Cognitive impairments predict the behavioral and psychological symptoms of dementia.

Introduction: The purpose of this study was to (1) validate the Thai version of the Neuropsychiatric Inventory Questionnaire (NPI-Q) as a screening tool for behavioral and psychological symptoms of dementia (BPSD), and (2) examine the relationship between cognitive performance and BPSD in an elderly population with amnestic mild cognitive impairment (aMCI) and dementia of Alzheimer's type (DAT). Methods: One hundred and twenty participants, comprising 80 aMCI and 40 DAT patients, and their respective caregivers were included in the study. Participants completed the NPI-Q and the Neuropsychiatric Inventory (NPI) within 2 weeks of each other and cognitive performance was primarily assessed using the Montreal Cognitive Assessment (MoCA). Results: The Thai NPI-Q had good validity and reliability. Pure exploratory bifactor analysis revealed that a general factor and a single-group factor (with high loadings on delusions, hallucinations, apathy, and appetite) underpinned the NPI-Q domains. Significant negative correlations between the MoCA total score and the general and single-group NPI-Q scores were found in all subjects (aMCI + DAT combined) and DAT alone, but not in aMCI. Cluster analysis allocated subjects with BPSD (10% of aMCI and 50% of DAT participants) into a distinct "DAT + BPSD" class. Conclusion: The NPI-Q is an appropriate instrument for assessing BPSD and the total score is largely predicted by cognitive deficits. It is plausible that aMCI subjects with severe NPI-Q symptoms (10% of our sample) may have a poorer prognosis and constitute a subgroup of aMCI patients who will likely convert into probable dementia.

A transformation of trigeminal neuralgia into SUNCT/SUNA: A case report and literature review / Uma transformação da neuralgia do trigêmeo em SUNCT/SUNA: relato de caso e revisão da literatura

Introduction: Trigeminal neuralgia and Short-lasting Unilateral Neuralgiform Headache with Conjunctival injection and Tearing (SUNCT)/Short-lasting Unilateral Neuralgiform Headache Attacks with Cranial Autonomic Symptoms (SUNA) are characterized by similar clinical manifestations, which may lead to diagnostic confusion. However, the transformation of trigeminal neuralgia into SUNCT/SUNA is a rare phenomenon. This report describes a case of trigeminal neuralgia transformation into SUNCT/SUNA due to neurovascular compression and reviews all previously published cases of trigeminal neuralgia to SUNCT/SUNA transformation in the literature. Case presentation: A 49-year-old Thai male patient presented with progressive right facial pain for a period of three months. One year prior, he developed trigeminal neuralgia along the maxillary branch of the trigeminal nerve, characterized by electrical shock-like pain in the right upper molar, exacerbated by eating. His symptoms were effectively managed with carbamazepine. Nine months later, he began experiencing recurrent electrical shock-like pain along the ophthalmic division of the right trigeminal nerve, accompanied by lacrimation, which failed to respond to continued treatment with carbamazepine. Three months prior to presentation, his symptoms evolved into SUNCT/SUNA, characterized by electrical shock-like pain in the right periorbital area and conjunctival injection, lacrimation. Neuroimaging revealed high-grade neurovascular compression of the right trigeminal nerve by the right superior cerebellar artery. The patient's symptoms resolved following microvascular decompression. Conclusion: Clinicians should be aware that patients with longer disease duration of trigeminal neuralgia who develop new neuralgic pain in the ophthalmic branch division with mild autonomic symptoms may be at risk for transformation into SUNCT/SUNA.

