Lesional location of intractable hiccups in acute pure lateral medullary infarction

Background & Objective: Hiccups is a disabling condition of lateral medullary infarction (LMI). Unlike other symptoms of LMI, the anatomical lesions of hiccups are not well known. Few studies have evaluated the relationship between the lesional location of LMI and hiccups. We performed this study to correlate hiccups and magnetic resonance imaging (MRI)-based lesional location in pure LMI. Methods: Between January 1997 and February 2013, we identified 24 patients with pure LMI who presented with hiccups in addition to typical lateral medullary syndrome. Sixty six pure LMI patients without hiccups were included as a control group. Clinical and radiologic findings were compared between the two groups. MRI-identified lesions were classified rostrocaudally as rostral, middle and caudal, and horizontally as typical, ventral, large, lateral and dorsal. Results: The pure LMI patients with hiccups had significantly more frequent aspiration pneumonia (P = 0.001) and longer hospital stay (P = 0.03). The patients with hiccups significantly more often had dorsal rather than ventral lesion at horizontal levels (P = 0.012). But, there were no rostro-caudal differences at vertical levels (P = 0.162). Conclusions: We suggest that pure LMI associated with hiccups often locates in the dorsal medulla at horizontal correlation. This MRI-based comparative study has advanced the understanding of the neural substrate for hiccups in LMI, and indicates that hiccups become predictable when specific lesional locations in the lateral medulla are considered.

Lesions in the splenium of the corpus callosum: Clinical and radiological implications

Background: Brain MRI may unexpectedly display abnormalities in splenium of the corpus callosum (SCC). However, the clinical implications of this lesion are unclear and are not always consistent with ischemic infarctions. We performed this study to clarify the clinical and radiological implications in patients with SCC lesions. Methods: We retrospectively reviewed consecutive patients with MRIreported SCC changes between 2009 and 2012. We analyzed clinical and radiological findings, etiologies, cognitive impairment, and clinical outcomes. Results: We found 30 patients (16 females; mean 50.5 years) who had SCC lesions on MRI. Confusion was the most common clinical finding in 50% of cases. Cerebral infarction was the most common etiology (50%). The most consistent SCC changes on MRI were low signal in T1WI, high signal on T2WI and FLAIR, and high signal on DWI. We classified SCC lesions into in situ SCC lesions (SCC only) and multiple (SCC plus) lesions for patients with multiple lesions. The clinical symptoms of SCC only lesions were relatively mild. Cognitive functions were evaluated by Mini Mental State Examination (MMSE) and clinical dementia rating (CDR) scale at the time of discharge and patients with SCC only lesions showed less impaired cognition compared with those with SCC plus lesions. Clinical outcomes were evaluated by the modified Rankin scale at 1 month and patients with SCC only lesions revealed good clinical outcomes compared with those with SCC plus lesions. Conclusions: MRI-reported SCC lesions may have heterogeneous etiologies and present with various symptoms. The clinical course and outcome are relatively good, particularly in small isolated and oval shaped SCC lesions.

Acute Stroke Associated With Combined Protein C and S Deficiency During Pregnancy

Pregnancy related stroke is rare and poorly understood. A 28-year-old pregnant woman at 20 weeks of gestation presented with sudden headache and left homonymous hemianopsia. MRI revealed acute right posterior cerebral artery territory infarction. Laboratory data revealed combined protein C and S deficiencies. Coagulation profiles returned to normal 6 months after the delivery. Although stroke can occur either with protein C or S deficiency, acute cerebral infarction associated with combined protein C and S deficiencies during gestation is very rare.

Cerebral Venous Thrombosis Occurred After Cyclosporine Administration

Cerebral venous thrombosis (CVT) is quite rare and underlying risk factors are diverse. We describe that 60-year-old man developed CVT after use of cyclosporine. He had suffered from leukocytoclastic vasculitis and urticarial vasculitis. Initial MR venogram revealed thrombosis in superior sagittal sinus, right transverse sinus and sigmoid sinus with multiple cortical and deep collateral veins. Anticoagulation was started and maintained for one year, then follow up MR venogram was normal. We suggest that cyclosporine might increase a risk of CVT.

