Co-occurrence of Marchiafava-Bignami Disease and Alcoholic Polyneuropathy in Chronic Alcoholic Patient Who Had Past History of Wernicke Encephalopathy: a Case Report

Marchiafava-Bignami disease (MBD), Wernicke encephalopathy (WE) and alcoholic polyneuropathy (AP) are distinct diseases and all have strong relationship with chronic alcoholism. A 70-year-old male who had altered mentality and ataxia of both lower limbs and had past history of WE 3 years previously admitted with 6 months history of impaired walking. He also had a symptom of altered sensorium by impaired consciousness for 2 days. In brain magnetic resonance imaging, the body, splenium of corpus callosum and bilateral frontal cortex were involved. The patient was diagnosed with MBD on the basis of the clinical features and the brain imaging findings. The electrodiagnostic findings implied demyelinating neuropathy in all extremities. He failed to recover his mentality and the function of the limbs remained poor finishing several treatment options including medications and physical therapy. The poor prognosis of this patient is thought to be associated with cortical involvement of MBD. We reported this very rare case who was affected by 3 distinct diseases of MBD, AP, and WE as complications of chronic alcohol abuse. Moreover, the case was relevant to a rare clinical presentation of MBD with cortical involvement which was associated with poor prognosis.

Cephalic Index of Korean Children With Normal Brain Development During the First 7 Years of Life Based on Computed Tomography

Objective@#To identify the normal range, distribution, and age-dependent differences in the cephalic index (CI) of Korean children with normal brain development and develop a classification of the current CI for Korean children up to 7 years of age. @*Methods@#We retrospectively analyzed 1,389 children who visited our hospital in the emergency room between October 2015 and September 2020 because of suspected head injuries. Finally, 1,248 children (741 male and 507 female) were enrolled after excluding abnormal medical or familial history and divided into 10 groups by age. The CI was measured using brain computed tomography and calculated according to the following equation: cephalic width/cephalic length×100. @*Results@#The averages of CI by age groups were as follows: 89.29 (0–3 months group, n=44); 91.41 (4–6 months group, n=63); 89.68 (7–9 months group, n=62); 87.52 (10–12 months group, n=41); 87.64 (≥2 years group, n=243); 86.63 (≥3 years group, n=178); 85.62 (≥4 years group, n=232); 85.77 (≥5 years group, n=201); 85.15 (≥6 years group, n=75); and 85.34 (≥7 years group, n=109). The CI of Korean children in normal brain development was confirmed to be large, showing a notable difference compared to that of Caucasians. @*Conclusion@#The current CI of Korean children will provide a valuable reference for diagnosing and treating cranial deformities, especially dolichocephaly and brachycephaly as well as to monitor the morphology of the cranium in clinics.

Cephalic Index of Korean Children With Normal Brain Development During the First 7 Years of Life Based on Computed Tomography

Objective@#To identify the normal range, distribution, and age-dependent differences in the cephalic index (CI) of Korean children with normal brain development and develop a classification of the current CI for Korean children up to 7 years of age. @*Methods@#We retrospectively analyzed 1,389 children who visited our hospital in the emergency room between October 2015 and September 2020 because of suspected head injuries. Finally, 1,248 children (741 male and 507 female) were enrolled after excluding abnormal medical or familial history and divided into 10 groups by age. The CI was measured using brain computed tomography and calculated according to the following equation: cephalic width/cephalic length×100. @*Results@#The averages of CI by age groups were as follows: 89.29 (0–3 months group, n=44); 91.41 (4–6 months group, n=63); 89.68 (7–9 months group, n=62); 87.52 (10–12 months group, n=41); 87.64 (≥2 years group, n=243); 86.63 (≥3 years group, n=178); 85.62 (≥4 years group, n=232); 85.77 (≥5 years group, n=201); 85.15 (≥6 years group, n=75); and 85.34 (≥7 years group, n=109). The CI of Korean children in normal brain development was confirmed to be large, showing a notable difference compared to that of Caucasians. @*Conclusion@#The current CI of Korean children will provide a valuable reference for diagnosing and treating cranial deformities, especially dolichocephaly and brachycephaly as well as to monitor the morphology of the cranium in clinics.