Introduction: Trigeminal neuralgia and Short-lasting Unilateral Neuralgiform Headache with Conjunctival injection and Tearing (SUNCT)/Short-lasting Unilateral Neuralgiform Headache Attacks with Cranial Autonomic Symptoms (SUNA) are characterized by similar clinical manifestations, which may lead to diagnostic confusion. However, the transformation of trigeminal neuralgia into SUNCT/SUNA is a rare phenomenon. This report describes a case of trigeminal neuralgia transformation into SUNCT/SUNA due to neurovascular compression and reviews all previously published cases of trigeminal neuralgia to SUNCT/SUNA transformation in the literature. Case presentation: A 49-year-old Thai male patient presented with progressive right facial pain for a period of three months. One year prior, he developed trigeminal neuralgia along the maxillary branch of the trigeminal nerve, characterized by electrical shock-like pain in the right upper molar, exacerbated by eating. His symptoms were effectively managed with carbamazepine. Nine months later, he began experiencing recurrent electrical shock-like pain along the ophthalmic division of the right trigeminal nerve, accompanied by lacrimation, which failed to respond to continued treatment with carbamazepine. Three months prior to presentation, his symptoms evolved into SUNCT/SUNA, characterized by electrical shock-like pain in the right periorbital area and conjunctival injection, lacrimation. Neuroimaging revealed high-grade neurovascular compression of the right trigeminal nerve by the right superior cerebellar artery. The patient's symptoms resolved following microvascular decompression. Conclusion: Clinicians should be aware that patients with longer disease duration of trigeminal neuralgia who develop new neuralgic pain in the ophthalmic branch division with mild autonomic symptoms may be at risk for transformation into SUNCT/SUNA

Use of the Montreal Cognitive Assessment Thai Version to Discriminate Amnestic Mild Cognitive Impairment from Alzheimer's Disease and Healthy Controls: Machine Learning Results.

BACKGROUND: The Montreal Cognitive Assessment (MoCA) is an effective and applicable screening instrument to confirm the diagnosis of amnestic mild cognitive impairment (aMCI) from patients with Alzheimer's disease (AD) and healthy controls (HCs). OBJECTIVES: This study aimed to determine the reliability and validity of the following: (a) Thai translation of the MoCA (MoCA-Thai) and (b) delineate the key features of aMCI based on the MoCA subdomains. METHODS: This study included 60 HCs, 61 aMCI patients, and 60 AD patients. The MoCA-Thai shows adequate psychometric properties including internal consistency, concurrent validity, test-retest validity, and inter-rater reliability. RESULTS: The MoCA-Thai may be employed as a diagnostic criterion to make the diagnosis of aMCI, whereby aMCI patients are discriminated from HC with an area under the receiver-operating characteristic (AUC-ROC) curve of 0.813 and from AD patients with an AUC-ROC curve of 0.938. The best cutoff scores of the MoCA-Thai to discriminate aMCI from HC is ≤24 and from AD > 16. Neural network analysis showed that (a) aberrations in recall was the most important feature of aMCI versus HC with impairments in language and orientation being the second and third most important features and (b) aberrations in visuospatial skills and executive functions were the most important features of AD versus aMCI and that impairments in recall, language, and orientation but not attention, concentration, and working memory, further discriminated AD from aMCI. CONCLUSIONS: The MoCA-Thai is an appropriate cognitive assessment tool to be used in the Thai population for the diagnosis of aMCI and AD.

Etiology of Dementia in Thai Patients.

INTRODUCTION: Molecular imaging has been developed and validated in Thai patients, comprising a portion of patients in the dementia registry. This should provide a more accurate diagnosis of the etiology of dementia, which was the focus of this study. METHODS: This was a multicenter dementia study. The baseline characteristics, main presenting symptoms, and results of investigations and cognitive tests of the patients were electronically collected in the registry. Functional imaging and/or molecular imaging were performed in patients with an equivocal diagnosis of the causes of dementia, especially in atypical dementia or young onset dementia (YOD). RESULTS: There were 454 patients in the study. The mean age of the patients was 78 years, with 60% female. Functional imaging and/or molecular imaging were performed in 57 patients (57/454 patients, 13%). The most common cause of dementia was Alzheimer's disease (AD; 50%), followed by vascular dementia (VAD; 24%), dementia with Lewy bodies (6%), Parkinson's disease dementia (6%), frontotemporal dementia (FTD; 2.6%), progressive supranuclear palsy (2%), multiple system atrophy (0.8%), and corticobasal syndrome (0.4%). YOD accounted for 17% (77/454 patients), with a mean age of 58 years. The causes of YOD were early onset amnestic AD (44%), VAD (16%), behavioral variant FTD (8%), posterior cortical atrophy (6.5%), and logopenic variant primary progressive aphasia (5.2%). CONCLUSION: AD was the most common cause of dementia in Thai patients and the distribution of other types of dementia and main presenting symptoms were similar to previous reports in Western patients; however, the proportion of YOD was higher.