Predictors of functional outcome of patients in neurological intensive care unit

Background: Little is known regarding the functional outcome and quality of life of neuro-ICU survivors. In Korea, the neuro-ICU concept was introduced relatively late and data about long term outcome and predictors concerning functional outcome is scarce. The main objective of this study was to analyze functional outcome and mortality, and to determine prognostic predictors for the outcome in patients admitted to Korean neuro-ICUs. Methods: Consecutive adult (≥ 15-years-of-age) patients admitted to a neuro-ICU due to various causes including ischemic or hemorrhagic stroke, and other neurological or neurosurgical problems such as traumatic brain injury, seizure, or drug intoxication during an 18-month period from July 2008 through December 2009 were included. Demographic and clinical variables were compared between groups stratifi ed based on 6-month modifi ed Rankin scale score. Results: Of 555 patients, there were signifi cant differences in age (P=0.013), sex (P=0.02), hospital stay (P<0.01), neuro-ICU stay (P<0.01), admission diagnosis (P=0.001), intubation (P<0.01), mechanical ventilation (P<0.01), tracheostomy (P<0.01), comorbid conditions such as atrial fi brillation (P<0.01), cardiac complication (P<0.01) and pulmonary complication (P<0.01), a high Therapeutic Intervention Scoring System (TISS-28) score (P<0.01), and a high Acute Physiology and chronic health evaluation (APACHE) II score (P<0.01) between favorable and unfavorable outcome groups. The overall mortality rate was 15.0% (n=83). In multivariable logistic regression analysis, age, sex, high TISS-28, high APACHE II score, intubation, and cardiac complication were independent predictors of unfavorable outcome. Conclusion: The identifi ed predictors for functional outcomes in Korean neuro-ICU patients will be an important aid in diagnosing and treating neuro-ICU patients.

Poor Outcome of Tuberculous Cerebellitis in an Adult

Acute cerebellitis is a clinically isolated condition showing cerebellar signs such as ataxia, dizziness and dysarthria. Most of them are associated with viral infection, which generally occur in childhood and show benign course without sequelae. Tuberculous cerebellitis is very rare and its outcome is not well described. The aim of this study is to describe the clinical features and course in a patient with tuberculous cerebellits. We will also discuss the possible prognostic factors in acute cerebellitis.

Ischemic Stroke among the Patients with End-Stage Renal Disease Who Were Undergoing Maintenance Dialysis

PURPOSE: In spite of higher incidence of stroke in end-stage renal disease (ESRD) patients compared to general population, the risk factor for stroke which is specific to ESRD is not fully understood. The ESRD patients who develop stroke may have certain additional risk factors compared to ESRD patients without stroke. We used registered data of Hallym Stroke Registry to elucidate the factors which affect development of ischemic stroke among the dialysis patients. MATERIALS AND METHODS: We recruited patients with acute ischemic stroke in ESRD patients undergoing maintenance dialysis. Dialysis patients without stroke were selected as control group with age and gender matching. We compared the demographic features, stroke risk factors, and laboratory findings in ESRD patients with or without ischemic stroke. RESULTS: The total of 25 patients with ESRD developed ischemic stroke. Fifty ESRD patients without stroke were chosen as the control group. The mean age of acute ischemic stroke patients was 59.80+/-9.94 and male gender was 48%. The most common ischemic stroke subtype was small vessel occlusion (n=12), followed by large artery atherosclerosis (n=7). The patients with stroke had more frequent history of hypertension and higher systolic/diastolic blood pressure at the time of admission than the ESRD patients without stroke. Total cholesterol and LDL-cholesterol levels were significantly lower in the stroke group. In multivariate analysis, LDL-cholesterol was found to be the only risk factor for ischemic stroke. CONCLUSION: The results of our study reveal that LDL-cholesterol is associated with greater risk for ischemic stroke in the patients on dialysis.