Ultrasound Imaging of the Trunk Muscles in Acute Stroke Patients and Relations With Balance Scales

Objective@#To examine the correlation between ultrasonographic trunk muscle parameters and balance scales in mild acute stroke patients. @*Methods@#A total of 55 stroke patients with hemiparesis and motor power grade ≥4 in the manual motor test were included. The Scale for the Assessment and Rating of Ataxia (SARA), Berg Balance Scale (BBS), Timed Up and Go Test (TUG), and Trunk Control Test (TCT) were used to evaluate patient balance function. Ultrasonographic parameters were measured on both non-paretic and paretic sides of the rectus abdominis, external oblique, internal oblique, transversus abdominis, and erector spinae muscles. Resting thickness and contraction thickness were measured in all muscles, and contractility and contractility ratio were calculated based on measured thicknesses. The differences between paretic and non-paretic muscle parameters, and the correlation between ultrasonographic parameters and balance scales were analyzed. Stroke patients were divided into two groups according to their fall risk. Ultrasonographic measurements between the two groups were compared. @*Results@#All muscles’ contraction thickness and contractility were significantly different between paretic and non-paretic sides (p<0.001). Contractility ratios of all trunk muscles showed a significant correlation with SARA, BBS, TUG, and TCT (p<0.05). Contractility ratios of all muscles were significantly different between high- and low-risk fall groups (p<0.05). @*Conclusion@#The contractility ratio in stroke patients reflects their balance disturbance and fall risk and it may serve as a new parameter for ultrasound imaging of trunk muscles.

Evaluation of Ataxia in Mild Ischemic Stroke Patients Using the Scale for the Assessment and Rating of Ataxia (SARA)

OBJECTIVE: To demonstrate the utility of Scale for the Assessment and Rating of Ataxia (SARA) for evaluation of posterior circulation-related features in patients with mild stroke. METHODS: Forty-five subjects, diagnosed with acute infarction in the cerebellum, basis pontis, thalamus, corona radiata, posterior limb of internal capsule, and their National Institutes of Health Stroke Scale (NIHSS) scores ≤5 were enrolled. SARA scores were graded by the cut-off value of severity in dependency of activities of daily living (ADL). SARA, Berg Balance Scale (BBS), Timed Up-and-Go (TUG), and Trunk Control Test (TCT) were correlated in regression analysis with the modified Rankin Scale (mRS) at discharge. Correlation between SARA and other tools was analyzed. Patients were divided based on mRS at admission (group A, mRS 0–2; group B, mRS 3–5). Scores between the two groups were compared. RESULTS: Among the subjects, 48.9% (22/45) scored above 5.5 on SARA, and even 11.1% (5/45) scored higher than 14.25, which is the cut-off value of ‘severe dependency’ in ADL. SARA showed significant value for prediction of mRS at discharge. SARA was correlated with BBS (r=-0.946, p < 0.001), TUG (r=-0.584, p < 0.001), and TCT (r=-0.799, p < 0.001). The SARA, BBS, TUG, and TCT scores between were lower in group B than in group A patients. SARA as well as BBS, TUG, and TCT reflect the functional severity of all patients. CONCLUSION: SARA is a complementary tool for evaluation of the severity of ataxia in mild stroke patients with features of posterior circulation.

Acute Cerebral Infarction as a Rare Thrombotic Event in Myelodysplastic Syndrome: A Case Report

Myelodysplastic syndrome (MDS) is a bone marrow failure syndrome characterized by cytopenia that results in high risks of infection and bleeding. However, there are few reports of cerebral infarction in MDS. We reported a 72-year-old female with MDS who developed acute cerebral infarction. Clinical history of the patient revealed no definite risk factors for stroke except diabetes mellitus and dyslipidemia that was well controlled. This case represented the rare occurrence of arterial thrombosis causing acute cerebral infarction in MDS, which may be due to complex chromosomal abnormality and inflammatory processes.

Acute Cerebral Infarction as a Rare Thrombotic Event in Myelodysplastic Syndrome: A Case Report

Myelodysplastic syndrome (MDS) is a bone marrow failure syndrome characterized by cytopenia that results in high risks of infection and bleeding. However, there are few reports of cerebral infarction in MDS. We reported a 72-year-old female with MDS who developed acute cerebral infarction. Clinical history of the patient revealed no definite risk factors for stroke except diabetes mellitus and dyslipidemia that was well controlled. This case represented the rare occurrence of arterial thrombosis causing acute cerebral infarction in MDS, which may be due to complex chromosomal abnormality and inflammatory processes.

