Gregory Youngnam Chang

Hematoma growth is a determinant of mortality and poor outcome after intracerebral hemorrhage

Background: Although volume of intracerebral hemorrhage (ICH) is a predictor of mortality, it is unknown whether subsequent hematoma growth further increases the risk of death or poor functional outcome. Methods: To determine if hematoma growth independently predicts poor outcome, the authors performed an individual meta-analysis of patients with spontaneous ICH who had CT within 3 hours of onset and 24-hour follow-up. Placebo patients were pooled from three trials investigating dosing, safety, and efficacy of rFVIIa (n = 115), and 103 patients from the Cincinnati study (total 218). Other baseline factors included age, gender, blood glucose, blood pressure, Glasgow Coma Score (GCS), intraventricular hemorrhage (IVH), and location. Results: Overall, 72.9% of patients exhibited some degree of hematoma growth. Percentage hematoma growth (hazard ratio [HR] 1.05 per 10% increase [95% CI: 1.03, 1.08; p < 0.0001]), initial ICH volume (HR 1.01 per mL [95% CI: 1.00, 1.02; p = 0.003]), GCS (HR 0.88 [95% CI: 0.81, 0.96; p = 0.003]), and IVH (HR 2.23 [95% CI: 1.25, 3.98; p = 0.007]) were all associated with increased mortality. Percentage growth (cumulative OR 0.84 [95% CI: 0.75, 0.92; p < 0.0001]), initial ICH volume (cumulative OR 0.94 [95% CI: 0.91, 0.97; p < 0.0001]), GCS (cumulative OR 1.46 [95% CI: 1.21, 1.82; p < 0.0001]), and age (cumulative OR 0.95 [95% CI: 0.92, 0.98; p = 0.0009]) predicted outcome modified Rankin Scale. Gender, location, blood glucose, and blood pressure did not predict outcomes. Conclusions: Hematoma growth is an independent determinant of both mortality and functional outcome after intracerebral hemorrhage. Attenuation of growth is an important therapeutic strategy.

Hemiballismus–hemichorea in older diabetic women: A clinical syndrome with MRI correlation

Article abstract Eight older women from two different continents, all with nonketotic hyperglycemia, presented with hemiballismus–hemichorea (HB-HC) and high signal intensity in the contralateral striatum on T1-weighted MRI scans. Correction of underlying hyperglycemia and supportive care resulted in resolution within days to weeks. This characteristic clinicoradiologic picture suggests a clinical syndrome with benign outcome.

Hypertensive brainstem encephalopathy : Three cases presenting with severe brainstem edema

Hypertensive encephalopathy (HTE) is manifested by headache, confusion, seizures, and visual disturbance and may progress to coma and death.1 CT or MRI scans usually show transient, predominantly posterior white matter involvement that rapidly improves with control of hypertension. The following three patients were unusual in having severe brainstem involvement without accompanying occipital lobe changes. Patient 1. A 54-year-old woman with a history of poorly controlled hypertension presented with 3 days of walking difficulty, right leg weakness, and mild headache with nausea. She denied any visual problems. Examination showed blood pressure (BP) of 210/144 mm Hg. She was confused with mild right hemiparesis. Funduscopic examination showed scattered posterior pole exudates and hemorrhages without disc edema. The T2-weighted and fluid-attenuated inversion-recovery (FLAIR) images showed hyperintense signals in the brainstem, with scattered mild signal changes in the cerebellum and periventricular white matter (figure, A and B). Diffusion-weighted MRI showed only a small left subcortical infarct. Figure. (A and B) Patient 1. MRI–fluid-attenuated …

Visual loss in cysticercosis Analysis of 23 patients

Of 23 cases with cysticercal visual loss, 13 had optic neuropathy (due largely to papilledema), 4 sustained chiasmal damage, and 6 had retrochiasmal lesions. Papilledema usually was associated with hydrocephalus, chiasmal involvement was caused by inflammation and compression from adjacent cysts, and retrochiasmal damage was produced by large parenchymal cysts or vasculitic cerebral infarction.

Cutis verticis gyrata, underrecognized neurocutaneous syndrome

I report two patients with cutis verticis gyrata.Characteristic of this neurocutaneous syndrome is the scalp tissue folds that generally run in an anterior-posterior direction. Although the etiology of the scalp abnormality is unclear, patients may have associated static encephalopathy, seizure disorder, or minor ocular abnormalities. The prognosis is benign. Other organ systems are spared and there is no malignant transformation of scalp tissue or brain parenchyma. NEUROLOGY 1996;47: 573-575

Combined Striatum, Brain Stem, and Optic Nerve Involvement due to Mycoplasma pneumoniae in an Ambulatory Child.

In children, Mycoplasma pneumoniae encephalitis has been characterized by acute onset of an encephalopathy associated with extrapyramidal symptoms and symmetric basal ganglia with or without brain stem involvement on magnetic resonance imaging. Our case, showing unilateral optic neuritis, ophthalmoplegia, no extrapyramidal symptoms, and typical striatal involvement on magnetic resonance imaging, broadens the spectrum of varying clinical manifestations of childhood M. pneumoniae-associated encephalopathy.