Safety and Efficacy of Ultrasound-Guided Fiducial Marker Implantation for CyberKnife Radiation Therapy

OBJECTIVE: To evaluate the safety and technical success rate of an ultrasound-guided fiducial marker implantation in preparation for CyberKnife radiation therapy. MATERIALS AND METHODS: We retrospectively reviewed 270 percutaneous ultrasound-guided fiducial marker implantations in 77 patients, which were performed from June 2008 through March 2011. Of 270 implantations, 104 were implanted in metastatic lymph nodes, 96 were in the liver, 39 were in the pancreas, and 31 were in the prostate. During and after the implantation, major and minor procedure-related complications were documented. We defined technical success as the implantation enabling adequate treatment planning and CT simulation. RESULTS: The major and minor complication rates were 1% and 21%, respectively. One patient who had an implantation in the liver suffered severe abdominal pain, biloma, and pleural effusion, which were considered as major complication. Abdominal pain was the most common complication in 11 patients (14%). Among nine patients who had markers inserted in the prostate, one had transient hematuria for less than 24 hours, and the other experienced transient voiding difficulty. Of the 270 implantations, 261 were successful (97%). The reasons for unsuccessful implantations included migration of fiducial markers (five implantations, 2%) and failure to discriminate the fiducial markers (three implantations, 1%). Among the unsuccessful implantation cases, six patients required additional procedures (8%). CONCLUSION: The symptomatic complications following ultrasound-guided percutaneous implantation of fiducial markers are relatively low. However, careful consideration of the relatively higher rate of migration and discrimination failure is needed when performing ultrasound-guided percutaneous implantations of fiducial markers.

Ipsilateral Tilt and Contralateral Sensory Change of Neck in Cortical Infarction

BACKGROUND: Numerous neck muscles are involved in neck movements, and so isolated neck weakness is extremely uncommon in cerebral infarction. CASE REPORT: We report herein the case of a 65-year-old woman with hypertension and acute cortical infarction, presenting with ipsilateral head tilt and contralateral sensory changes in the neck and shoulder area, which has never been described before. CONCLUSIONS: Transient neck weakness and sensory deficits can occur in acute cortical infarction. The motor representation of the neck muscles can be at the same level of the cortical sensory representation, near to the level of the trunk representation, which is in contrast to Penfield's findings. Several possible mechanisms for the ipsilateral tilt are described.

Trigeminal Neuralgia due to Pontine Infarction

No abstract available.

A Case With Suspected Tick Paralysis

Tick paralysis is caused by a neurotoxin secreted by female tick. Characteristic initial manifestation is bilateral flaccid ascending paralysis similar to Guillain-Barr? syndrome. The predominant electrophysiological abnormality is a reduction in complex muscle action potentials. Here, we present a 62-year-old man who initially experienced a sudden biting pain on his scalp. Subsequently he developed bilateral lower extremity paralysis that ascended symmetrically involving the upper extremities. Within 2 weeks, the patient showed a full recovery without treatment.

Complete Binocular Blindness as the First Manifestation of HIV-Related Cryptococcal Meningitis

Ocular complications of HIV-related cryptococcal meningitis are reasonably common, but complete binocular blindness as the first manifestation of HIV is extremely rare. A 58-year-old man presented with binocular blindness. He experienced blurred vision for 3 days before the blindness. Mild pleocytosis was present in the cerebrospinal fluid, from which Cryptococcus neoformans was cultured. Serology revealed positivity for HIV antibody. He was treated with antifungal and antiretroviral therapy. This case indicates that HIV-related cryptococcal meningitis should be taken into consideration when determining the cause of unexpected sudden binocular blindness.

Irreversible Parkinsonism due to Acute Organophosphate Intoxication

Only a few case studies describe reversible parkinsonism after organophosphate poisoning and their brain imagings are found to be normal. However, we experienced chronic, irreversible parkinsonism by acute organophosphate poisoning with bilateral basal ganglia lesions found on a brain MRI. We suggest that brief, large amounts of organophosphate intoxication can produce irreversible parkinsonism according to individual susceptibility and further studies including the investigation of insecticides as an environmental factor of parkinsonism should be done using neuroimagings.

A Case of Morvan Syndrome

Neuromyotonia, or Isaacs' syndrome, consists of continuous muscle fiber activity caused by hyperexcitability of the peripheral nerves. Rarely, these patients also develop CNS symptoms characterized by confusion, insomnia, hallucinations, and agitation. A rare disease consisting of neuromyotonia, autonomic symptoms, and CNS dysfunction is called Morvan's syndrome. We report a 24-year-old man who presented with insomnia, malaise, anorexia, hyperhidrosis, palpitation and myokymia in both the lower extremities. The pathomechanism of Morvan's syndrome is related to the voltage-gated K+ channel (VGKC) antibodies.

