Predictors of Aspiration Pneumonia in the Elderly With Swallowing Dysfunction: Videofluoroscopic Swallowing Study

Objective@#To identify the variables of videofluoroscopic swallowing study (VFSS) that are useful for predicting the risk of aspiration pneumonia in elderly patients with dysphagia. @*Methods@#A total of 251 patients (aged 65 years or more) were included and divided into a pneumonia group (n=133) and a non-pneumonia group (n=118). The pneumonia group included patients who had been diagnosed with aspiration pneumonia, and individuals in the non-pneumonia group did not have pneumonia but were referred for VFSS. The medical records and results of VFSS were reviewed and compared between the groups retrospectively. @*Results@#The pneumonia group exhibited a male preponderance and a higher 8-point Penetration-Aspiration Scale (8PPAS) score. The mean values of 8PPAS score for swallowing thick liquid and rice porridge was significantly higher in the pneumonia group. The pharyngeal delay time (PDT) and pharyngeal transit time (PTT) were significantly longer in the pneumonia group. The amounts of vallecular and pyriform sinus residue were increased in the pneumonia group. The delay in swallowing reflex and the decrease in laryngeal elevation were more frequently observed in the pneumonia group. Among those variables, PDT and PTT were identified as significant predictors of aspiration pneumonia based on logistic regression analysis. @*Conclusion@#The present study delineated the findings of VFSS, suggesting an increased risk of aspiration pneumonia in elderly patients with dysphagia. The results demonstrate that prolonged PDT and PTT are significant predictors of aspiration pneumonia.

Predictors of Aspiration Pneumonia in the Elderly With Swallowing Dysfunction: Videofluoroscopic Swallowing Study

Objective@#To identify the variables of videofluoroscopic swallowing study (VFSS) that are useful for predicting the risk of aspiration pneumonia in elderly patients with dysphagia. @*Methods@#A total of 251 patients (aged 65 years or more) were included and divided into a pneumonia group (n=133) and a non-pneumonia group (n=118). The pneumonia group included patients who had been diagnosed with aspiration pneumonia, and individuals in the non-pneumonia group did not have pneumonia but were referred for VFSS. The medical records and results of VFSS were reviewed and compared between the groups retrospectively. @*Results@#The pneumonia group exhibited a male preponderance and a higher 8-point Penetration-Aspiration Scale (8PPAS) score. The mean values of 8PPAS score for swallowing thick liquid and rice porridge was significantly higher in the pneumonia group. The pharyngeal delay time (PDT) and pharyngeal transit time (PTT) were significantly longer in the pneumonia group. The amounts of vallecular and pyriform sinus residue were increased in the pneumonia group. The delay in swallowing reflex and the decrease in laryngeal elevation were more frequently observed in the pneumonia group. Among those variables, PDT and PTT were identified as significant predictors of aspiration pneumonia based on logistic regression analysis. @*Conclusion@#The present study delineated the findings of VFSS, suggesting an increased risk of aspiration pneumonia in elderly patients with dysphagia. The results demonstrate that prolonged PDT and PTT are significant predictors of aspiration pneumonia.

Post-stroke Aphasia as a Prognostic Factor for Cognitive and Functional Changes in Patients With Stroke: Ischemic Versus Hemorrhagic

Objective@#To investigate the comprehensive outcomes in aphasic patients, including their cognitive and functional status after ischemic or hemorrhagic stroke. It also aimed to clarify whether aphasia is a prognostic factor for cognitive and functional improvements in stroke patients. @*Methods@#Sixty-seven ischemic or hemorrhagic stroke patients in the subacute stage who had been diagnosed with aphasia using the Korean version of Frenchay Aphasia Screening Test (K-FAST) were included in the study. Forty-six stroke patients without aphasia were used as controls. All patients were examined with the Korean version of the Western Aphasia Battery (K-WAB). Cognitive and functional assessments of the patients including the Korean version of Mini-Mental State Examination (K-MMSE), and the Korean version of Modified Barthel Index (K-MBI) were performed during admission and 4 weeks after the initial assessments. @*Results@#The initial and follow-up total K-MMSE and K-MBI scores were significantly lower in aphasic patients than in non-aphasic controls. The K-WAB scores highly correlated with the total K-MMSE scores at the follow-up stage in all aphasic stroke patients. The K-WAB scores moderately correlated with the follow-up scores of the K-MBI in ischemic stroke patients but not in hemorrhagic stroke patients. @*Conclusion@#Aphasia influences the cognitive and functional status of stroke patients and has a greater impact on cognitive improvement. Aphasia severity can be one of the prognostic factors for cognitive status in aphasic patients with stroke.

