The Importance of Middle Cerebral Artery Stenosis In Patients With A Lacunar Infarction In The Carotid Artery Territory

BACKGROUND: It is well known that a lacunar infarction may develop by an atherosclerosis of the large intracranial arteries at the site of the perforating arteries. However, their frequency, clinical, and radiological findings have rarely been described. METHODS: Carotid angiograpies were carried out in 26 Korean patients with lacunar infarctions in the carotid arterial territory. They all had classical lacunar symptoms with a computed tomogram (CT) or a magnetic resonance image (MRI) evidence of a small infarction. A transesophageal echocardiography (TEE) was carried out in fifteen patients when either an angiography result was normal, the potential source of cardioembolism was suggested, or no other atherothrom-botic causes of stroke were found. Tc-99m single positron emission computed tomograms (SPECT) were performed in nine patients. We divided patients into two groups; one for patients with MCA occlusive lesion, and another for those without it. The clinical and radiological features were compared between the two groups. RESULTS: Twenty patients (77%) demonstrated abnormal angiographic findings. Fourteen of them showed atherosclerotic changes in the proximal MCA at the site of the orifice of the lenticulostriatal arteries, while another three showed stenosis in the intracranial portion of the internal cerebral artery (ICA), and the other three in the extracranial ICA. Among six patients with normal angiograms, a TEE demonstrated embolic sources of embolism in two patients. The temporal profile and findings of MRI and SPECT in patients with MCA stenosis differed from those with ICA stenosis or normal angiograms. Unstable temporal profiles exclusively occurred in patients with MCA stenosis. The most patients with conglomatory aggregations of the lacune in a MRI showed MCA lesions. The SPECT findings were even more characteristic in that patients with MCA lesions showed relatively large areas of decreased perfusion. CONCLUSIONS: The atherosclerotic diseases at the orifice of the lenticulostri-atal arteries were the most common causes of lacunar infarctions in the carotid artery territory. They were clearly different from those without MCA occlusive lesions in terms of preceding transient ishemic attacks, unstable temporal profiles, uni-lateral multiple lacunes with conglomatory MRI findings, and widespread perfusion defects SPECT.

Three Cases of Gelastic seizure

Gelastic (laughing) epilepsy characterized as paroxysmal involuntary laughing episodes usually begins in infancy or childhood. It is known to be poorly respond to medical or surgical treatments. This unique seizure is rare and associated with variable etiologies, especially with hypothalamic harmatoma. But still, relationship between harmatoma and seizure is unclear. We presented three cases of gelastic seizures which were diagnosed by clinical history, 24 hour video EEG monitoring and radiological studies. Two of them were associated with hypothalamic harmatoma, but etiology of one case with normal brain structure can not be documented. Anticonvulsant agents were prescribed on all cases and surgical interventions(gamma knife surgery or subtotal resection) were done on harmatoma cases. After medical and surgical treatments, one case showed poor prognosis but two cases showed exellent outcome with seizure free state.

The onset of ischemic stroke in the coronary heart disease patients

BACKGROUND: Coronary heart disease (CAD) has been known to be a risk factor of ischemic stoke. But, in our country, there has been no systematized study about the incidence of ischemic stroke (IS) after CAD, influencing factors and interval to ischemic stroke . So there is a possibility of different result from previous studies in other countries. METHODS: In this study, we analyzed the stroke influencing factors, interval and stroke type of 2192 CAD patients composed of myocardial infarction (MI) (554 patients) and angina pectoris (1638 patients) who admitted Yonsei university Severance hospital since 1992 Jan. to 1994 Dec. through 3 year follow up. RESULTS: After 3 year follow up of 2192 CAD patients, total 40 cases of ischemic stroke (including transient ischemic attack) developed. Among total CAD patients, influencing factors of IS were atrial fibrillation (p<0.001) and ejection fraction lower than 55 % (p=0.034). Especially atrial fibrillation was the most powerful influencing factor (odds ratio=7.8201, 95 % confidence interval=2.9281-20.8854). IS occurrence was most frequent up to 1 year after diagnosis of CAD(60 % of IS cases), especially highest frequency was demonstrated up to 1 month (50 % of the IS cases within 1 year). This pattern was same to all CAD types. There were not any differences of incidence and interval to IS between acute MI and angina pectoris patients. In MI (554 patients) patients 2.5 % (14 cases) incidence of IS was demonstrated for 3 years and influencing factors of IS occurrence were age (p=0.044) and atrial fibrillation (p=0.004). The outstanding treatment of minimizing IS occurrence was not demonstrated. In angina pectoris (1638 patients) patients, 1.6 % (26 cases) incidence of IS was demonstrated for 3 years and influencing factors of IS occurrence were 1) atrial fibrillation (p=0.0031), 2) Diabetes mellitus (p=0.0058) 3) left ventricular hypertrophy (p=0.0057) 4) hypertension (p=0.0228). There was not an outstanding treatment which let IS occurrence minimalized in sta.

Influence of circadian and activity patterns in onset of cerebral infarction

BACKGROUND AND OBJECTIVES: Stroke onset is known to vary by several factors. Although it has been known that stroke may develop most frequently in the morning, its association with the type of activity has quite rarely been described. METHODS: We prospectively investigated by interview the time of and the activity during or before the onset of stroke in patients with acute cerebral infarction from Aug. 1995 to Mar. 1996. The activities were subdivided into basal metabolic rate state, sedentary, light, moderate, and heavy movements based on the caloric expenditure. RESULTS: One hundred-twenty five patients were enrolled. The time of day when ischemic stroke most frequently occurred was from 8:00 AM to noon. The type of activity was significantly associated with stroke onset in that it developed most commonly during and just after sleep or resting. The relationship between the onset of stroke and such patterns of onset time and the activity was found only in the atherothrombotic infarction, but not in the other stroke types. CONCLUSION: We demonstrated that stroke has clear diurnal variation. Our observations also suggested that the activity may be significantly associated with stroke onset. These findings may be useful for better understanding of the pathogenesis and prevention of ischemic stroke.