A Case with Neuro-Sweet Syndrome

Sweet's syndrome, or acute febrile neutrophilic dermatosis, is an unusual disease characterized by fever, leukocytosis, and distinctive skin lesions. Common complications include arthralgia, arthritis, conjunctivitis, and iridocyclitis. However, the involvement of the central nervous system in this disease, termed `neuro-Sweet syndrome' is rarely reported. We present a patient with recurrent encephalitis for 15 years, accompanied with neutrophilic dermatosis, and characterized by HLA-B54 and Cw1, with good responsiveness to corticosteroid.

Asymptomatic Extrapontine Myelinolysis in Diabetic Woman

Osmotic myelinolysis syndrome in central nervous system is classified into central pontine myelinolysis(CPM) and extrapontine myelinolysis(EPM). The former can cause a spastic quadriplegia, pseudobulbar palsy, and varying degree of mental disorder, but the latter a movement disorder(tremor, dystonia, parkinsonism, and chorea, etc), behavior change(mood instability, personality change, agitated delirium, and disinhibition, etc), and cognitive dysfunction. Although a few cases of asymptomatic CPM have been reported, asymptomatic EPM were rare. A 67-year-old woman with diabetes mellitus and old cerebral infarction has suffered from the common bile duct stone. She had hyponatremia(Na=126mEq/L) on admission and was corrected rapidly. Incidental findings of her brain MRI showed EPM. We experienced a case of bilateral middle cerebellar peduncle myelinolysis incidentally without neurological presentations and report a rare case of asymptomatic EPM recoverd in diabetic woman after rapid correction of hyponatremia.

The Clinical Properties of Deep Small Basal Ganglia Infarctions: Lacune or Small Striatocapsular Infarction?

BACKGROUND: Small subcortical infarctions of basal ganglia can be divided into either lacunes or striatocapsular infarctions by size of lesion. However, there are some controversies concerning the size criteria of lacune and striatocapsular infarction. To better understand differences among these patients, we elucidated clinical and other properties of deep small basal ganglia infarctions (DSBIs), which could not be clearly classified as either lacunes or striatocapsular infarction by their sizes only. METHODS: We analyzed 27 patients with acute ischemic lesion of basal ganglia with which the size varying from 1.5 cm to 3 cm in their maximal diameters. We assessed clinical features, laboratory data, stroke risk factors, and radiologic findings such as MRI and MR angiography. RESULTS: These patients could be largely divided into two distinct groups, either with or without associated cortical symptoms and signs. The most common clinical feature was motor weakness that was found in all but one patient. Sensory disturbances, altered deep tendon reflexes, and positive Babinski signs were also commonly found. Ten of the 27 patients showed cortical manifestations such as eyeball deviation, visual field defect, aphasia and neglect. Eight of the 10 patients with cortical manifestations showed MCA or ICA stenotic lesions. CONCLUSIONS: We found that many patients with 1.5 cm to 3 cm sized DSBIs could have the features of either lacune or striatocapsular infarction. Careful evaluation of clinical and radiologic findings should be performed in patients with clinically appearing lacunar syndrome in order to differentiate lacunar infarction of small vessel disease from striatocapsular infarction of other various pathophysiologies. Echocardiogram, cerebral angiogram and perfusion and diffusion MRI could be recommended for further evaluation and to better understand the pathogenesis in these patients.

Electrophysiological Evidence of Demyelination in Patients with Diabetic Neuropathy

BACKGROUND: Diabetic neuropathy is one of the most common neuropathies. Although pathologic studies show both segmental demyelination and axonal loss in diabetic neuropathy, the relative importance of segmental demyelination is debated. Conduction block (CB) is a physiologic hallmark of segmental demyelination. If segmental demyelination were a main pathology of diabetic neuropathy, CB should be common. We undertook this study to determine the prevalence of CB in diabetic patients. METHODS: Fifty-two consecutive diabetic patients (M=30, F=22) were referred to EMG laboratory and underwent routine nerve conduction studies (NCS). CB was defined by two methods. One was > 20% drop in peak-to-peak amplitude and 50% drop in the amplitude and area. Clinical findings, electrophysiological data, and effectiveness of immunomodulating therapy for some patients with CB were reviewed. RESULTS: A total 326 nerves were studied. The criteria for 20% and 50% CB were met in 35 nerves in 19 patients and 7 nerves in 6 patients, respectively (prevalence=10.7%, 2.1%, respectively). Some patients with CB were treated with IVIG or steroid and had a good response. CONCLUSIONS: CB in diabetic neuropathy is not a common finding. The rarity of CB in diabetic neuropathy suggests that segmental demyelination is not a prominent part of the underlying pathology. The presence of CB and good responsiveness to immunomodulating therapy in diabetic neuropathy also suggest alternative or additional causes for neuropathy, such as chronic inflammatory demyelinating polyneuropathy.