Associations between hypoxia parameters in obstructive sleep apnea and cognition, cortical thickness, and white matter integrity in middle-aged and older adults.

OBJECTIVE: This study aimed to investigate the association between each parameter of intermittent hypoxia in obstructive sleep apnea (OSA) and the cognitive profile, cortical thickness, and white matter integrity in middle-aged and older adults. METHODOLOGY: Participants were newly diagnosed with moderate or severe OSA from the King Chulalongkorn Memorial Hospital, Bangkok, Thailand. Respiratory parameters from polysomnography were extracted. Each participant was tested on a battery of neuropsychological tests and underwent an MRI scan of the brain. Cortical thickness analysis and diffusion tensor imaging analysis were performed. Participants were classified as having either severe or mild hypoxia based on parameters of hypoxia, i.e., oxygen desaturation index, lowest oxygen saturation, and the percentage of total sleep time spent below 90% oxygen saturation. RESULTS: Of 17 patients with OSA, there were 8 men (47%). Median age was 57 years and median AHI was 60.6. Comparison of cortical thickness between the severe and the mild group of each hypoxic parameter revealed two clusters of cortical thinning at the right inferior frontal gyrus (p-value = 0.008) and right inferior parietal gyrus (p-value = 0.006) in the severe desaturation group and a cluster of cortical thinning at the superior parietal gyrus (p-value = 0.008) in the high oxygen desaturation index group. There was no difference in cognitive function or white matter integrity between groups. CONCLUSIONS: The magnitude of the degree and frequency of desaturations in OSA are associated with a decrease in cortical thickness at the frontal and parietal regions.

Efficacy and economic evaluation of delivery of care with tele-continuous EEG in critically ill patients: a multicentre, randomised controlled trial (Tele-cRCT) study protocol.

INTRODUCTION: Some critically ill patients are confirmed by continuous electroencephalography (cEEG) monitoring that non-convulsive seizure (NCS) and/or non-convulsive status epilepticus (NCSE) are causes of their depressed level of consciousness. Shortage of epilepsy specialists, especially in developing countries, is a major limiting factor in implementing cEEG in general practice. Delivery of care with tele-continous EEG (tele-cEEG) may be a potential solution as this allows specialists from a central facility to remotely assist local neurologists from distant areas in interpreting EEG findings and suggest proper treatment. No tele-cEEG programme has been implemented to help improve quality of care. Therefore, this study is conducted to assess the efficacy and cost utility of implementing tele-cEEG in critical care. METHODS AND ANALYSIS: The Tele-cRCT study is a 3-year prospective, randomised, controlled, parallel, multicentre, superiority trial comparing delivery of care through 'Tele-cEEG' intervention with 'Tele-routine EEG (Tele-rEEG)' in patients with clinical suspicion of NCS/NCSE. A group of EEG specialists and a tele-EEG system were set up to remotely interpret EEG findings in six regional government hospitals across Thailand. The primary outcomes are functional neurological outcome (modified Rankin Scale, mRS), mortality rate and incidence of seizures. The secondary outcomes are cost utility, length of stay, emergency visit/readmission, impact on changing medical decisions and health professionals' perceptions about tele-cEEG implementation. Functional outcome (mRS) will be assessed at 3 and 7 days after recruitment, and again at time of hospital discharge, and at 90 days, 6 months, 9 months and 1 year. Costs and health-related quality of life will be assessed using the Thai version of the EuroQol-five dimensions-five levels (EQ-5D-5L) at hospital discharge, and at 90 days, 6 months, 9 months and 1 year. ETHICS AND DISSEMINATION: This study has been approved by the ethics committees of the Faculty of Medicine, Chulalongkorn University, and of Ramathibodi Hospital, Mahidol University, and registered on Thai Clinical Trials Registry. The results will be disseminated in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: TCTR20181022002; preresults.