Analysis of Vertical Ground Reaction Force Variables Using Foot Scans in Hemiplegic Patients

OBJECTIVE: To analyze the differences in the vertical ground reaction force (GRF) variables of hemiplegic patients compared with a control group, and between the affected and unaffected limbs of hemiplegic patients using foot scans. METHODS: Patients (n=20) with hemiplegia and healthy volunteers (n=20) underwent vertical force analysis. We measured the following: the first and second peak forces (F1, F2) and the percent stances at which they occurred (T1, T2); the vertical force impulse (VFI) and stance times. The GRF results were compared between the hemiplegic patients and control individuals, and between the affected and unaffected limbs of hemiplegic patients. Additionally, we analyzed the impulse of the unaffected limb according to the motor assessment scale (MAS), Brunnstrom stage, and a Timed Up and Go Test. RESULTS: The F1s and F2s of the affected and unaffected limbs were significantly less than those of the normal control individuals (p<0.05). The T1s of both the affected and unaffected limbs of the patients were greater than control individuals, whilst the T2s were lower (p<0.05). Greater impulses and stance times were recorded on both sides of the patients than in the limbs of the control individuals (p<0.05). The MAS, Brunnstrom stage and Timed Up and Go Test results were significantly correlated with the VFI of the unaffected limbs (p<0.05). CONCLUSION: The high impulse values of the unaffected limb were associated with complications during gait rehabilitation. Therefore, these results suggest that unaffected limbs should also be taken into consideration in these patients.

Changes in Activation of Abdominal Muscles at Selected Angles During Trunk Exercise by Using Ultrasonography

OBJECTIVE: To investigate the changes of activation of the abdominal muscles depending on exercise angles and whether the activation of rectus abdominis differs according to the location, during curl up and leg raise exercises, by measuring the thickness ratio of abdominal muscles using ultrasonography. METHODS: We examined 30 normal adults without musculoskeletal problems. Muscle thickness was measured in the upper rectus abdominis (URA), lower rectus abdominis (LRA), obliquus externus (EO), obliquus internus (IO), and transversus abdominis (TrA), at pre-determined angles (30degrees, 60degrees, 90degrees) and additionally at the resting angle (0degrees). Muscle thickness ratio was calculated by dividing the resting (0degrees) thickness for each angle, and was used as reflection of muscle activity. RESULTS: The muscle thickness ratio was significantly different depending on the angles in URA and LRA. For curl up-URA p=0 (30degrees90degrees), p=0.44 (30degrees90degrees), p=0.44 (30degrees>90degrees), respectively, by one-way ANOVA test-and for leg raise-URA p=0 (30degrees<60degrees), p=0 (60degrees<90degrees), p=0 (30degrees<90degrees) and LRA p=0.01 (30degrees<60degrees), p=0 (60degrees<90degrees), p=0 (30degrees<90degrees), respectively, by one-way ANOVA test-exercises, but not in the lateral abdominal muscles (EO, IO, and TrA). Also, there was no significant difference in the muscle thickness ratio of URA and LRA during both exercises. In the aspect of muscle activity, there was significant difference in the activation of RA muscle by selected angles, but not according to location during both exercises. CONCLUSION: According to this study, exercise angle is thought to be an important contributing factor for strengthening of RA muscle; however, both the exercises are thought to have no property of strengthening RA muscle selectively based on the location.

Ultrasonographic Measurement of Transverse Abdominis in Stroke Patients

OBJECTIVE: To compare transverse abdominis (TrA) contractility in stroke patients with hemiparesis and healthy adults using musculoskeletal ultrasonography. METHODS: Forty-seven stroke patients with hemiparesis and 25 age-matched healthy control subjects participated in this study. Stroke patients were divided into three groups on the basis of their degree of ambulation. Group A consisted of 9 patients with wheelchair ambulation, group B of 23 patients with assisted ambulation, and group C of 15 patients with independent ambulation. Inter-rater reliability regarding ultrasonographic measurement of abdominal muscle thickness in the control group was assessed by two examiners. The TrA contraction ratio (TrA contracted thickness/TrA resting thickness) was measured during abdominal drawing-in maneuver and was compared between the patients and the control group and between the ambulation groups. RESULTS: The inter-rater reliability ranged from 0.900 to 0.947. The TrA contraction ratio was higher in the non-paretic side than in the paretic side (1.40+/-0.62 vs. 1.14+/-0.35, p<0.01). The TrA contraction ratio of the patient group was lower in the non-paretic side as well as in the paretic side than that of the control group (right 1.85+/-0.29, left 1.92+/-0.42; p<0.001). No difference was found between the ambulation regarding the TrA contraction ratio. CONCLUSION: The TrA contractility in hemiparetic stroke patients is significantly decreased in the non-paretic side as well as in the paretic side compared with that of healthy adults. Ultrasonographic measurement can be clinically used in the evaluation of deep abdominal muscles in stroke patients.

