Clinical Reasoning: A 75-Year-Old Women Presenting with Hand Tremor

No abstract available.

Unilateral Hypoglossal Neuropathy in Multifocal Acquired Demyelinating Sensory and Motor Neuropathy: Differential Diagnosis of Motor Neuron Disease

Multifocal acquired demyelinating sensory and motor neuropathy (MADSAM) is a peripheral neuropathy characterized by multifocal weakness and associated sensory impairment. MADSAM is associated with multifocal persistent conduction block and other signs of demyelination. The incidence of cranial nerve involvement in MADSAM was recently reported to be approximately 15%. However, reports of hypoglossal neuropathy occurring in MADSAM are rare. Unilateral hypoglossal neuropathy in MADSAM is usually misdiagnosed as motor neuron disease. We report a patient with MADSAM presenting with tongue hemiatrophy.

Feasibility, Safety, and Follow-up Angiographic Results of Endovascular Treatment for Non-Selected Ruptured Intracranial Aneurysms Under Local Anesthesia with Conscious Sedation

BACKGROUND: At most centers, general anesthesia (GA) has been preferred for endovascular treatment (EVT) of ruptured intracranial aneurysms (RIAs). In this study, we analyzed procedural results, clinical outcomes, and follow-up angiographic findings for patients undergoing EVT for RIA under local anesthesia (LA) with conscious sedation (CS). METHODS: We retrospectively evaluated 308 consecutive patients who underwent EVT for RIAs at a single institution between June 2009 and February 2017. EVT under LA with CS was considered for all patients with aneurysmal subarachnoid hemorrhage, regardless of Hunt and Hess (HH) scale score. RESULTS: EVT was performed for 320 aneurysms in 308 patients with subarachnoid hemorrhages. The mean patient age was 55.5±12.6 years. Moderate (III) and poor (IV, V) HH grades were observed in 75 (24.4%) and 77 patients (25%), respectively. Complete occlusion immediately after EVT was achieved for 270 (84.4%) of 320 aneurysms. Thromboembolic complications and intraprocedural ruptures occurred in 25 (7.8%) and 14 cases (4.3%), respectively. The morbidity rate at discharge (as defined by a modified Rankin scale score of 3 or greater) was 27.3% (84/308), while the mortality rate was 11.7% (36/308). Follow-up angiographic results were available for 210 (68.1%) of 308 patients. Recanalization was observed in 64 (29.3%) of 218 aneurysms in 210 patients. CONCLUSION: Based on our experience, EVT for RIAs under LA with CS was feasible, regardless of the clinical grade of the subarachnoid hemorrhage. Complication rates and follow-up angiographic results were also comparable to those observed when GA was used to perform the procedure.

Two Bleeding Foci in a Mixed Vascular Malformation of the Brain

A cavernous angioma (CA) and a developmental venous anomaly may consist a mixed vascular malformation (MVM). Two bleeding foci were observed in a MVM of a man with epilepsy. The hemodynamic association between the two foci was not clear. An advance of neuroimaging may enhance the susceptibility of detection of MVMs. We should consider a MVM when a daughter bleeding focus occurs near the main bleeding focus associated with a CA.

Arterial Spin Labeling Perfusion MRI of Crossed Cerebellar Diaschisis in a Patient with Simple Partial Status Epilepticus

Crossed cerebellar diaschisis (CCD) is known to be due to a contralateral supratentorial lesion decreasing blood flow and the metabolism in a cerebellar hemisphere. Arterial spin labeling (ASL) is an imaging technique that utilizes arterial blood water as a tracer for quantifying the regional cerebral blood flow in magnetic resonance imaging (MRI). This case was a patient with simple partial status epilepticus (SPSE) and CCD confirmed by ASL-perfusion MRI. Controlling the SPSE resulted in improvement of CCD being observed in the follow-up ASL-perfusion MRI.

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.

Effects of age, sex, and body mass index on sudomotor and cardiovagal functions in a healthy Korean population

Background: Hypertension results from an impaired baroreceptor reflex and enhanced sympathetic activity. The prevalence of hypertension differs among ethnicities and is more frequent in South Asians than in Caucasians, suggesting that baseline autonomic nervous system functions and their regulation may also differ among ethnic groups. In most studies, the reference values for clinical autonomic function tests are obtained from heterogeneous ethnic populations, or ethnic factors are not considered in the study design. Obtaining reference data in a homogenous ethnic group and comparing them within various ethnic groups could be helpful to detect ethnic differences in autonomic functions. The aim of this study was to identify normative reference values for standard autonomic reflex measurements in a homogeneous Korean population. Methods: A total of 181 healthy Korean volunteers (age, 20–74 years) underwent standard autonomic function tests: heart rate difference during deep breathing, Valsalva maneuver, and the quantitative sudomotor axon-reflex test. Mean and 5th and 95th percentile values were obtained for each age group. We also analyzed factors (age, sex, and body mass index) that can influence autonomic functions. Results: The heart rate difference during deep breathing and expiratory-inspiratory ratio were higher in males than in females and were inversely related to age. The Valsalva ratio was inversely related to age. Males had higher sweat volumes at all body areas evaluated than those of females, and only forearm sweat volume was significantly different between the age groups. Conclusions: Cardiovagal function was affected by age and sex in Koreans. Sudomotor function was affected by sex, and only forearm sweat volume was affected by age and sex. These results represent preliminary normative clinical autonomic data in a Korean population comprised of a single ethnicity

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.

