Transient paralysis by loculation of the injectant associated with epidural injection

@#Transient paralysis occasionally occurs after an epidural injection, but the reasons for this are still unknown. We present here a patient with transient paralysis following loculation of the injectant associated with the procedure. A 50-year-old woman with a history of two previous spinal operations complained of a burning sensation and radiating pain. A caudal block and right S1 transforaminal epidural block were performed. Loculation of the block injectant into the right L5 and S1 epidural space was confirmed through computed topographic imaging. She showed transient weakness of the right lower limb, which completely recovered after 1 day. This case shows that extra care should be taken when performing an epidural injection in a patient with adhesions around the injection site and appropriate adjustments should be made to the volume of the injectant.

Pusher syndrome improved by secondary newly developed stroke

@#Pusher syndrome is a neurological disorder where the patient actively pushes away from the non-hemiparetic side following brain damage. We experienced a case in whom intractable pusher syndrome associated with thalamic hemorrhage improved following a newly developed pontine infarction. A 63-year-old man showed severe pusher syndrome after an initial thalamic hemorrhage. After approximately 2 years, a pontine infarction developed and improved the persistent pusher syndrome. We postulate that it resulted from involvement of the medial lemniscus with interruption of the distorted upward proprioceptive signal of body orientation.

The Clinical Significance of the Mini-Nutritional Assessment and the Scored Patient-Generated Subjective Global Assessment in Elderly Patients With Stroke

OBJECTIVE: To evaluate the clinical usefulness of the subjective assessments of nutritional status (Mini-Nutritional Assessment [MNA] and scored patient-generated subjective global assessment [PG-SGA]), compared with the objective (hematological, biochemical, and anthropometric) assessments, and to identify the correlation between the MNA and the scored PG-SGA in elderly patients with stroke. METHODS: Thirty-five stroke patients, aged 60 to 89 years old, participated in our study. The MNA, the scored PG-SGA and objective factors were evaluated. The objective malnutrition state was defined based on laboratory outcomes. According to the MNA and the scored PG-SGA classifications, total patients were respectively divided into three groups; well-nourished (W), at risk of malnutrition (R), and malnourished (M), and into four groups; normally nourished (A), suspected or mildly malnourished (B), moderately malnourished (C), and severely malnourished (D). RESULTS: Mean age and body mass index of subjects were 70.6 years and 22.2 kg/m2, respectively. Twenty-six (74.3%) patients were identified to be at an objectively malnourished state. In MNA, 3 (8.6%) patients were classified as group W, 13 (37.1%) as R, and 19 (54.3%) as M. Total MNA scores and three categorization had mild correlation with objective grouping (r=0.383, r=0.350, p<0.05, respectively). Restructuring into two groups by combining group R and M made strong correlation (r=0.520, p<0.01). On the basis of scored PG-SGA, 6 (17.1%) patients were sorted as group A, 10 (28.6%) as B, 15 (42.9%) as C, and 4 (11.4%) as D, respectively. Total scores and the grouping into four indicated meaningful correlation with the objective distinction (r=-0.403, p<0.05, r=0.449, p<0.01, respectively). There was a significant correlation between the MNA scores and the PG-SGA scores (r=-0.651, p<0.01). CONCLUSION: It is proposed that the MNA and the scored PG-SGA would be useful in screening malnourished elderly patients with stroke.

Fear of Falling in Subacute Hemiplegic Stroke Patients: Associating Factors and Correlations with Quality of Life

OBJECTIVE: To determine the associating factors of fear of falling (FOF) and the correlations between FOF and quality of life (QOL) on subacute stroke patients in Korea. METHOD: Fifty hemiplegic subacute stroke patients in our clinic were recruited. We directly asked patients with their fear of falling and interviewed them with the Korean version of falls efficacy scale-international (KFES-I). We divided the participants into two groups; with FOF and without FOF. We compared these groups with the strength of hemiplegic hip abductor, knee extensor, ankle plantar flexor, functional ambulation category (FAC) scale, stroke specific quality of life (SSQOL), and hospital anxiety depression scale (HADS). RESULTS: Thirty-four participants were enrolled, and more than half of the patients with subacute stroke had FOF. We compared the patients with and without FOF. According to the results, FOF was associated with the strength of hemiplegic hip abductor, knee extensor and ankle plantar flexor, FAC, total SSQOL, and domains (energy, mobility, self care, upper extremity function) of SSQOL (p<0.05). FOF was also associated with the anxiety score of HADS (p<0.05). KFES-I had a significant negative correlation with the strength of hemiplegic hip abductor, knee extensor and ankle plantar flexor, FAC, total SSQOL, and domains (energy, mobility, self care, upper extremity function) of SSQOL (p<0.01). CONCLUSION: The FOF was associated with not only QOL but also with the physical and psychological factors, and in particular, anxiety. Therefore, further concerns about FOF in subacute stroke patients might be required.

