Paired stimulation study of the median nerve sensory action potential in diabetic patients.

OBJECTIVES: Conventional nerve conduction studies (NCS) are not sensitive to detect mild diabetic neuropathy. In order to detect subtle changes, we compared the conventional NCS with the relative refractory period (RRP) measurement of the median sensory nerve action potential by a paired stimulation method. METHODS: Subjects were 29 diabetic patients whose conventional NCS were all normal. They were divided into two groups: neurologically symptomatic and asymptomatic groups. Twenty-eight age-matched control subjects were also studied. RESULTS: The RRP of the symptomatic diabetic patients (5.9 +/- 0.5 ms) and that of the asymptomatic patients (5.6 +/- 0.5 ms) was significantly longer than that of the control subjects (4.9 +/- 0.6 ms). There was no significant difference in RRP between the symptomatic and asymptomatic patients. This may be due to the fact that NCS reflects mainly large myelinated fiber function and early symptoms represent mainly thin myelinated or unmyelinated fiber function. CONCLUSIONS: The RRP measurement could reveal some mild involvement of peripheral nerves undetectable by conventional NCS, even though they caused no clinical symptoms.

[A case of visual agnosia for picture with right occipital lobe infarction].

We report a 74-year-old right-handed man with visual agnosia for picture due to right occipital lobe infarction. The patient had a remarkable impairment in visual recognition for standardized pictures made by Snodgrass and Vanderwart, in addition to left hemianopsia, left visuospatial neglect, and mild prosopagnosia. The visual agnosia for picture was generally recognized as a mild-type of the visual object agnosia, which was extremely rare in the patients with right occipital lesion. We discussed the mechanism of the visual agnosia in the right occipital lesion. Therefore, it raises the possibility that the broad impairment of the right occipital artery territory including parahippocampal gyrus as well as corpus callosum can cause the visual agnosia for picture.

[Coronary artery bypass grafting on the beating heart in patients with severe cardiac dysfunction; on the necessity of cardiopulmonary bypass].

Six patients with severe cardiac dysfunction due to acute myocardial infarction underwent coronary artery bypass grafting on beating hearts, because we were afraid of difficulty in weaning from the cardiopulmonary bypass (CPB). The first two operations were performed without use of CPB (group A) and the following cases were done with CPB (group B). All patients received emergent operations except one, and three patients needed intra-aortic balloon pumping support perioperatively. Although all patients had three vessel disease, the number of the graft was one or two. Anesthesia was maintained by fentanyl, midazolam, sevoflurane and nitrous oxide. All patients in group B could be weaned from the CPB easily. In a patient of group A, hypotension persisted during cardiac procedure. In a patient of group B, ventricular fibrillation occurred when the coronary artery was occluded by snares. In another patient of group B, we discontinued inotropic agents and used verapamil during CPB for a easy cardiac procedure and myocardial protection. We conclude that coronary artery bypass grafting on the beating heart in the patients with severe cardiac dysfunction due to acute myocardial infarction should be performed with CPB to maintain systemic hemodynamics, to protect myocardium during occlusion of the coronary artery, and to make the surgical procedure easy.

[A case of "apraxia of eyelid opening" secondary to right hemisphere infarction--assessment of various symptoms of the eye and eyelid].

A 68-year-old right-handed woman showed "apraxia of eyelid opening" during an acute phase of hemorrhagic infarction in the right middle cerebral artery distribution. She showed paradoxical contraction of the bilateral orbicularis oculi muscles both against our order to open her eyes and even against her hand-movement to help her eyes open, although she could voluntarily open her eyes. She was diagnosed as "apraxia of eyelid opening". Her eyes kept closed in most of time. Spontaneous blepharospasm and a right conjugate gaze preference were also seen. These symptoms disappeared 2 weeks after the hemorrhagic infarction. Because most of cases in previous reports as well as this patient showed "apraxia of eyelid opening" after a right cerebral involvement, we propose that this symptom may attribute to right cerebral dysfunction.

[A case report of cerebral achromatopsia with bilateral occipital lesion].

An 80-year-old right-handed man suddenly became impossible to recognize any color 7 years prior to admission. He complained that everything looked like of the same color, monochromatic. On admission, he could not discriminate any color and any familial face. Left homonymous hemianopsia associated with right lower partial visual filed defect was observed, but visual acuity of both eyes was well preserved. Visual-visual color tasks (Ishihara, matching, Hue test, Panel-D15) disclosed the disturbances in color perception. However, he could roughly distinguished red or brown from the other colors. The color test was also impaired regarding the visual-verbal color tasks (naming, pointing). However, verbal description of the color concept, which was shown by the verbal-verbal color tasks, was well preserved. In addition, we observed left hemispatial neglect, disturbance of face recognition and topographical disorientation. MRI revealed old hemorrhagic infarcts in the bilateral occipital and temporal lobes, including the bilateral lateral and medial occipito-temporal gyri. Disturbance of color recognition in this case was diagnosed as cerebral achromatopsia on the basis of clinical characteristics and MRI findings. This is the first case of cerebral achromatopsia of which lesions were detected by MRI in detail.

Japanese crossed Wernicke's aphasia.

