Dysphagia Aortica Initially Misdiagnosed as Poststroke Dysphagia: A Case Report / 대한연하장애학회지

Dysphagia aortica is a rare form of mechanical dysphagia characterized by extrinsic compression of the esophagus by the aorta. A 69-year-old male reported experiencing swallowing difficulties for five months, along with nausea, abdominal discomfort, weight loss, and severe reflux. Considering his age and a medical history of hypertension and stenosis of the cerebral artery, poststroke dysphagia was initially suspected. However, brain magnetic resonance imaging revealed no evidence of acute or subacute stroke. Further evaluation was achieved via enhanced chest computed tomography to locate the focus of the systemic inflammation. A thoracic aortic aneurysm about 8.7×5.0 cm in size, with signs of impending rupture, was observed. This case reinforces that a high possibility for dysphagia aortica should be considered under conditions of unclear etiology of dysphagia but the presence of associated symptoms, such as progressive intolerance to solids and ultimately to liquids, weight loss, and nausea.

Respiratory Arrest Induced by Presbyesophagus: A Case Report / 대한연하장애학회지

Presbyesophagus is a unique cause of dysphagia in the elderly, which features incomplete relaxation of the lower esophageal sphincter, dilatation of the esophagus, decreased esophageal peristaltic pressures, abnormal esophageal contractions, and delayed emptying of the esophagus. An 88-year-old woman underwent surgery for a femur fracture.The day after surgery, respiratory arrest occurred during a meal. Breathing resumed after oxygen supply with airway opening. She complained of dysphagia and nausea during a meal, and the videofluoroscopic swallowing study and esophagography showed delayed emptying of the esophagus, abnormal esophageal contraction, and dilatation of the esophagus. This case shows that esophageal dysfunction in the elderly with poor general medical conditions can worsen abruptly.

Esophagostomy as an Alternative to Gastrostomy for Dysphagia in Muscular Dystrophy: A Case Report / 대한연하장애학회지

Many people with muscular dystrophy develop dysphagia that can result in an inability to use the oral route in severe cases. In such cases, an alternative feeding method is selected, including a nasogastric tube or a gastrostomy.This case report describes a 40-year-old man with muscular dystrophy who was managed for swallowing difficulty and respiratory failure. Oromotor muscle weakness caused prolonged mealtimes, difficulty with swallowing a solidform diet, aspiration signs, and weight loss. Consequently, an alternative feeding method was required. An abdominal radiograph showed massive aerophagia, and the transverse colon was located over the stomach. As a result, the colon interfered with the puncture route, which could lead to colon perforation. Therefore, cervical esophagostomy was selected, where the patient obtained nutrition through a cervical esophagostomy tube. This case showed that when gastrostomy cannot be performed due to aerophagia, cervical esophagostomy can successfully support nutrition for the mid to long-term in muscular dystrophy patients.

Late-Onset Spinal Subdural Hematoma after Acupuncture

Acupuncture is generally regarded as a safe procedure and as a popular treatment for patients with musculoskeletal disorders. We report a case of a 47-year-old male patient with late-onset tetraplegia, developed after acupuncture. He had no trauma, medical, and social history relevant to tetraplegia. Right after the acupuncture, he felt discomfort in his right arm. After 6 days, all 4 extremity weakness developed. Whole-spine magnetic resonance imaging revealed the presence of spinal subdural hematoma extending from the C5 vertebra to the coccyx level. Hand coordination dysfunction, neurogenic bladder, and neuropathic pain were other symptoms. After the management, he recovered muscle strength, but incomplete bladder control and neuralgia were sustained. It is important to be aware of the possibilities of severe complications after acupuncture.