Right sensory alien hand phenomenon from a left pontine hemorrhage.

Background Acute onset of a sensory alien hand phenomenon has been observed only from a supratentorial lesion involving the non-dominant hand, mostly from a right posterior cerebral artery infarction. A single acute vascular lesion resulting in a dominant hand sensory alien hand syndrome has not been previously documented. Case Report A 78-year old right-handed woman exhibited right sensory alien hand phenomenon from a left pontine hemorrhage. Disturbance of proprioceptive input and visuospatial perception are likely to play a role in manifesting the sign. Conclusions Dominant-hand sensory alien hand phenomenon may occur in an acute setting from a left pontine hemorrhage.

Isolated Dysphagia Due to a Medullary Infarction: A New Lacunar Syndrome

Trichloroethylene and perchloroethylene (PCE) are the major constituents of commercially available solutions used in dry cleaning shops. We describe the appearance of severe bilateral optic neuritis (ON) with unexpectedly high levels of PCE metabolites in blood and chloroform in urine in a 57-year-old woman owner of a small dry cleaning shop where she worked for about 20 years using PCE. Environmental concentrations collected for 1 h 2 times a day (morning and afternoon) biannually had always been inside the limits (25–50 ppm, 170–339 mg/m3) allowed by current laws [1]. One day before the development of symptoms she had spent more than 9 h ironing clothes and fabrics immediately after withdrawal from the dry cleaning machine. In a control performed 2 weeks after acute toxicity, in the breathing zone where the ironing table was located, air samples collected for 30 min on charcoal and analyzed by desorption with carbon disulfide gas chromatography, showed peaks of 439 mg/m3 (64 ppm) near the basket containing freshly dry-cleaned fabrics, and a concentration in steam rising to 1,716 mg/m3 (252 ppm) during ironing. The onset of symptoms was apparently abrupt. Following one night of malaise, she woke up with severe headache. She was totally blind except for residual light perception. She complained of intense retroorbital pain, and eye movements induced the appearance of bright, luminous phosphenes and increment of retroorbital pain. Pupils were in mid-position, light reflex was slow but bilaterally present. A partial right third nerve palsy was noticed for 2 days, but completely disappeared on the 5th day. At the fundus observation the eye ground appeared normal, there were no signs of edema, ischemia or inflammation, intraocular pressure was 16 mm Hg. A first magnetic resonance imaging (MRI) of the head and orbits, with and without gadolinium, was performed on day 2, and was normal. A second MRI performed with long time echo short tau inversion recovery (LTE-STIR) imaging of orbits and chiasmal portion of optic nerves was performed on day 10, showing increment of intraorbital signals of both optic nerves [2]. T2 weighted axial images obtained at the same time were normal. A third MRI with gadolinium was performed on day 75, and was also normal (fig. 1). Three weeks after the onset of ON she could see only the central 2–3° radius of the visual fields, as tested with Humphrey Field Analyzer, exploring with 80 points the central 10°, 15° and 30° of visual fields (programs 10.1, 10.5), with confrontation campimetry, with tangent screen perimetry. The size of the residual visual fields did not change in the 1-year Fig. 1. a MRI performed 10 days after acute onset of bilateral optic neuritis. Coronal LTE-STIR image shows increased signal intensity bilaterally, with disappearance of the dural ring (arrowhead). b STIR MRI performed 70 days later, notice the hypointense nerve with a normal dural ring (arrowhead).

Imitative arm levitation from a recurrent right thalamic hemorrhage: A case report

Unwilled but purposeful hand movement in which the patient does not have conscious control is unusual. When one hand mimics the other, the term mirror movement is used. Mirror movements are often seen in patients with a congenital anomaly, where activation of the uncrossed corticospinal tract has been implicated.1 Imitative ipsilateral limb movements (i.e., arm levitation when attempting to lift the leg) have rarely been mentioned in the literature, and the anatomic correlate of such unusual movements is unknown. We report a patient with a recurrent right thalamic hemorrhage in which the left arm would rise spontaneously when he attempted to lift the paretic left leg. A 70-year-old right-handed man presented with a sudden worsening of left hemiparesis of 3 weeks. He had a right thalamic hemorrhage 2 years before that resulted in a left body thalamic pain syndrome accompanied by a residual ipsilateral mild hemiparesis and sensory loss. Since the latest stroke, the wife noticed his left arm would elevate intermittently. The patient stated he became aware of the left …

Clinical recognition of varicella zoster virus vasculopathy.

Introduction: It is important to recognize acutely evolving ischemic stroke attributable to reactivation of varicella zoster virus vasculopathy since antiviral agents are effective. Methods: Three cases seen by the author over a 2-year period are highlighted. Results: All patients presented with an evolving arterial or venous ischemia in the background of postherpetic neuralgia proceeding for weeks to months. Conclusion: Chronic neuralgic pain in a dermatomal distribution of an evolving central nervous system vasculopathy is an important clue to its recognition.