Thai-version Migraine Disability Assessment (MIDAS) questionnaire: concurrent validity, test-retest reliability, internal consistency, and factors predictive for migraine-related disability.

Background: A Thai-version of the Migraine Specific Quality of Life Questionnaire (MSQ 2.1) is available, but a qualified questionnaire used specifically for disability assessment was not available. The most relevant practical disability assessment tested during this study was the Migraine Disability Assessment (MIDAS) Questionnaire. Objectives: To test the concurrent validity, test-retest reliability, and internal consistency of a Thai-version MIDAS questionnaire, and factors to predict disability in people with migraine. Methods: We conducted the present prospective study at a tertiary care teaching hospital in Bangkok. The original English MIDAS Questionnaire was translated into Thai with back-translation into English and the language equivalence was assessed. The Thai-version MIDAS Questionnaire was tested for concurrent validity, test-retest reliability, and internal consistency, and factors including duration of migraine history, migraine characteristics, and comorbidity were assessed for the ability to predict migraine-related disability of migraineurs. Results: Of the 58 participants, 31 were eligible to be included. The validity of the Thai-version questionnaire between the MIDAS total score and the mean headache severity (question B), the mean pain duration per attack, and the mean pain numerical rating scale (NRS) score were moderately correlated with a Spearman correlation coefficient range 0.42-0.58. The test-retest reliability of MIDAS grade had a weighted κ of 0.66, and for individual questions of the MIDAS total score, questions A and B assessed by intraclass correlation coefficients ranged 0.89-0.98. The internal consistency had a Cronbach α of 0.98. The mean pain NRS score in the past 3 months was an independent predictive factor for migraine-related disability. Conclusion: The Thai-version MIDAS Questionnaire has moderate concurrent validity, acceptable internal consistency, and excellent test-retest reliability. It would be helpful to assess clinical outcomes. Future study with a standardized translation process for the Thai-version questionnaire and a larger sample size is warranted to confirm internal consistency and determine all probable predictive factors for migraine-related disability.

Clinical Recommendations for the Use of Donepezil 23 mg in Moderate-to-Severe Alzheimer's Disease in the Asia-Pacific Region.

BACKGROUND: The 'Asia-Pacific Expert Panel (APEX) for donepezil 23 mg' met in November 2015 to review evidence for the recently approved high dose of donepezil and to provide recommendations to help physicians in Asia make informed clinical decisions about using donepezil 23 mg in patients with moderate-to-severe Alzheimer's disease (AD). SUMMARY: In a global phase III study (study 326) in patients with moderate-to-severe AD, donepezil 23 mg/day demonstrated significantly greater cognitive benefits versus donepezil 10 mg/day, with a between-treatment difference in mean change in the Severe Impairment Battery score of 2.2 points (p < 0.001) in the overall population and 3.1 points (p < 0.001) in patients with advanced AD. A subanalysis of study 326 demonstrated that the benefits and risks associated with donepezil 23 mg/day versus donepezil 10 mg/day in Asian patients with moderate-to-severe AD were comparable to those in the global study population. KEY MESSAGE: Donepezil 23 mg is a valuable treatment for patients with AD, particularly those with advanced disease. The APEX emphasized the importance of patient selection (AD severity, tolerability of lower doses of donepezil, and absence of contraindications), a stepwise titration strategy for dose escalation, and appropriate monitoring and counseling of patients and caregivers in the management of patients with AD.

Reversible Cerebral Vasoconstriction Syndrome: A Report on Three Cases.

Reversible cerebral vasoconstriction syndrome (RCVS), a recently recognized syndrome, is defined as an intermittent segmental vasospasm of cerebral arteries accompanied by thunderclap headache. The major complications of RCVS include ischemic or hemorrhagic stroke, which may cause morbidity and mortality. It is important to detect RCVS in clinical practice because misdiagnosis may lead to inappropriate treatment. In Thailand, there are only two reported cases of RCVS, which may reflect an underdiagnosis of this syndrome. To raise awareness of RCVS, we reported a case series of three RCVS cases. Two of the presented cases had interesting precipitating factors, and two cases had an unusual delayed clinical course.

