed a cholesterol cleft on the arcuate artery. We concluded it as warfarin induced atheroembolic renal disease. Careful observation of kidneys is necessary in the case of renal abnormalities after using anticoagulation, considering the possibility of cholesterol embolism due to anticoagulant therapy.

Acute Ischemic Stroke in Moyamoya Syndrome Associated with Thyrotoxicosis

BACKGROUND: A few cases of moyamoya syndrome associated with thyrotoxicosis have been reported. However, studies on the association of hyperthyroidism with moyamoya syndrome are insufficient. CASE REPORT: Here we report a case of hyperthyroidism associated with moyamoya syndrome in a 41-year-old woman with aphasia and right side weakness. Brain imaging revealed acute cerebral infarction of left middle cerebral artery territory and occlusion of bilateral distal internal carotid arteries. CONCLUSION: Antithyroid medication stabilized the patient's neurologic deterioration, suggesting that thyrotoxicosis could aggravate acute cerebral infarction caused by moyamoya syndrome.

A Practical Definition of Epilepsy

In 2005, the ILAE conceptually defined epilepsy as a disorder of the brain, characterized by an enduring predisposition to generate epileptic seizures and by its psychosocial consequences. In clinical practice, this definition of epilepsy is usually taken to mean at least two unprovoked seizures more than 24 h apart. The operational definition for special circumstances that do not meet the criteria of two unprovoked attacks has been recommended. In 2014, the ILAE refined the practical definition of epilepsy. With this definition, epilepsy is a disease of the brain with either: (1) at least two unprovoked (or reflex) seizures occurring more than 24 h apart; (2) one unprovoked (or reflex) seizure and a probability of further seizures similar to the general recurrence risk (at least 60%) after two unprovoked seizures, occurring over the next 10 years; (3) diagnosis of an epilepsy syndrome. Epilepsy is considered to be resolved for individuals past the applicable age of an age-dependent epilepsy syndrome or those who have remained seizure-free for the past 10 years, without seizure medicines for the past 5 years.

Relation of Bony Carotid Canal Diameter and Clinical Manifestations in Patients with Moyamoya Disease / 대한임상신경생리학회지

BACKGROUND: Moyamoya disease is characterized by a progressive stenosis or occlusion of the intracranial internal carotid artery and/or the proximal portion of the anterior cerebral artery and middle cerebral artery. Whether the onset time was childhood or adulthood, the bony carotid canal diameter might be different, but reflects the size of internal carotid artery passing through the bony carotid canal. In this study, we aimed to identify the relationship between bony carotid canal diameter and clinical manifestation. METHODS: 146 consecutive patients diagnosed with moyamoya disease by brain imaging studies were included. We measured the diameter of a transverse portion of bony carotid canal on bone window of a brain computed tomography(CT) image. Patients were divided into two groups, ischemic or hemorrhagic stroke according to clinical manifestation. As a result, 115 patients were included. The Suzuki stage was used as criteria for disease progression. RESULTS: Bony carotid canal diameter was 3.6 ± 0.5 (right) and 3.6 ± 0.4 (left) in the hemorrhagic stroke group, and 3.7 ± 0.4 (right) and 3.6 ± 0.4 (left) in the ischemic stroke group. The bony carotid canal diameter of the moyamoya vessels (3.6 mm) was smaller than the diameter of non-moyamoya vessels (3.8 mm), significantly (p= 0.042). However, there was no difference in the collateral patterns and clinical manifestation in a comparison of both groups. CONCLUSIONS: In our study, there was no significant difference of clinical manifestations and collateral patterns depend on the bony carotid canal diameter in patients with moyamoya disease. These findings suggest that the clinical presentations of moyamoya disease are not related to the onset time of the disease.

Reversible Encephalopathy Caused by Reactive Hypereosinophilia due to Toxocariasis

A 69-year-old male admitted to the psychological department due to delusion. One week later, he developed pneumonia and deep drowsy mental status. Despite improvement of pneumonia, his mental status got worse and he was referred to neurological department. The complete blood count tests showed repeated hypereosinophilia. The serologic tests revealed toxocariasis. He was treated with steroid and albendazole and his mental state rapidly improved. Toxocariasis is a common cause of reactive hypereosinophilia, which may be an underestimated etiology of reversible encephalopathy.