Proteomic Changes in Rat Gastrocnemius Muscle After Botulinum Toxin A Injection

OBJECTIVE: To observe the changes in protein expression induced by botulinum toxin A (BoNT-A) injection and to characterize the molecular and cellular action of mechanisms of BoNT-A injection on skeletal muscles using proteomic elements as biomarkers. METHODS: BoNT-A was injected into left gastrocnemius muscles of 12 Sprague-Dawley rats (2 months of age) at a dosage of 5 units/kg body weight. For the controls same volume of normal saline was injected to right gastrocnemius muscle of each rat. Muscle samples were obtained at 4 time points (3 rats per time point): 3, 7, 14, and 56 day post-injection. To reveal the alterations in muscle protein, we performed 2-dimensional electrophoresis (2DE) and compared Botox group and normal saline group at each time point. Altered protein spots in 2DE were identified using matrix-assisted laser desorption/ionization-time-of-flight mass spectrometer (MALDI-TOF MS) proteomics analysis. RESULTS: Compared with normal saline group, 46 protein spots showed changed protein expression. Twelve protein spots demonstrated increased volume and 34 protein spots demonstrated decreased volume. Among spots of decreased volume, 17 spots showed statistically significant differences. Thirty-eight identified proteins were associated with alterations in energy metabolism, muscle contractile function, transcription, translation, cell proliferation, and cellular stress response. CONCLUSION: BoNT-A gives influences on muscle contractile function and energy metabolism directly or indirectly besides neurotoxic effects. Proteomic expression provides better understanding about the effect of BoNT-A on skeletal muscle.

Relationship between Physical Examinations and Two-Dimensional Computed Tomographic Findings in Children with Intoeing Gait

OBJECTIVE: To evaluate the validity of physical examinations by assessment of correlation between physical examinations and CT measurements in children with intoeing gait and the causes of intoeing gait by age using CT measurements. METHOD: Twenty-six children with intoeing gait participated in this study. The internal and external hip rotation, thigh-foot angle and transmalleolar angle were measured. In addition, femoral anteversion and tibial torsion of the subjects were assessed using a CT scan. The measurements of torsional angles were performed twice by two raters. The correlation coefficients between physical examinations and CT measurements were calculated using Pearson correlation. The data was analyzed statistically using SPSS v12.0. RESULTS: The correlation coefficients between physical examinations and CT measurements were not high. Before 5 years of age, intoeing gait was caused by femoral anteversion in 17.86%, tibial torsion in 32.29% and the combination of causes in 35.71% of cases. After 6 years of age, the contributions changed to 29.17%, 8.33% and 45.83%, respectively. CONCLUSION: Before 5 years of age, the common cause of an intoeing gait was tibial torsion, whereas after 6 years of age it was femoral anteversion. Regardless of age, the most common cause of intoeing gait was a combination of causes. This study shows poor correlation between physical examinations and CT. Therefore, it is limiting to use physical examination only for evaluating the cause of intoeing gait in clinical practice.

Percutaneous Endoscopic Gastrostomy Versus Percutaneous Radiologic Gastrostomy: A Comparison of Complications in Brain Injured Patients

OBJECTIVE: To compare complications of percutaneous endoscopic gastrostomy (PEG) and percutaneous radiologic gastrostomy (PRG) in brain injured patients. METHOD: The records of brain injured patients who received either PEG or PRG between January 2001 and July 2008 in Busan paik hospital were reviewed retrospectively. Documented complications (infection, leakage, blockage/delayed feeding, aspiration pneumonia, tube displacement, pain, ileus, bleeding, tube fell/pulled out, bradycardia/hypotension) were recorded and compared. RESULTS: There were 44 brain injury patients with dysphagia. All patient received PEG or PRG successfully. (32 PEG, 12 PRG) The incidences of complications were 50% in both PEG group (16 in 32) and PRG group (6 in 12). In PEG group sixteen patients developed complications, 27 minor and two major. In PRG group six patients developed complications, 11 minor and one major. The most common complication of PEG was wound infection (37.9%). But there were no wound infection in PRG group. And there were no deaths in both PEG and PRG group. CONCLUSION: Both endoscopic and radiologic gastrostomy tube placements are safe and effective methods. But in high infection risk group such as old ages, DM or CRF patients who have brain injury with dysphagia, PRG is safer method than PEG.