The Etiological Spectrum of Acute Sensory Myelitis

BACKGROUND AND PURPOSE: Acute myelitis patients exhibiting only sensory deficits upon initial presentation are not commonly encountered in clinical practice, but they definitely exist. Since acute sensory myelitis has not been investigated previously, this study evaluated the etiological spectrum of the condition with the aim of describing the clinical characteristics thereof. METHODS: Patients with acute myelitis who presented at the Ewha Womans University Medical Center (during 1999-2012) and the National Cancer Center (during 2005-2014) with only sensory symptoms as first clinical features were enrolled in this study. Their medical records, electrophysiological and laboratory data, and MRI findings were analyzed retrospectively. RESULTS: Of a total of 341 acute myelitis patients, 52 (15%) were identified as having acute sensory myelitis. The male-to-female ratio of these patients was 35:17, and their age at the onset of the condition was 41.7+/-10.5 years (mean+/-SD; range, 24-72 years). Acute sensory myelitis developed in patients with multiple sclerosis (MS; 14%), neuromyelitis optica spectrum disorder (NMOSD; 17%), and acute myelitis associated with concurrent systemic diseases including Behcet's disease and cancer (6%). Despite detailed evaluation, the etiology of 33 patients with acute myelitis could not be determined. Longitudinally extensive transverse myelitis on spinal MRI and progression of the sensory level were observed most commonly in NMOSD patients (89% and 78%, respectively); however, these patients did not exhibit sensory dissociation. Residual negative sensory symptoms were observed more frequently in NMOSD patients (33%) than in those with acute myelitis of unknown cause (24%) or MS (14%). During the long-term follow-up (4.7+/-2.7 years) of patients who did not undergo maintenance immunotherapy, a monophasic clinical course was common in those with acute myelitis of unknown cause (76%), but not in NMOSD or MS patients. CONCLUSIONS: Accurate identification of the diverse nature of acute sensory myelitis may assist in patient care.

Effects of 1 Hz Repetitive Transcranial Magnetic Stimulation on Cortical Excitability and Seizure Reduction in Intractable Neocortical Epilepsy / 대한간질학회지

BACKGROUND & OBJECTIVES: Repetitive transcranial magnetic stimulation (rTMS) can modulate the excitability of cortical networks, possibly reduce the excitability by low frequency stimulation. In this study, we are conducting a study using 1 Hz rTMS in patients with intractable neocortical epilepsy. We wish to see whether 1Hz rTMS induces considerable changes in the cortical excitability and whether it leads to a significant reduction in seizure frequency in individual patients. METHODS: Patients with intractable neocortical epilepsy were recruited, and 1 Hz rTMS (110% of resting motor threshold, 1800 stimuli twice a day) was delivered to the seizure focus for 5 consecutive days. Resting motor threshold (r-MT), MEP amplitudes at different intensities, intracortical inhibition (ICI) and intracortical facilitation (ICF) were measured as TMS indices for motor cortical excitability. TMS measures were repeated before and after daily rTMS session, and again after 2 weeks. RESULTS: Four patients (aged 15 to 53, 3 females and 1 male, 2 TLE and 2 FLE) were described here:cortical excitability in 2 neocortical TLE patients showed lower r-MT and reduced ICF in ipsilateral hemisphere to epileptic focus. One of them with cortical dysplasia showed increased r-MT and ICI, and decreased ICF after daily rTMS session. This patient was seizure-free for 10 weeks, after which the seizure frequency returned to the baseline. CONCLUSIONS: Our preliminary data shows that 1 Hz rTMS may decrease cortical excitability and/or intracortical facilitation, and increase intracortical inhibition after daily rTMS. These findings suggest possible therapeutic effects of low frequency rTMS for patients with intractable neocortical epilepsy.

A Case of Primary Lymphoma Presenting as Cauda Equina Syndrome

Primary CNS lymphoma (PCNSL) which is localized in the cauda equina of the spinal cord is very rare. A 75-year-old man had pain in both legs and gait disturbance for the last 45 days. Painful paresthesia and weakness in both legs worsened during a one month period and he was unable to stand up by himself. In a physical examination, lym-phadenopathy nor organomegaly was found. A neurological examination revealed a dominantly proximal muscle weak-ness of the lower extremities. All modalities of sensation were decreased in both legs and a Romberg test was found positive. A CSF cytology demonstrated a large B-cell lymphoma. Following an extensive evaluation of the patient, the lymphoma was found to be limited in the cauda equina. The patient was treated with systemic dexamethasone. After the treatment, his symptoms were improved and a follow up lumbar spine MRI showed shrunken cauda equina lesions.