Post-Traumatic Ictogenesis and Epileptogenesis / 대한신경손상학회지

For ictogenesis, initial step is intrinsic bursts of pacemaker neurons and, through exaggerated circuits or networks, the involved neurons become hyperexcitable state. Hypersynchrony of hyperexcitable neurons can induce paroxysmal depolarization shift for developing seizure. The mechanism underlying the development of post-traumatic epilepsy still remains to be elucidated. By traumatic brain injury, breakdown of blood-brain barrier (BBB) may lead network changes, long-lasting epileptiform activity and eventual neurodegeneration. Recently the concept of inflammation and epileptogenesis is widely accepted. In the surgically resected brain tissue from refractory partial epilepsy patients, there are hallmarks of a chronic inflammatory state and, also, via animal experiments, we can find the role of inflammation in the genesis of seizure and epilepsy. Inflammatory mediators (IL-1b, TGF-beta1 and COX-2) are associated with the epileptogenic brain. They can reduce seizure threshold, induce neurodegeneration, neurogenesis, and synaptic plasticity, and also disregulate BBB permeability. The increase in knowledge about a role of inflammation in epileptogenesis may support the use of specific anti-inflammatory drugs for developing disease-modifying treatments that can interfere epileptogenesis.

Korean Version of Revised Terminology and Concepts for Organization of Seizures and Epilepsies: Report of the ILAE Commission on Classification and Terminology, 2005-2009 / 대한간질학회지

No abstract available.

Successful Treatment of Intractable Hiccup with Levetiracetam / 대한간질학회지

Hiccups may be considered a form of myoclonus of diaphragm. Valproic acid has been considered the drug of choice in treatment of intractable hiccups; however, its various adverse events limit its use in the clinical basis, especially in elderly or complicated patients. Levetiracetam was known as a safe antiepileptic drug. However, the anti-hiccup property of the levetiracetam has been rarely reported. We report a 69-year old male patient who developed sudden persistent hiccups and was successfully treated with levetiracetam. Levetiracetam should be considered as alternative treatment option in selected patients with intractable hiccups.

Korean Version of Revised Terminology and Concepts for Organization of Seizures and Epilepsies: Report of the ILAE Commission on Classification and Terminology, 2005-2009

No abstract available.

Successful Treatment of Intractable Hiccup with Levetiracetam

Hiccups may be considered a form of myoclonus of diaphragm. Valproic acid has been considered the drug of choice in treatment of intractable hiccups; however, its various adverse events limit its use in the clinical basis, especially in elderly or complicated patients. Levetiracetam was known as a safe antiepileptic drug. However, the anti-hiccup property of the levetiracetam has been rarely reported. We report a 69-year old male patient who developed sudden persistent hiccups and was successfully treated with levetiracetam. Levetiracetam should be considered as alternative treatment option in selected patients with intractable hiccups.

Korean Survey on the Epileptic Women with Child Bearing Age / 대한간질학회지

The first nation-wide, hospital-based survey on the epileptic women with child bearing age had conducted between June 2004 and May 2005, under the supervision of Korean Epilepsy Society. One thousand epileptic women in reproductive age from 46 hospitals and 500 age-matched healthy women were subjected to this study. Besides physiological issues including menstruation, contraception, pregnancy, and lactation, problems in social and individual daily life, concomitant illness, factors associated with antiepileptic drug treatments were also inquired. Compared to healthy group, higher incidence of menstruation irregularity, contraception and artificial abortion were reported in women with epilepsy. The main reason for contraception and artificial abortion in epileptic women was fear about fetal malformations. Almost half of epileptic women were reluctant to breast feeding because of their disease and/or medications. Also, epileptic women answered to have problems in social life, marriage, job recruitment and need proper information about their disease. Epileptic women, especially in reproductive age, confronted many additional troubles and physicians should be aware of these problems in managing those patients. Misconceptions about pregnancy, contraception, lactation should be undeceived by adequate education.