Application of Artificial Intelligence in the Area of Dysphagia / 대한연하장애학회지

The development and performance of Artificial intelligence (AI) have been revolutionary ever since adoption of deep learning algorithms. It is expected that AI will induce tremendous changes in many parts of society and industry, including medicine. The spread of AI is accelerated by the availability of extensive Open Source Libraries and common platforms. Importance of data acquisition is increasingly emphasized for AI learning. Digitalization of images and medical records will contribute greatly to the application of AI technology in medical fields. Support systems for reading diagnostic images and decision-making for patient care are currently under development, depending on the efficiency and precision of AI. Evaluation and management of dysphasia can be potentiated by AI, although there is not much research in this field. Automated reading of videofluoroscopy, analysis of cervical auscultation, and dysphagia coaching system have all shown promising results. Hopefully, safer and more efficient care of dysphagia patients will be possible through more active research on the utilization of AI technology.

Repetitive Transcranial Magnetic Stimulation Enhances Recovery in Central Cord Syndrome Patients

OBJECTIVE: To investigate the effect of repetitive transcranial magnetic stimulation (rTMS) on neurological and functional recovery in patients with central cord syndrome (CCS) involving the upper extremities between the treated and non-treated sides of the treated group and whether the outcomes are comparable to that of the untreated control group. METHODS: Nineteen CCS patients were treated with high-frequency (20 Hz) rTMS over the motor cortex for 5 days. The stimulation side was randomly selected, and all the subjects received conventional occupational therapy during the rTMS-treatment period. Twenty CCS patients who did not receive rTMS were considered as controls. Clinical assessments, including those by the International Standard for Neurological Classification of Spinal Cord Injury, the Jebsen-Taylor Hand Function Test, and the O'Connor Finger Dexterity Test were performed initially and followed up for 1 month after rTMS treatment or 5 weeks after initial assessments. RESULTS: The motor scores for upper extremities were increased and the number of improved cases was greater for the treated side in rTMS-treated patients than for the non-treated side in rTMS-treated patients or controls. The improved cases for writing time and score measured on the Jebsen-Taylor Hand Function Test were also significantly greater in number on the rTMS-treated side compared with the non-treated side and controls. There were no adverse effects during rTMS therapy or the follow-up period. CONCLUSION: The results of the application of high-frequency rTMS treatment to CCS patients suggest that rTMS can enhance the motor recovery and functional fine motor task performance of the upper extremities in such individuals.

Influence of Hip Fracture on Knee Pain During Postoperative Rehabilitation

OBJECTIVE: To investigate whether fracture type, surgical procedure, or fracture grade affect knee pain during postoperative rehabilitation after a hip fracture. METHODS: We conducted a retrospective case-controlled study of 139 patients during postoperative rehabilitation after surgery for hip fractures. Patients were divided into two groups: patients experiencing knee pain during the first week of postoperative rehabilitation, and patients without knee pain. We compared the types of fracture, surgical procedure, and fracture grade between the two groups. RESULTS: We enrolled 52 patients (37.4%) with knee pain during the first weeks of postoperative rehabilitation. For type of fracture, knee pain was more common with intertrochanteric fracture than with femur neck fracture (48.8% vs. 21.1%, respectively; p=0.001). For the surgical procedure, there was no significant difference between the groups. For the fracture grade, the grades classified as unstable fractures were more common in the group of intertrochanteric fracture patients with knee pain than in those without knee pain (74.1% vs. 36.4%, respectively; p=0.002). CONCLUSION: Intertrochanteric fracture affected knee pain after hip fracture surgery more than did femur neck fracture, particularly in unstable fractures. Furthermore, there was no difference in each fracture type according to the surgical procedure. Careful examination and management for knee pain is needed in patients with hip fracture surgery.

Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016

“Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” is the 3rd edition of clinical practice guideline (CPG) for stroke rehabilitation in Korea, which updates the 2nd edition published in 2014. Forty-two specialists in stroke rehabilitation from 21 universities and 4 rehabilitation hospitals and 4 consultants participated in this update. The purpose of this CPG is to provide optimum practical guidelines for stroke rehabilitation teams to make a decision when they manage stroke patients and ultimately, to help stroke patients obtain maximal functional recovery and return to the society. The recent two CPGs from Canada (2015) and USA (2016) and articles that were published following the 2nd edition were used to develop this 3rd edition of CPG for stroke rehabilitation in Korea. The chosen articles' level of evidence and grade of recommendation were decided by the criteria of Scotland (2010) and the formal consensus was derived by the nominal group technique. The levels of evidence range from 1++ to 4 and the grades of recommendation range from A to D. Good Practice Point was recommended as best practice based on the clinical experience of the guideline developmental group. The draft of the developed CPG was reviewed by the experts group in the public hearings and then revised. “Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” consists of ‘Chapter 1; Introduction of Stroke Rehabilitation’, ‘Chapter 2; Rehabilitation for Stroke Syndrome, ‘Chapter 3; Rehabilitation for Returning to the Society’, and ‘Chapter 4; Advanced Technique for Stroke Rehabilitation’. “Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” will provide direction and standardization for acute, subacute and chronic stroke rehabilitation in Korea.

Factors Associated With Upper Extremity Functional Recovery Following Low-Frequency Repetitive Transcranial Magnetic Stimulation in Stroke Patients

OBJECTIVE: To investigate the factors related to upper extremity functional improvement following inhibitory repetitive transcranial magnetic stimulation (rTMS) in stroke patients. METHODS: Forty-one stroke patients received low-frequency rTMS over the contralesional hemisphere according to a standard protocol, in addition to conventional physical and occupational therapy. The rTMS-treated patients were divided into two groups according to their responsiveness to rTMS measured by the self-care score of the Korean version of Modified Barthel Index (K-MBI): responded group (n=19) and non-responded group (n=22). Forty-one age-matched stroke patients who had not received rTMS served as controls. Neurological, cognitive and functional assessments were performed before rTMS and 4 weeks after rTMS treatment. RESULTS: Among the rTMS-treated patients, the responded group was significantly younger than the non-responded group (51.6±10.5 years and 65.5±13.7 years, respectively; p=0.001). Four weeks after rTMS, the National Institutes of Health Stroke Scale, the Brunnstrom recovery stage and upper extremity muscle power scores were significantly more improved in the responded group than in the control group. Besides the self-care score, the mobility score of the K-MBI was also more improved in the responded group than in the non-responded group or controls. CONCLUSION: Age is the most obvious factor determining upper extremity functional responsiveness to low-frequency rTMS in stroke patients.

Diagnosis of Spasmodic Dysphonia Manifested by Swallowing Difficulty in Videofluoroscopic Swallowing Study

Spasmodic dysphonia is defined as a focal laryngeal disorder characterized by dystonic spasms of the vocal cord during speech. We described a case of a 22-year-old male patient who presented complaining of idiopathic difficulty swallowing that suddenly developed 6 months ago. The patient also reported pharyngolaryngeal pain, throat discomfort, dyspnea, and voice change. Because laryngoscopy found no specific problems, an electrodiagnostic study and videofluoroscopic swallowing study (VFSS) were performed to find the cause of dysphagia. The VFSS revealed continuous twitch-like involuntary movement of the laryngeal muscle around the vocal folds. Then, he was diagnosed with spasmodic dysphonia by VFSS, auditory-perceptual voice analysis, and physical examination. So, we report the first case of spasmodic dysphonia accompanied with difficulty swallowing that was confirmed by VFSS.

