Two Cases of Carbamazepine Induced Bradyarrhythmia: Potentially Lethal Side Effect in Elderly Patients

Although potential hematologic complications of carbamazepine (CBZ) have been well known, the cardiac effects of CBZ are not widely appreciated. We report two cases of severe bradyarrhythmia induced by the usual dosage of CBZ. Two elderly patients complained of chest discomfort and dyspnea after CBZ medication. Their EKGs showed sinus bradycardia with junctional escape rhythm. After the discontinuation of CBZ, cardiac conduction abnormality were resolved. Even though cardiac side effect of CBZ is rare, it is potentially lethal in elderly patients.

Diffuse Signal Changes in Corpus Callosum after Decompression Surgery of Hydrocephalus

Wide spread MR signal changes in the corpus callosum can occur after shunt operation in patients with hydrocephalus. Although the mechanism of these signal changes remains unclear, neural compression caused by active hydrocephalus and changes of conditions after shunt operation may contribute to the development of these changes. We present a patient who underwent successful ventriculo-peritoneal shunt operation for hydrocephalus and had diffuse signal changes in the corpus callosum in MR images taken 2 years after the surgery.

Mortality Rate and Early Prognostic Factors In Patients With Severe

BACKGROUND & OBJECTIVES: Severe hemispheric infarction(SHI) reportedly has various range of high mortality. Recently it has been reported that more aggressive therapeutic intervention, such as decompressive hemicraniectomy or mild hypothermia might has potential benefits in the management of SHI. However, the mortality and the prognosis of Sill under the conservative treatment were rarely studied yet in Korea. METHODS: Sixty-six patients with CT proven SHI were subjected among 1649 acute stroke patients registered at the Hallym Stroke Data Bank since Jan. 1993. We analyzed the computerized databases for the mortality and compared inclusively demographic features, clinical characteristics, etiology, therapy modalities and CT findings of fatal group with those of survivors. RESULTS: Twenty-five patients were expired among 66 SI-il patients(mean age: 64.9+/-11.5, male to female ratio;37:29). The mean time to expire was 160.4 hours. The fatal group had a significantly higher incidence of cardioembolism. uncontrolled BP during the acute stage, and extensive infarction territory(MCA+ACA). Risk factors for ischemic stroke such as hypertension, hyperlipidemia. smoking, previous stroke history, diabetes mellitus. and old age were not related to mortality low densities and hyperdense MCA signs on brain imaging were not different between two groups. CONCLUSIONS: The early mortality rate of Sill under the conservative care was 38% in a referral hospital of Korea. intractable hypertension in the acute stage, cardioembolism and extent of infarct area may have predictable values of early mortality of SHI.

Isolated Unilateral Internuclear Ophthalmoplegia After Head Trauma

No abstract available.

Cortical Deformation Zone in Neocortical Epilepsy: 3D Surface-Projection Rendering of Brain MRI / 대한간질학회지

PURPOSE: The detection of epileptogenic lesion plays an important role in the management of patients with partial epilepsy. Although the development of MRI improved the examination of cerebral hemispheres greatly, many patients with neocortical temporal lobe epilepsy (TLE) or extratemporal lobe epilepsy (extra-TLE) still show no lesion in conventional two-dimensional (2D) images. To increase the yield of MRI in those patients, we performed three-dimensional (3D) surface-projection rendering (SPR) of the cerebral hemispheres. METHODS: Conventional 2D MRI (T1, T2, FLAIR, thin slice SPGR) and 3D SPR were performed in 24 patients with neocortical TLE and extra-TLE, and 20 normal subjects. Sulcogyral patterns were evaluated blindly to clinical information. The locations of the epileptogenic zone, ictal onset zone (IOZ) and irritative zone (IRZ) were determined by intracranial EEG monitoring and epilepsy surgery. RESULTS: The 2D MRI identified epileptogenic lesions in five of the 10 neocortical TLE (50%) and five of the 14 extra-TLE (35.7%). 3D SPR revealed abnormal sulcogyral patterns in 9 of the 10 neocortical TLE (90%) and 9 of the 14 extra-TLE (64.3%). Cortical deformation zones with sulcogyral anomalies included the whole area of IOZ in 10 (55.5%) and IRZ in 6 (33.3%), overlapped with IOZ in 7 (38.9%) and IRZ in 11 (61.1%), were connected to IOZ in 1 (5.6%) and IRZ in 1 (5.6%). CONCLUSION: 3D SPR of volumetric MRI data can detect epileptogenic structural lesions of neocortical epilepsy that are not visible in the conventional 2D images.

