Recanalization with Wingspan stent for acute middle cerebral artery occlusion in failure or contraindication to intravenous thrombolysis: a feasibility study.

BACKGROUND AND PURPOSE: Recanalization with the Wingspan stent, which can be deployed rapidly and safely, is an option for treating acute ischemic stroke when intravenous thrombolysis has failed or is contraindicated. This study was performed to evaluate feasibility, efficacy, and safety of recanalization for acute middle cerebral artery occlusion using the Wingspan stent. MATERIALS AND METHODS: We collected 10 patients with acute MCA occlusion in whom recanalization was not achieved with a standard intravenous thrombolysis, or who were ineligible for intravenous thrombolysis, or who presented after 3 hours of symptom onset and in whom the stent placement could be completed within 8 hours from symptom onset. We analyzed angiographic and clinical results. RESULTS: Successful recanalization with the Wingspan stent was achieved in all patients. The mean NIHSS score on admission was 12.7 points (range 4-21). The occlusion sites were located in the 1st segment (n = 7; 2 left, 5 right) and 2nd segment (n = 3, all right) of the MCA. The mean time interval from stroke symptom onset to stent placement was 344.8 ± 76.3 minutes. No intracranial hemorrhage, vessel perforations, or dissections occurred in any patient. Nine patients improved on the NIHSS at 7 days. One patient did not have a change in the NIHSS score, even though the occluded artery was completely recanalized. At 7 days, the NIHSS score of all patients was 4.4 ± 4.7 (median 4, range 0-13). At discharge, an mRS of ≤ 3 was achieved in all patients and an mRS of ≤ 2 was achieved in 7 patients (70%). CONCLUSIONS: This small case series demonstrates the feasibility of using the Wingspan stent safely and effectively for MCA occlusions when standard treatments are ineffective or not available.

Characteristics of postictal psychosis in a psychiatric center.

The clinical characteristics of 12 cases of postictal psychosis treated at Taipei City Psychiatric Center, Taipei, Taiwan, were retrospectively reviewed. Increased seizure frequency, especially with generalized tonic-clonic seizures, was the major risk factor predisposing to postictal psychosis. The psychotic symptoms were variable with delusions and/or hallucinations. These patients showed a much longer history of epilepsy (21.9 +/- 10.7 years) prior to the development of postictal psychosis than has been previously reported. The possible mechanisms in the pathophysiology of psychosis in epileptics were discussed.

Genetic risk factors of sporadic Alzheimer's disease among Chinese in Taiwan.

To evaluate the genetic factors for AD among a Chinese population in Taiwan, we studied the polymorphisms of six candidate genes of Alzheimer's disease (AD), including the regulatory region of apolipoprotein E (Apo-E, G-186T), the promoter of apolipoprotein E (Apo-E, A-491T), the bleomycin hydrolase gene (BH, A1450G), a mutation of alpha(2)-macroglobulin gene (A2M G2998A), low-density lipoprotein receptor-related protein gene (LRP, C766T), and alpha(1)-antichymotrypsin gene (ACT, -15Ala/Thr) in AD patients and non-affected elder individuals among Taiwanese Chinese. Eighty-two AD patients and 110 non-affected individuals were recruited for this study. We used polymerase chain reaction (PCR) and restriction enzyme digestion to identify their genotypes. The statistical examination was performed by combining the results of our previous reports - apolipoprotein E epsilon4 (ApoE-4), presenilin-1 intronic polymorphism (PS-1, allele 1/2), and the five-nucleotide deletion of alpha(2)-macroglobulin gene (A2M). Among these nine candidate genes of AD, the ApoE-4 allele is the only independent genetic risk factor for AD. The other candidate genes in this study were not associated with the occurrence of AD. In addition, there are no gene-gene interactions.

Polymorphisms of the parkin gene in sporadic Parkinson's disease among Chinese in Taiwan.