Efficacy and Safety of Levetiracetam as Adjunctive Treatment in a Multicenter Open-Label Single-Arm Trial in Korean Patients with Refractory Partial Epilepsy: Over 1-Year Follow-Up / 대한간질학회지

PURPOSE: This prospective, open-label study evaluated the efficacy and safety of adjunctive levetiracetam (LEV) in Korean adults with uncontrolled partial epilepsy. METHODS: A total of 100 patients whose partial seizures were inadequately controlled on their current antiepileptic drugs were enrolled and received LEV (1000-3000 mg/day). Seizure count and adverse events (AEs) were recorded by patients. Global evaluation scale (GES) and quality of life (QOLIE-31) were also evaluated. Additionally effectiveness over 1-year follow-up was investigated. RESULTS: Ninety-two patients completed the short-term 16-week trial. The median percent reduction in weekly seizure frequency over the treatment period was 43.2%. The > or =50% and > or =75% responder rates were 45.4% and 36.1%, respectively. Seizure freedom was observed in 17 patients throughout the initial 16-week treatment period. On investigator's GES, 81 patients were considered improved, with 41 patients showing marked improvement. Most QOLIE-31 scales improved significantly. At the end of the trial, 79 chose to continue follow-up treatment with LEV. At the follow-up visit (ranging 60 to 81 weeks), 64 patients were still taking LEV; during the last 16 weeks, 65.6% of patients had > or =50% reduction, 50.0% had > or =75% reduction, and 35.9% had a 100% reduction. Seven patients showed continuous seizure freedom from the initiation of LEV treatment. During the entire treatment period, LEV was withdrawn in 36 patients; due to lack of efficacy in 22, AEs in six, both in three, other reasons in five. CONCLUSION: Adjunctive LEV therapy in patients with refractory partial epilepsy was effective and well-tolerated, as evidenced by the high seizure freedom and retention rates in both the short-term trial and the long-term follow-up.

Is the Intensive Anticonvulsant Treatment for Control of Acute Posthypoxic Myoclonic Status Epilepticus Necessary?

BACKGROUND: Acute posthypoxic myoclonic seizure is not an uncommon presentation in clinical practices. However, there have been only a few reports which include detailed description on the treatment of acute posthypoxic myoclonic status. METHODS: We retrospectively analyzed the etiology, clinical course, nature and duration of myoclonus after hypoxic brain damage during a ten year period from 1992 to 2002. Patients who had possible explanations for myoclonic seizure other than hypoxic-ischemic events were excluded. RESULTS: Eighty-two patients aged 24 to 81 years old were included in this study. All but 3 patients with pulmonary edema had a history of cardiorespiratory arrest caused by probable cardiogenic origin, acute asthma attack and upper airway obstruction. Ictal EEGs demonstrated intermittent generalized spike and polyspike activities or biPLEDs. Most patients died within a week and 6 patients remained in persistent vegetative states. The clinical outcome was not affected by the drug response of myoclonic status epilepticus or etiology of hypoxia. CONCLUSIONS: Posthypoxic myoclonic status reflects severe and diffuse cortical damage, and implies a very poor prognosis. It may be a transient manifestation of severe cortical damage before massive and irreversible neocortical neuronal death, and aggressive anticonvulsant drug treatment would not be necessary in most patients.

Concomitant Absence and Occipital Lobe Epilepsy in an Adolescent

The incidence of absence and occipital lobe epilepsy appearing in the same young individual is quite rare. A fourteen year-old girl has had two types of recurrent seizures: 1)simple partial seizure with secondary generalization probably originating in the left occipital lobe, and 2)absence seizure. Electroencephalogram demonstrated frequent spikes on the left occipital region with or without bilateral synchronization and generalized 3 Hz spike and wave complexes during hyperventilation procedure and photic stimulation.

