Usefulness of Extracorporeal Treatment for Combined Intoxication with Controlled-Release Carbamazepine and Topiramate

Controlled-release carbamazepine (CBZ) could be more harmful than the regular form in special situations due to their respective biochemical characteristics. When primary treatment is not effective in acute intoxication, extracorporeal treatment (ECTR) could be an option. We recently applied ECTR to a patient with combined intoxication of topiramate and controlled-release CBZ who deteriorated despite receiving primary treatment. The patient improved after administering ECTR. Early ECTR intervention may be beneficial for the treatment of CBZ intoxication, especially of the controlled-release form.

Age, hypertension, and genetic polymorphisms and their relative associations with white matter hyperintensities in Korean patients with Alzheimer’s disease

Objectives: White matter hyperintensities are known to influence dementia in Alzheimer’s disease. Genetic components are suggested as putative risk factors for vascular pathology and cognitive decline. This study aimed to determine whether there is an association between candidate genetic polymorphisms and the severity of white matter hyperintensities in patients with Alzheimer’s disease. Methods: Seventy-five patients diagnosed with Alzheimer’s disease underwent genetic tests for specific alleles of apolipoprotein E, angiotensin-converting enzyme, and methylenetetrahydrofolate reductase. All patients underwent brain magnetic resonance imaging scans and neuropsychological tests. The severity of white matter hyperintensities was semiquantified using the CREDOS rating scale, and patients were divided into three groups according to their rating. Results:The severity of white matter hyperintensities was related to age and hypertension. However, none of the gene polymorphisms we tested was found to be associated with the severity of white matter hyperintensities. Conclusion:The genetic polymorphisms found in apolipoprotein E, angiotensin-converting enzyme and methylenetetrahydrofolate reductase did not contribute to white matter hyperintensities in Alzheimer’s disease.Only age and hypertension factors were found to be contributory to white matter hyperintensities.

Evaluation of Hippocampal Volume Based on Various Inversion Time in Normal Adults by Manual Tracing and Automated Segmentation Methods

PURPOSE: To investigate the value of image post-processing software (FreeSurfer, IBASPM [individual brain atlases using statistical parametric mapping software]) and inversion time (TI) in volumetric analyses of the hippocampus and to identify differences in comparison with manual tracing. MATERIALS AND METHODS: Brain images from 12 normal adults were acquired using magnetization prepared rapid acquisition gradient echo (MPRAGE) with a slice thickness of 1.3 mm and TI of 800, 900, 1000, and 1100 ms. Hippocampal volumes were measured using FreeSurfer, IBASPM and manual tracing. Statistical differences were examined using correlation analyses accounting for spatial interpretations percent volume overlap and percent volume difference. RESULTS: FreeSurfer revealed a maximum percent volume overlap and maximum percent volume difference at TI = 800 ms (77.1 +/- 2.9%) and TI = 1100 ms (13.1 +/- 2.1%), respectively. The respective values for IBASPM were TI = 1100 ms (55.3 +/- 9.1%) and TI = 800 ms (43.1 +/- 10.7%). FreeSurfer presented a higher correlation than IBASPM but it was not statistically significant. CONCLUSIONS: FreeSurfer performed better in volumetric determination than IBASPM. Given the subjective nature of manual tracing, automated image acquisition and analysis image is accurate and preferable.

An infant with cerebellar tumor presenting with torticollis as the only initial symptom

Torticollis is an usual symptom that can be the result of various disorders, such as sternocleidomastoid muscle pathology, bony abnormalities of the cervical spine, disorders of the central or peripheral nervous system, various ocular diseases, and brain tumors, especially in children. A 12-month-old male visited our hospital because of torticollis. He was normal on systemic examination, with no neurological abnormality, and his cervical spine CT was also normal. About 4 weeks later, he revisited the emergency department due to vomiting with altered mental status, and was diagnosed with a cerebellar tumor with hemorrhage. Although torticollis is known to be an important sign of a posterior fossa tumor, associated neurological or ocular symptoms are usually present. We report here a patient with posterior fossa tumor where torticollis was the only initial presenting symptom.

An infant with cerebellar tumor presenting with torticollis as the only initial symptom

Torticollis is an usual symptom that can be the result of various disorders, such as sternocleidomastoid muscle pathology, bony abnormalities of the cervical spine, disorders of the central or peripheral nervous system, various ocular diseases, and brain tumors, especially in children. A 12-month-old male visited our hospital because of torticollis. He was normal on systemic examination, with no neurological abnormality, and his cervical spine CT was also normal. About 4 weeks later, he revisited the emergency department due to vomiting with altered mental status, and was diagnosed with a cerebellar tumor with hemorrhage. Although torticollis is known to be an important sign of a posterior fossa tumor, associated neurological or ocular symptoms are usually present. We report here a patient with posterior fossa tumor where torticollis was the only initial presenting symptom.