Clinical Practice Guideline for Stroke Rehabilitation in Korea 2012

"Clinical Practice Guideline for Stroke Rehabilitation in Korea 2012" is a 2nd edition of clinical practice guideline (CPG) for stroke rehabilitation in Korea, which updates the 1st edition published in 2009. After 1st stroke rehabilitation CPG, many studies concerning stroke rehabilitation have been published and the necessity for update has been raised. The Korea Centers for Disease Control and Prevention supported the project "Development of Clinical Practice Guideline for Stroke Rehabilitation" in 2012. Thirty-two specialists in stroke rehabilitation from 18 universities and 3 rehabilitation hospitals and 10 consultants participated in this project. The scope of this CPG included both ischemic and hemorrhagic stroke from the acute to chronic stages. The purpose of this CPG is to provide guidelines for doctors and therapists to make a decision when they manage stroke patients and ultimately, to help stroke patients obtain maximal functional recovery and return to the society. "Clinical Practice Guideline for Stroke Rehabilitation in Korea 2012" consists of 'Chapter 1; Introduction of Stroke Rehabilitation', 'Chapter 2; Rehabilitation for Stroke Syndrome, 'Chapter 3; Rehabilitation for Return to the Society', and 'Chapter 4; Advanced Technique for Stroke Rehabilitation'. Both the adaptation and de novo development methods were used to develop this 2nd edition of CPG. The appraisal of foreign CPGs was performed using 'Korean appraisal of guidelines for research and evaluation II' (K-AGREE II); moreover, four CPGs from Scotland (2010), Austrailia (2010), USA (2010), Canada (2010) were chosen for adaptation. For de novo development, articles that were published following the latest foreign CPGs were searched from the database system, PubMed, Embase, and Cochrane library. Literatures were assessed in the aspect of subjects, study design, study results' consistency, language and application possibility in the Korean society. The chosen articles' level of evidence and grade of recommendation were decided by the criteria of Scotland (2010) and the formal consensus was derived by the nominal group technique. The levels of evidence range from 1++ to 4 and the grades of recommendation range from A to D. GPP (Good Practice Point) was recommended as best practice based on the clinical experience of the guideline developmental group. The draft of the developed CPG was reviewed by the experts group in the public hearings and then revised.

Prognosis for Patients With Traumatic Cervical Spinal Cord Injury Combined With Cervical Radiculopathy

OBJECTIVE: To delineate cervical radiculopathy that is found in combination with traumatic cervical spinal cord injury (SCI) and to determine whether attendant cervical radiculopathy affects the prognosis and functional outcome for SCI patients. METHODS: A total of 66 patients diagnosed with traumatic cervical SCI were selected for neurological assessment (using the International Standards for the Neurological Classification of Spinal Cord Injury [ISNCSCI]) and functional evaluation (based on the Korean version Modified Barthel Index [K-MBI] and Functional Independence Measure [FIM]) at admission and upon discharge. All of the subjects received a preliminary electrophysiological assessment, according to which they were divided into two groups as follows: those with cervical radiculopathy (the SCI/Rad group) and those without (the SCI group). RESULTS: A total of 32 patients with cervical SCI (48.5%) had cervical radiculopathy. The initial ISNCSCI scores for sensory and motor, K-MBI, and total FIM did not significantly differ between the SCI group and the SCI/Rad group. However, at discharge, the ISNCSCI scores for motor, K-MBI, and FIM of the SCI/Rad group showed less improvement (5.44+/-8.08, 15.19+/-19.39 and 10.84+/-11.49, respectively) than those of the SCI group (10.76+/-9.86, 24.79+/-19.65 and 17.76+/-15.84, respectively) (p<0.05). In the SCI/Rad group, the number of involved levels of cervical radiculopathy was negatively correlated with the initial and follow-up motors score by ISNCSCI. CONCLUSION: Cervical radiculopathy is not rare in patients with traumatic cervical SCI, and it can impede neurological and functional improvement. Therefore, detection of combined cervical radiculopathy by electrophysiological assessment is essential for accurate prognosis of cervical SCI patients in the rehabilitation unit.

