Do-Young Kwon

Transcranial brain sonography in Parkinson's disease with restless legs syndrome

Substantia nigra (SN) hyperechogenicity assessed by transcranial brain sonography (TCS) is a characteristic finding in idiopathic Parkinsons disease (PD). In contrast, SN hypoechogenicity on TCS has been recently demonstrated in restless legs syndrome (RLS). RLS is one of the most common sleep problems in PD, but the pathophysiologic relationship between these two disorders has not been thoroughly elucidated. We compared the SN echogenicities of PD patients with and without RLS to investigate whether comorbid RLS in PD affects SN echogenicity and to explain the echogenic differences between idiopathic RLS (iRLS) and secondary PD–related RLS (pRLS). Sixty‐three PD patients (median age 64.6 ± 10.6 years), 40 iRLS patients (53.1 ± 11.7 years), and 40 healthy controls (69.1 ± 2.3 years) were enrolled in our study. All subjects answered a sleep questionnaire and underwent TCS. PD patients were subdivided into two groups, PD with RLS (PD+RLS, n = 26) and PD without RLS (PD‐RLS, n = 37), and the sonographic findings of each group were compared. Although significant hyperechogenicity was detected in both the SN and SN/midbrain ratios in both PD subgroups compared with the controls and the iRLS group (P < 0.001), there were no significant differences in SN echogenicity between the PD+RLS and PD‐RLS groups. Meanwhile, iRLS patients showed significant SN hypoechogenicity. In conclusion, comorbid RLS in PD did not have an impact on the sonographic SN findings. These results suggest that the pathogenesis of pRLS and iRLS involve different mechanisms. Further study will be required to clarify the association between RLS and PD.

Multiple Arterial Embolism After Illicit Intranasal Injection of Collagenous Material

Local injections of various materials to the face have become increasingly popular for cosmetic purposes. These procedures can cause serious adverse effects if they are not done properly or if they are performed with improper materials. Embolic arterial occlusion is rare but can be a devastating complication after injection in the facial area. Here we report multiple embolic occlusions involving branches of the internal carotid artery (ICA) and the external carotid artery (ECA) with anatomical considerations. In this case, a reticular pattern of skin necrosis, retinal branch artery occlusion (RAO), acute cerebral infarction, and secondary subarachnoid hemorrhage (SAH) occurred immediately after illegal intranasal injection of a collagenous substance. This is the most extensive and devastating case of embolic complications involving branches of the ICA and ECA after illicit facial injection for cosmetic purposes ever reported.

Efficacy of early administration of escitalopram on depressive and emotional symptoms and neurological dysfunction after stroke: a multicentre, double-blind, randomised, placebo-controlled study.

BACKGROUND Mood and emotional disturbances are common in patients with stroke, and adversely affect the clinical outcome. We aimed to evaluate the efficacy of early administration of escitalopram to reduce moderate or severe depressive symptoms and improve emotional and neurological dysfunction in patients with stroke. METHODS This was a placebo controlled, double-blind trial done at 17 centres in South Korea. Patients who had had an acute stroke within the past 21 days were randomly assigned in a 1:1 ratio to receive oral escitalopram (10 mg/day) or placebo for 3 months. Randomisation was done with permuted blocks stratified by centre, via a web-based system. The primary endpoint was the frequency of moderate or severe depressive symptoms (Montgomery-Åsberg Depression Rating Scale [MADRS] ≥16). Endpoints were assessed at 3 months after randomisation in the full analysis set (patients who took study medication and underwent assessment of primary endpoint after randomisation), in all patients who were enrolled and randomly assigned (intention to treat), and in all patients who completed the trial (per-protocol analysis). This trial is registered with ClinicalTrials.gov, number NCT01278498. FINDINGS Between Jan 27, 2011, and June 30, 2014, 478 patients were assigned to placebo (n=237) or escitalopram (n=241); 405 were included in the full analysis set (195 in the placebo group, 210 in the escitalopram group). The primary outcome did not differ by study group in the full analysis set (25 [13%] patients in the placebo group vs 27 [13%] in the escitalopram group; odds ratio [OR] 1·00, 95% CI 0·56-1·80; p>0·99) or in the intention-to-treat analysis (34 [14%] vs 35 [15%]; OR 1·01, 95% CI 0·61-1·69, p=0·96). The study medication was generally well tolerated; the most common adverse events were constipation (14 [6%] patients who received placebo vs 14 [6%] who received escitalopram), muscle pain (16 [7%] vs ten [4%]), and insomnia (12 [5%] vs 12 [5%]). Diarrhoea was more common in the escitalopram group (nine [4%] patients) than in the placebo group (two [1%] patients). INTERPRETATION Escitalopram did not significantly reduce moderate or severe depressive symptoms in patients with acute stroke. FUNDING Dong-A Pharmaceutical and Ministry for Health, Welfare, and Family Affairs, South Korea.

