Treatment-resistant diabetic chorea manifesting with psychiatric symptoms: a case report.

We report a case of a 69-year-old man with treatment-resistant diabetic chorea presenting psychiatric symptoms. The right chorea lasted for 3 months and was refractory to control of diabetes mellitus or administration of haloperidol and benzodiazepines. Only administration of tiapride was efficacious. Magnetic resonance spectrometry and dopamine transporter-single photon emission computed tomography suggested that sustained ischemia at the striatum may lead to impaired expression of dopamine transporters, thereby resulting in deterioration in the indirect pathway. Tiapride inhibited dopamine D2 receptors, thereby restoring the function of the indirect pathway and resulting in improvement of diabetic chorea.

[Real-time 3D reconstruction CT-jejunography guided direct percutaneous endoscopic jejunostomy for levodopa-carbidopa intestinal gel treatment in a patient with prior gastrojejunostomy].

A 68-year-old woman with Parkinson's disease, who had previously undergone Roux-en-Y gastrojejunostomy for early gastric cancer, complained of wearing-off and troublesome dyskinesia that had progressed over 7-years. After the introduction of levodopa-carbidopa intestinal gel therapy (LCIG) by nasojejunal tube, she had a good clinical response. Percutaneous endoscopic gastrostomy with a jejunal extension tube was difficult in this case, due to lack of gastrostomy site and fibrous postoperative adhesion. We introduced LCIG by direct percutaneous endoscopic jejunostomy (D-PEJ) which offers a less invasive procedure to operative tube placement. The factors affecting the success of D-PEJ could interfere with transillumination, abdominal thickness and the location of other organs. We determined the optimum site of catheter insertion with the assistance of real-time 3D reconstruction CT-jejunography. She was discharged home on postoperative day 14 without any procedure-related complications. Real-time 3D reconstructive CT-jejunography guided D-PEJ is a useful method for a patient who benefit from LCIG with prior gastrojejunostomy.

Clinical Characteristics of Driving-related Stroke Occurring as a Recurrent Stroke.

BACKGROUND: Although the number of seemingly healthy subjects who suffer a minor stroke increases, there are no data on how frequently they sustain another stroke while driving. METHODS: A single-center, retrospective study was conducted to clarify the clinical characteristics of driving-related stroke occurring as a recurrent stroke by analyzing data prospectively acquired between January 2009 and June 2019 on 3452 acute stroke patients. RESULTS: One hundred-thirty five patients (85 ischemic stroke [IS] and 50 hemorrhagic stroke [HS]) had suffered a driving-related stroke. Of them, 22 (16%) had suffered a prior stroke (recurrent stroke group), while 113 had never suffered a stroke before (first-time stroke group). While the use of anti-thrombotics was significantly more common in the RS group, other variables including the frequency of road traffic accidents, did not differ significantly. The first stroke-recurrent stroke interval ranged from 0.2 to 18 years. The stroke type at the time of recurrence was IS in the majority of patients with prior IS. When compared to 432 patients with recurrent IS unrelated to driving, patients with recurrent IS related to driving (n = 16) had significantly higher frequency of lacunar strokes (56% vs 27%, P = .02) and lower frequency of cardioembolic strokes (6% vs 29%, P = .04). CONCLUSION: The current finding that 16% of patients who presented with driving-related stroke had previously suffered a stroke indicates that drivers with a prior stroke may be at increased risk for recurrent stroke while driving, and prolonged follow-up be necessary for minor stroke patients who resume driving.

[Wilson's disease presenting as Asperger syndrome].

A 24-year-old man, who had been treated for 3 years as Asperger syndrome in adolescence due to behavioral disturbances, lack of social awareness and inability to socialize, was referred to our hospital shortly after tremors developed. On the basis of clinical features, laboratory findings and the brain MRI, a diagnosis of Wilson's disease (WD) was made. WD was further confirmed by genetic testing (the mutation of ATP7B gene). He was started with trientine hydrochloride 500 mg/day, and after 1 year of follow-up, his psychiatric symptoms have improved. Since psychiatric symptoms may precede the neurological symptoms, the possibility of WD should be always considered in the differential diagnosis of psychiatric disorders in young adults.