Skin Temperature Changes in Patients With Unilateral Lumbosacral Radiculopathy

OBJECTIVE: To clarify the relationship of skin temperature changes to clinical, radiologic, and electrophysiological findings in unilateral lumbosacral radiculopathy and to delineate the possible temperature-change mechanisms involved. METHODS: One hundred and one patients who had clinical symptoms and for whom there were physical findings suggestive or indicative of unilateral lumbosacral radiculopathy, along with 27 normal controls, were selected for the study, and the thermal-pattern results of digital infrared thermographic imaging (DITI) performed on the back and lower extremities were analyzed. Local temperatures were assessed by comparing the mean temperature differences (DeltaT) in 30 regions of interest (ROIs), and abnormal thermal patterns were divided into seven regions. To aid the diagnosis of radiculopathy, magnetic resonance imaging (MRI) and electrophysiological tests were also carried out. RESULTS: The incidence of disc herniation on MRI was 86%; 43% of patients showed electrophysiological abnormalities. On DITI, 97% of the patients showed abnormal DeltaT in at least one of the 30 ROIs, and 79% showed hypothermia on the involved side. Seventy-eight percent of the patients also showed abnormal thermal patterns in at least one of the seven regions. Patients who had motor weakness or lateral-type disc herniation showed some correlations with abnormal DITI findings. However, neither pain severity nor other physical or electrophysiological findings were related to the DITI findings. CONCLUSION: Skin temperature change following lumbosacral radiculopathy was related to some clinical and MRI findings, suggesting muscle atrophy. DITI, despite its limitations, might be useful as a complementary tool in the diagnosis of unilateral lumbosacral radiculopathy.

The Influence of Laterality of Pharyngeal Bolus Passage on Dysphagia in Hemiplegic Stroke Patients

OBJECTIVE: To investigate swallowing laterality in hemiplegic patients with stroke and recovery of dysphagia according to the laterality. METHOD: The sample was comprised of 46 dysphagic patients with hemiplegia after their first stroke. The sample's videofluoroscopic swallowing study (VFSS) was reviewed. Swallowing laterality was determined by the anterior-posterior view of VFSS. We measured width difference of barium sulfate liquid flow in the pharyngoesophageal segment. If there was double or more the width of that from the opposite width in the pharyngoesophageal segment more than twice on three trials of swallowing, then it was judged as having laterality. Subjects were assigned to no laterality (NL), laterality that is ipsilateral to hemiplegic side (LI), and laterality that is contralateral to hemiplegic side (LC) groups. We measured the following: prevalence of aspiration, the 8-point penetration-aspiration scale, and the functional dysphagia scale of the subjects at baseline and follow up. RESULTS: Laterality was observed in 45.7% of all patients. Among them, 52.4% were in the hemiplegic direction. There was no significant difference between groups at baseline in all measurements. When we compared the changes in all measurements on follow-up study, there were no significant differences between groups. CONCLUSION: Through this study, we found that there was no significant relation between swallowing laterality and the severity or prognosis of swallowing difficulty. More studies for swallowing laterality on stroke patients will be needed.

Age Factor in Rehabilitation Outcome

In stroke rehabilitation, risk factors, clinical course, and outcome of functional recovery can be different among age groups. In animal model of stroke, aged animals are more severely impaired behaviorally, and the functional recovery is delayed and reduced. Development of the glial scar and apoptosis is accelerated, and the timing of the cellular and genetic response is altered. The functional outcome is usually favorable in young adult patients, but it appears that the outcome of pediatric stroke is unfavorable. In most studies, the clinical symptoms are more severe, and functional recovery is poorer in elderly stroke patients. However, it is not clear whether or not the poor outcome is attributable to the old age per se. It is apparent that co-morbidity and risk factors also signficantly affect the outocme of stroke patients. Elderly stroke patients can achieve functional improvement through the rehabilitation program, if they were not disabled at the onset of stroke, and had few co-morbidities and risk factors. Physiatrists should be aware of those differences and can make a rehabilitatin plan that is appropriate for age of the patient.