Ictal Cerebral Perfusion Patterns in Partial Epilepsy: SPECT Subtraction / 대한핵의학회잡지

PURPOSE: To investigate the various ictal perfusion patterns and find the relationships between clinical factors and different perfusion patterns. MATERIALS AND METHODS: lnterictal and ictal SPECT and SPECT subtraction were performed in 61 patients with partial epilepsy. Bath positive images showing ictal hypoperfusion and negative images revealing ictal hypoperfusion were obtained by SPECT subtraction. The ictal perfusion patterns of subtracted SPECT were classified into focal hypoperfusion, hypoperfusion-plus, combined hypoperfusion-hypoperfusion, and focal hypoperfusion only. RESULTS: The concordance rates with epileptic focus were 91.8% in combined analysis of ictal hypoperfusion and hypoperfusion images of subtracted SPECT, 85.2% in hypoperfusion images only of subtracted SPECT, and 68.9% in conventional ictal SPECT analysis. Ictal hypoperfusion occurred less frequently in temporal lobe epilepsy (TLE) than extratemporal lobe epilepsy. Mesial temporal hypoperfusion alone was seen only in mesial TLE while lateral temporal hypoperfusion alone was observed only in neocortical TLE. Hippocampal sclerosis had much lower incidence of ictal hypoperfusion than any other pathology. Some patients showed ictal hypoperfusion at epileptic focus with ictal hypoperfusion in the neighboring brain regions where ictal discharges propagated. CONCLUSION: Hypoperfusion as well as hypoperfusion in ictal SPECT should be considered for localizing epileptic focus. Although the mechanisrn of ictal hypopertusion could be an intra-ictal early exhaustion of seizure focus or a steal phenomenon by the propagation of ictal discharges to adjacent brain areas, further study is needed to elucidate it.

Clinical Factors Influencing Quality of Life in Patients with Epilepsy

BACKGROUND: Epilepsy has been known to adversely affect a patient's quality of life (QOL). We investigated the status of QOL and tested the influences of clinical factors upon QOL in epileptic patients. METHODS: We evaluated 125 adult patients (mean age, 30.4 years, male:female=1:0.86) with epilepsy. The demographic, social (marriage, employment, religion, education duration), and clinical data (seizure onset age, seizure pattern during the last 1 year, treatment duration, number of antiepileptic drug) were obtained. Quality of life in epilepsy-31 (QOLIE-31) and Beck Depression Inventory-Korean version (KBDI) were used. The relationships of demographic, social, and clinical factors with QOL in epileptic patients were evaluated. RESULTS: The mean subscores of QOLIE-31 items were 52.6 (medication effects), 50.9 (cognitive functioning), 50.9 (social functioning), 50.5 (energy/fatigue), 48.4 (seizure worry), 46.8 (overall QOL), and 45.7 (emotional well-being), and the overall score was 49.6. Sex, marriage, religion, and duration of treatment did not affect QOL. The age of patients had a weak linear positive correlation with overall QOL and emotional well-being. Employed patients had a significantly high score in overall QOL, emotional well-being, cognitive functioning, social functioning, and overall score. The patients given polytherapy had lower scores of QOLIE-31 items except seizure worry and energy/fatigue. Seizure free patients had significantly higher scores in seizure worry, overall QOL, social functioning, and overall score. Depression negatively influenced all subscales and overall score. CONCLUSIONS: Age, employment state, number of antiepileptic drugs, seizure pattern, and depression were significant clinical factors affecting QOL in patients with epilepsy.

