Comparison of dementia in stroke survivors and patients with parkinson’s disease in Thai subjects.

Comparison of dementia in stroke survivors and patients with Parkinson’s disease was done at Siriraj Hospital during 1990-1994. Two hundred and twelve Thai stroke survivors and 132 patients with Parkinson’s disease were enrolled in this study. The mean age of the study groups were 62.78 (SD 11.12) years for stroke survival group and 67.72 (SD 9.12) years for Parkinson’s diseases group. The mean duration of stroke suffering was 2.09 (SD 2.74) years whereas the mean duration of suffering from Parkinson’s disease was 3.5 (SD 3.53) years. All patients of both groups were screened for depression by using Thai Geriatric Depression Scale and patients with Alzheimer’s disease were excluded from the study. Thai Mental State Examination (TMSE) is a standard test used in this study to identify dementia. Seventy stroke patients (33.02%) scored below 23 points (cut-off point for dementia) and 34 patients (25.76%) of Parkinson’s disease scored below 23 points which they were classified as definite dementia. Anyone who scored below 20 points was classified as severe dementia which there were 40 patients (18.88%) in stroke group and 24 patients (18.18%) in Parkinson’s disease group. Patient who scored between 20-22 points was classified as mild to moderate dementia which there were 30 patients (14.15%) in stroke group and 12 patients (9.09%) in Parkinson’s disease group. Fifty-eight patients (27.36%) in stroke group and 37 patients (28.03%) in Parkinson’s disease group scored between 23-25 points and they were classified as borderline dementia. Comparison of the subset of demenyia yesting in TMSE between stroke group and Parkinson's disease group revented no statistically significant difference in any degree of dementia. Subset tests of orientation, language and abstract thinking, and recall seemed to be more affected in Parkinson's disease group whereas subset test of registration was equally impaired in both groups. There were no difference in subset tests of dementia in mild to moderate dementia group of both patients with stroke and Parkinson's disease. In conclusion we could not differentiate pattern of dementia between stroke survivors and patients with Parkinson's disease even they were severely demented.

Rabbit syndrome: An idiopathic case with tongue tremor.

A 50 year old man presented with mouth and tongue tremor for 6 months. He lead no previous exposure to any narcoleptic drugs. Physical examination revealed healthy except abnormal movement of his mouth and tongue without any signs of parkinsonism. Investigations s howled normal blood chemistry profile, chest radiography, electrocardiography and electro encephalopathy. Benztropine 2 milligram three times a day was prescribed for him and he responded dramatically within a few days and all symptoms were disappeared within two weeks. He was a regular attendant to our Movement Disorder Clinic at Siriraj Hospital for 4 consecutive years without any evidence of parkinsonism signs. He once stopped medication by his own for 2 weeks and movement disorder of rabbit syndrome recurred but all his symptoms were controlled after read ministration of benztropine. This is the first report of rabbit syndrome in Thailand with spontaneous occurring and tongue tremor. Now only 30 reported cases were in the world literature.

The comparative study of CSF findings in AIDS and non-AIDS patients with cryptococcal meningitis.

The ceredrospinal fluid of patients with AIDS and Cryptococcus neoformans infection (n = 62) and those of non-AIDS with Cryptococcus neoformans infection (n = 31) were analysed for white cell count, protein and CSF sugar/blood sugar levels. The mean value of white cell count (39.43/cumm VS 160.83/cumm) and protein (77.91 mg/dl Vs 118.2 mg/dl) in patient with AIDS and cryptococcal infection were statistically significant lower than non-AIDS patients with cryptococcal infection (p < 0.005 and p < 0.01), whereas there were no difference in CSF sugar/levels. Two-thirds of the patients with AIDS and cryptococcal infection had the white cell count less than 10 cell/cumm. These data shows that AIDS aptients have lower immune response to cryptococcus neoformans than non-AIDS patients. Thus it is advisable that Indian ink preparation of CSF is always necessary for AIDS patients in spite of normal white cell count in the CSF.

Parkinson plus syndromes.