A Case of Herpes Zoster Peripheral Polyneuropathy Manifested by Foot Drop in Chronic Myeloid Leukemia

In herpes zoster infection, neurological complications may be overlooked because pain is a more prominent symptom and because peripheral polyneuropathy associated with weakness is rare. A 57-year-old male visited our hospital, complaining of pain and skin eruptions on the right flank. He was diagnosed as having herpes zoster and the symptoms were alleviated by administration of acyclovir for a week. After three weeks, the herpes zoster relapsed. He was re-admitted and diagnosed with chronic myeloid leukemia (CML), and imatinib mesylate was prescribed for five weeks. Ten weeks after the onset of herpes zoster, bilateral foot drops and numbness of the right foot dorsum developed. Through an electrodiagnostic study, he was diagnosed as having peripheral polyneuropathy that was suspected to be caused by neural invasion by varicella zoster virus. After administration of famciclovir, not only the pain but also the neurologic symptoms improved. We herein report a case of peripheral polyneuropathy that was supposed to be related to herpes zoster.

Myofascial Pain Syndrome in Patients with Cervical Vertigo

OBJECTIVE: To delineate the clinical manifestation of myofascial pain syndrome (MPS) around the face, neck and shoulders in patients with cervical vertigo (CV) and to determine whether treatment of MPS can improve CV. METHOD: We evaluated 72 patients who were diagnosed with CV and 72 patients as controls who had MPS in the neck and shoulder without vertigo symptoms. Clinical evaluations for MPS were performed on all subjects, and vestibular function tests were also performed in patients with vertigo symptoms. Most patients and controls received treatments including trigger point injection, physical therapy or medication, and were then followed up. RESULTS: Seventy CV patients (97%) had MPS in the face, neck and shoulders. The distribution of trigger points in CV patients differed from that in controls, especially in the lateral neck muscles (odds ratio=0.361, p=0.019). The gender, age, symptom duration and number of trigger points were not different between CV patients and controls. 57 CV patients and 56 controls that had received treatments were followed up. Vertigo symptoms improved in 40 CV patients (70%) after treatment of MPS and pain symptoms improved in 77% of CV patients and 75% of controls after treatment. CONCLUSION: Most CV patients had myofascial pain syndrome and the distribution of trigger points differed from that in controls. Treatment for myofascial pain syndrome could improve vertigo symptoms in CV patients, but further study is required to delineate the relationship between MPS and CV.

Collet-Sicard Syndrome in a Patient with Jefferson Fracture

Collet-Sicard syndrome is a rare condition characterized by the unilateral paralysis of the 9th through 12th cranial nerves. We describe a case of a 46-year-old man who presented with dysphagia after a falling down injury. Computed tomography demonstrated burst fracture of the atlas. Physical examination revealed decreased gag reflex on the left side, decreased laryngeal elevation, tongue deviation to the left side, and atrophy of the left trapezius muscle. Videofluoroscopic swallowing study (VFSS) revealed frequent aspirations of a massive amount of thick liquid and incomplete opening of the upper esophageal sphincter during the pharyngeal phase. We report a rare case of Collet-Sicard syndrome caused by Jefferson fracture.