The Montreal Cognitive Assessment-Basic: A Screening Tool for Mild Cognitive Impairment in Illiterate and Low-Educated Elderly Adults.

OBJECTIVES: To assess the validity of a newly developed cognitive screening tool, the Montreal Cognitive Assessment-Basic (MoCA-B), in screening for mild cognitive impairment (MCI) in elderly adults with low education and varying literacy. DESIGN: Cross-sectional. SETTING: Community hospital in Bangkok, Thailand. PARTICIPANTS: Cognitively normal controls (n = 43) and individuals with MCI according to the National Institute on Aging-Alzheimer's Association work group criteria (n = 42) aged 55 to 80 with less than 5 years of education. MEASUREMENTS: MoCA-B scores. RESULTS: Mean MoCA-B scores were 26.3 ± 1.6 for illiterate controls and 21.3 ± 3.8 for illiterate participants with MCI (P < .001) and 26.6 ± 2.0 for literate controls and 23.0 ± 2.1 for literate participants with MCI (P < .001). MoCA-B scores did not differ significantly according to literacy, and multiple regression suggested no association with age or education. The optimal cutoff score of 24 out of 25 yielded 81% sensitivity and 86% specificity for MCI (area under the receiver operating characteristic curve = 0.90, P < .001). Test-retest reliability was 0.91 (P < .001), and internal consistency was 0.82. Administration time was 15 to 21 minutes. CONCLUSION: The MoCA-B appears to have excellent validity and addresses an unmet need by accurately screening for MCI in poorly educated older adults regardless of literacy.

Blepharoclonus: anatomical localization and etiological consideration..

Blepharoclonus refers to myoclonic rhythmic eyelid closure. This is an extremely rare abnormal movement of the eyelids. The symptom has an ill-defned anatomical localization and hypothesized etiologies are diverse. We describe a 42 year-old woman with known poorly controlled hypertension (HTN) who presented with a three-week history ofataxia, dysmetria, and uncontrolled eyelid twitching. The bilateral abnormal eyelid movement occurred during either eyelid closure or opening, and was compatible with blepharoclonus. MRI revealed multiple cerebral infarctions at red nucleus, dentate nucleus, and inferior olives. These foci are within Guillain-Mollaret's triangle. The ataxia and dysmetria gradually improved within three weeks. While the blepharoclonus improved, it persisted after one year offollow-up. Our conclusion was one of HTN leading to a lacunar infarct that manifested partially as blepharoclonus. Due to the neuroimaging findings and clinical course, we propose that blepharoclonus may be a variant ofpalatal myoclonus and may be considered as another lacunar syndrome.

Idiopathic hypertrophic pachymeningitis at King Chulalongkorn Memorial Hospital.

