Survey on Public Awareness of Neurology in Korea

Background@#Neurology in Korea is a field of clinical practice and research that has been developing for over 30 years, but due to its relatively short history, public awareness is low compared to other clinical fields. The Korean Neurological Association conducted a survey to evaluate the Korean public’s awareness of neurology and the necessity of a name change. This study details the second survey conducted on the topic, with the first being conducted in 2013. The two surveys were compared to identify how the public’s awareness of neurology has improved since 2013 and determine how this can be improved. @*Methods@#The survey was conducted by Gallup Korea, where 1,000 participants were randomly selected and interviewed through telephone surveys. @*Results@#Of the 1,000 participants, 78.5% were familiar with Neurology, similar to the results of the 2013 survey. Meanwhile, when asked about neurological diseases, only 27.9% of the participants recognized neurological diseases correctly. The most accurately recognized symptoms related to Neurology were tremors (57.8%), strokes (55.5%), and dizziness (49.7%). In 2013, 61.7% of the participants thought a name change was necessary. In comparison, only 38.4% responded it needed to change in the recent survey. @*Conclusions@#The preference for Neurology’s current name in Korea has improved since 2013 despite no significant change in the public’s awareness of neurology. More active public relations activities are needed to improve awareness of neurology in the future.

Survey on Public Awareness of Neurology in Korea

Background@#Neurology in Korea is a field of clinical practice and research that has been developing for over 30 years, but due to its relatively short history, public awareness is low compared to other clinical fields. The Korean Neurological Association conducted a survey to evaluate the Korean public’s awareness of neurology and the necessity of a name change. This study details the second survey conducted on the topic, with the first being conducted in 2013. The two surveys were compared to identify how the public’s awareness of neurology has improved since 2013 and determine how this can be improved. @*Methods@#The survey was conducted by Gallup Korea, where 1,000 participants were randomly selected and interviewed through telephone surveys. @*Results@#Of the 1,000 participants, 78.5% were familiar with Neurology, similar to the results of the 2013 survey. Meanwhile, when asked about neurological diseases, only 27.9% of the participants recognized neurological diseases correctly. The most accurately recognized symptoms related to Neurology were tremors (57.8%), strokes (55.5%), and dizziness (49.7%). In 2013, 61.7% of the participants thought a name change was necessary. In comparison, only 38.4% responded it needed to change in the recent survey. @*Conclusions@#The preference for Neurology’s current name in Korea has improved since 2013 despite no significant change in the public’s awareness of neurology. More active public relations activities are needed to improve awareness of neurology in the future.

Prevalence of Treated Epilepsy in Korea Based on National Health Insurance Data

The Korean national health security system covers the entire population and all medical facilities. We aimed to estimate epilepsy prevalence, anticonvulsant utilization pattern and the cost. We identified prevalent epilepsy patients by the prescription of anticonvulsants under the diagnostic codes suggesting seizure or epilepsy from 2007 Korean National Health Insurance databases. The information of demography, residential area, the kind of medical security service reflecting economic status, anticonvulsants, and the costs was extracted. The overall prevalence of treated epilepsy patients was 2.41/1,000, and higher for men than women. The age-specific prevalence was the lowest in those in their thirties and forties. Epilepsy was more prevalent among lower-income individuals receiving medical aid. The regional prevalence was the highest in Jeju Island and lowest in Ulsan city. New anticonvulsants were more frequently used than old anticonvulsants in the younger age group. The total annual cost of epilepsy or seizure reached 0.46% of total medical expenditure and 0.27% of total expenditure on health. This is the first nationwide epidemiological report issued on epilepsy in Korea. Epilepsy prevalence in Korea is comparable to those in developed countries. Economic status and geography affect the prevalence of epilepsy.