Parkinson plus syndrome was first described in 1997 and it is accounted for 10 per cant of parkisonian patients. In Thailand there was no such case documented. We thus reported th first three patients with Parkinson plus syndrome in Thailand. Two patients (60 years old man and 51 years old woman) presented with classical parkinsonism which few years later developed cerebellar and brainstem signs (dysarthria, nystagmus, dysdiadocholinesia and progressivedysphagia).Computed brain scanning showed marked atrophy of brainstem and cerebellum. They were both diagnosed as olivopontocerebellar atrophy variety of Parkinson plus syndrome. The first patient was deteriorated in the neurological deficits that needed to be confined in bed six years later but his intellectual function was still preserved. The third patient, a 51 years old man presented with parkinsonism that was not responsed to levodopa therapy, then 2 years later he developed myoclonus of the left arm, progressive dysarthria, gait difficulty and deterioration of his intellectual function. Magnetic resonance imaging of the brain showed marked atrophy of brainstem, cerebellum, basal ganglia and cerebral cortex. Single photon emission tomography showed bilateral decreased perfusion of both parietal lobes and basal ganglia. Multiple system atrophy category of Parkinson plus syndrome was diagnosed. He was still survived at his fifth years of illness but in a dependent state at home. Patient with Parkinson plus syndrome must be diagnosed from parkinsonism because it has differ natural history treatment and prognosis.

CSF finding in AIDS patients: Report of 112 cases.

One hundred and twelve cerebrospinal fluids from acquired immunodeficiency syndrome (AIDS) patients were analysed at Department of Neurology, Faculty of Medicine, Siriraj Hospital, Mahidol University during 1900-1993.The increasing rate rising from 3 (0.28%) cases to 12 (1.19%) cases, 33 (3.4%), 64 (7.4%) cases in 1990, 1991 1992 and 1993 respectively. The India ink preparation and latex agglutination revealed that 62 cases (-55%) of these patients had been infected with cryptococcus neoformans. Fach year the infection of this fungus in AIDS patients were increasing from 1 (33%) cases in 1990 to 5 (41%) cases in 1991, 20 (61%) case in 1992 and 36 (56%)cases in 1993. The mean value of white cell count, protein, and sugar of the AIDS patients infected with cryptococcus neoformans. were 39.43 cell/cumm (SD = 76.23), 77.91 mg/dl (SD = 62.91) and 35.46 mg/dl (SD = 19.48) respectively. These compositions were statistically significant lower than the AIDS patients that have the other complications. This study indicated that the AIDS patients have the low immune response to cryptococcus neoformans which is the major caused of the central nervous system disease in AIDS patients in Thailand.

Neuroleptic malignant syndrome: A case report and review of the literature .

A case report of neuroleptic malignant syndrome was documented. A 54 year old woman had 2 week history of neuroleptic drug (haloperidol) therapy for her recent psychiatric symptoms. She developed high fever, stupor and muscle rigidity with leucocytosis and raised serum creatine phosphokinase. Investigations revealed no source of systemic infection and lumbar puncture showed no definite evidence of infection. She was successfully treated with bromocriptine and supportive procedure. She gained her consciousness four days later in spite of complication with pneumonia. She was discharged home after 5 weeks of admission with normal sensorium. Literature review for this syndrome was doe extensively.

Short-latency somatosensory-evoked potentials in healthy Thais.

Median, ulnar and tibial short-latency somatosensory-evoked potentials were recorded from 112 neurologically normal subjects. Absolute latencies and interpeak latencies were analysed. Absolute latencies were correlated with height (r=0.37-0.59, P<0.01) but not with age (r=0.16-0.55, P>0.05). Interpeak latencies were not correlated either with height or age, except median/ulnar N9-N19 which were correlated with age and height (r=0.34, .044, P<0.01). Males had longer absolute and interpeak latencies than females (P<0.05) which were probably due to height difference (P<0.001). Hence, height is the most important variables for predicting absolute latencies, except in age group over 60 year old that the absolute and interpeak latencies were significantly delayed (P<0.05). The equations foe such predictions were verified. Hence, any absolute latencies should be corrected for height prior to considering them to be abnormal.

Diagnostic values of short latency somatosensory evoked potentials in stroke.

Short latency somatosensory evoked potentials (SSEPs) were elicited by stimulation of the median and tibial nerves in 55 patients with cerebrovascular diseases. There were 28 males and 27 females. The mean age was 52.7+14.9 years (range 20-83). Every patient presented as an acute hemiplegic with and without sensory loss. The CT findings were classified into 6 groups, thalamic, internal capsule, subcortical white matter, basal ganglia, occlusion of proximal branch of middle cerebral artery and transient ischemic attack. The abnormality rate of median SSEPs was 63.6 percent (35/55) and tibial SSEPs was 67.3 percent (37/55). In thalamic stroke both median and tibial SSEPs abnormality rates were 80 percent (8/10), in ganglionic stroke the rates were 75 percent (9/12). The internal capsule abnormality rates were 75 percent (9/15). Subcortical white matter there was 57.1 percent (4/7) and 80 percent (8/10) in occlusion of the main branch of middle cerebral artery. The SSEPs specificity, positive and negative predictive values between cerebral hemorrhage and infarction were 42.8, 47.4 and 87.2 percent respectively. Hence, SSEPs might be of value in localizing anatomical lesions but not to differentiate between hemorrhagic and ischemic stroke.

