Isolated Middle Cerebral Artery Stenotic Disease

BACKGROUND: Middle cerebral artery (MCA) steno-occlusive disease is known to be more common in Eastern than in Western, however, clinical characteristics have not been well documented. We aimed to find clinical characteristics of isolated MCA disease comparing with other MCA steno-occlusive disease. METHODS: Patients with lesion in M1 portion of MCA divided into three groups by angiographic finding ; isolated MCA stenosis (IMCAS, n=39), isolated MCA occlusion (IMCAO, n=29), and multiple (ICA, BA or VA) steno-occlusion involving MCA (Combined, n=48). Patients with evidence of cardioembolic MCA occlusion and Moyamoya disease were excluded. We analyzed clinical features, neuroimaging findings, and prognosis retrospectively. RESULTS: MRI showed large deep (36%), small deep (26%), cortical (21%), and mixed (cortical & deep, 15%) infarct in IMCAS group ; mixed (38%), large deep (21%), small deep (17%), and cortical (17%) infarct in IMCAO group ; large deep (31%), cortical (23%), small deep (17%), and no lesion (17%) in Combined group. Site of MCA steno-occlusion on angiogram was middle (44%), distal (39%), and proximal (18%) in IMCAS group ; proximal (48%), middle (35%), and distal (17%) in IMCAO group ; middle (42%), proximal (31%), and distal (27%) in Combined group. Patient's neurologic status, assessed by NIHSS, during first 7 days was 'not changed' or 'worsening' (>93%) in all 3 groups. Neurologic outcome at 3 months later was improving (65%) in IMCAS group by modified Rankin scale. CONCLUSIONS: Isolated MCA stenotic disease was not significantly different from iso-lated MCA occlusion group or Combined group in clinical features, neuroimaging findings, and prognosis.

Nocturnal dip in patients with cerebrovascular disease occurring during sleep: prospective assessment by using Ambulatory Blood Pressure Monitoring

BACKGROUND:There is little knowledge regarding the possible pathogenetic mechanism of cerebrovascular disease occurring during sleep. We conducted a prospective study using ambulatory blood pressure monitoring to elucidate the specific characteristics and mechanism in cerebrovascular disease occurrence during sleep. METHODS: Stroke were cat-egorized into the small artery disease and large artery disease, cardiogenic disease, and intracerebral hemorrhage. 24- hour ambulatory blood pressure was carried out within 7 days after stroke onset in 20 patients (11 small artery disease, 7 large artery disease, 1 hemorrhage, 1 Moyamoya disease), and in 21 control patients (10 small artery disease, 9 large artery disease, 2 hemorrhage), that were admitted with stroke occuring during awakening time. The mean day-time and night-time systolic and diastolic blood pressure, mean day-time and night-time pulse rate, percentage of nocturnal blood pressure ([mean daytime BP - mean nighttime BP / average BP for the entire 24 hour] x100) were calculated. RESULTS: There was no significant difference between patients with cerebrovascular disease occurring during sleep and controls in mean day-time and night-time systolic and diastolic blood pressure, mean day-time and night-time pulse rate. Absence of normal nocturnal blood pressure dip in all stroke subtypes was noted. But, the magnitude of reduced nocturnal blood pressure decline in small artery disease group was significant smaller than in large artery disease and control groups (p<.005). CONCLUSIONS: Relatively preserved nocturnal blood pressure dip in small artery disease group with cerebrovascular disease occurring during sleep is thought that the cerebral ischemia in this subgroup is produced by excessive falls in the nighttime blood pressure or lowering of night-time blood pressure by antihypertensive agents.

Two Cases of Chronic Acquired Hepatocerebral Degeneration with Parkinsonian Symptoms

Chronic acquired hepatocerebral degeneration (CAHD) is a progressive or episodic neurologic syndrome that occurs occasionally in patients who have chronic liver disease or portocaval shunt. The clinical features of CAHD include action and postural tremors, generalized chorea, asterixis, myoclonus, dystonia, resting tremor, gait ataxia, and variable impairments of intellectual function. We experienced 2 cases of CAHD with unusual neurologic manifestations, which were hypokinetic parkinsonian symptoms. Both cases had a history of liver cirrhosis and the same symptoms. They had masked faces, cogwheel rigidiy in both wrists, slurred speech, tongue tremor, bradykinesia, and gait ataxia. They had normal mental status and no pathologic reflex. Brain MRI showed abnormal, increased signal on T1-weighted images in the globus pallidus and mesencephalon bilaterally. The hypokinetic parkinsonian symptoms disappeared when given doses levodopa.