BACKGROUND: Idiopathic Hypertrophic Pachymeningitis (IHP) is a rare chronic inflammatory disorder of the dura. Classic clinical symptoms include headaches and cranial neuropathy. Because of scarce clinical data from Thailand, the present study aimed to determine the clinical features, neuroimaging findings, natural histories, therapeutic options, and outcomes for treatment of IHP in a tertiary care center. MATERIAL AND METHOD: A retrospective study was carried out on all adult IHP patients hospitalized at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, between January 2000 and November 2011. Diagnostic criteria included 1) clinical symptom compatibility with IHP, 2) neuroimaging to reveal enhanced hypertrophic dura compatible with clinical syndrome, and 3) ruled out secondary causes of LHP, using appropriate clinical profiles and investigations including tissue biopsy. RESULTS: Thirty-two patients were enrolled with 21 females and 11 males, mean age of 49.03 +/- 16.12 years. The two most common symptoms were headache (93.8%) and diplopia (43.8%). The most common neurological finding was multiple cranial neuropathies (84.4%). Cranial nerve III was affected in 56.3% of the patients, followed by other cranial nerves including CN VI, IV, V and II. Headache without a neurological deficit was observed in 12.5% of the cases. Focal and diffuse enhanced thickening of the dura were observed in 96.9% and 3.1% of the cases respectively. Focal thickening in the supratentorium included the cavernous sinus, orbital apex, sphenoid wing, and superior orbital fissure. Focal thickening in the infratentorium included the falx cerebelli, the dura at the base of the skull, Meckel's cave, and foramen magnum. CSF examination showed lymphocyte pleocytosis with a slight increase in CSF proteins. Headache subsided in all of the patients after treatment with corticosteroid In relapsing and recurrent patients, a combined treatment of steroids and azathioprine was prescribed. With the combined treatment, clinical complete recovery, relapsing and recurrence were detected in 40%, 40% and 20% of the cases respectively. All relapsing and recurrence were due to rapid tapering of for early discontinuation of the steroids treatment. Only one patient had a spontaneous remission. CONCLUSION: The most common clinical manifestations of IHP were headache and multiple cranial nerve involvement. Almost all of the patients had good initial response to steroid therapy. Relapse or recurrence was usually caused by rapid tapering off or early discontinuation of the steroid treatment. Long-term treatment with combined immunosuppression may be necessary in some cases.

Spontaneous craniocervical arterial dissection: a clinical and vascular neuroimaging study.

BACKGROUND: Spontaneous craniocervical arterial dissection (SCAD) is an important cause of stroke in the young and middle-aged population. However clinical data of SCAD is limited in Thailand. This present study aims to describe the clinical profiles of SCAD in a tertiary care center in Thailand. MATERIAL AND METHOD: All SCAD patients admitted to King Chulalongkorn Memorial Hospital between January 1997 and October 2011 were enrolled. All of the patients fulfilled vascular imaging diagnostic criteria for SCAD. Clinical profiles, associated risk factors, vascular neuroimaging patterns, treatments, and outcomes were analyzed by SPSS program version 17. RESULTS: Fifty patients with SCAD were identified (0.5% of total hospitalized ischemic cerebrovascular disease and subarachnoid hemorrhage (SAH) patients). SCAD was found in 1.6% of patients under the age of 45 years. Eighty-six percent of the patients were diagnosed during the last five years of this present study period. Internal carotid artery dissection (ICAD) and vertebral artery dissection (VAD) were detected in 42% and 58% respectively. The mean age was 48.3 +/- 15.3 years. Atherosclerotic risk factors included hypertension (16%), diabetes mellitus (24%), and dyslipidemia (28%). History of previous minor head injury and migraine were encountered in 8% and 4% respectively. Headache was detected in 80% of the cases. Localized headache was observed in 64% of the cases. Diffuse headache due to SAH was detected in 14% of the cases. Neurological syndromes at presentation were ischemic stroke (72%), transient ischemic attack (TIA) (80%), and SAH (16%). Pathognomonic vascular neuroimaging patterns of dissection included wall hematoma (36%), flame-shaped appearance (28%), dissecting pseudoaneurysm (24%), and intimal flap (8%). Other vascular imaging features included dissecting vessel stenosis (58%) and dissecting vessel occlusion (18%). Treatment consisted of anticoagulants (60%), antiplatelets (10%), surgical intervention (22%), and conservative management (8%). Neurological outcomes at discharge with MRS 0-3 were 72%. No recurrent dissection or recurrent cerebrovascular events were observed during the six-month follow-up period In this present study, significant differences between ICAD and VAD in terms of percentage of SAH, severity, and outcomes were observed CONCLUSION: SCAD results in diverse cerebrovascular events such as ischemic stroke, TIA, and SAH in the young and middle-aged population. Advances in vascular neuroimaging play a crucial role in the diagnosis of SCAD. Prompt management is essential for SCAD with a rather favorable outcome.

Relationship between poststroke depression and ischemic lesion location.

