Byung Jo Kim

Intracranial hypotension induced by cervical spine chiropractic manipulation

Study Design. Case report. Objectives. We report a case of intracranial hypotension ensuing after a spinal chiropractic manipulation leading to cerebrospinal fluid (CSF) isodense effusion in the upper cervical and thoracic spine. Summary of Background Data. The etiology of intracranial hypotension is not fully understood, but CSF leakage from spinal meningeal diverticula or dural tears may be involved. Methods. A 36-year-old woman presented with neck and both shoulder pain 4 days earlier. She undertook a spinal chiropractic manipulation. After this maneuver, she complained of a throbbing headache with nausea and vomitting. Her headache worsened, and lying down gave the only measure of limited relief. In CSF study, it showed dry tapping. Brain MRI showed pachymeningeal gadolinum enhancement. Thoracic spine MRI showed CSF leakage. After admission to the hospital, she was treated by hydration and pain control over several days. However, her headache did not improve. Results. She was treated by epidural blood patch. Afterwards, her headache was improved. This is the first case of spontaneous intracranial hypotension in which spinal chiropractic manipulation coincided with the development of symptoms and in which a CSF collection in the upper cervical and thoracic spine was demonstrated radiographically in Korea. Conclusions. From this case, we can understand the etiology of intracranial hypotension and consider the complication of chiropractic manipulation.

Stereopsis and Color Vision Impairment in Patients with Right Extrastriate Cerebral Lesions

Background and Aim: The extrastriate cortex is a visual processing structure beyond the striate cortex. This region contains cells that differ in selectivity for different features of stimuli such as color, motion and stereopsis. We studied stereopsis and color vision in patients with right extrastriate cerebral lesions. Methods: Patients with right extrastriate cerebral lesions determined by MRI were recruited among consecutive inpatients. Patients with cognitive impairment (Mini Mental Status Examination score <24) were excluded. An ophthalmologist performed cortical visual testing: visual acuity, stereopsis, color vision and strabismus within 1 week after the insult. Results: Cortical visual testing was performed in 12 patients. Among the patients studied, 11 demonstrated abnormalities: reduced stereoacuity (8/12), color vision abnormalities (7/12). Seven patients showed complex cortical visual abnormalities. However, only 2 patients complained of subjective clinical symptoms. The MRI lesions in patients with disturbance of stereopsis were located in the dorsal occipitoparietal area and the ventral occipitotemporal area. Color vision abnormalities corresponded to lesions in the ventral occipitotemporal area. Conclusions: Patients with lesions in the right extrastriate cortex tend to have disturbance of stereopsis and color vision abnormalities, even in the absence of visual complaints.

Pathological Laughter as an Unusual Manifestation of Acute Stroke

vealed an acute infarction in the left side of the rostral basis pontis ( fig. 1 A). CT angiography showed a severe stenosis in the midbasilar artery. Nearly all of her neurological deficits had disappeared by the time she was discharged. However, she complained of general weakness, anorexia and a depressed mood. We prescribed a selective serotonin reuptake inhibitor (SSRI; citalopram 20 mg/day) in addition to the anticoagulation therapy. Two months later, she experienced sudden dizziness, dysarthria and mild difficulty swallowing. She also noted transient alternating right and left facial paresthesia. She was alert and cooperative. The reDear Sir, Poststroke pathological laughter can develop during the acute or chronic stage following cerebral infarcts. The latter delayed-onset type, commonly known as emotionalism, is usually associated with the bilateral involvement of the descending corticobulbar pathways as a component of pseudobulbar palsy [1, 2] . The former, called ‘fou rire prodromique’ by Fere in 1903 [3] , has been reported in just a few cases and is often confused with the delayed-onset form. This acute-onset type has been considered to be a unique situation rather than a symptom of acute ischemia because the spells of laughter are generally transient, often herald stroke as a single episode [4] or immediately follow the onset of focal deficits [5] . However, the clinical significance of the acute-onset type remains controversial. A recent case report suggested that the acute-onset type of pathological laughter might be a symptom of acute stroke [6] . We report a patient who experienced fluctuating pathological laughter simultaneously with neurological deficits following recurrent bilateral pontine infarcts, which supports the hypothesis that ‘the acute-onset type of pathological laughter is one of the symptoms of acute stroke’.

Ophthalmoplegic Migraine With Alternating Unilateral and Bilateral Internal Ophthalmoplegia

We describe a patient with ophthalmoplegic migraine and internal ophthalmoplegia with alternating unilateral involvement and bilateral involvement in whom brain MRI scan showed alternating gadolinium enhancement on the cisternal portion of the oculomotor nerve.

MRI artifact mimicking root compression by interbody cage displacement.