Late-Onset Post-radiation Lymphedema Provoked by Bee Venom Therapy: A Case Report

Lymphedema is a common complication associated with cancer itself or with cancer treatment. Lymphedema infrequently occurs after drug therapy. Bee venom is one of the materials used in acupuncture, and it has been used in the treatment of a variety of inflammatory diseases including arthritis. We report a 74-year-old male patient with late-onset post-radiation lymphedema provoked by bee venom therapy. He was free of lymphedema for 5 years after the complete remission of prostate cancer which had been treated with transurethral resection and radiation therapy. The patient developed left leg swelling after undergoing bee venom therapy for left hip pain. Computed tomography and lymphoscintigraphy showed lymphedema without tumor recurrence or infection. The lymphatic system was suspected to be injured by bee venom therapy and lymphedema was provoked. Bee venom therapy should be used cautiously in patients prone to lymphedema.

Repetitive Transcranial Magnetic Stimulation for Wernicke-Korsakoff Syndrome: A Case Report

A 57-year-old man who was diagnosed with Wernicke-Korsakoff syndrome showed severe impairment of cognitive function and a craving for alcohol, even after sufficient supplementation with thiamine. After completing 10 sessions of 10 Hz repetitive transcranial magnetic stimulation (rTMS) at 100% of the resting motor threshold over the left dorsolateral prefrontal cortex, dramatic improvement in cognitive function and a reduction in craving for alcohol were noted. This is the first case report of the efficacy of a high-frequency rTMS in the treatment of Wernicke-Korsakoff syndrome.

A Prospective Comparison between Bedside Swallowing Screening Test and Videofluoroscopic Swallowing Study in Post-Stroke Dysphagia

To reveal test discrepancies between early bedside swallowing screening test (BSST) and standard videofluoroscopic swallowing study (VFSS) and thereby to achieve an evaluation standard for post-stroke dysphagia which prevent aspiration pneumonia or unnecessary diet restrictions. Consecutive 252 first-ever stroke patients admitted to stroke unit of 1 tertiary university hospital from May 2009 to May 2010. BSST was performed within 3 days after onset and VFSS within 2 weeks after BSST. The findings between BSST and VFSS were compared. BSST and VFSS were performed in 186 patients. Of the 116 patients who passed BSST, aspiration was newly detected in VFSS in 16 patients (14%). Diet recommendation was changed in 95 of the 186 patients (51%) after VFSS, with 28% (n = 52) being changed to a more conservative level compared to the recommendation based on initial BSST. The data support the need for reassessment using VFSS even when BSST is performed in the acute stage of stroke.

Bilateral Anterior Opercular Syndrome With Partial Kluver-Bucy Syndrome in a Stroke Patient: A Case Report

Bilateral anterior opercular syndrome and partial Kluver-Bucy syndrome are associated with bilateral middle cerebral artery lesions. The combination of these two syndromes has only been reported in a child with limbic encephalitis. In this case, a 44-year-old woman with bilateral middle cerebral artery infarction, which occurred 2 years prior, could walk independently. However, she showed automatic-voluntary dissociation and anarthria with preserved writing skills. She also presented hypersexuality, hypermetamorphosis, and memory disturbances. Here, we report a case of an adult stroke patient who suffered from bilateral anterior opercular syndrome accompanied by partial Kluver-Bucy syndrome.

Bilateral Anterior Opercular Syndrome With Partial Kluver-Bucy Syndrome in a Stroke Patient: A Case Report

Bilateral anterior opercular syndrome and partial Kluver-Bucy syndrome are associated with bilateral middle cerebral artery lesions. The combination of these two syndromes has only been reported in a child with limbic encephalitis. In this case, a 44-year-old woman with bilateral middle cerebral artery infarction, which occurred 2 years prior, could walk independently. However, she showed automatic-voluntary dissociation and anarthria with preserved writing skills. She also presented hypersexuality, hypermetamorphosis, and memory disturbances. Here, we report a case of an adult stroke patient who suffered from bilateral anterior opercular syndrome accompanied by partial Kluver-Bucy syndrome.