Predictive Factors for the Relapse of Seizure after Withdrawal from the Monotherapy of the Antiepileptic Drug in Cryptogenic Partial Epilepsy / 대한간질학회지

PURPOSE: There is no apparent consensus about the successful policy of antiepileptic drug (AED) withdrawal, nor about definite factors to make patients remain seizure-free. We attempted to find out the predictive factors for seizure relapse after withdrawal of AED in patients with cryptogenic partial epilepsy. METHODS: This is a case-controlled and hospital-based observational study. A total of 91 crytogenic partial epileptic patients in whom seizure had been successfully controlled by AED monotherapy for more than two years were subjected to drug withdrawal. Patients with history of febrile convulsion, status epilepticus, and abnormal intelligence were excluded. Subjects were divided into two groups; the first group consisted of patients with seizure free more than 2 years after withdrawal of AED and another group with seizure recurrence during tapering or after drug withdrawal. The group with successful withdrawal had 48 patients, and, in 43 patients, seizure was recurred. Clinical profiles were compared between the two groups. RESULTS: There was no significant difference in gender, family history, age at onset, number of seizure attacks before AED initiation, duration of illness before treatment, and seizure or epilepsy classifications between the two groups. However, an abnormal EEG finding was associated with seizure relapse (Chi-square test p<0.05). On the other hand, the number of seizure attacks and the interval between the AED initiation and the time when a seizure free period was achieved had a correlation with seizure relapse, but was not statistically significant. CONCLUSIONS: Abnormal EEG findings was the predictive factor for seizure relapse after withdrawal from AED monotherapy in cryptogenic partial epilepsy.

Factors related to Blood Pressure Reduction during Acute Period of Ischemic Stroke

BACKGROUND: High blood pressure (BP) or BP reduction in acute ischemic stroke may be associated with poor outcomes. We investigated the factors associated with BP changes in acute ischemic stroke. METHODS: We examined consecutive ischemic stroke patients having symptom onset within 24 hours. We excluded patients with cardioembolism or stroke of other determined etiology. We assessed initial systolic/diastolic BP and the degree of BP reduction for 3 hospital days. We analyzed the following potential predictors: age, sex, stroke risk factors, severity of neurologic deficits, infarct size, occlusive lesions in the main cerebral arteries, and antihypertensive medication use. RESULTS: 112 patients were evaluated. The initial systolic/diastolic BP was 153/90 mmHg and systolic/diastolic BP reduction was 22/8 mmHg. In multivariate analyses, initial systolic BPs were significantly higher in patients with hypertension (p=0.007), and were negatively associated with prior regular antihypertensive medication use (p=0.018). Initial high systolic and diastolic BPs were strong predictors of systolic and diastolic BP reduction, respectively (p<0.001 and p<0.001). Diabetes mellitus was also an independent predictor of systolic BP reduction (p=0.011). CONCLUSIONS: Initial high BP was significantly associated with high degree of BP reduction in acute ischemic stroke. Acute ischemic stroke patients with diabetes mellitus may show significant systolic BP reduction, which requires further confirmation.

Paroxysmal Stabbing Headache in the Retroauricular Regions

BACKGROUND: Paroxysmal stabbing or ice pick-like headaches located in the extratrigeminal areas are not uncommon in clinical practice. However, clinical characteristics of acute stabbing headaches initially presented in the retroauricular regions have rarely been described in detail. METHODS: Among the subjects referred to Hallym University Medical Center, due to the acute-onset stabbing headache during the last five years, sixty-six consecutive patients in which stabbing symptoms were confined to the retroauricular regions at initial presentation were prospectively included. RESULTS: All patients were neurologically and otologically considered to be normal at the initial presentation. The nature of pain lasted for short intervals of time, and were moderate to severe in intensity for most patients. All but five ran a self-limited benign course, recovering completely in 3 days to 30 days, mostly within 2 weeks. During the clinical course, subsequent Bell's palsy developed in 2 patients, and otic or cervical zoster lesions followed in three cases. Those among the 61 subjects with unknown etiology, the headaches were preceded by flu-like symptoms or upper respiratory tract infections in 21 subjects (34%) and physical, mental or both kinds of stresses were reported in 15 subjects. CONCLUSIONS: Most of paroxysmal stabbing headaches confined to the retroauricular regions are very short-lasting in nature, and show self-limiting and benign course, suggesting lesser occipital neuralgia or a variant of primary stabbing headache involving cervical nerves. However, the possibility of subsequent zoster infection or peripheral type of facial palsy should be considered, even though neurologically not remarkable at initial presentation.