Magnetic resonance imaging (MRI) is one of the most reliable diagnostic tools for the assessment of spine-related problems before and after surgery. However, physicians should be aware of the possibility that MRI artifacts could lead to misdiagnosis, especially in cases after spine surgery involving the insertion of materials. A 72-yr-old woman presented to a university-affiliated spinal intervention clinic with complaints of severe rightsided low-back and leg pain that radiated to the great toe and lasted for 4 wks. Two years before, she underwent interbody fusion with bilateral facetectomy for low-back and bilateral leg pain that had lasted for more than 10 yrs and that had been caused by spondylolisthesis at the level of L4–5. She had been doing very well for 2 yrs after the surgery, but she suddenly experienced severe low-back and leg pain radiating to the right great toe, which became progressively worse. She underwent physical therapy for a period of 3 wks, but her symptoms were not relieved. Her symptoms worsened mostly with sitting, bending, and driving. Her symptoms were somewhat better when lying down. On examination, right-side ankle dorsiflexion was slightly weakened (grade IV). The straight-leg-raising test was positive on the right side. MRI study revealed a rightsided posterior extrusion of material from the intervertebral disc at the level of L4–5 into the spinal canal (Fig. 1). However, a computed tomography scan revealed that there were abnormal findings in MRI caused by an artifact in the interbody cage (Fig. 2). Extraforaminal disc protrusion on the right side at the level of L5–S1 was found by careful, repeated inspection of the MRI findings. The patient’s symptoms were significantly improved by transforaminal epidural injection three times with 2-wk intervals. At a 3-mo follow-up visit, her back pain was completely resolved, and she experienced only mild intermittent symptoms in her right leg. There is still no generally accepted modality for assessing fusion status after spine surgery. MRI has been increasingly used to evaluate fusion status after spine surgery because it can offer a more accurate diagnosis and aid in the identification of undetected tiny lesions when used with other methods. After spinal fusion operation for degenerative disc disease, up to 30% of patients experience persistent or recurrent pain. It is crucial, therefore, to make a correct diagnosis in patients with recurrent pain. MRI was considered the most useful tool and should be the All correspondence and requests for reprints should be addressed to Byung-Jo Kim, MD, PhD, Department of Neurology, Korea University Medical Center, #126-1, Anam-Dong 5Ga, Seongbuk-Gu, Seoul, 136-705, Korea. FIGURE 1 Lumbosacral spine magnetic resonance images after interbody fusion with cage. T2-weighted sagittal (A) and axial (B) images reveal the presence of a material extruding into the spinal canal on the right side at the level of L4–5, resulting in root compression. VISUAL VIGNETTE

Dissociation of Cardinal Motor Signs in Parkinson’s Disease Patients

Most cardinal motor signs in Parkinson’s disease (PD) are more pronounced on one side than on the other. Unusually, one type of cardinal motor sign is found on one side while other motor signs are more pronounced on the contralateral side, the so-called dissociation of motor signs. The aims of this study were to determine the frequency of motor sign dissociation and to study the clinical characteristics of the dissociation group. To this end, clinical characteristics including the Unified Parkinson’s Disease Rating Scale, Mini-Mental State Examination, Non-Motor Symptom Questionnaire and Frontal Lobe Assessment Battery were analyzed for 411 patients during consecutive follow-up visits. Dissociation was noted in 29 (7.06%) of the 411 patients. Dissociation of tremor and rigidity-bradykinesia was the most common type of dissociation pattern (17/29). There were no significant differences in demographic factors and clinical profiles between the dissociation and control groups. We suspect that each cardinal motor sign is pathogenetically different. The presence of dissociation did not affect the natural history of PD.

Successful treatment of postcraniectomy orthostatic headache with lumbar epidural blood patches.

Postcraniectomy orthostatic headache is a rare, but disabling, condition which can often interfere with patient rehabilitation. Previously, postsurgical CSF leaks have generally been managed with surgical repair. We present the case of a 32‐year‐old man with postcraniectomy orthostatic headache which was successively managed with repeated lumbar epidural blood patches.