Dipole Source Localization of Periodic Sharp Wave Complexes in Creutzfeldt-Jakob Disease

BACKGROUND: Patients with Creutzfeldt-Jakob disease (CJD) show periodic sharp wave complexes (PSWCs) on electroencephalography (EEG) during the course of their illness. However, the source location of PSWCs and the pathophysiological mechanism remains unclear. METHODS: Ten patients with sporadic CJD who showed typical PSWCs on EEG underwent brain magnetic resonance imaging (MRI) and positron emission tomography (PET, n=8) or single-photon emission computed tomography (SPECT, n=2) scans. A 30-second epoch from the EEG was selected for analysis. The recording was separated blindly using independent component analysis. The separate independent components were subjected to dipole source localization using a single dipole model. The source locations were compared with neuroimaging findings in each patient. RESULTS: Two to three independent components responsible for the PSWCs seen in CJD were identified. The EEG recording reconstructed from the selected independent components accounted for about 70% of the variance in the original recording. All but one patient had dipole sources localized in both cortical and subcortical areas. One patient had only subcortical dipole sources in both caudate nuclei. The cortical locations included the cingulate, insula, frontal, temporal, and occipital areas. The subcortical sources were located in the striate, thalamic, and subthalamic nuclei. All the dipole sources were localized within lesions seen as neuroimaging abnormalities. CONCLUSIONS: These results suggest that a subcortical mechanism, in addition to cortical structures, is involved in producing the generalized periodic discharges in CJD.

Cortical Representation to Odorant Stimulation: Statistical Non-parametric Mapping of Low Resolution Electro magnetic Tomography (LORETA)

BACKGROUND: Although olfactory stimulation has been known to produce effects on human mood and cognition, the specific EEG patterns of activity was reported diversely. The purpose of this study was to investigate EEG changes by odorant using low resolution electromagnetic tomography (LORETA) in young healthy subjects. METHODS: The EEG's of nineteen (10 males, 9 females) non-smoking right-handed college students were recorded after odorant stimulation. A nineteen-channel EEG was recorded referenced to linked ears before and during olfactory stimulation. Olfactory stimulation was presented with lavender essential oil by blotter method. The LORETA power was computed from ten 2-s epochs, separately for the different EEG frequencies. The power values were logarithmically transformed and paired sample t-tests were done for each voxel and frequency band (1.5-30 Hz). Statistical results were displayed 3-dimensionally on the standard brain template. RESULTS: All subjects experienced positive feelings (relaxed and pleasant) by olfactory stimulation with lavender oil (p<0.01). The LORETA power of theta and alpha band was increased in the dorsolateral and medial frontal areas, predominantly in the posterior cingulate gyri. The alpha LORETA power was also increased in bilateral orbitofrontal regions and the left perisylvian region including the insular cortex. Beta power was increased in the posterior cingulated gyri and mesial temporal region, predominantly on the left side. CONCLUSIONS: These results suggest that olfaction associated with emotional feeling might induce brain electrical power changes not only in the limbic system but also in the neocortex with lateralization to the dominant hemisphere.

Comparative Study between Visusal Analysis and Low Resolution Electromagnetic Tomography (LORETA) Method in the Localization of Epileptiform Discharges

BACKGROUND: LORETA (Low Resolution Electromagnetic Tomography) produces a three-dimensional current density mapping from digitized EEG (electroencephalography) data. A comparison between visual waveform analysis of scalp EEG and LORETA method may be helpful for the exact localization of epileptiform discharges. METHODS: Digital EEG data from 20 subjects showing epileptiform discharges that were localized in the left or right frontotemporal regions (F7, F8) were studied. Those EEG waves were recorded using international 10~20 system. Phase reversals in bipolar montage were converted to referential montage and waveforms were analyzed visually. Those spike waves were converted into three-dimensional potential density mapping by LORETA method and maximum negative potential density region was determined. RESULTS: The same localization in the frontotemporal region (F7, F8) between two methods was noted in 16 subjects (80.0%). The discordant localization by LORETA method was noted in 4 subjects (20.0%). In different localiza-tion subjects, their locations were frontopolar region (Fp1, Fp 2) in 2 subjects, lateral temporal region (T7, T8) in 1 and posterior temporal region (P7, P8) in 1 subject, respectively. CONCLUSIONS: Even though the localization of epileptiform discharges by visual waveform analysis is a traditional method, electrical potential density mapping by LORETA can be a useful adjunctive localization method. If detailed localization is needed, LORETA method should increase accuracy.