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.

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.

Recent Update of Clinical Drug Trials in Alzheimer's Disease

The prevalence of Alzheimer's disease (AD) is increasing as the global population ages. Currently available treatments for AD target cholinergic and glutamatergic neurotransmission. There have been modest symptomatic effects, but disease modifying effects have not been accomplished. This is even true of clinical trials of bapineuzumab and solanezumab, two humanized monoclonal antibodies that bind amyloid. Therefore, innovations in clinical trial designs are necessary, including revised diagnostic criteria and treatment at the earliest stages of AD. Several prevention trials started in 2013, emphasizing these innovative principles of clinical trial design. In this review, we will discuss the paradigm shift for AD clinical treatment trials and ongoing preventative trials.

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.

Tumor of Meckel's Cave Presented With Recurrent Transient Monocular Blindness

No abstract available.

Cerebral Infarction in a Patient with Suicidal Near Hanging

Hanging is one of the most common causes of suicidal death. Most hanging victims are dead when discovered, and hence there are few reports of near-hanging patients or survivors of a hanging injury. We experienced a patient with motor aphasia who survived a hanging injury. Consecutive workup revealed a cerebral infarction on the left middle cerebral artery territory, which was considered to be the cause of his aphasia.

Parry-Romberg Syndrome with Intermittent Exotropia

Parry-Romberg syndrome, or progressive facial hemiatrophy, is a rare and acquired neurocutaneous disease of unknown etiology that is classically characterized by progressive and self=limited atrophy of the skin, subcutaneous tissues, and underlying bone structures. Ophthalmic involvement is reportedly not uncommon, and the most common ocular finding is enophthalmos. Here we report a 46=year=old woman with Parry=Romberg syndrome who presented with intermittent exotropia of the right eye. To the best of our knowledge, this is the first description of intermittent exotropia in a patient with Parry-Romberg syndrome.

Guillain-Barre Syndrome With Treatment-Related Fluctuations

No abstract available.

Acute Disseminated Encephalomyelitis Caused by Scrub Typhus

No abstract available.

Changes in Cerebral Vascular Reserve Capacity after Carotid Artery Stenting: A 6-Month Follow-up Study

BACKGROUND: Assessment of cerebral vascular reserve capacity prior to carotid artery stenting is used for predicting hyperperfusion syndrome. However, the changes in vascular reserve capacity after carotid stenting are not fully understood. In this study we investigated the effects of carotid artery stenting on the restoration of vascular reserve capacity using (99m)TC-hexamethylpropylene amine oxime (HMPAO) single-photon-emission computed tomography (SPECT). METHODS: The study population comprised 29 patients who underwent carotid artery stenting. Patients were divided into groups according to occlusion of the contralateral internal carotid artery (unilateral group vs bilateral group) and according to the presence or absence of symptoms related to carotid stenosis (symptomatic group vs asymptomatic group). Pre- and postacetazolamide-activated (99m)TC-HMPAO SPECT were performed prior to stent insertion and at 1 and 6 months postoperatively. Vascular reserve capacity was assessed based on pre-, and 1- and 6-month postacetazolamide gamma count ratio (Post0, Post1, and Post6, respectively) and cerebrovascular reactivity (CVR0, CRV1, and CRV6, respectively). RESULTS: The postacetazolamide gamma count ratio and cerebrovascular reactivity tended to improve at 1 month after stenting, but tended to deteriorate at 6 months after stenting in the unilateral group compared with the bilateral group [Post0-Post1=0.045+/-0.078 (mean+/-SD), p=0.014; Post0-Post6=0.025+/-0.063, p=0.042; Post1-Post6=-0.020+/-0.047, p=0.102; CVR0-CVR1=0.043+/-0.071, p=0.008, CVR0-CVR6=0.019+/-0.063, p=0.097; CVR1-CVR6=-0.024+/-0.047, p=0.008] and in the symptomatic group compared with the asymptomatic group (Post0-Post1=0.058+/-0.106, p=0.038; Post0-Post6=0.048+/-0.103, p=0.061; Post1-Post6=-0.010+/-0.048, p=0.700; CVR0-CVR1=0.037+/-0.083, p=0.074; CVR0-CVR6=0.014+/-0.073, p=0.344; CVR1-CVR6=-0.023+/-0.054, p=0.055). CONCLUSIONS: The observed increases in postacetazolamide gamma count ratio and cerebrovascular reactivity at 1 month followed by decreases at 6 months may reflect the restoration of vascular reserve capacity. Carotid artery stenting can improve vascular reserve capacity, especially in patients with unilateral stenosis and with symptomatic stenosis.