Effects of Indoor Rowing Exercise on the Body Composition and the Scoliosis of Visually Impaired People: A Preliminary Study

OBJECTIVE: To evaluate the effects of rowing exercise on body composition, laboratory data, fitness and scoliosis in visually impaired people. The majority of visually impaired people do not participate in active sports due to efficiency and safety issues. Rowing is a safe whole-body exercise with aerobic and anaerobic components. METHODS: Twenty subjects were recruited from among those admitted to a facility for visually impaired people (16 men and 4 women). Laboratory data, body composition, physical fitness, Cobb's angle, and fall index were checked before and after 6 weeks (5 days a week) of indoor rowing using Concept2 Model E. RESULTS: After the training, fat mass and total body fat percent decreased significantly. In the fitness test, back strength and trunk flexion score increased significantly. Laboratory data showed significant increases in serum protein and albumin and decreases in low-density lipoprotein (LDL) cholesterol. There were 9 subjects with scoliosis and after the training Cobb's angle decreased by 1.11degrees+/-1.55degrees, though this was not statistically significant. CONCLUSION: Visually impaired people frequently have abnormal body composition, low physical fitness, and scoliosis. A rowing exercise program can be helpful, with a positive effect on body composition and physical fitness; however, with respect to scoliosis, we need an earlier intervention program in visually impaired people.

Effect of the Presence of Brain-Derived Neurotrophic Factor Val66Met Polymorphism on the Recovery in Patients With Acute Subcortical Stroke

OBJECTIVE: To investigate the effect of brain-derived neurotrophic factor (BDNF) Val66Met polymorphism on the recovery after subcortical stroke, using the modified Rankin Scale (mRS). METHODS: Subcortical stroke patients with copies of BDNF Val66Met polymorphism (n=7) were compared to their controls (n=7) without a copy of BDNF Val66Met polymorphism after matching for initial severity, location and type of stroke. The mRS scores at 1 and 3 months after discharge from the neurorehabilitation unit were compared between the groups. RESULTS: A repeated measures ANOVA for mRS revealed significant interaction between time and group (F(2, 24) =37.2, p<0.001) and a significant effect of time (F(2, 24)=10.8, p<0.001), thereby reflecting significant differences between the Met allele (+) group and the Met allele (-) group. There was a significant difference in mRS scores at 3 months post-discharge between the two groups (p=0.01) although no difference was evident in mRS scores at 1 month post-discharge between the two groups. There were significant improvements between mRS scores on admission and mRS scores at 1 month post-discharge (p=0.02), and between mRS scores at 1 month post-discharge and mRS scores at 3 months post-discharge (p=0.004) in the Met allele (-) group. CONCLUSION: BDNF Val66Met polymorphism may be associated with worse functional outcome in Korean patients with subcortical stroke. Therefore, BDNF Val66Met polymorphism should be considered as an important prognostic factor for recovery and responses to rehabilitation therapies after stroke in Korean patients. There is a need for developing different rehabilitation strategies for the population with BDNF Val66Met polymorphism. Further studies assessing different outcomes for various functional domains of stroke recovery are needed to clarify the role of BDNF Val66Met polymorphism.

The Factors Associated with Good Responses to Speech Therapy Combined with Transcranial Direct Current Stimulation in Post-stroke Aphasic Patients

OBJECTIVE: To determine factors associated with good responses to speech therapy combined with transcranial direct current stimulation (tDCS) in aphasic patients after stroke. METHOD: The language function was evaluated using Korean version of Western aphasia battery (K-WAB) before and after speech therapy with tDCS in 37 stroke patients. Patients received speech therapy for 30 minutes over 2 to 3 weeks (10 sessions) while the cathodal tDCS was performed to the Brodmann area 45 with 1 mA for 20 minutes. We compared the improvement of aphasia quotient % (AQ%) between two evaluation times according to age, sex, days after onset, stroke type, aphasia type, brain lesion confirmed by magnetic resonance image and initial severity of aphasia. The factors related with good responses were also checked. RESULTS: AQ% improved from pre- to post-therapy (14.94+/-6.73%, p<0.001). AQ% improvement was greater in patients with less severe, fluent type of aphasia who received treatment before 30 days since stroke was developed (p<0.05). The adjusted logistic regression model revealed that patients with hemorrhagic stroke were more likely to achieve good responses (odds ratio=4.897, p<0.05) relative to infarction. Initial severity over 10% in AQ% was also found to be significantly associated with good improvement (odds ratio=8.618, p<0.05). CONCLUSION: Speech therapy with tDCS was established as a treatment tool for aphasic patients after stroke. Lower initial severity was associated with good responses.

