Hung Youl Seok

C-reactive protein is a predictor of early neurologic deterioration in acute ischemic stroke.

Although the association between elevated C-reactive protein (CRP) level and long-term outcome after ischemic stroke is well known, the association between CRP and early neurologic deterioration (END) has not yet been thoroughly studied. We investigated the impact of CRP on END in patients with acute ischemic stroke. From a prospectively collected, multicenter stroke registry, 428 patients with acute ischemic stroke diagnosed within 24 hours of onset were enrolled in the study. Patients with hemorrhagic stroke, transient ischemic attack, and thrombolysis were excluded. END was defined as a >2-point increase in the National Institutes of Health Stroke Scale score within a 72-hour period. Data considered potentially associated with CRP level and the END were collected. END was observed in 47 patients. CRP level, time before arrival at the hospital, age, female sex, hematocrit, high-density lipoprotein (HDL) cholesterol level, hemoglobin A(1c) level, and internal carotid artery occlusion were significantly associated with END. On logistic regression analysis, CRP level, internal carotid artery occlusion, and HDL cholesterol proved to be independent variables. Our data suggest that CRP level at admission is significantly associated with END in acute ischemic stroke. HDL cholesterol and internal carotid artery occlusion are also associated with END.

Increased Corticomuscular Coherence in Idiopathic REM Sleep Behavior Disorder.

The authors hypothesized that if locomotor drive increases along with rapid eye movement (REM) sleep without atonia in idiopathic REM sleep behavior disorder (RBD), then RBD patients would have greater corticomuscular coherence (CMC) values during REM sleep than at other sleep stages and than in healthy control subjects during REM sleep. To explore this hypothesis, we analyzed beta frequency range CMC between sensorimotor cortex electroencephalography (EEG) and chin/limb muscle EMG in idiopathic RBD patients. Eleven drug naive idiopathic RBD patients and 11 age-matched healthy control subjects were included in the present study. All participants completed subjective sleep questionnaires and underwent polysomnography for one night. The CMC value between EEGs recorded at central electrodes and EMGs acquired at leg and chin muscles were computed and compared by repeated measures analysis of variance (ANOVA). Sleep stages and muscle (i.e., chin vs. leg) served as within-subject factors, and group served as the between-subject factor. Repeated measures ANOVA revealed no significant main effect of group (F1,20 = 0.571, p = 0.458) or muscle (F1,20 = 1.283, p = 0.271). However, sleep stage was found to have a significant main effect (F2.067,41.332 = 20.912, p < 0.001). The interaction between group and sleep stage was significant (F2.067,41.332 = 3.438, p = 0.040). RBD patients had a significantly higher CMC value than controls during REM sleep (0.047 ± 0.00 vs. 0.052 ± 0.00, respectively, p = 0.007). This study reveals increased CMC during REM sleep in patients with RBD, which indicates increased cortical locomotor drive. Furthermore, this study supports the hypothesis that sufficient locomotor drive plays a role in the pathophysiology of RBD in addition to REM sleep without atonia.

Cross-sectional area reference values of nerves in the lower extremities using ultrasonography.

Introduction: Cross‐sectional area (CSA) reference values of lower extremity nerves using ultrasonography have only been reported in a few studies and have been limited to white populations. Methods: For this study, 94 healthy Korean volunteers were recruited for measurement of the CSA at 7 sites of lower extremity nerves. The side‐to‐side difference in CSA was calculated for each nerve, and reference ranges were derived. External validity evaluation for the reference values was performed with 10 newly recruited volunteers at a different institution. Results: Nerve CSA was correlated significantly with body mass index, weight, and height; however, the absolute value of the side‐to‐side difference had no significant correlation with demographic factors. The external validity was adequate for all sites, ranging from 80% to 100%. Conclusions: The lower extremity nerve CSA values obtained in this study may provide normal reference values for the Asian population. Muscle Nerve 50: 564–570, 2014

Lengthened Cutaneous Silent Period in Fibromyalgia Suggesting Central Sensitization as a Pathogenesis

The pathogenesis of fibromyalgia (FM) has not been clearly elucidated, but central sensitization, which plays an important role in the development of neuropathic pain, is considered to be the main mechanism. The cutaneous silent period (CSP), which is a spinal reflex mediated by A-delta cutaneous afferents, is useful for the evaluation of sensorimotor integration at the spinal and supraspinal levels. To understand the pathophysiology of FM, we compared CSP patterns between patients with FM and normal healthy subjects. Twenty-four patients with FM diagnosed in accordance with the 1990 American College of Rheumatology classification system and 24 age- and sex-matched healthy volunteers were recruited. The CSP was measured from the abductor pollicis brevis muscle. Demographic data, number of tender points, and visual analog scale and FM impact questionnaire scores were collected. The measured CSP and clinical parameters of the patient and control groups were compared. In addition, possible correlations between the CSP parameters and the other clinical characteristics were analyzed. Mean CSP latencies did not differ between patients (55.50 ± 10.97 ms) and healthy controls (60.23 ± 11.87 ms; p = 0.158), although the mean CSP duration was significantly longer in patients (73.75 ± 15.67 ms) than in controls (63.50 ± 14.05 ms; p = 0.021). CSP variables did not correlate with any clinical variables. The significantly longer CSP duration in FM patients suggests central dysregulation at the spinal and supraspinal levels, rather than peripheral small fiber dysfunction.