Seizure Induction by Artemisia Annua in an Epilepsy Patient Taking Levetiracetam

Artemisia annua is a wormwood. Because it may induce Cytochrome P450 2C19 enzyme, Artemisia annua may have an influence on antiepileptic drugs which are substrates for the enzyme. This influence may negatively affect seizure control of epilepsy patient. We present a patient whose seizures were induced by Artemisia annua, despite he was taking levetiracetam which is not a substrate for the hepatic enzyme. Therefore there would be another mechanism of seizure induction of Artemisia annua besides hepatic metabolism.

Seizure-induced Cerebral Edema Mimicking Multiple Cerebral Infarction

No abstract available.

Myeloma-associated Amyloidosis Presenting as Orthostatic Intolerance / 대한임상신경생리학회지

Amyloidosis is a systemic disorder associated with clonal plasma cell dyscrasia. Nephrotic syndrome, congestive heart failure, autonomic and peripheral neuropathy is often associated features in amyloidosis. Early diagnosis is most important because of different prognosis by stage. The diagnosis can be delayed since symptoms of amyloidosis may vary or nonspecific. We describe a patient of myeloma-associated amyloidosis, who showed orthostatic intolerance as the first symptom of the disease.

Asymptomatic Rheumatoid Meningoencephalitis Presented After Discontinuation of Methotrexate

Rheumatoid meningoencephalitis is a rare, but severe complication of rheumatoid arthritis (RA). A 64-year-old woman with the history of RA presented with abnormal behaviors and memory impairments since stopping methotrexate due to asymptomatic meningitis before 1 month. Brain MRI still demonstrated leptomeningeal enhancement in right fronto-temporal area, compared with the previous. Brain biopsy revealed multiple yellowish suppurative streaks in dura, and microscopically lymphoplasmic infiltrations and fibroid necrosis surrounded by granuloma. Soon after beginning treatment with corticosteroid and methotrexate, her symptoms improved.

Retrospective Assessment of the Implementation of Critical Pathway in Stroke Patients in a Single University Hospital

OBJECTIVE: To evaluate the effects of the implementation of critical pathway (CP) in stroke patients treated at a single university hospital. METHODS: A retrospective medical review collected data from 497 patients who had suffered acute stroke in the rehabilitation center. Stroke outcomes were compared between before and after the implementation of CP based on factors including demographic factors, stroke characteristics, pre-existing medical conditions, medical complications, functional states, and length of stay (LOS). RESULTS: After the implementation of CP, the patients showed significantly higher stage for upper proximal (p=0.008) and lower extremity (p=0.001) on Brunnstrom stage and significantly lower scores for modified Rankin Scale (p=0.003) at transfer. For those with pre-existing medical conditions, there were significantly increased osteoarthritis (p=0.002) and valvular heart disease (p=0.011). Regarding medical complications during acute inpatient rehabilitation, there were significantly decreased shoulder pain (p=0.001) and dysphagia (p=0.017), and significantly increased gastrointestinal symptoms (p=0.001). Functional gain and efficiency of stroke patients during rehabilitation center hospitalization did not significantly change after implementation of CP. But, shorter LOS of total hospitalization, pre-rehabilitation center hospitalization, and rehabilitation center hospitalization were evident. CONCLUSION: After the implementation of CP, patients less often developed complications and displayed no changes in functional gain and efficiency. They had shorter LOS of total hospitalization, pre-rehabilitation center hospitalization and rehabilitation center hospitalization.

Susceptibility-Weighted MR Imaging for the Detection of Developmental Venous Anomaly: Comparison with T2 and FLAIR Imaging

PURPOSE: We evaluated the diagnostic value of susceptibility-weighted imaging (SWI) for the detection of developmental venous anomaly (DVA). MATERIALS AND METHODS: Retrospective review of 1068 brain MR examinations found 28 DVAs in 28 patients (2.6%) on contrast-enhanced T1-weighted images. SWI, T2, and FLAIR images of 28 patients with DVA and 28 sex- and age-matched control patients without DVA were analyzed by blinded readers on each type of sequences. All images were independently reviewed by two radiologists who were blinded to other MR imaging finding. In cases of discrepancy, two reviewers reached a consensus later. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of each MR sequence for the detection of DVA were determined. Statistical analysis was performed by using the Mcnemar test. The significance level was p < 0.05. RESULTS: The sensitivity, specificity, PPV, and NPV of SWI for the detection of DVA were 85.7%, 92.9%, 92.3%, and 86.7%, respectively. T2 and FLAIR images showed sensitivity of 35.7% and 35.7%, specificity of 92.9% and 96.4%, PPV of 83.3% and 90.9%, and NPV of 59.1% and 60.0%, respectively. On SWI, the sensitivity and NPV for the detection of DVAs were significantly higher than those of T2 and FLAIR images (p < 0.05). CONCLUSION: SWI was sensitive and specific for the detection of DVA.

Assessment of Cerebral Vascular Reserve Capacity Prior to Carotid ArteryStenting: Brain Single Photon Emission Computed Tomography images and Magnetic Resonance Arterial Spin Labeling images

No abstract available.

Ictal Images of Simple Partial Status Epilepticus

No abstract available.