Massive Hemoptysis after Generalized Tonic Clonic Seizure Requiring Mechanical Ventilation

A 38-year-old woman presented with massive hemoptysis ( 200 mL/ 24 hours) occurring abruptly after generalized tonic clonic seizure. She experienced similar episodes of hemoptysis on three later occasions. Although the coexistence of hemoptysis and seizure has been reported, albeit rarely, as a clinical manifestation of postictal neurogenic pulmonary edema, massive hemoptysis after seizure is an extremely rare event with no recurrent cases of such episodes having ever been reported. The coexistence of hemoptysis and seizure increases the difficulty in diagnosis for the clinician. We describe the differential diagnosis among the diseases capable of causing seizure and hemoptysis.

The Changes of EEG Nonlinear Parameter in Sleep and Wakefulness States

BACKGROUND: Up to now, sleep stages have traditionally been determined by the visual inspection of individual EEG waves. However, the exact physiological meaning of the sleep waves is not known. The purpose of this study was to try and find out the physiological parameters of the EEG of the sleep and wakefulness states by calculating one of the non-linear chaos parameter, the largest Lyapunov exponent (LLE), of EEG time series. METHODS: The digital EEG of the wakefulness with eye opening (WEO), wakefulness with eye closure (WEC), stage1 (S1), stage2 (S2), stage3 or 4 (S34) were recorded at centroparietal region (C4-P4 bipolar derivation) in 10 normal subjects. Lyapunov exponents of 50 EEG time series in different states were compared. RESULTS: LLE's of WEO, WEC, S1, S2, S34 showed an increas-ing tendency as states switched from wakefulness to sleep. LLE of sleep was larger than that of awake state. CONCLUSIONS: The EEG of the sleep state appeared to be more chaotic than that of the awake state. This nonlinear chaos parameter can be used as a physiological parameter of normal sleep and awake states.

Independent Component Analysis of Eyeball Movements

Independent Component Analysis (ICA) is a signal processing algorithm to separate independent sources from unknown mixed signals and can be applied to separate artifacts and independent neural sources from EEG recordings. This study was designed to extract individual components of eyeball movements from scalp EEG. Digital EEG signals were recorded using the international 10-20 system during eye closure, eye opening, and blinking. 18 EEG tracings using bipolar montage were analyzed by ICA algorithm into 18 independent components. Each of the components was reviewed, selected, and reconstructed into an original montage. Among 18 components, two components which were thought to represent eyeball movements were obtained. Each of the components was inversely projected into the original bipolar montage. This inverse projection showed separated vertical and horizontal eyeball movements components. These results suggest that the ICA analysis of EEG can separate vertical and horizontal eyeball movements and may be applied to separate other EEG artifacts and source signals from unknown mixed sources recordings of EEG.

A Case of Fly Catcher's Tongue Phenomenon in Hallervorden-Spatz Disease

Hallervorden-Spatz disease (HSD) is a rare, progressive, autosomal recessive hereditary disorder characterized by pyramidal and extrapyramidal signs, speech disturbances, mental deterioration and retinal degeneration during childhood or adolescence. In late-onset form after the age of 20, parkinsonian features may be the predominant clinical manifestation. Meanwhile, involuntary tongue movements are rare and poorly understood, which have been reported in tardive dyskinesia, neuroacanthocytosis, chronic epilepsy, and after head trauma. We report a case of a patient with 'fly catcher's tongue' as a major clinical presentation, accompanied with mild parkinsonism, and typical MR findings of HSD.

Surgical Application of Magnetic Resonance Imaging Anatomy for Temporal Lobe Epilepsy Surgery