The effects of peripheral leukocytes on the hippocampal neuronal changes in transient global ischemia and unilateral cerebral hemispheric infarction

The participation of activated leukocytes and subsequent production of chemical mediators has been well accepted in the pathophysiology of hypoxic-ischemic injury. This study was performed to see the effects of leukocytes on hippocampal neuronal damage in transient global ischemia induced by 10-min occlusion of bilateral common carotid arteries (CCAs) with reperfusion for various times, and in complete unilateral ischemia induced by 24-hr ligation of left CCA. Leukopenia was induced by intraperitoneal injection of cyclophosphamide for 4 days. The results showed that hippocampal neuronal damages were worse at 6-hr reperfusion in leukopenic experimental group than in the control group. In comparison, 24-hr and 3-day reperfusion leukopenic groups showed less numbers of damaged neurons and milder changes. The 5-day reperfusion group showed inconsistent changes. Unilateral CCA occlusion showed extensive infarction in 83.3% of gerbils in the control group, compared to 25% of gerbils in the experimental group (p<0.05). These results strongly suggest that the number of peripheral leukocytes were closely related to the development of delayed neuronal damage of hippocampus in transient global ischemia and the incidence of infarction induced by 24-hr unilateral CCA ligation.

Morphological Analysis of Short and Long Term Changes after Ligation of Unilateral Common Carotid Artery in Gerbils

BACKGROUND: The ligation of the unilateral common carotid artery (CCA) in the gerbil has been known as an ischemic animal model showing various changes including selective neuronal necrosis as well as infarction. This study was performed to analyze the short and long term morphological changes of transient unilateral forebrain ischemia with special attention to astroglial proliferation. METHODS: 67 mongolian gerbils were subjected to 2 hr, 3 hr, 4 hr, or 5 hr of forebrain ischemia by the unilateral CCA ligation method. Each of the ischemic groups were examined after a 1 day, 3 day, or 7 day period of reperfusion. Long term reperfusion groups consisted of 2, 3, and 4 weeks of reperfusion after 5hr of unilateral CCA ligation. Morphological changes were analyzed by H-E staining and an immunohistochemical reaction with GFAP antibody. RESULTS: The ligation of the unilateral CCA, induced unilateral hemispheric infarction in 14 gerbils, selective neuronal necrosis (SNN) involving caudate in 1 gerbil, and delayed neuronal necrosis (DND) of the hippocampal CA1 neurons in 2 gerbils. Infarction was most frequent in 1 day reperfusion groups and did not show any differences according to the duration of ischemia. The GFAP reaction was strongly positive in the center of infarction at a 1 day period and negative at a 3 & 7 day period. The surrounding brain parenchyme progressively revealed increased positive reactions. Gerbils with SNN and DND showed moderately or markedly increased GFAP positive reactions in the unilateral caudate, thalamus, and hippocampus, whereas no apparent changes were shown by a H-E stain. CONCLUSIONS: Reactive astrogliosis is a stereotyped reaction of ischemic brain injury and is a more sensitive parameter than neuronal changes.

A case of GDC(guglielmi detachable coil) embolization in an unruptured intracranial aneurysm

The Guglielmi Detachable Coil(GDC), a soft platinum alloy micro-coil, has been used to treat certain intracranial aneurysms for recent several years. This detachable platinum coil was soldered to a stainless steel delivery guidewire. Intra-aneurysmal thrombosis was then initiated by applying a low positive direct electric current to the guidewire. Thrombosis occurred because of the attraction of negatively charged platinum coil positioned within the aneurysm. The passage of electric current detached the platinum coil tithin the clotted aneurysm from the stainless steel guide wire by electrolysis in 4 to 12 minutes. A 24-year-old unmarried woman visited our hospital complaining of severe headache on the right occipital area. The MRI and angiography demonstrated an unruptured right posterior communicationg artery aneurysm, emasured 10 x 15 mm in diameter with a medium sized neck. We tried GDC therapy for the aneurysm not to subject the patient to craniectomy, and the angiograhy after two times of GDC trials revealed a successful occlusion of the aneurysm . Adicussion about the problems during and after the procedure was presented, along with a brief review of the literature including the theoretical basis, clinical results and comparison with surgical treatment.