The role of genetics in Parkinson's disease (PD), previously controversial, is now documented by several studies. A major breakthrough has been the discovery of two single-gene defects in familial PD. A single base pair change at position 209 from G to A (G209A) in the fourth exon of the alpha-synuclein gene has been identified in cases of autosomal dominant familial PD. Mutations in the Parkin gene can induce autosomal recessive juvenile parkinsonism. A polymorphism of R/W366 in the Parkin gene was found to be associated with a protective factor for sporadic PD. We surveyed the polymorphisms of the Parkin gene, including S/N167, R/W366 and V/L380, in 92 cases of sporadic PD and 98 nonaffected individuals in Taiwanese Chinese. The allele frequencies of these polymorphisms are not significantly different between PD and nonaffected controls. We conclude that polymorphisms of the Parkin gene, S/N167, R/W366, V/L380, are not genetic factors for sporadic PD among Chinese in Taiwan.

Kleine-Levin syndrome and psychosis: observation from an unusual case.

OBJECTIVE: This study evaluated the possible pathologic relation between Kleine-Levin syndrome (KLS) and mood disorders. BACKGROUND: A 28-year-old man with a remote history of KLS had the sudden onset of a manic episode with psychotic features after the end of hypersomnolence. METHOD: The patient received an extensive laboratory examination, including single photon emission computed tomography and magnetic resonance imaging. RESULTS: Single photon emission computed tomography showed decreased tracer perfusion in the basal ganglion, hypothalamus, and right frontotemporal region. Magnetic resonance imaging revealed a cystic lesion in the pineal region. CONCLUSIONS: Hypothalamic dysfunction has been described in KLS and mood disorders, but pineal gland dysfunction has been mentioned only rarely. The clinical and neuroimaging findings suggest the need for further study of KLS.

No association of alpha-2 macroglobulin gene five-nucleotide deletion with AD in Taiwan Chinese.

The alpha-2 macroglobulin five-nucleotide deletion (A2M-2) allele frequency was not significantly higher in the AD group than the control group (0.062 versus 0.101, p > 0.1). The odds ratio for AD in individuals with the A2M-2 allele was 0.582 (95% CI, 0.25 to 1.40). These results do not support the association between A2M-2 and AD in the Chinese population, although the allele frequency of A2M-2 is lower than that found in the Caucasian population. Therefore, A2M-2 might not be a significant risk factor of AD among Taiwan Chinese.

No mutation of G209A in the alpha-synuclein gene in sporadic Parkinson's disease among Taiwan Chinese.

The role of genetics in Parkinson's disease (PD), previously controversial, is now supported by several studies. A major breakthrough has been the discovery of a single gene defect in familial Parkinson's disease. A single base pair change at position 209 from G to A (G209A) in the fourth exon of the alpha-synuclein gene has been identified in cases of familial PD. We looked for this mutation in 65 cases of sporadic PD in Taiwan Chinese patients but found none of these patients with this mutation. We conclude that mutation of G209A in the alpha-synuclein gene plays no role in sporadic PD among Taiwan Chinese.

Association of apolipoprotein E genotype and intronic polymorphism of the presenilin-1 gene with Alzheimer's disease in elderly Taiwan Chinese.

We studied the apoliprotein E (apo-E) allele frequencies and intronic polymorphism of the presenilin-1 (PS-1) gene in 55 patients with late-onset Alzheimer's disease (AD) and 93 age- and sex-matched controls. The apoE epsilon4 allele frequency was significantly higher in the AD group than in the control group (0.255 versus 0.070, P<0.0001). The odds ratio for AD in individuals with either one or two epsilon4 alleles was 5.22 (95% confidence interval: 2.32-11.70). The polymorphism within the region composing intron 3' to exon 8 of the PS-1 gene showed a similar distribution between AD patients and controls. This is the first study on the intronic polymorphism of the PS-1 gene in Chinese. Our results support an association between apoE epislon4 and AD in Chinese, but not between the intronic polymorphism of the PS-1 gene and AD. However, the allele frequency of apo-E epsilon4 among Chinese is lower than that among Caucasians. The interaction between apo-E and PS-1 genotypes is still unclear.

Effectiveness of low-dose ASA in prevention of secondary ischemic stroke, the ASA Study Group in Taiwan.