Short-Term and Long-Term Effects of Integrated Fall Prevention Program in the Korean Elderly

OBJECTIVE: To evaluate the short-term and long-term effects of integrated fall prevention program comprised of exercise program to improve physical function, education of fall prevention strategy and environmental improvement in elderly Korean. METHOD: Elderly who were at high risk for fall participated in 8-week integrated fall prevention program. Outcome measures including fall efficacy scale (FES), activity-specific balance confidence (ABC), flexibility test, balance function test, short physical performance battery (SPPB) and isokinetic knee strength were evaluated and compared before and after the program. One year after the program, fall experience and frequency, FES and ABC were followed up by mail questionnaire. RESULTS: Among 63 participants enrolled at the baseline, 43 completed the program. Flexibility, balance function and SPPB improved significantly whereas FES, ABC, anthropometric measure data and knee strength were not changed. One year after the program, the number of fallers decreased significantly. CONCLUSION: Integrated fall prevention program may improve flexibility and balance function, and can reduce the risk of fall in the elderly population.

Effects of Full-Time Integrated Self Upper-Extremity Training Program on Functional Recovery and Length of Stay in Stroke Patients

OBJECTIVE: To investigate the effects of full-time integrated self upper-extremity training program (FISUTP) on functional recovery and length of stay in stroke patients. METHOD: Fifty-nine patients were enrolled and divided into FISUTP and control groups. The FISUTP group (n=29) underwent conventional physical and occupational therapy and FISUTP daily during their hospital stay, whereas control group (n=30) received only daily conventional therapy (physical and occupational therapy). The outcome was measured by Korean version of modified Barthel index (K-MBI), Fugl-Meyer motor assessment (FMA), and length of stay (LOS). RESULTS: FISUTP group showed significantly shorter LOS and higher improvement in functional status changes (K-MBI changes and FMA changes) during hospital day than control group (p<0.05). CONCLUSION: The results showed FISUTP is an effective treatment for the improvement of functional outcome and reduction of hospital stay in stroke patients.

Effects of Critical Pathway on the Start of Rehabilitation in Stroke Patients of Single University Hospital

OBJECTIVE: To evaluate the effects of rehabilitation-start critical pathway (Rehab-CP) based on modified Rankin scale (mRS) on stroke outcomes. METHOD: We compared stroke outcome between before and after the carrying into effect of Rehab-CP by retrospective medical record review. First-onset stroke patients admitted to neurology department, and transferred to rehabilitation department were included in the analysis. Hospital length of stay (LOS), home discharge rate, functional outcome such as mRS, Brunnstrom stage, Korean version of modified Barthel index, Fugl-Meyer scale, mini-mental status examination, Berg Balance scale at discharge and 3 months after onset were analyzed. RESULTS: Thirty-nine patients before the commencement of Rehab-CP and 46 patients after the Rehab-CP were compared. Length of stay in neurology department were 2.5 days shorter in after Rehab-CP group as compared to before Rehab-CP group (p=0.056) and total LOS were 1.9 days shorter in after Rehab-CP group (p=0.485), although this did not reach statistical significant difference. There were no differences in home discharge rate, and other functional outcomes between two groups (p>0.05). CONCLUSION: Rehabilitation-start CP based on mRS may decrease LOS without affecting functional outcome, and this result primarily comes from the shortening of stay in neurology department before transfer to rehabilitation ward.