Clinical and laboratory evaluations of the vertiginous and dizzy patients

Vertigo, a definite rotational sensation, consists of a variety of syndromes. The purpose of this study was to accumulate information on various aspects of vertigo or dizziness. We performed a retrospective study about vertigo patients, who had admitted to our hospital for recent 2 years. From January 1994 to December 1995, 214 patients with the complaints of 'vertigo' and 'dizziness', who admitted to the department of Neurology, Ewha Womans University Hospital, were accepted for this study. All data were recorded on computer-oriented questionnaires in digital forms. The study forms consisted of five parts; (1) history and associated symptoms, (2) physical, neurologic and bedside examinations, (3) laboratory and brain imaging studies, (4) special tests including brainstem auditory evoked potentials and (5) clinical diagnosis. Of these 214 patients, secure diagnosis could be made in 186 patients or 86.9%. Of these, 92 patients had peripheral causes of vertigo, and 94 had central causes. Vestibular disorders accounted for the largest proportion of complaints of vertigo(48/92 or 52%). Of 94 patients with central causes of vertigo, vertebrobasilar insufficiency was the leading cause(25/94 or 27%). The most common site of the brain lesion proved by MRI was cerebellum(23/94 or 25%). BAEP study revealed abnormal findings in 6 cases of the 16 patients with central causes. This study not only offered a clinical information about vertigo, but also could be beneficial for further researches.

A Case of Bezafibrate-induced Myopathy

One case of bezafibrate-induced myopathy was experienced and presente with a brief review of literatures. A 80-year-old woman with diabetes mellitus developed generalized myalgia and chest tightness 2 days before admission. The patient was treated with bezafibrate (800mg/day) for the previous 3 months. Serum creatine kinase, LDH and AST were markedly increased. Muscle biopsy revealed type 2 fiber atrophy. Withdrawal of the drug under the impression of bezafibrate-induced myopathy was followed by rapid clinical improvement.

The Measurement of Plasma B-Endorphin in Acute Carbon Monoxide Poisoning

Pathophysiology of acute carbon monoxide poisoning is not clear. It is generally accepted that hypoxic and/or anoxic insult is very significant role in the pathophysiology of acute acrbon monoxide poisoning, but many arguments are documented especially focal hypoxia or metabalic acidosis within brain parenchyme. In sofar such a focal change seems to be largely depend upon focal change of neuroendocrine substances including B-endorphin. Also B-endorphin is known to be responsble to the pathogenesis of cerebral ischemia. Though the possible relationship between the alteration of level of B-endorphin and hypoxia, it is seldom to pay attention to the role of B-endorphin in carbon monoxide intoxication. We measured plasma B-endorphin in acute carbon monoxide intoxication and compared with the value of control group. There was no difference between control group and acute carbon monoxide poisoning group, the possible role of B-endorphin in acute carbon monoxide poisoning should not be excluded. We suggest the more comprehensive and newly programmed study seems to need for clarifying the possible role of B-endorphin in acute carbon monoxide poisoning.

Somatosensory Evoked Potentials in Adult Polio-like Syndrome Following Acute Hemorrhagic Conjunctivitis

Electrodiagnostic studies were carried out in 4 patients with neurological complications of acute hemorrhatic conjunctivitis at Severance Hospital on 1983. Both motor and sensory nerve conduction studies were normal even in the involved limbs. The electromyography, however, reveals denervation potentials and neuropathic MUPs. The somatosensory evoked potentials taken in median nerve stimulated at the wrist and peroneal nerve stimulated around the knee showed normal latencies, shapes and amplitudes almost symmetrically.

The Effect of High-dose Intravenous Steroid("pulse") Therapy in Neurologic Disease-Preliminary Report

High dose intravenous methyl prednisolone was administered to patients with multiple sclerosis (4), transverse myelitis (6), and arachnoiditis (I). Almost complete remission was noted in 5 cases (4 with transverse myelitis and one with multiple sclerosis) and partial improvement in 3 patients (2 with multiple sclerosis and I with arachnoiditis ) within 3 days after therapy. The benefits of this therapy, however, was not that dramatic when started late after the onset of neurologic deficits.