Vascular risk factors and the effect of white matter lesions on extrapyramidal signs in Alzheimer's disease.

BACKGROUND Extrapyramidal signs (EPSs), which are important characteristics of Parkinsons disease (PD), occur frequently in Alzheimers disease (AD). Although AD and PD share common clinical features such as EPSs, these diseases vary with respect to vascular risk factors. The presence of vascular risk factors increases the risk of AD; however, these factors have been known to be inversely associated with PD. We aimed to assess the effect of vascular risk factors and white matter lesions (WMLs) on EPSs in AD. METHODS We recruited 1,187 AD patients and 333 controls with neither cognitive impairment nor EPSs. All participants underwent detailed clinical evaluations which included assessments of vascular risk factors, cognitive function, and EPSs, as well as WMLs on brain MRIs. EPS subtypes were classified into tremor-dominant, postural instability gait difficulty, or indeterminate; WMLs subtypes were classified into periventricular WML (pvWML) or deep WML (dWML). RESULTS EPSs were present in 17.9% of subjects with AD and were significantly associated with vascular risk factors such as age, male gender, diabetes mellitus, and WMLs. Additionally, a multivariate logistic regression analysis showed that EPSs in AD were associated with pvWML (odds ratio (OR), 1.61-2.52), not with dWML. With respect to EPS subtypes, the majority (78.4%) of EPSs in AD were postural instability gait difficulty, which was also associated with WMLs (OR 1.84-2.41), pvWML (OR 2.09-3.14), and dWML (OR 1.83-3.42). CONCLUSIONS EPSs in AD are associated with selected vascular risk factors as well as WMLs.

Hypergonadotropic Hypogonadism in Spinocerebellar Ataxia Type 2: A Case Report

INTRODUCTION The association between cerebellar ataxia and hypogonadism is seen rarely and is not well recognized. Spinocerebellar ataxia (SCA) is an autosomal dominantly inherited, progressive ataxia disorder, and SCA type 2 (SCA2) characteristically presents with a highly variable phenotype with multisystemic involvement. Although the clinical spectrum of SCA2 is broad, hypogonadism has not been reported as an accompanying symptom. AIM To report a case study that describes hypergonadotropic hypogonadism as a non-neurological manifestation of cerebellar ataxia in a patient with a hereditary trinucleotide repeat expansion disorder, SCA2. METHODS Case report of a man admitted to an academic medical center. RESULTS A 45-year-old man with a history of azoospermia in work-up for infertility was admitted for evaluation of a left-side hand tremor, instability on walking and impaired balance. Upon physical examination, the patient had a micropenis about 3 cm in length and had decreased testicular size (12 cc each) on orchidometry, but normal secondary sexual characteristics and average stature. Laboratory tests showed the presence of hypergonadotropic hypogonadism. A brain magnetic resonance imaging scan showed marked atrophy involving both the cerebellum and pons. Genetic analysis for hereditary ataxia demonstrated the presence of a 37 CAG triplet expansion in the mutated allele (genotype 22/37) in the SCA2 gene, confirming the diagnosis of SCA2. CONCLUSION The present study suggests that a common genetic implication may be shared between these neurologic and non-neurologic signs, and there may be various associations between these heterogeneous manifestations. The clinical spectrum of the SCA2 should be widened, and further data collection is needed to elucidate the relationship among the clinical manifestations.

Movement Disorders Following Cerebrovascular Lesions: Etiology, Treatment Options and Prognosis.

Post-stroke movement disorders are uncommon, but comprise an important part of secondary movement disorders. These exert variable and heterogeneous clinical courses according to the stroke lesion and its temporal relationships. Moreover, the predominant stroke symptoms hinder a proper diagnosis in clinical practice. This article describes the etiology, treatment options and prognosis of post-stroke movement disorders.

Generalized Chorea Induced by an Unilateral Anterior Cerebral Artery Territorial Infarction

Generalized chorea caused by unilateral cerebral infarction has rarely been reported. A 58-year-old woman presented involuntary movement in her all extremities after acute cerebral infarction on her right anterior cerebral artery territory. The involuntary movements were diagnosed as generalized chorea. We didn’t find any cause of generalized chorea except the acute cerebral infarction. Here, we described the case of generalized chorea after unilateral cerebral infarction discussing the possible mechanisms.