Recovery of Post-stroke Cognitive Function during Subacute Stage

OBJECTIVE: The purpose of this study is to find the change in post-stroke cognitive function during subacute phase, and to investigate factors associated with this change. METHOD: The cognitive function was evaluated using Mini-Mental Status Examination (MMSE) at the beginning of rehabilitation (mean 23.1 ± 12.6 days after onset) and discharge (mean 88.1 ± 29.8 days after onset) in 56 stroke patients. At the same time functional status was also evaluated using modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS) and modified Barthel Index (MBI). Then we compared the improvements of MMSE scores between two time period according to age, sex, stroke profile, and initial functional status. We also determined the correlation between cognitive and functional gain. RESULTS: MMSE scores improved from rehabilitation start to discharge (3.14 ± 5.4, p = 0.000). MMSE scores improved more when patients were male, older than 65 years, and had hemorrhagic and cortical lesions (p<0.05). And, MMSE scores improved more when patients had a higher functional level initially (mRS≤2, NIHSS≤1, MBI≥75), (p<0.05) and improvement of MMSE score was significantly correlated with initial MBI score (r = 0.351, p<0.05). CONCLUSION: Cognitive function recovered during subacute phase of stroke, and improvement of cognitive function at this phase were associated with sex, age, stroke profiles, initial functional status. These results would provide us an information to plan cognitive rehabilitation in these patients.

The Comparison of Post-stroke Related Depression Scales

OBJECTIVE: To compare the characteristics between geriatric depression scale (GDS), Hamilton depression rating scale (HDRS) and post-stroke depression scale (PSDS) in the aspect of diagnosis and severity assessment for post-stroke depression. METHOD: 45 post-stroke patients were included for this study. Subjects were classified through DSM-IV criteria into three different groups; depression-free, minor depression and major depression. GDS, HDRS, PSDS were also assessed in all subjects simultaneously. Three depression assessment scales were compared between groups based on DSM-IV criteria, and the sensitivity and specificity using cut-off value were analyzed. RESULTS: All scales showed the significant differences between depression group and depression-free group. GDS showed higher sensitivity and specificity than HDRS and PSDS and GDS showed the significant difference between minor depression and no depression group, but other scales did not. HDRS and PSDS in major depression group showed the significant differences compared with minor depression group (p<0.05), but GDS did not. CONCLUSION: GDS may be more useful to identify the presence of depression compared to GDRS and PSDS. However, to measure the severity of depression, HDRS and PSDS may be more useful than GDS.

Chronic Left Upper Quadrant Abdominal Pain Diagnosed as Diabetic Thoracic Polyradiculopathy: A case report

Diabetic thoracic polyradiculopathy is an unusual cause of severe, chronic abdominal pain in patient with diabetes mellitus of variable duration. The diagnosis can be made by careful history taking, physical examination and paraspinal and abdominal muscle electromyography. Since there are so many diseases that cause similar abdominal pain, it is hard to diagnose diabetic thoracic polyradiculopathy. A 41-year-old female patient with diabetes mellitus had been taken to the department of internal medicine due to unexplained chronic left upper quadrant abdominal pain. Upper gastrointestinal endoscopy, abdominal computed tomography, urologic and gynecologic examinations had been done but failed to find the cause of abdominal pain. We diagnosed chronic abdominal pain of the patient as diabetic thoracic polyradiculopathy confirmed by electromyography and report this case with a brief review of the related literatures.

The Effect of Levodopa on Akinetic Mutism in Bilateral Anterior Cerebral Artery Infarction: A case report

Akinetic mutism is a clinical syndrome in which the patient is unable to speak (mutism) or move (akinesia). Various brain lesions can induce akinetic mutism. We attended a 71-year-old woman who presented with akinetic mutism caused by bilateral anterior cerebral artery infarction. The patient improved after the administration of levodopa com-bined with carbidopa, in response to visual and verbal stimuli. Increased verbal output and spontaneous motor activities were also noted. Levodopa may be helpful to the treatment of akinetic mutism.