The Compliance of Stroke Patients for Secondary Prevention: In Seoul & Kyunggi province

BACKGROUND: The secondary prevention of stroke which is defined as the control of risk factors and continuous antithrombotic therapy if indicated plays an important role in decreasing stroke recurrence. Unlike most developed countries, the stroke mortality in Korea has yet to be on the decline. It is well known that treatment non-compliance for secondary prevention after a stroke is associated with stroke recurrence and poor functional outcome. There has been no investigation about outpatient treatment compliance of Korean stroke patients who were previously hospitalized. This study aimed to explore the behavior and preference for treatment of stroke patients after discharge and to assess the recurrence rate of stroke for those patients who were not compliant with therapy for secondary prevention and their reasons for not being compliant. METHODS: Study subjects included three hundred thirty-eight stroke patients who were admitted to the Hallym Stroke Center between Jan. 1 and Dec. 31 of 1995. Those who died during hospitalization and those who were discharged to go home on impending death were excluded. The mean age was 63.6 years and the male to female ratio was 1.2 to 1. Telephone inquiries were performed with patients or caregivers regarding the recurrence of stroke, the reasons for non-compliance with secondary preventive management and other kinds of care they received for stroke. RESULTS: Among two hundred six patients (60.9%) not given a follow up on the out-patient basis, 110 patients completed telephone interviews and 102 patients were found to be non-compliant. Nineteen patients (17.7 %) of this non-compliant group reportedly had a recurrent stroke. The age, level of education, and Rankin score were factors which influenced the compliance of patients. Non-compliant patients were currently under the care of: 1) oriental medicine and/or acupuncture (n=56); 2) alternative medicine (n=17); 3) inadvertent over-the-counter drugs (n=16); and 4) no treatment at all (n=26). The reasons for non-compliance included: 1) biased preponderance of oriental medicine (n=44); 2) ignorance about the importance of secondary prevention (n=36); 3) inconvenience of the bureaucratic procedure of hospitals (n=34); 4) economic burden (n=17); 5) dissatisfaction with medical care (n=10); and 6) other reasons (n=6). CONCLUSIONS: Secondary prevention care for Korean stroke patients seems to be inadequately achieved. The proper education of patients and their caregivers about the importance for the secondary prevention of stroke is needed to decrease stroke recurrence in Korea.

MRI and Electrophysiological findings in a case of Tabes Dorsalis

By doing MRI of spinal cord and elctrophysiological studies we were going to correlate MRI and electrophysiologi-cal findings with the known pathology of tabes dorsalis. A 45 year old male patient developed gait ataxia with a tin-gling sense in hands and feet in september of 1996. Neurological examination revealed impaired position sense in his great toes and thumbs with profound instability in the Romberg test, and areflexias in his knee and ankle jerks. Serum VDRL and TPHA test results were positive. CSF revealed pleocytosis(WBC : 16/cubic mm), elevated protein level, and reactive VDRL and FTA-ABS tests. Spinal MRI showed high signal intensity in the posterior part of the entire length of the cervical cord without enhancement with Gadolinium. Follow-up spinal MRI of the cervical area, which was taken two years after penicillin treatment did not show any interval change and spinal MRI of thoracolumbar area also showed similar finding to that of the cervical cord. Nerve conduction studies before and after the penicillin trea-ment showed normal findings except absent H-reflexes. However, the somatosensory evoked potentials with posterior tibial nerve stimulation did not show any abnormalities, which were incompatible with previous report and the known pathologic abnormality. Normal somatosensory evoked potentials suggests using any other pathways than the posterior column in conducting somatosensory evoked potentials.