Anterior temporal lobectomy is the most popular surgical method for mesiobasal temporal lobe epilepsy. The key point in anterior temporal lobectomy is to resect lateral neocortex as little as possible, and mesiobasal structures as much as possible without surgical complication. We analyzed surgical anatomy on MRI scans of 20 persons to evaluate the relationships of anatomical structures related with surgical steps in anterior temporal lobectomy. On the oblique axial scan, the distance from temporal pole to anterior margin of hippocampus was 29.8+/-1.5mm. The length of hippocampus to the level of posterior margin of cerebral peduncle was 25.6+/-2.4mm. On the oblique coronal image through hippocampal head, the distance between the surface of superior temporal sulcus and lateral margin of temporal horn roof was 32.5+/-2.2mm. The angle between middle fossa base line and the line connecting superior temporal sulcus and lateral margin of temporal horn roof was 33.6+/-5.2 degree. The distance between lateral temporal surface and brain stem, and that between lateral temporal surface and collateral sulcus was 49.9+/-1.9mm and 40.6+/-3.3mm, respectively. The distance between collateral sulcus and lateral margin of temporal horn roof was 14.2+/-1.8mm, and the angle between middle fossa base line and the line connecting lateral margin of temporal horn roof and collateral sulcus was 60.4+/-7.4 degree. On the sagittal image, the angle between superior temporal sulcus and hippocampal axis was 18.8+/-1.1 degree. In conclusion, surgical complication of anterior temporal lobectomy can be reduced by careful consideration of anatomical relationships between anatomical structures encountered in each surgical steps in anterior temporal lobectomy.

Magnetic Resonance Imaging Anatomy for Surgical Application in Subtemporal Selective Amygdalohippocampectomy

Although subtemporal amygdalohippocampectomy is the ideal approach for pure mesial temporal lobe epilepsy from the view point that it can resect amygdala, hippocampusis, and parahippocampal gyrus selectively, this approach has not gained wide popularity due to shortcomings such as temporal lobe retraction and possible injury to temporal lobe draining veins. We analized surgical anatomy on MRI scan of 20 persons for the purpose of modifing the subtemporal approach to overcome the inherent shortcomings. The distance from temporal pole to anterior margin of temporal horn was 29.8+/-5mm(range, 28.5-31mm). Anterior margin of hippocampus was located 1.8+/-9mm(range, 1-3mm) anterior to dorsum sella. The length of hippocampus to the level of posterior margin of cerebral peduncle was 25.6+/-4mm. External auditary meatus divided the hippocampus, from anterior to the level of posterior margin of cerebral peduncle, in the ratio of 1.52: 1. On the coronal image through interpeduncular cistern, the distance between lateral margin of temporal lobe and collateral sulcus was 40.6+/-.3mm(37-45mm). On the coronal image through interpeduncular cistern and through the external auditary meatus, the height from temporal base to the choroidal fissure was 30.0+/-.7mm and 21.3+/-.5mm, respectively, and the angle between temporal base line and a line from collateral sulcus to choroidal fissure was 45.7+/-.6 degree and 33.2+/-.9 degree, respectively. In conclusion, our results indicate that external auditary meatus(EAM) is anatomical landmark for subtemporal amygdalohippocampectomy, and skull base approach focused on either EAM or anterior to EAM is necessary to minimize morbidity due to temporal lobe retraction and draining vein injury.

Long-term Outcome of Uvulopalatopharyngoplasty in Obstructive Sleep Apnea Syndrome Patients: Comparison between Changes of Subjective Symptoms and Objective Indexes Including Respiratory and Sleep Parameters / 대한이비인후과학회지

BACKGROUND: Uvulopalatopharyngoplasty(UPPP) is the most frequently performed surgical treatment of obstructive sleep apnea syndrome(OSAS). Even though polysomnogram is the best method to evaluate the results after UPPP, the patients are often unwilling to undergo postoperative testing, particularly if the patients' symptoms have improved. As the perioperative evaluation of UPPP only based on subjective symptoms may lead to incorrect results, objective indexes such as respiratory parameters and sleep structures should also be analyzed. OBJECTIVES: To evaluate the long-term outcome of UPPP in OSAS patients by comparing preoperative subjective symptoms and objective indexes with postoperative results. MATERIALS AND METHODS: We compared preoperative subjective symptoms and objective indexes including respiratory and sleep parameters in 16 OSAS patients who underwent UPPP and were followed up for 15 months or more. RESULTS: Snoring improved in 10(62.5%) of the 16 patients and apnea in 13(81.3%). In respiratory parameters, apnea index(AI) and respiratory disturbance index(RDI) decreased more than 50% in 11 patients(68.8%), respectively. There was no significant change of sleep structure except for in stage I. Only changes of subjective apnea symptom were significantly correlated with changes of AI and RDI, but there were no correlations between the other variables. CONCLUSIONS: In evaluating the surgical outcome after UPPP of OSAS patients, objective analysis on long-term follow-up is needed in addition to assessment of subjective symptom changes.