Cyclic Vomiting Syndrome Developed after Stroke

Cyclic vomiting syndrome is characterized by recurrent episodes of stereotyped vomiting separated by regular symptom-free periods. We describe a case of cyclic vomiting syndrome developed after stroke, which has not been reported to date. A 69-year-old woman experienced recurrent vomiting following left cerebral infarct. The patient's vomiting pattern was consistent with cyclic vomiting syndrome, and the diagnosis of cyclic vomiting syndrome was established by exclusion of other known disorders which could have resulted in vomiting. She was treated with imipramine hydrochloride and her symptom was well controlled.

Treatment of Dysphagia with Pyridostigmine Bromide in a Patient with the Pharyngeal-Cervical-Brachial Variant of Guillain-Barre Syndrome

A 24-year-old male developed bulbar palsy, ophthalmoplegia, ptosis, and shoulder weakness bilaterally 2 weeks after he had experienced an upper respiratory infection. The electrodiagnostic study demonstrated axonal polyradiculoneuropathy. The repetitive nerve stimulation study (RNS) showed no significant decrement of the compound muscle action potentials (CMAPs). The videofluoroscopic swallowing study (VFSS) showed severe impairment of the pharyngeal phase of swallowing. He was diagnosed as having the pharyngeal-cervical-brachial variant of Guillain-Barre syndrome. The patient's dysphagia was not improved for 3 months. A follow up RNS showed a significant decrement of the CMAPs. Pyridostigmine bromide was tried to improve the dysphagia. The patient showed immediate improvement of his dysphagia on the VFSS after the trial with pyridostigmine bromide. Pyridostigmine bromide was given before each meal for 8 days and he showed continuous improvement of his dysphagia. The follow up VFSS after 3 months showed complete recovery of dysphagia.

The Influence of Sour Taste on Dysphagia in Brain Injury: Blind Study

OBJECTIVE: To verify the influence of sour taste on swallowing and the presence of reflex cough when sour material was swallowed in patients with dysphagia secondary to brain injury. METHOD: Fifty dysphagic brain injury patients who underwent videofluoroscopic swallowing study (VFSS) were recruited. The patients who had shown severe aspiration at 2 ml of liquid were excluded. The dysphagic patients were given 5 ml each of a sour tasting liquid (SOUR) and a thin liquid barium (LIQUID) in random order. An expert analyzed the result of VFSS by reviewing recorded videotapes. Analysis components consisted of the Penetration-Aspiration-Scale (PAS) score, oral transit time (OTT), pharyngeal transit time (PTT), pharyngeal delay time (PDT) and the reflex cough presence. RESULTS: The PAS score for SOUR was significantly lower than the one for LIQUID (p=0.03). The mean OTT for SOUR was significantly shortened compared to that for LIQUID (p=0.03). The mean PTT and PDT were also shortened in SOUR, although the differences were not statistically significant (p=0.26 and p=0.32, respectively). There was no significant difference between SOUR and LIQUID regarding the presence of reflex cough (p=1.00). CONCLUSION: The sour taste could enhance sensorimotor feedback in the oropharynx, thus lowering the chances of penetration-aspiration caused by shortening of the oropharyngeal passage times. There was no significant difference in the presence of reflex cough produced between LIQUID and SOUR.

Change of Visual Perception in Geriatric Strokes after Visuomotor Coordination Training

OBJECTIVE: To assess the effect of visuomotor coordination training on the visual perception of geriatric stroke patients. METHOD: Thirty (n=30) cooperative geriatric stroke patients were randomly assigned into 2 groups. The control group received conventional rehabilitation therapy, and intervention group received additional visuomotor coordination training with Dynavision for 30 minutes a day, 3 times a week for 4 weeks. We assessed visual perception and functional status before and after intervention by measuring K-MMSE, K-MBI, K-DRS scores, and by conducting Computerized Neuropsychological Test (CNT) (Maxmedia, Seoul, Korea) 1) visual memory; visual span backward & forward, 2) visual attention; visual continuous performance test (correct response, reaction time), 3) visuomotor coordination; trail making A test. RESULTS: The intervention group showed significant improvement in visual attention (p0.05). Both groups showed significant increase in K-MMSE and K-MBI scores (p0.05). CONCLUSION: Dynavision training improved the primary visual skill - visual attention, but did not improve higher order visual skills, such as visual memory, visuomotor coordination, cognition or functional performance in the elder stroke patients. Dynavision could be a useful tool for cognitive rehabilitation in patients with cognitive impairment and attention deficit by improving visual attention.