The first magnetic resonance image of multiple sclerosis in Thailand.

The authors reported a 36 year old nurse with the symptoms of diplopia and fight hemiparesis for six days. She had been suffering from numbness on and off over the right side of the body for eight years for which was prescribed anxiolytic drugs. Examination revealed normal fundi, left lateral rectus paresis and horizontal phasic nystagmus. Mild right hemiparesis with exaggerated reflexes and fight Babinski sign were noted. Clumsiness of fight arm and fight leg were recorded as well as fight hemihypalgesia. Various investigations were performed. AII studies were within normal range, including blood chemistry profile, VDRL, ESR. LE, ANF, and anti-DNA. CT-scan showed normal result as well as lumbar puncture and transcranial Doppler ultrasonography. Evoked responses showed abnormal brainstem and somatosensory response, while the visual response was normal. Magnetic resonance image (MRI) was done and revealed multiple plaques over the left pons and periventricular region in both T1 and T2 weighted image. Prednisolone 60 mg/d was prescribed and she recovered satisfactorily. Within ten days, she was discharged home without any weakness. The numbness was diminished as ewll as her double vision. This is the first demonstration in Thailand using the expensive, noninvasive, sensitive and accurate MRI on MS. Investigating neurological patients using MRI still needs to be considered for cost-benefit.

Hemiparesis in herpes ophthalmicus: Report of a rare occurrence.

Report of a case of a 25 year-old Thai man who developed acute behavioural change and right hemiparesis one month after herpes zoster ophthalmicus (HZO) of the left trigeminal nerve. Neurological examination revealed disorientation and memory deficit with mild right central facial palsy and hemiparesis. CSF examination revealed 100 wbc with 97% lymphocyte. CT scan showed hypodensity over the left parietal region with gyral enhancement after contrast injection. Carotid angiogram revealed arteritis of left anterior and middle cerebral arteries, confirming the diagnosis of herpes zoster ophthalmicus associated cerebral angiitis. The patient recovered eventually on symptomatic treatment.

Plasmapheresis in fulminating acute inflammatory polyradiculoneuropathy: The first experience at Siriraj Hospital.

A first experience of plasmapheresis in treatment of fulminating acute inflammatory polyradiculoneuropathy at Siriraj Hospital was reported with an excellent outcome. A 62 year old man had progressive motor weakness of all extremities and progressed to involve bulbar muscles and respiratory muscles within 24 hours. He was intubated and needed assisted ventilation since the admission. His motor power of all limbs showed a flaccid improvement after the total removal of 5,200 ml. He was discharged home after six weeks of hospitalization and total days of ventilation was twenty four days. He had a stormy clinical course in the intensive care unit with severe chest infection of mixed organisms (Klepsiella and Pseudomonas). His motor power regained to grade 4/5 MRC grading on discharging day with healed tracheostomy scar. Rationals for using plasmapheresis in this condition were discussed in detail as well as its usage in other illnesses.

Thalamic neglect: Report of three cases and review of the literatures.

Three patient of thalamic neglect are documented and it is the first kind hitherto reported in Thailand The first and second cases were presented with left hemiparesis in hypertensive patients with sensory and visual neglect over the left side. They also showed constructional apraxia on drawing pictures. CT scan revealed fight thalamic bleeding with blood leakage into ventricles.

Cerebellar infarction with obstructive hydrocephalus report of a case with non-surgical treatment.

This is a report of a 60 year old woman who had an abrupt onset of right sided weakness, headache, vomiting and alteration of consciousness. She had a lumbar puncture performed which resulted in comatose and an enlarged right cerebellar infarction with marked hydrocephalus. Surgical intervention was refused and frusemide was given intravenously to reduce the formation of cerebrospinal fluid. She gained her consciousness on the tenth day after overcoming superimposed infection of both pneumonia and urinary tract infection. She was discharged on her nineteenth hospital day with minimal right hemiparesis (grade 4/5 MRC grading). Clinical features and management of cerebellar infarction was reviewed in detail.