Seizures occurring while driving in patients with and without diagnosis of epilepsy: Frequency and association with automobile accidents.

Seizure may occur during any human activity, including driving. The objectives of this study were to report the frequency of seizure occurring while driving, clarify patient characteristics and analyze the behavioral patterns of drivers afflicted by seizure. A single-center, retrospective study was conducted using prospectively acquired data. Data of 658 adult seizure patients who visited our emergency department between January 2011 and December 2016 were used for analysis, focusing on daily activities immediately before seizure. Nineteen of the 658 patients (2.9%) sustained seizure while driving. The 658 patients were dichotomized on the basis of whether he or she had been diagnosed with epileptic seizure (ES). Seven of the 307 patients with ES vs. 12 of the 351 patients without ES sustained seizure while driving. The frequencies did not differ significantly between the two groups (2.3% vs. 3.4%, p = 0.49). Structural lesions on brain imaging studies were found in 6 of the 12 patients without ES (50%). Sixteen of the 19 patients (84%) caused automobile accidents after seizure. Among the 7 patients with ES, antiepileptic drugs had not been prescribed in 3 (43%). Although seizures occurring while driving have been studied extensively, most researchers focused on patients with ES. This study was unique because it focused on patients without ES, and the current findings that seizures in patients without ES outnumbered seizures in those with ES may be informative to clinical neuroscientists and emergency physicians. Prospective studies are expected to identify individuals at risk for first seizure occurring while driving.

Stroke while driving: Frequency and association with automobile accidents.

Background Cardiovascular events while driving have occasionally been reported. In contrast, there have been few studies on stroke while driving. Aim The objectives of this study were to (1) report the frequency of stroke while driving and (2) evaluate its association with automobile accidents. Methods Clinical data prospectively acquired between January 2011 and December 2016 on 2145 stroke patients (1301 with ischemic stroke, 585 with intracerebral hemorrhage, and 259 with subarachnoid hemorrhage) were reviewed to identify patients who sustained a stroke while driving. The ratio of driving to performing other activities was evaluated for each stroke type. Furthermore, the drivers' response to stroke was reviewed to understand how automobile accidents occurred. Results Among the 2145 patients, 85 (63 ischemic stroke, 20 intracerebral hemorrhage, and 2 subarachnoid hemorrhage) sustained a stroke while driving. The ratio of driving to performing other activities was significantly higher in ischemic stroke (4.8%) than in intracerebral hemorrhage (3.4%) or subarachnoid hemorrhage (0.8%). A majority of drivers either continued driving or pulled over to the roadside after suffering a stroke. However, 14 (16%) patients were involved in automobile accidents. In most patients, an altered mental status due to severe stroke was the presumed cause of the accident. Conclusion Stroke occurred while driving in 4.0% of all strokes and accidents occurred in 16% of these instances.

Clinical characteristics of stroke occurring in the toilet: Are older adults more vulnerable?

AIM: While autonomic imbalance during defecation/micturition can cause hemodynamic instability, stroke occurring in the toilet has rarely been investigated. The objective of the present study was to clarify the frequency and clinical characteristics of toilet-related stroke. METHODS: Clinical data prospectively acquired between January 2011 and December 2015 on 1939 patients with acute stroke (1224 cerebral infarctions [CI], 505 intracerebral hemorrhages [ICH] and 210 subarachnoid hemorrhages [SAH]) were reviewed to identify patients with a toilet-related stroke. For each stroke type, the ratios of stroke occurring during defecation/micturition to those occurring during other activities were calculated. Subsequently, how patients with toilet-related stroke were brought to medical attention was investigated. Whether older patients (aged >65 years) had an elevated ratio of toilet-related stroke was investigated in each stroke type. RESULTS: A total of 108 patients (41 CI, 37 ICH and 30 subarachnoid hemorrhages) sustained a stroke in the toilet. The ratio of toilet-related stroke was highest in subarachnoid hemorrhages (14.3%), followed by ICH (7.3%). Circadian differences existed among the three stroke types: toilet-related CI were more likely to occur in the night-time than ICH. Patients with toilet-related CI were significantly more likely to sustain cardioembolic stroke. In all three stroke types, <40% of patients could call for help by themselves. Older patients showed a significantly higher proportion of toilet-related stroke in CI, but not in hemorrhagic strokes. CONCLUSIONS: The toilet is a closed space where stroke occurs disproportionately frequently. Effort to reduce the incidence of toilet-related strokes is warranted, as early patient detection is not always feasible. Geriatr Gerontol Int 2018; 18: 250-255.