This randomized double-blind controlled study was carried out to investigate the effect of 100 mg acetylsalicylic acid (ASA) per day on the secondary prevention of ischemic stroke. Patients who suffered a first ischemic stroke from 13 participating hospitals were enrolled. They were independent or only partially dependent in activities of daily living and all had received brain CT for diagnosis. Eligible patients were randomly allocated to the 100 mg ASA or the nicametate citrate (a vasodilator) groups, and trial medications were started within three to six weeks after the onset of stroke. The primary end point was cerebral reinfarction, and intracranial hemorrhage was classified as an adverse event. Four hundred and sixty-six patients participated in this study; and 222 cases (136 males and 86 females) were allocated to the ASA group while 244 cases (150 males and 94 females) were assigned to the nicametate group. No significant difference in baseline characteristics between the two groups was observed. Cerebral reinfarction developed 6.3% (14/222) in the ASA group and 11.9% (29/244) in the nicametate group. According to the Cox's proportional hazards model, the estimated risk ratio (ASA group vs. nicametate group) was 0.538, with a 95% confidence interval of 0.284-1.019. The result was of borderline statistical significance. The risk for cerebral reinfarction was reduced by almost 50% among those who took 100 mg ASA versus those who took nicametate.

Traumatic brainstem deafness with normal brainstem auditory evoked potentials.

A 48-year-old woman became totally deaf after a head injury. Magnetic resonance imaging showed bilateral contusions around the inferior colliculi and the brainstem auditory evoked potentials (BAEP) failed to show any abnormality. This case demonstrates that small, symmetrical, bilateral lesions around the inferior colliculi may cause deafness and may still be associated with a normal BAEP.

Intravenous double-dose contrast computed tomography in the diagnosis of spinal arteriovenous malformations: report of four cases.

Spinal IV double-dose computed tomography (DCT) followed by reformation imagings was performed on 4 patients. Three cases received double-dose contrast injections, one case received a conventional single dose contrast material. 'Dots' enhancement on axial CT scanning and 'vasculature-like' hyperdense enhancement on sagittal and coronal reformation imagings were found in four cases of spinal arteriovenous malformation (AVM). Two were at the cervical region and two at the thoracic level. Typical serpentine filling defects were noted in the myelogram of three cases of spinal AVM. One patient suffered from acute onset of paraplegia (case 2), requiring that she received immediate surgical intervention after DCT scanning without myelography. Time for the whole procedure lasted approximately 20 minutes. In addition DCT followed by reformation imaging may be used as a noninvasive preliminary screening procedure for spinal AVMs.

Retinopathy, neuropathy and nephropathy in non-insulin-dependent diabetic patients.

In 1978, an epidemiological survey for adult diabetes was conducted in Taipei City. A total of 219 Chinese non-insulin-dependent diabetic patients were discovered and 217 of them were examined for retinopathy, neuropathy and nephropathy. Among the 110 men and 107 women studied, 63.1% were free of complications and the prevalences for retinopathy, nephropathy and neuropathy were 24.0%, 12.9% and 23.5%, respectively. The clinical and biochemical data of the patients were compared. For those with and those without complications, the diabetic duration (8.2 +/- 6.7 vs 4.1 +/- 2.7, years), percentage of insulin treatment (8.8% +/- 0.7%), percentage of hypertension (42.5% vs 26.3%), and the fasting plasma glucose (182.8 +/- 63.6 vs 135.0 +/- 44.6, mg/dl) were significantly different. Diabetic duration and glycemic control consistently correlated with retinopathy, nephropathy and neuropathy. Hypertension and insulin treatment were also associated positively with the complications. The more complications the diabetic patients had, the poorer the glycemic control, the longer the diabetic duration, a higher percentage of insulin treatment and hypertension were found.

Dynamic reactivities of dextransucrase.