Cervical Multifidus Muscle Atrophy in Patients with Unilateral Cervical Radiculopathy

OBJECTIVE: To assess the atrophy of cervical multifidus muscles in patients with unilateral cervical disc herniation or radiculopathy quantitatively and to investigate whether asymmetric muscle atrophy has the relationship with the severity of cervical disc herniation or radiculopathy. METHOD: Twenty-four patients who had cervical disc herniation in magnetic resonance imaging (MRI) were evaluated. The patients were divided into 2 groups; patients with unilateral cervical radiculopathy in electrodiagnosis (RAD) and patients without definite radiculopathy (HIVD). Twenty six controls without disc herniation were also evaluated. Cervical multifidus muscles from C4-5 to C7-T1 levels were detected in T1 axial MRI, and total cross-sectional area (CSA) of multifidus muscle (TMA) and pure muscle CSA (PMA) were measured. RESULTS: The ratios of TMA in involved side to TMA in uninvolved side (ITMA/UTMA) and PMA in involved side to PMA in uninvolved side (IPMA/UPMA) in HIVD and RAD groups was significantly lower than those in control group especially at C7-T1 level (p<0.05). We divided the levels of cervical spine into three parts according to lesions found in MRI or electrodiagnosis; above lesion level, at lesion level and below lesion level. Abnormal cases of IPMA/UPMA were not different among levels in HIVD group, but RAD group showed that most of abnormal cases were below lesion (60%). CONCLUSION: Asymmetric multifidus atrophy was seen in patients with cervical disc herniation and radiculopathy. The ratio of pure muscle CSA between involved and uninvolved sides might be a useful parameter to differentiate patients with unilateral cervical radiculopathy from patients without radiculopathy.

Effect of Stimulation Intensity and Location of Cerebral Infarction on Motor Evoked Potentials in the Rat

OBJECTIVE: To investigate the change of motor evoked potential (MEP) in the cerebral infarction, and observe the effect of stimulation intensity and location of cerebral infarction, using rat model of cerebral ischemia induced by endothelin-1 (ET-1). METHOD: Middle cerebral artery (MCA) infarct, cortical infarct, and internal capsular infarct were induced in Spraugue-Dawley rats, by injecting ET-1 stereotaxically. MEP was recorded in forelimb by transcranial magnetic stimulation at 100%, 120%, and 150% of motor threshold by a small figure-8 coil. The location of cerebral infarction was confirmed histologically by 2,3,5-triphenyltetrazolium chloride (TTC) staining. RESULTS: In MCA infarct, MEP was not recorded at all intensity. In internal capsular infarct, no MEP was recorded at 100% of motor threshold, and amplitude was decreased at 120%. In cortical infarct, MEP was not recorded at 100%, but amplitude was maintained at 120% and 150%. Latency did not change significantly at all intensity. CONCLUSION: Amplitude of MEP decreased after cerebral infarction, but latency did not change. Decrease in amplitude was larger with deeper location of cerebral infarction. Cerebral cortex was stimulated at 100% of motor threshold, subcortical structure was stimulated at 120%, and deeper structure was stimulated at 150%, respectively.

Videofluoroscopic Findings in Infants with Aspiration Symptom

OBJECTIVE: To describe the findings of videofluoroscopic study (VFSS) and investigate the usefulness of VFSS as a predictor of aspiration pneumonia in infants with aspiration symptoms. METHOD: Thirty-eight infants with aspiration symptoms were divided into two groups: those who showed aspiration symptom but had no pneumonia (Aspiration group); those with episode of aspiration pneumonia (Pneumonia group). The subjects' medical records and the results of VFSS were reviewed. RESULTS: In aspiration group, oral phase was normal and the abnormalities were found only in pharygeal phase in a small number of subjects. On the other hand, pneumonia groups showed poor lip closure and bolus formation in oral phase. Abnormalities of pharyngeal phase were reduced laryngeal elevation, coating of pharyngeal wall, increased residue of valleculae, and delay of pharyngeal transit time. Penetration and aspiration were more frequently observed (p <0.05). Aspiration pneumonia occurred more frequently among infants who had supraglottic penetration (p <0.05). CONCLUSION: Mild abnormalities were found only in pharyngeal phase in aspiration group, whereas VFSS abnormalities were observed in both oral and pharyngeal phase in infants with pneumonia. Our results suggest that VFSS would be useful in predicting the development of pneumonia in infants with aspiration symptoms.