The 30-day mortality rate and the causes of death following acute ischemic stroke

BACKGROUND: Most stroke-related deaths occur shortly after the onset of symptoms. Analysis of early deaths after stroke is important, since some deaths may be preventable. It also helps to improve the quality of stroke management. We investigated the early mortality and the causes of death in acute ischemic stroke patients. METHODS: We reviewed the medical records of six hundred fifty-one consecutive acute ischemic stroke patients who admitted to HLMC (Hallym University Medical Center) between January 1993 and December 1996. The 30-day mortality rate and the cause of death in each case were assessed. RESULTS: Fifty patients (mean age, 67.7 years, male : female=1 : 1.3) of total 651 patients (mean age, 65.4 years, male : female=1:0.78) died within 30 days (7.7%). Thirty-three (7%) patients of the 471 patients who had supratentorial lesion and sixteen (10.5%) of the 151 patients who had infratentorial lesion died within 30 days. The 30-day mortality rate according to each stroke subtype were 8.2% in large-artery atherosclerosis (n=21), 26.4% in cardioembolism (n=14), 1.2% in small-vessel occlusion (n=3), 33.3% in strokes with other determined etiology (n=1), 12.1% in strokes with undetermined etiology (n=11). Twenty-eight patients (56%) died due to direct stroke-related causes such as herniation, evolving stroke and massive hemorrhagic transformation. Twenty-two patients (44%) died from indirect stroke-complicated causes such as sepsis (n=7, 14%), heart disease (n=6, 12%), pneumonia (n=5, 10%), massive bleeding at tracheostomy site (n=1, 2%), pulmonary edema (n=1, 2%) and unknown cause (n=2, 4%). Forty patients (80%) died in the first 10 days and the main causes of death were herniation and evolving stroke. After the first 10 days, ten patients (20%) died of relative immobility (pneumonia, sepsis, pulmonary embolism). CONCLUSION: To reduce the early mortality within the first 10 days after the onset, aggressive control of IICP with the amelioration of brain edema must be emphasized. Whilst, to reduce the early mortality after the first 10 days, vigorous efforts to prevent and treat complications, such as pneumonia, pulmonary embolism and sepsis should be done.

Hemichorea-hemiballism with striatal high signal intensity on T1-weighted images in diabetes

Hemichorea-hemiballsim has been reported as a rare Implication of nonketotic hyperglycemia. Recently, Some reports revealed that brain magnetic resonance images of nonketotic hyperglycemic patients with hemichorea-hemiballism showed characteristic contralateral striatal signal abnormality, We present six patients with hemichorea-heniiballism. All of them had diabetes mellitus and performed brain MR images. The MR images of them showed high signal intensity on Tl-weighted images and low signal intensity on T2 weighted images in the striatum contralateal to the involuntary movement. In general, the striatal high signal intensity on TI weighted images are presumed to have developed following hemorrhagic transformation, osmotic myelinolysis, or mild ischemia with reversible deposition of calcium or other material occurred in association with nonketotic hyperglycemia. However the precise mechanism of this signal change is not clear yet and needs pathological confirmation.

Bilateral Paramedian Thalamic Infarction: Mimicking Wernicke Encephalopathy

A 48-year-old man was admitted due to sudden disorientation and dysarthria. He has been drinking almost everyday for the past 25 years. At the time of the admission, he was alert but confused. Neurologic examination revealed disorientation to time, memory disturbances, decreased amount of speech, dysarthria, limitation of extraocular movement, ataxia of left limbs, and unsteady gait. He was treated with thiamine under the impression of Wernick's encephalopathy. Ataxia of limbs and unsteady gait improved but limitation of extraocular movement and disturbed higher cortical function remained. MRI of the brain taken 24 hours after the onset showed asymmetrical bilateral paramedian thalamic high signal lesions on 72-weighted images. We report here a case of bilateral paramedian thalamic infarction clinically mimicking Wernicke's encephalopathy.