Dextransucrase, from Streptococcus sanguis ATCC 10558, was immobilized on hydroxylapatite and was "charged" in short pulses with labeled sucrose, as previously described [V. K. Parnaik, G. A. Luzio, D. A. Grahame, S. L. Ditson, and R. M. Mayer (1983) Carbohydr. Res. 121, 257-268]. The "charged" enzyme has been shown to contain both bound glucose and gluco-oligosaccharides. The reactivity of this form of the enzyme has been studied, and shown to have unexpected behavior. Earlier pulse-chase experiments [J. F. Robyt, B. K. Kimble, and T. F. Walseth (1979) Arch. Biochem. Biophys. 165, 634-640; S. L. Ditson and R. M. Mayer (1984) Carbohydr. Res. 126, 170-175], carried out with high concentrations of unlabeled sucrose in the chase, resulted in a rapid decrease in isotope at the reducing termini of enzyme-bound oligosaccharides. However, in the present work, in which the pulsed enzyme was chased with low concentrations of unlabeled sucrose, we observed an increase in the radioactive reducing termini. The possibility that this was due to the enzymatic hydrolysis of dextran has been ruled out. Data presented demonstrate that the enzyme catalyzes the depolymerization of the bound oligosaccharides. Individual glucosyl residues of the oligosaccharides are transferred to acceptors, such as added maltose to form a trisaccharide, or water to form glucose. Similarly, the glucosyl residues can be transferred to added fructose to form sucrose. The studies also provide evidence that the oligosaccharides are slowly released from the enzyme. The ability of the enzyme to catalyze the reverse of the glucosyl transfer reaction involving acceptors was also examined. It was observed that glucose residues transferred by dextransucrase to an acceptor can also be removed to produce sucrose when fructose is added.

Radiculomyelitis following acute haemorrhagic conjunctivitis.

The clinical manifestations and natural history of radiculomyelitis following a newly reported disease--acute haemorrhagic conjunctivitis (AHC)--have been studied in 33 patients in Taiwan, and the following observations made: All the patients in this series were adults at ages ranging from 21 to 55 years; the salient initial neurological manifestations were radicular pains and acute flaccid paralysis which developed from five to thirty-seven days after the onset of AHC. In some patients, signs and symptoms indicating involvement of the meninges, cranial nerves and the white matter of the cord were observed; motor paralysis was the most striking feature during the whole clinical course; it consisted of flaccid asymmetrical weakness in one or more limbs, usually being more severe in the lower limbs than in the upper, and often more proximal than distal. Atrophy in the severely affected muscles usually became apparent in the second or third week of the weakness; the prognosis regarding the return of function in the affected muscles was dependent on the severity of the involvement. Permanent incapacitation due to paralysis and muscular atrophy in the affected proximal muscles of lower limbs was the main sequel in severe cases. The pattern and prognosis of flaccid motor paralysis were reminiscent of acute poliomyelitis in which the anterior horn cells of the spinal cord are mainly involved. Pleocytosis ranging from 11 to 270 per mm3 was noted in the majority of the patients when the cerebrospinal fluid was examined within the first three weeks from the onset of neurological symptoms; the total protein level was raised invariably from the second week onwards in all specimens, and remained so throughout the subsequent course as long as the seventh week or later. Tissue culture neutralization tests were performed on the sera from 9 patients; significant rises in the antibody titres (greater than or equal to 1:16) to AHC virus antigens were found in 8 cases, and in 2 of them a fourfold rise in the paired sera was noted. The differentiation of this syndrome from poliomyelitis and from Guillain-Barré syndrome, the relative freedom of children from neurological complications of AHC and the aetiological relationship of AHC virus to the syndrome have been discussed. It is concluded that this unusual neurological syndrome is caused by the neurovirulent properties of the AHC virus.

Neurologic complications with elevated antibody titer after acute hemorrhagic conjunctivitis.

Nine patients with polyradiculomyeloneuropathy after acute hemorrhagic conjunctivitis (AHC) infection were studied serologically. All except one patient had neutralization titers larger than or equal to 1:16 against the prototype J670/71 strain of AHC virus in at least one of their serum samples. The development of a significant fourfold rise in antibody titer against AHC virus occurred in one of the patients who developed neurologic complications five days after the onset of AHC infection.