The Clinical Efficacy of Portable Monitoring Devices(MESAM IV and Edentec) in Evaluating Sleep Apnea Syndrome: A Comparative Study with Simultaneously Recorded Standard Polysomnography / 대한이비인후과학회지

BACKGROUND: Standard polysomnography is generally used in the diagnosis of sleep apnea syndrome. However, this technique is laborious, costly and inconvenient as a screening test or a test for epidemiological study. A simple screening test for sleep apnea, administered at home, would provide physicians with a convenient and less costly means of evaluating possible sleep apnea. OBJECTIVES: The aim of this study was to evaluate the validity of portable sleep monitoring devices. The validity of measurements made by the portable sleep monitoring devices was assessed by comparing respiratory parameters obtained using the portable sleep monitoring devices with those obtained using standard polysomnography. MATERIALS AND METHOD: Eighteen patients were collected and divided into two groups. Direct comparison was made between data obtained by the portable monitoring devices(MESAM IV in group 1 and Edentec in group 2) and data simultaneously obtained by standard polysomnographic techniques. RESULTS: In group 1, oxygen desaturation index(ODI) and heart variation index(HVI) in MESAM IV were significantly correlated with apnea index(AI) and respiratory disturbance index(RDI) in standard polysomnography. In group 2, AI and RDI in Edentec were significantly correlated with those in standard polysomnography. CONCLUSIONS: The results of this study suggest that portable monitoring devices(MESAM IV and Edentec) may be useful in screening test of sleep apnea syndrome.

A CASE OF SURVIVOR WHO SHOWED ALPHA COMA APTER AN ATTEMPTED SUICIDE BY HANGING

A case of survivor who showed alpha coma after an attempted suicide by hanging was reported. A 44 years old women was admitted to the hospital because of respiratory arrest following a hanging attempt on July 3, 1996. She was found pendant completely. On admission she was comatose and the pupils were not reactive to light. The systolic pressure was 100 mmHg, and diastolic pressure was 80mmHg and she had no self respiration and immediately an endotracheal intubation was instituted. After three hours from the onset, the weak spontaneous respiration was restored and the pupils reacted briskly to light. On the 1st day the brain computed tomography (CT) revealed no abnormal findings. An electroencephalogram (EEG) showed widespread alpha activity without occipital dominance a moderate amount of regular, 8 approximately 10 Hz, 10 approximately 30 microvolt potentials. This alpha rhythm had persisted until 24 hours from the onset. At 36 hours later she was still comatose, presenting flaccid quadriplegia with no responses to stimulations. On the 2nd hospital day she was drowsy and on the 3rd day she had become conscious. She showed gradual progress towards complete nerologic recovery. This is the first presentation of a survivor from alpha coma caused by anoxic encephalopathy following a hanging attempt in Korea.

Effects of taurine on generalized seizure activity in the rat thalamocortical slice

Rat thalamocortical slices maintain synoptic connections between thalamus and cortex. When perfused with low Mg++-ACSF, thalamocortical slices exhibited two main types of spontaneous bursting activity. One is monotonic burst of 3-15 Hz and another is multiphasic bursts which have a tonic burst firing period and a late phase of clonic burst firing. These bursts are similar in frequency and during to EEG recordings from human generalized seizures. Exploiting the advantages of in vitro preparations, the electrophysiological action of taurine were studied. Exogeneous application of taurine profoundly decreased spontaneous bursting activities, which it caused only slight reduction of electrically evoked response in cortical layer. Taurine-induced current was blocked by 40 uM bicuculline, GABA receptor antagonist, in acutely isolated coritcal neurons. These results suggest that endogeneous taurine may regulate the hyperexcitablility through GABAa receptor.