Unilateral periodic limb movements during sleep as a prodromal stroke symptom: A case report

Periodic limb movements in sleep (PLMS) is characterized by recurrent episodes of repetitive, stereotyped limb movements that occur during sleep. There have been a few reports on this condition developing after a stroke, but the movements in these reports were not prodromal stroke symptoms. We describe a case in which PLMS developed as a prodromal stroke symptom. A 78-year-old man experienced right hemiplegia and dysarthria following left striatocapsular infarct. After acute care, he was transferred to our center for rehabilitation. During rehabilitation, he complained of right-side involuntary leg movements during sleep. According to his history, it had been developed 10 days before the appearance of right hemiplegia. Polysomnography confi rmed the diagnosis of PLMS. We propose that PLMS can be a prodromal stroke symptom resulting from a pyramidal tract lesion without involvement of sensory components.

Epidural Abscess and Vertebral Osteomyelitis Induced by Epidural Injection: A case report

Epidural abscess and vertebral osteomyelitis induced by epidural injection is rare but one of the most serious complications. A 58-year old woman complained of aggrevating radicular pain to bilteral lower legs, tenderness on coccygeal area and claudication, after epidural injection for management of intractable sciatica. MRI and ultrasound revealed epidural abscess compressing dural sac at the level of L5-S1 vertebral body, sacrococcygeal abscess, and later S5- 1stcoccyx osteomyelitis. We report epidural abscess and vertebral osteomyelitis induced by caudal epidural injection.

Nocturnal Polyuria Developed in Patients with Central Pontine Myelinolysis: A case report

Central pontine myelinolysis is a demyelinating disease of central pons. Nocturnal polyuria is defined as increased urination during nighttime with a nocturnal fraction exceeding from 20% to 33%. We have experienced nocturnal polyuria developed in two patients with central pontine myelinolysis. In these cases, serum antidiuretic hormone and urine osmolality were lower at nighttime than daytime. It suggests that nocturnal polyuria is caused by abnormal diurnal variation of antidiuretic hormone. In the first case, nocturnal polyuria was recovered spontaneously and also follow up brain MRI showed decreased signal intensity in pons. In the second case, nocturnal polyuria was improved after the treatment of intranasal desmopressin. It appeares that central pontine myelinolysis can cause nocturnal polyuria due to the interruption of antidiuretic hormone pathway. The symptom of nocturnal polyuria can be treated by desmopressin.

Usefulness of Scintigraphic Swallowing Study in Brain Injury Patients with Laryngeal Aspiration

OBJECTIVE: We investigated the usefulness of the scintigraphic swallowing study in selecting the patients with low risk of aspiration pneumonia among those who showed small amount of laryngeal aspiration in videofluoroscopy. METHOD: Scintigraphic swallowing study was performed in 22 patients with brain injury who showed small amount of laryngeal aspiration in videofluoroscopy. Oral feeding was tried in the patients who showed airway clearing function or no aspiration in scintigraphic swallowing study, and they were followed up for possible aspiration pneumonia. RESULTS: Total of sixteen patients showed no aspiration in scintigraphic swallowing study. Five patients showed laryngeal aspiration, but preserved airway clearing function. One patient showed impairment of airway clearing function. Oral feeding was tried in 21 patients. Oral feeding was successful in 18 of 21 patients but not in 3 patients because of dysphagia or cough. Only 1 patient developed pneumonia after 246 days of follow up. CONCLUSION: Scintigraphic swallowing study is useful to select the patients with low risk of aspiration pneumonia among the patients who showed small amount of laryngeal aspiration in videofluoroscopy.

The Shoes Designed to Inhibit Excessive External Rotation of Hemiplegic Foot with Plastic Ankle Foot Orthosis: A case report

Hemiplegic patients with an ankle foot orthosis (AFO) has a tendency to show external rotation of affected side foot. External rotation inhibiting shoes (ERIS) were designed to inhibit excessive rotation of hemiplegic foot. ERIS were applied to two hemiplegic patients who were able to walk independently with a plastic AFO. Both of them showed an excessive external rotation of hemiplegic foot after AFO apply. Each patient tried to walk with a pair of common shoes first and ERIS later. The external rotation angle, step length, stride length, cadence, speed were measured by footprint method. The external rotation angle of hemiplegic foot was significantly decreased with ERIS than with common shoes. However they did not show consistent improvement in the step length, stride length, cadence and speed. We reported that hemiplegic patients who walked with ERIS showed remarkable reduction in excessive external rotation of hemiplegic foot.