BACKGROUND: Depression is more frequently detected in stroke patient compared to other medical illness with equal disability. The relationship between poststroke depression and ischemic stroke lesion location is controversial. OBJECTIVE: To determine the relationship between early onset poststroke depression and ischemic stroke lesion location. MATERIAL AND METHOD: A cross-sectional analysis was conducted. In-patients diagnosed with first acute ischemic stroke were enrolled. CT scan and MRI of the brain were performed to confirm the diagnosis of ischemic stroke as well as ischemic stroke subtypes and to determine the ischemic stroke lesion locations. Hamilton Depression Rating Scale was used to assess early onset poststroke depression within two weeks after the onset of stroke. Statistical analysis was conducted to determine the relationship between early onset poststroke depression and ischemic stroke lesion location as well as early poststroke depression and other potential factors. RESULTS: Thirty-nine patients were enrolled. The mean age (+/- SD) is 59.7 (+/- 12.3) years. Male: female ratio was 2:1. Early onset post stroke depression was found in 11 patients (28.2%). Mild depressive, less than major depressive, and major depressive level were found in five patients (12.8%), five patients (12.8%), and one patient (2.6%) respectively. Factors that statistically significantly related to early onset poststroke depression are left sided stroke lesion, female gender and absence of hypertension. CONCLUSION: Left sided stroke lesion, female gender, and absence of hypertension are factors contributing to early onset poststroke depression.

Association between genetic polymorphisms and sites of cervicocerebral artery atherosclerosis.

Ischemic stroke is a multifactorial disease with strong genetic elements. The purpose of this case-control study was to find relationships between apolipoprotein E (APOE), angiotensin-converting enzyme (ACE), and methylenetetrahydrofolate reductase (MTHFR) genotypes and atherosclerosis of the extracranial internal carotid and intracranial arteries in the Thai population. Patients aged >45 years with significant intracranial stenosis (IC group) or extracranial carotid artery stenosis (EC group) diagnosed by duplex ultrasound and/or computed tomography angiography (CTA) or magnetic resonance angiography (MRA) were studied. The control group comprised volunteers with no history of stroke and no evidence of significant cervicocerebral artery stenosis by ultrasound. Genomic DNA was extracted and genotyped for APOE isoforms, ACE insertion/deletion (I/D) polymorphism, and MTHFR C677T polymorphisms. There were 141 cases (83 in the IC group and 58 in the EC group) and 167 controls. The APOE ε3/ε4 genotype and APOE ε4 allele were significantly associated with extracranial carotid artery stenosis (odds ratio, 2.55; 95% confidence interval, 1.07-6.05 and odds ratio, 2.85; 95% confidence interval, 1.35-5.99, respectively). These associations were not observed in patients with intracranial atherosclerosis. There was no significant association between ACE and MTHFR polymorphisms and stenosis at any site. In a multivariate model, sex, diabetes mellitus, hypertension, ischemic heart disease, and APOE ε4 allele remained predictive of extracranial atherosclerosis. In our Thai population, the ε4 allele in the APOE gene contributes to the genetic susceptibility of extracranial internal carotid atherosclerosis. The low prevalence of extracranial carotid stenosis in this population might result from low frequencies of the APOE ε4 allele.

Isolated motor neglect following infarction of the posterior limb of the right internal capsule: a case study with diffusion tensor imaging-based tractography.

Motor neglect is an impairment in the ability to initiate movement not attributable to muscle weakness. The neural network of this syndrome is not precisely defined. We present the diffusion tensor imaging (DTI)-base tractography findings in an acute stroke patient presenting with isolated motor neglect following infarction in the posterior limb of the internal capsule within the anterior choroidal artery territory. A left-handed 17-year-old woman presented with an acute onset of motor neglect of her left arm. Motor tasks performed with the affected limb were awkward; however, the tasks could be accomplished with effort. Magnetic resonance imaging (MRI) including DTI of the brain were performed. DTI-based tractography extracted the fiber tracts originating from regions of interest placed on the ischemic lesion. MRI revealed an acute ischemic infarction at the posterior part of the posterior limb of the right internal capsule within the territory of the anterior choroidal artery. DTI-based tractography showed fiber tracts projecting from the lesion to the posterior part of the supplementary motor area and some fiber tracts projecting to posterior aspects of the thalamus. DTI-based tractography may be a useful tool for visualizing white matter pathways in vivo following an acute infarction. Our case study supports the notion that fiber tracts connecting the posterior part of the posterior limb of the internal capsule, supplementary motor area, and posterior aspect of the thalamus are key areas of a neural network involved in motor neglect syndrome.