Tibial neuropathy associated with Behcet's disease

A 39-yr-old female patient was admitted to the neurology department reporting a burning pain and a tingling sensation on the left sole, which was followed by weakness of the left toes for 92 wks. Two years previously, she had experienced similar symptoms on the right sole, which improved with conservative management. On admission, recurrent oral ulcers, genital ulcers, and a uveitis history were identified, which met the diagnostic criteria of Behcet_s disease (BD). A neurologic examination showed slight weakness in flexion, extension, and abduction of the left toes (Medical Research Council grade IV), and a sensory examination revealed hypoesthesia on the left sole and on the anterior one third of the right sole. Deep tendon reflexes were normoactive, no pathologic reflexes were observed, and Tinel_s sign was positive at the left medial malleolus. Nerve conduction studies revealed decreased amplitude of the compound motor action potentials and no F-waves in either tibial nerves. Needle electrode examination revealed positive sharp waves in muscles innervated by the left tibial nerve and large amplitude polyphasic motor unit potentials in bilateral tibial nerve innervated muscles. Ankle magnetic resonance imaging (MRI) 2 wks after symptom onset revealed diffuse swelling with heterogeneous enhancement in the left tibial nerve at the calf level and high signal intensities in the left flexor hallucis longus, flexor digitorum longus, and tibialis posterior muscles. (Figs. 1A, B) There was no evidence of a structural lesion compressing the tibial nerve. Lower extremity MRI at thigh level revealed no signal change in the sciatic nerve or surrounding muscles, and lumbar spine MRI showed no evidence of root compression. Her sensory symptoms improved significantly after administering intravenous steroid (1000 mg methylprednisolone) for 5 days. FIGURE 1 Sagittal fat-suppressed fast T2-weighted (A) and fat-suppressed gadolinium-enhanced T1-weighted spin-echo magnetic resonance images (B) show diffuse swelling and heterogeneous enhancement of the left tibial nerve (arrows) at the calf level. All correspondence and requests for reprints should be addressed to: Byung-Jo Kim, MD, PhD, Department of Neurology, Korea University Medical Center, 126-1, Anam-Dong 5Ga, Seongbuk-Gu, Seoul 136-705, Korea.

Cervical Cord Atrophy Caused by Vertebral Artery Dolichoectasia

No author has any conflict to disclose. A 72-year-old woman visited a neurology clinic complaining of slowly progressing right side hemiparesis, atrophy of the right hand intrinsic muscle and gait ataxia that had begun 3 years previously. Neurologic examination revealed increased deep tendon reflexes with positive pathologic reflexes on both sides. MRI demonstrated a curved dilated vertebral artery compressing the upper cervical cord and lower medulla at the cervicomedullary junction, which was more severe on the right side (fig. 1). We suggested decompression surgery of the vertebral artery. However, because of the atrophic changes to the spinal cord and the risk of Received: June 20, 2011 Accepted: September 5, 2011 Published online: November 10, 2011

A Patient with Chronic Inflammatory Demyelinating Polyneuropathy Associated with an Intracranial Plasmacytoma

Chronic inflammatory demyelinating polyneuropathy is an acquired peripheral neuropathy that can be associated with paraproteinemia. We present an unusual case of a 31-yr-old man with chronic inflammatory demyelinating polyneuropathy associated with intracranial plasmacytoma. A 31-yr-old man visited our hospital complaining of progressive symmetric motor weakness and sensory dysfunction in the proximal and distal lower limbs over 3 mos. The neurologic findings revealed bilateral proximal and distal lower-limb weakness with selective loss of vibration and joint position sense in both lower limbs. The motor examination showed normal strength in both upper limbs. The motor strength in his hip joint muscles was 4 /4 bilaterally, 4 /4 in the knee extensors, 4/4 at both knee flexors, and 4 /4 in all other muscle groups below the knee, based on the Medical Research Council grade. The sensory examination was normal except for diminished vibratory and joint position sense in both the lower legs and feet. He also had decreased muscle stretch reflexes of both the knees and ankles. A nerve conduction study showed conduction blocks, temporal dispersion, reduced conduction velocities, and prolonged distal latencies of the right median, right ulnar, and right tibial nerves. Also, F-waves were not observed in the right peroneal and right tibial nerves. A cerebral spinal fluid study showed an elevated protein level (233 mg/dl; normal range, 10–45 mg/dl) with no pleocytosis (WBC 0/ l). A nerve biopsy of the sural nerve showed no abnormal findings. A simple skull x-ray (Fig. 1) and diffusion-weighted MRI, which were obtained because of a syncopal attack during evaluation, demonstrated a mass in his parietal bone. Further studies showed lambda-type monoclonal gammopathy in serum protein electrophoresis/immunofixation electrophoresis. The serum IgG was measured to be 1530 mg/dl (normal range, 650–1600 mg/ dl), and the 2-microglobulin was also increased to 2.6 mg/l (normal range, 1–2.4 mg/l). The mass was confirmed as a plasmacytoma by the conventional MRI (Fig. 1) and biopsy. Despite a thorough systemic evaluation, no other abnormalities were identified. Chronic inflammatory demyelinating polyneuropathy is rarely associated with various hematologic malignancies, including plasmacytomas. Plasmacytomas are discrete, presumably solitary, masses of neoplastic plasma cells in either the bone marrow (intramedullary) or various extramedullary sites. Plasmacytomas most frequently (60%) involve the vertebrae and other various skeletal structures, such as the ribs, skull, pelvis, femurs, clavicles, and scapulas, but craniocerebral involvement is the least frequent (0.7%). It is well known that monoclonal gammopathies with unknown significance should be considered in patients with chronic inflammatory demyelinating polyneuropathy, but it is also crucial to evaluate or exclude any other critical systemic conditions.