A right-handed Japanese man with no personal or family history of left-handedness developed severe Wernicke's aphasia, a mild constructional disorder, and slight left hemiparesis. MRI revealed infarction in the territory of the righ middle cerebral artery, including areas homologous to Broca's and Wernicke's areas. The cerebral blood flow in these areas remained diminished even after language activation. The most likely explanation is that language production occurred in the left Broca's area, while language comprehension occurred in the right Wernicke's area (a dissociated aphasia).

[Guillain-Barré syndrome preceded by diarrhea with the infection of Campylobacter jejuni].

We report a 77-year-old woman with Guillain-Barré syndrome following Campylobacter jejuni infection. She was admitted complaining of mild weakness in the left leg. Seven days before, she had severe diarrhea, which continued several days. After admission, the weakness soon worsened resulting in tetraparesis, and the respiration became so impaired that she was supported by the artificial ventilator. Deep tendon reflexes were absent in four limbs, and no sensory disturbance was noted. CSF contained the protein as low as 20.4 mg/dl in concentration; no pleocytosis was seen. Muscle action potentials evoked by the stimulation of nerves were markedly reduced in amplitude, but conduction velocity along the nerve was decreased mildly. Campylobacter jejuni was detected by bacterial culture of the stool; the antibody was positively raised against this bacteria in serum. By 90 hospitals days, she was restored to spontaneous respiration.

[A case of left atrial giant thrombus which appeared in a short period].

We reported a case with left atrial giant thrombus (LAGT) which appeared over a period of six months. The patient was a 65-year-old woman who came to our hospital complaining of syncopal attack. Her electrocardiogram showed atrial fibrillation with very slow ventricular response, and there was cardiac arrest for 1500 ms, mitral stenosis and regurgitation, aortic and tricuspid regurgitations were recognized in the echocardiogram. By coronary angiography, 90% stenosis in the left circumflex artery (LCX) was found, and using transseptal left atrium heart catheterization, pressure gradient from the left atrium to the left ventricle was also measured. We diagnosed that her valvular diseases were mild. To protect her from unconsciousness and heart failure, a permanent pacemaker was implanted and PTCA for LCX lesion was performed. After six months, we found LAGT by echocardiography. It is very rare that LAGT is formed in a short period. We suggested that the changes of hemodynamics caused by transseptal left atrial catheterization or the permanent pacemaker implantation effected the formation of the LAGT.

[The effect of open heart surgery and an operation on thoracic aneurysm on organs and the prevention of an organ system failure: comparison between the group using ulinastatin and not using group].

We studied the effect of the open heart surgery and the thoracic aortic aneurysm surgery on renal, liver and respiratory function and the coagulofibrinolytic system. We also investigated as to whether ulinastatin was effective or not with regard to preventing an organ system failure. The renal function, liver function and the coagulofibrinolytic system were preserved, although there was a greater number of severe cases in the group which used ulinastatin (US group) than in the group that did not use ulinastatin (non-US group). In the US group, PaO2 did not decrease postoperatively. However, in the non-US group, PaO2 decreased significantly after the operation. The variables in relation to using ulinastatin, examined by a stepwise method, included kind of disease, emergency operation, PaO2, BUN and serum plasminogen. The multiple coefficient for these five variables was 0.623 (p less than 0.01) and the contribution was 38.8%. It was suggested that ulinastatin could prevent an organ system failure, especially respiratory failure, after open heart surgery and the thoracic aortic aneurysm surgery.

Disposition of glycyrrhetic acid and its glycosides in healthy subjects and patients with pseudoaldosteronism.

As a first step to elucidate the disposition of traditional Chinese formulations which contain licorice, the disposition of plain licorice was investigated in humans. Glycyrrhetic acid (GLA) was measured by an enzyme immuno-antibody technique. Glycyrrhetic glycosides (GLA-GS), such as glycyrrhizin, were measured after acid hydrolysis to GLA by the enzyme immuno-antibody assay. Five normal subjects were orally administered a decoction of licorice containing 133 mg of glycyrrhizin. It was found that the time required for maximum serum concentration of GLA-GS was less than 4 h after the administration. Although there were large individual differences, it was found that GLA-GS was eliminated from the blood for the most part within 72 h. On the other hand, GLA reached maximum serum concentration at about 24 h after administration and in two of the five cases it was still detected in the blood even after 96 h. Urinary excretion of GLA was about 2% of the total dose of glycyrrhizin administered. This suggested that there were great differences among the subjects in the absorption and urinary excretion of GLA-GS. The serum GLA levels in two clinical cases who presented pseudoaldosteronism by licorice containing formulations were as high as 70-80 ng/ml, with GLA-GS levels being very low. This fact suggests that pseudoaldosteronism develops in association with GLA rather than with GLA-GS.

MRI of callosal disconnection due to cerebral infarction.

Magnetic resonance imaging (MRI) was performed to study two cases of callosal disconnection due to cerebral infarction. Both cases had pure alexia and right homonymous hemianopsia. Midsagittal inversion recovery (IR) images demonstrated that the corpus callosum was completely intact, and coronal IR images revealed involvement of the lingual gyrus, fusiform gyrus, forceps major, inferior longitudinal fascicle, and optic radiation in the dominant cerebral hemisphere in both cases. Midline sagittal images provided direct visualization of the corpus callosum but did not provide sufficient information for the study of callosal disconnection syndromes. Coronal reconstructions aided in visualizing the relationship of lesions to the adjacent structures of cerebral white and gray matter. MRI may be one of the most useful tools for understanding the process of interhemispheric transference of information.