A national registry to determine the distribution and prevalence of Parkinson's disease in Thailand: implications of urbanization and pesticides as risk factors for Parkinson's disease.

BACKGROUND: Parkinson's disease (PD) occurs worldwide but prior to this review of data from the Thailand Parkinson's Disease Registry there had been no nationwide PD registry reported globally. OBJECTIVE: To determine the distribution and prevalence of PD in Thailand and related risk factors in order to more adequately develop and allocate prevention and treatment resources where they are most needed and to ascertain risk factors that are specific to the Thai population. DESIGN: The Thailand Parkinson's Disease Registry is a new resource, and data collection began in March 2008. Data is collected by the Registry from physicians, and a mechanism is also provided for patients to self-report. This data was further analyzed by the capture-recapture methodology (CRM) to assess reporting biases. METHODS: The three main sources of data input to the Registry, i.e. (1) public hospitals, (2) private hospitals and (3) self-registration, require checking for duplicates and also allow estimation of completeness of recording (the degree of underreporting) in this disease registry. There is underreporting because of poor record keeping and administrative procedures in some facilities, and there is an unknown number of persons with PD who are not properly diagnosed because of inadequate facilities and staffing in some areas. Since our data sources should be overlapping in some way, and assuming that the likelihood of being detected in one system is independent of the others, we estimated these data sources' actual coverage and the expected total number of patients utilizing the 'capture-recapture' statistical technique. RESULTS: As of March 2011, the Thailand PD Registry had identified 40,049 PD patients. Employing log-linear modeling, the CRM analysis based on the three data sets estimated underreporting of 20,516 cases. The revised estimated total is thus 60,565 cases, resulting in a crude and age-adjusted prevalence of 95.34 and 424.57 PD cases/100,000 population, respectively. The prevalence of PD was 126.83/100,000 in urban areas and 90.82/100,000 in rural areas (p < 0.001). Preliminary regional comparisons revealed a higher prevalence of PD in residents of the central plain valley of Thailand, an area with a large amount of pesticide use. CONCLUSIONS: The combination of a passive registry and the CRM technique allowed us to derive population prevalence estimates for PD in Thailand. Thai PD prevalence estimates were similar to previous ones published for Asian countries; in addition, they suggested that urbanization and exposure to pesticides may both be risk factors for PD in the Thai population.

Lactic acidosis associated with severe neuromuscular weakness and stavudine therapy.

Nucleoside analogue reverse-transcriptase inhibitors (NRTIs) especially stavudine, used for the treatment of HIV infection have been rarely associated with lactic acidosis syndrome (LAS) and severe neuromuscular weakness mimicking Guillain Barre syndrome. A 36-year-old man presented with a one-week history of nausea, vomiting, epigastric pain, dyspnea associated with progressive muscle weakness and numbness in glove and stocking pattern. He had symptomatic HIV infection, diagnosed 2 years before the admission and was treated with GPOvir (lamivudine, stavudine and nevirapine). Physical examination revealed afebrile dyspnic drowsy man with crepitation in both lungs and hepatomegaly. Neurological examination showed areflexic symmetrical weakness of both extremities and decreased pin-prick sensation in glove and stocking pattern as well as loss of vibration and touch sensation in both hands and feet. He developed cardiopulmonary arrest and was intubated. Investigations revealed severe lactic acidosis (lactic acid = 21.1 mg/dl). Electrophysiological studies revealed severe sensorimotor axonopathy predominantly involved the lower extremities. Stavudine was discontinued. Severe LAS dramatically improved and polyneuropathy gradually recovered with symptomatic as well as supportive interventions. Monitoring of LAS and neuromuscular weakness is advocated in HIV patient who receive stavudine therapy. Immediate discontinuation of the medication after detection of these complications may prevent this fatal complications.