Effects of taurine on generalized seizure activity in the rat thalamocortical slice

Rat thalamocortical slices maintain synoptic connections between thalamus and cortex. When perfused with low Mg++-ACSF, thalamocortical slices exhibited two main types of spontaneous bursting activity. One is monotonic burst of 3-15 Hz and another is multiphasic bursts which have a tonic burst firing period and a late phase of clonic burst firing. These bursts are similar in frequency and during to EEG recordings from human generalized seizures. Exploiting the advantages of in vitro preparations, the electrophysiological action of taurine were studied. Exogeneous application of taurine profoundly decreased spontaneous bursting activities, which it caused only slight reduction of electrically evoked response in cortical layer. Taurine-induced current was blocked by 40 uM bicuculline, GABA receptor antagonist, in acutely isolated coritcal neurons. These results suggest that endogeneous taurine may regulate the hyperexcitablility through GABAa receptor.

Two Patients of REM Sleep Behavior Disorders with Narcolepsy or Periodic Limb Movement Disorder

Rapid-eye-movement (REM) sleep behavior (RBD) is a form of REM sleep motor dyscontrol characterized by complex, vigorous, and frequently violent behaviors without atonia during the REM sleep. The motor dyscontrol may include not only cataplexy and sleep paralysis but alto periodic limb movements during REM and non-REM sleep. We examined two patients with charateristic episodes of behavioral manifestations during the REM sleep as well as with other sleep disorders such as narcolepsy and periodic limb movement disorder. The one patina was an 18 year-old man who had childhood-onset RBD associated with narcolepsy since 10 years old. The polysomnographic studies showed excessive augmentation of chin EMG and 6 attacks of violent behavior during REM sleep. He also complained of cataplexic symptomes. Multiple sleep latency tests (MSLT) showed four sleep onset REMs and two episodes of violent behavior during the REM sleep. The other patient was a 74 year-old man who complained of violent behaviors during the REM sleep and polysomnographic studies showed excessive augmentation of chin EMG during the REM sleep and periodic leg movements for 24min. And 14sec. During the sleep. We report two patients with RBD which were associated with narcolepsy, and periodic limb movememt disorder irrespectively, suggesting that RBD, narcolepsy and periodic limb movement disorder could occur coincidently and be understood as a motor dyscontrol during REM sleep.

Intraoperative Electroencephalographic Changes During Carotid Endarterectomy

Continuous electroencephalographic (EEG) monitoring is the widely used method of operative surveillance during carotid endarterectomy. EEG changes have been well known when cerebral ischemic event occurs during the carotid endarterectomy. But in our country intraoperative EEG monitoring during the operation was not popular and was not reported yet. We have experienced four patients showing EEG changes during the operation. EEG monitoring was performed using four channel differential montages in four patients with carotid artery disease. We evaluated the changes of EEG monitoring during the carotid endarterectomy. We also performed somatosensory evoked potentials (SEP) monitoring to backup the EEG monitoring which could miss the small embolic subcortical infarction. They revealed significant EEG changes which were the decreased fast activities and increased slowing during the carotid cross clamping. They were normalized after insertion of shunt. In one subject EEG change reappeared while the shunt was inserted, because the shunt was kinked, In all subjects, the significant changes of SEP were not observed after declamping of ICA or reposition of kinked shunt. There were not any immediate postoperative neurologic deficits in all patients. EEG monitoring might be considered as an useful method to detect ischemic changes during carotid endarterectomy and to know whether the inserted shunt is working well, Key Words : Intraoperative neuromonitoring, Carotid endarterectomy.

Apolipoprotein E Polymorphism in Korean Patients with Down's Syndrome

An association between the apolipoprotein E 4(APOE 4) allele and pathological changes in Alzheimer's disease(AD) is now well established. We analyzed the APOE genotype in patients with another amyloid forming disease, Down's syndrome(DS). It is well-known that patients with DS develop the neuropathological features of AD if they reach middle adult life. The amyloid precursor protein gene is located m chromosome 21 and increased expression of this gene over a patient's lifetime is thought to underlie the development of this pathology. We examined the APOE genotypes of 19 cytogenetically confirmed DS patients. The allele frequencies in this group did not differ from the general population. Our data suggest that the APOE 4 is not essential pathomechanism of AD pathology in patients with DS. Prospective analysis of the occurrence of AD in DS population and APOE genotype is warranted.