Clinical Characteristics of Stroke Occurring while Bathing.

BACKGROUND: Stroke can occur during any human activity. Although cardiac arrests or drowning accidents while bathing have been studied extensively, there are few studies focusing on stroke occurring while bathing. The objectives of this study were to evaluate the clinical characteristics of stroke occurring while bathing and the association between stroke and drowning accidents. METHODS: Clinical data prospectively acquired between January 2011 and December 2015 on 1939 patients with stroke (1224 cerebral infarctions [CIs], 505 intracerebral hemorrhages [ICHs], and 210 subarachnoid hemorrhages [SAHs]) were reviewed to identify patients who sustained a stroke while bathing. The ratio of bathing-related strokes to strokes occurring during other activities was evaluated. Moreover, the demographics of these 2 groups were compared in each stroke type. RESULTS: Among the 1939 patients, 78 (CI, 32; ICH, 28; and SAH, 18) sustained a stroke while bathing. The ratio of bathing to other activities in the SAH group was the highest (8.6%), followed by the ICH group (5.5%), whereas that in the CI group was the lowest (2.6%). Regardless of stroke type, only a minority of patients were found to have collapsed inside the bathtub. CONCLUSIONS: The higher ratio of bathing in hemorrhagic strokes may indicate that there is a small risk of hemorrhagic stroke while bathing in vulnerable subjects. This retrospective study did not establish a causal relationship between bathing and stroke nor identify risk factors, which means that future prospective studies are warranted. The finding that the great majority of bathing-related stroke patients were found to have collapsed outside the bathtub suggests that the involvement of stroke in drowning accidents in the bathtub may be small.

Paraneoplastic Dermatomyositis in Hepatocellular Carcinoma with Colonic Perforation: A Case Report.

BACKGROUND: Dermatomyositis (DM) is an autoimmune disease characterized by cutaneous Gottron papules, heliotrope rash, and proximal myopathy. It may also present as a paraneoplastic syndrome that can complicate a variety of different cancers, such as lung, cervical, and breast cancer. However, the association with hepatocellular carcinoma (HCC) is extremely rare. Moreover, to our knowledge, there are no previous reports of colonic perforation following steroid pulse treatment for a DM patient. CASE SUMMARY: A 61-year-old male complained of a skin rash that began in his neck and spread to his face and abdomen. On physical examination, the patient was also found to have symmetrical proximal muscle weakness, abdominal pain, heliotrope rash in the periorbital skin, and poikiloderma on his face and abdomen. Serum level of muscle enzymes was remarkably increased. Muscle examination revealed symmetrical proximal weakness. The diagnosis of DM was made, and steroid treatment was started for symptomatic relief. A search for causative malignancy revealed HCC. Despite steroid therapy for DM, his symptoms did not improve. Additionally, C-reactive protein elevation was seen along with severe abdominal pain on day 14 of admission. Shortly after this, the patient died of septic shock due to suppurative peritonitis after perforation of the ascending colon. CONCLUSION: Here, we present a rare case of DM caused by non-hepatitis-associated advanced HCC with colonic perforation. The cause of colonic perforation is still unclear. This case demonstrates the need to carefully monitor abdominal pain in DM patients as symptoms can be masked by steroid therapy.

Fulminant ependymitis following intraventricular rupture of brain abscess.

