[A case of Guillain-Barré syndrome with elevated IgG anticardiolipin antibody titer with recurrent deep venous thromboses].

We report a 76-year-old woman with Guillain-Barré syndrome (GBS) who developed recurrent deep venous thromboses (DVT). She has had no past medical history of thromboembolic events or fetal loss. Because D-dimer was elevated from the early stage of her illness, heparin, and then warfarin, was given as prophylaxis for thromboembolic events. On Day 103, she developed marked edema in her legs, and DVT was diagnosed in the left popliteal vein by ultrasound. Three days later, the patient developed pulmonary embolism, and an inferior vena cava filter was implanted. Although D-dimer became temporarily normal, it increased again, and recurrent DVT was diagnosed in bilateral femoral veins on Day 167. IgG anticardiolipin antibody titer was found to be highly elevated at 79 U/ml (normal range: < 10). However, anti-beta 2 glycoprotein I antibody, which has been proven to be associated with antiphospholipid syndrome (APS), was negative. Thus, IgG anticardiolipin may have played an important role in the thromboembolic events in this patient. We speculate that the occurrence of APS may be associated with anticardiolipin antibody, which may form in some patients with GBS secondary to myelin damage.

Changes in stroke rehabilitation outcomes after the implementation of Japan's long-term care insurance system: a hospital-based study.

OBJECTIVE: To explore the changes in stroke rehabilitation outcomes after the introduction of Japan's long-term care insurance (LTCI) system. DESIGN: Stroke patients discharged during a 3-yr period before and after the implementation of LTCI were compared (before-LTCI vs. after-LTCI). Outcome measures included onset to admission interval, length of stay, and correlation between discharge site and functional level at discharge. RESULTS: A total of 201 patients in the before-LTCI group and 252 patients in the after-LTCI group were eligible for the study. Shorter mean length of stay (P < 0.01) and higher rates of discharge to a rehabilitation facility (P < 0.01) were found in the after-LTCI group. Logistic regression analysis revealed that the patients with higher activities of daily living scores or ambulatory status at discharge were more likely to be discharged to home after inpatient rehabilitation in both groups (P < 0.01). The rate of discharge to home was similar in both groups. CONCLUSIONS: Within this rehabilitation hospital's experience, the mean length of stay was reduced after the implementation of the LTCI. Although it was one of the primary goals of the LTCI, the rate of discharge to home did not significantly increase. Further evaluation and modification of the LTCI and more efforts to improve a patient's activities of daily living and ambulatory status at discharge will be necessary to promote in-home care in Japan.

Brainstem auditory-evoked potentials as an objective tool for evaluating hearing dysfunction in traumatic brain injury.

Because of the violent nature of traumatic brain injury, traumatic brain injury patients are susceptible to various types of trauma involving the auditory system. We report a case of a 55-yr-old man who presented with communication problems after traumatic brain injury. Initial results from behavioral audiometry and Weber/Rinne tests were not reliable because of poor cooperation. He was transferred to our service for inpatient rehabilitation, where review of the initial head computed tomographic scan showed only left temporal bone fracture. Brainstem auditory-evoked potential was then performed to evaluate his hearing function. The results showed bilateral absence of auditory-evoked responses, which strongly suggested bilateral deafness. This finding led to a follow-up computed tomographic scan, with focus on bilateral temporal bones. A subtle transverse fracture of the right temporal bone was then detected, in addition to the left temporal bone fracture previously identified. Like children with hearing impairment, traumatic brain injury patients may not be able to verbalize their auditory deficits in a timely manner. If hearing loss is suspected in a patient who is unable to participate in traditional behavioral audiometric testing, brainstem auditory-evoked potential may be an option for evaluating hearing dysfunction.

[A case of cerebellar ataxia showing severe dystonia masquerading as myoclonic jerky movements on arm extension].

A 43-year-old man was admitted to our hospital due to unstable walking, head tilting to the left and difficulty in extending his arm. He was quite healthy until the age of 20 years, when these symptoms appeared and progressed slowly afterward. Due to his unstable walking, he started to use a wheelchair when he was 39 years old. He had no family history of similar disease. On admission, neurological examination revealed spasmodic torticollis, ataxic speech and marked limb and truncal ataxia. Myoclonic jerky flexion of the forearm was induced when he raised and extended his forearm. He also showed mild hyperreflexia in the lower limbs without pathological reflexes. He had weakness and atrophy of the left supraspinatus, infraspinatus, deltoid and biceps brachii muscles and mild superficial sensory impairment in the left axillary nerve territory due to cervical spondylotic radiculopathy of the left C5 root. MRI of the brain demonstrated severe bilateral atrophy of the cerebellar hemispheres and vermis but minimal atrophy of the cerebrum and brainstem. Because surface electromyography revealed continuous discharge with phasic components in the biceps and wrist flexor muscles on extending the upper limbs, the jerky flexion movement of the forearm was considered to be primarily dystonia. Although no giant SEP was observed, a C-response was detected in the long-loop reflex in response to right median nerve stimulation. Nuclear examinations showed diffuse hypoperfusion and decreased glucose metabolism in the cerebellum. Based on these findings, we hypothesized that cerebellar dysfunction may have induced severe dystonic movement resembling myoclonus. We would like to name this complicated involuntary movement an "arm thrust". This is the first case to be reported of sporadic, chronic, progressive cerebellar ataxia accompanied by severe dystonic movement, especially on stretching the forearms, that mimics myoclonic movement.