Incidental Right Sided Aortic Arch in a Patient With Right Pontine Infarction

No abstract available.

The Effect of Extracorporeal Shock Wave Therapy on Lower Limb Spasticity in Subacute Stroke Patients

OBJECTIVE: To evaluate the effect of extracorporeal shock wave therapy (ESWT) on lower limb spasticity in subacute stroke patients. METHODS: We studied thirty hemiplegic subacute stroke patients with ankle plantar flexor spasticity. ESWT was applied for 1 session/week, with a total of 3 sessions at the musculotendinous junction of medial and lateral gastrocnemius muscles. Patients were evaluated both clinically and biomechanically at baseline, after sham stimulation, and at immediately 1 week and 4 weeks after ESWT. For clinical assessment, Modified Ashworth Scale (MAS), clonus score, passive range of motion of ankle, and Fugl-Myer Assessment for the lower extremity were used. A biomechanical assessment of spasticity was conducted by an isokinetic dynamometer. Two parameters, peak eccentric torque (PET) and torque threshold angle (TTA), were analyzed at the velocities of 60degrees/sec, 180degrees/sec, and 240degrees/sec. RESULTS: After sham stimulation, there were no significant changes between each assessment. MAS and PET (180degrees/sec and 240degrees/sec) were significantly improved immediately and 1 week after ESWT. However, these changes were not significant at 4 weeks after ESWT. PET (60degrees/sec) and TTA (60degrees/sec, 180degrees/sec, and 240degrees/sec) were significantly improved immediately after ESWT. Yet, these changes were not significant at 1 week and 4 weeks after ESWT as well. CONCLUSION: Lower limb spasticity in subacute stroke patients was significantly improved immediately after ESWT. Although the therapeutic effect of ESWT reduced with time and therefore was not significant at 4 weeks after ESWT, the degree of spasticity was lower than that of the baseline. Future studies with a larger sample of patients are warranted in order to verify the protocols which can optimize the effect of ESWT on spasticity.

Middle Cerebral Artery Territory Infarction Caused by Giant Middle Cerebral Artery Dissecting Aneurysm

Dissecting aneurysm of the intracranial arteries is a rare cause of stroke. This condition may induce both ischemic stroke and hemorrhagic stroke by occlusion of the parent artery via direct distortion and stretching, compression secondary to growth of the aneurism, and distal embolization of any intra-aneurysmal thrombi. A patient with an infarction in the right middle cerebral artery territory and a mass lesion located in the right basal ganglia and temporal lobe was examined in this study. The consequent workup suggested that the mass lesion was a huge dissecting aneurysm that had resulted in a cerebral infarction.

Middle Cerebral Artery Territory Infarction Caused by Giant Middle Cerebral Artery Dissecting Aneurysm

Dissecting aneurysm of the intracranial arteries is a rare cause of stroke. This condition may induce both ischemic stroke and hemorrhagic stroke by occlusion of the parent artery via direct distortion and stretching, compression secondary to growth of the aneurism, and distal embolization of any intra-aneurysmal thrombi. A patient with an infarction in the right middle cerebral artery territory and a mass lesion located in the right basal ganglia and temporal lobe was examined in this study. The consequent workup suggested that the mass lesion was a huge dissecting aneurysm that had resulted in a cerebral infarction.

Incidentally Discovered Direct Carotid-Cavernous Fistula in a Patient With Anterior Choroidal Artery Territory Infarction

Direct carotid cavernous fistula (CCF), which is an abnormal communication between the intracavernous carotid artery and the cavernous sinus, is a very rare condition that is generally associated with head trauma, intracavernous aneurysms, and certain connective-tissue diseases. The case of a patient with an infarction in the anterior choroidal artery territory is described herein. Cerebral angiography was performed during consecutive workups to investigate the discrepancy between the magnetic resonance angiography data. An unexpected direct CCF of the ipsilateral side of the infarction was found. It is possible that the CCF had influenced the development of the infarction in the anterior choroidal artery territory.

Incidentally Discovered Direct Carotid-Cavernous Fistula in a Patient With Anterior Choroidal Artery Territory Infarction

Direct carotid cavernous fistula (CCF), which is an abnormal communication between the intracavernous carotid artery and the cavernous sinus, is a very rare condition that is generally associated with head trauma, intracavernous aneurysms, and certain connective-tissue diseases. The case of a patient with an infarction in the anterior choroidal artery territory is described herein. Cerebral angiography was performed during consecutive workups to investigate the discrepancy between the magnetic resonance angiography data. An unexpected direct CCF of the ipsilateral side of the infarction was found. It is possible that the CCF had influenced the development of the infarction in the anterior choroidal artery territory.

Perfusion MR Imaging of Seizure-related Cerebral Cortical Lesion: A Case Report

When cerebral cortical hyperintensities on diffusion-weighted image are seen in patients with suspected acute stroke accompanying seizure, it is necessary to differentiate whether they are caused by infarction or seizure-related change. We report a case of seizure-related cortical hypertensities in a patient with suspected acute infarction. With perfusion MR imaging, we could differentiate from acute infarction.