A 48-year-old man with a history of a penetrating brain injury was referred with a presumptive diagnosis of bacterial meningitis. Examination revealed a brain abscess in addition to meningitis. Blood and cerebrospinal fluid (CSF) cultures were negative for bacteria, and empirical IV antibiotic therapy with vancomycin (VCM) and meropenem was initiated. Despite initial improvement, however, his condition rapidly deteriorated into coma following intraventricular rupture of the abscess and hydrocephalus. Thereafter, an emergency ventriculostomy was performed and the abscess was evacuated. Bacterial cultures of the pus were negative. To manage the hydrocephalus, 150-200 ml of CSF were drained daily. Intraventricular administration of VCM (20 mg q.d.) was added to the IV antibiotic therapeutic regimen after surgery. Although the primary abscess rapidly decreased in size, ependymitis developed in the fourth ventricle. This new lesion, which resulted from CSF dissemination from the primary abscess, was refractory to treatment, and eventually disappeared after the intraventricular VCM dosage was increased from 20 to 30 mg and continued for 30 days. A possible reason for the development of fulminant ependymitis and why it was refractory to treatment despite the shrinkage of the primary lesion may be that physiological CSF flow from the lateral to the fourth ventricle was lost due to CSF drainage, and the stagnant CSF flow coupled with an insufficient VCM level in the fourth ventricle facilitated the rapid growth of pathogens. Although intraventricular antibiotic administration is efficacious for treating ruptured brain abscesses, it may be associated with the unexpected development of secondary lesions.

Gliomatosis cerebri mimicking chemotherapy-induced leukoencephalopathy in a patient with non-Hodgkin's lymphoma.

Patients with hematological malignancies may develop white matter lesions, which are usually associated with chemotherapy. Magnetic resonance imaging (MRI) is the imaging modality of choice for identifying chemotherapy-induced, or "toxic", leukoencephalopathy. Brain biopsy in patients with hematological malignancies suspected of sustaining toxic leukoencephalopathy has rarely been performed, because its characteristic MRI findings are considered pathognomotic. Biopsy may be indicated in atypical cases, however, and it may yield unexpected results. We describe a case with white matter lesions that developed in an elderly man treated for non-Hodgkin's lymphoma. The lesions, initially diagnosed with toxic leukoencephalopathy based on MRI findings, turned out to be gliomatosis cerebri.

Influence of age and anti-platelet/anti-coagulant use on the outcome of elderly patients with fall-related traumatic intracranial hemorrhage.

Ground-level fall is the most common cause of traumatic intracranial hemorrhage (TICH) in the elderly. Many studies on geriatric TICH have regarded patients aged ≥65 years as a single group, but substantial heterogeneity is likely to exist within this population. Eighty-two elderly patients with fall-related TICH treated in our institution during a 6-year period were stratified into 3 age groups (65-74, 75-84, and ≥85 years), and intergroup differences in the demographics and outcomes at discharge were evaluated. The influence of the use of anti-platelet/anti-coagulant (AP/AC) agent on outcomes was also investigated. Comparison of demographic variables demonstrated significant differences in the frequency of preinjury alcohol consumption and use of AP/AC agents between the 3 groups, indicating that the causes or triggers of fall might be substantially different between the 65-74 years group and the other two groups combined. The frequency of unfavorable outcomes increased with age, and the increase was statistically significant. The 82 patients were divided into two subgroups depending on the use of AP/AC agents. The outcomes of the ≥85 years group taking AP/AC agents were particularly poor compared with those of the ≥85 years group not using AP/AC agents. Advancing age may be associated with unfavorable outcomes in elderly patients with fall-related TICH, and patients aged ≥85 years taking AP/AC have the greatest risk of unfavorable outcomes. Physicians must consider the risk/benefit analysis before prescribing AP/AC agents to patients aged ≥85 years.

Bilateral retrobulbar optic neuritis, Guillain-Barré syndrome and asymptomatic central white matter lesions following adult measles infection.

A 28-year-old woman presented with classic signs of measles and subsequently developed bilateral retro-bulbar optic neuritis and Guillain-Barré syndrome. Her radiographic and CSF findings were consistent with acute measles encephalitis. However, encephalopathy, such as behavioral changes and alteration in consciousness, was not presented. Improvements in the clinical, radiographic, and electrophysiological studies were observed during the steroid therapy. The overlap of CNS and PNS involvement as neurological complications of measles infection is very rare.