Differences in therapeutic responses and factors affecting post-stroke depression at a later stage according to baseline depression

Background and Purpose The pathophysiology of post-stroke depression (PSD) is complex and may differ according to an individual’s mood immediately after stroke. Here, we compared the therapeutic response and clinical characteristics of PSD at a later stage between patients with and without depression immediately after stroke. Methods This study involved a post hoc analysis of data from EMOTION (ClinicalTrials.gov NCT01278498), a placebo-controlled, double-blind trial that examined the efficacy of escitalopram (10 mg/day) on PSD and other emotional disturbances among 478 patients with acute stroke. Participants were classified into the Baseline-Blue (patients with baseline depression at the time of randomization, defined per the Montgomery-Asberg Depression Rating Scale [MADRS] ≥8) or the Baseline-Pink groups (patients without baseline depression). We compared the efficacy of escitalopram and predictors of 3-month PSD (MADRS ≥8) between these groups. Results There were 203 Baseline-Pink and 275 Baseline-Blue patients. The efficacy of escitalopram in reducing PSD risk was more pronounced in the Baseline-Pink than in the Baseline-Blue group (p for interaction=0.058). Several risk factors differentially affected PSD development based on the presence of baseline depression (p for interaction <0.10). Cognitive dysfunction was an independent predictor of PSD in the Baseline-Blue, but not in the Baseline-Pink group, whereas the non-use of escitalopram and being female were more strongly associated with PSD in the Baseline-Pink group. Conclusions Responses to escitalopram and predictors of PSD 3 months following stroke differed based on the presence of baseline depression. Our data suggest that PSD pathophysiology is heterogeneous; therefore, different therapeutic strategies may be needed to prevent PSD emergence following stroke.

Validity and Reliability Study of the Korean Tinetti Mobility Test for Parkinson’s Disease

Objective Postural instability and gait disturbance are the cardinal symptoms associated with falling among patients with Parkinson’s disease (PD). The Tinetti mobility test (TMT) is a well-established measurement tool used to predict falls among elderly people. However, the TMT has not been established or widely used among PD patients in Korea. The purpose of this study was to evaluate the reliability and validity of the Korean version of the TMT for PD patients. Methods Twenty-four patients diagnosed with PD were enrolled in this study. For the interrater reliability test, thirteen clinicians scored the TMT after watching a video clip. We also used the test-retest method to determine intrarater reliability. For concurrent validation, the unified Parkinson’s disease rating scale, Hoehn and Yahr staging, Berg Balance Scale, Timed-Up and Go test, 10-m walk test, and gait analysis by three-dimensional motion capture were also used. We analyzed receiver operating characteristic curve to predict falling. Results The interrater reliability and intrarater reliability of the Korean Tinetti balance scale were 0.97 and 0.98, respectively. The interrater reliability and intra-rater reliability of the Korean Tinetti gait scale were 0.94 and 0.96, respectively. The Korean TMT scores were significantly correlated with the other clinical scales and three-dimensional motion capture. The cutoff values for predicting falling were 14 points (balance subscale) and 10 points (gait subscale). Conclusion We found that the Korean version of the TMT showed excellent validity and reliability for gait and balance and had high sensitivity and specificity for predicting falls among patients with PD.

Is a variability of platelet inhibitory effect of anti-platelet agents important for predicting new lesion in atherothrombotic stroke?

Dear Editor, Dual anti-platelet agents (DAPTs), including aspirin and clopidogrel, are necessary during ‘‘acute’’ period in ‘‘atherothrombotic’’ stroke. However, there is currently conflicting evidence for the efficacy of DAPT in secondary prevention during the acute period. Variability in the pharmacodynamics of the platelet inhibitory effect of anti-platelet agents is a potential cause, because the risk for recurrent vascular events could be still high in cases of high residual platelet reactivity despite anti-platelet treatments in coronary heart disease and ischemic stroke. We prospectively enrolled patients with large artery atherosclerosis stroke, admitted to our hospital within 48 h of the onset of symptoms, who were naı̈ve to clopidogrel. Patients were administered a loading dose of 300mg clopidogrel (and additionally a 300mg of aspirin if naı̈ve to aspirin) followed by a maintenance dose of 75mg clopidogrel and 100mg aspirin. Newly developed ischemic lesions (NDILs) were identified through follow-up diffusion-weighted MR imaging (DWI) performed within seven days of admission. Residual platelet function tests (Verifynow system) following aspirin and clopidogrel treatment were performed on the same day as the follow-up DWI. This two-year pilot trial included 54 patients (42% men), with a mean age of 67.0 12.5 years. NDILs were detected in 22 patients (40.7%) and were associated with initial multiple lesions. NDILs were not, however, associated with the degree of stenosis, location of the initial lesion, or residual platelet reactivity to each of the antiplatelet agents. Multivariable analysis demonstrated that the NDILs group was independently associated with initial multiple lesions and the serum level of fibrinogen