Atypical spontaneous intracranial hypotension with a head-shaking headache.

Spontaneous intracranial hypotension (SIH) is typically characterized by orthostatic headache; however, various atypical manifestations of SIH have been reported recently. We report here the case of a 46‐year‐old man with headache secondary to SIH, which was nonorthostatic, triggered only when the patient shook his head. We suggest that SIH should be suspected in patients with headache induced by head‐shaking, even without orthostatic features, especially when the headache is accompanied by other symptoms commonly associated with SIH.

Epidural adhesiolysis complicated by cefazolin-induced status epilepticus: Two cases

Cefazolin is a strong epileptogenic agent. We describe two patients presenting with status epilepticus, apparently caused by intrathecal leakage of cefazolin via incidental dural puncture during spinal epidural adhesiolysis. Our cases suggest that the local use of antibiotics, particularly cefazolin, in the form of a mixture with contrast medium during a spinal procedure is not advisable, because of the possible incidental intrathecal leakage and the high convulsive potential of the antibiotics.

The Impacts of Influenza Infection and Vaccination on Exacerbation of Myasthenia Gravis

Background and Purpose Upper respiratory infection (URI), including influenza, may exacerbate the symptoms of myasthenia gravis (MG), which is an autoimmune disease that causes muscle weakness. There is also concern that the influenza vaccine may trigger or worsen autoimmune diseases. The objective of this study was to determine the impacts of influenza infection and vaccination on symptom severity in MG patients. Methods Patients diagnosed with MG were enrolled from 10 university-affiliated hospitals between March and August 2015. Subjects completed a questionnaire at the first routine follow-up visit after enrolling in the study. The patient history was obtained to determine whether a URI had been experienced during the previous winter, if an influenza vaccination had been administered before the previous winter, and whether their MG symptoms were exacerbated during or following either a URI or vaccination. Influenza-like illness (ILI) was defined and differentiated from the common cold as a fever of ≥38℃ accompanied by a cough and/or a sore throat. Results Of the 258 enrolled patients [aged 54.1±15.2 years (mean±SD), 112 men, and 185 with generalized MG], 133 (51.6%) had received an influenza vaccination and 121 (46.9%) had experienced a common cold (96 patients) or ILI (25 patients) during the analysis period. MG symptoms were aggravated in 10 (40%) patients after ILI, whereas only 2 (1.5%) experienced aggravation following influenza vaccination. The rate of symptom aggravation was significantly higher in patients experiencing an ILI (10/25, 40%) than in those with the common cold (15/96, 15.6%, p=0.006). Conclusions The results of this study suggest that the potential risk of aggravating autoimmune disease is higher for ILI than for influenza vaccination, which further suggests that influenza vaccination can be offered to patients with MG.

Fulminant lymphocytic myocarditis associated with orbital myositis and diaphragmatic paralysis

Although the clinical presentation of myocarditis is very diverse, ranging from mild dyspnea to hemodynamic collapse, myocarditis accompanied with extracardiac myositis is extremely rare. We report a single case of fulminant myocarditis associated with orbital myositis and diaphragmatic paralysis in a 40-year-old man, which was successfully managed by immunosuppressive therapy with steroid.

Medial plantar proper digital neuropathy caused by a ganglion cyst.

A 20-yr-old man presented with numbness and a tingling sensation along the medial aspect of the right great toe. His symptoms worsened during physical activities and were partially relieved by rest. During the previous few months, he had been wearing poorly fitting boots for all activities. On examination, hypesthesia to pinprick was present over the medial aspect of the right great toe. No mass was palpable, but Tinel sign was positive at the medial plantar aspect of the right hallux. Results of nerve conduction studies of the right tibial motor nerve and right medial plantar mixed nerve were normal. However, on antidromic stimulation of the right medial plantar proper digital nerve (MPPDN), the sensory nerve action potential was absent. A diagnosis of MPPDN neuropathy was made. He was advised to avoid lengthy walks and to wear correctly fitting shoes. During the subsequent 2 mos, no improvement occurred. Foot magnetic resonance imaging (Fig. 1A, B) revealed an elongated cystic lesion along the course of the MPPDN, close to the plantar surface of the right hallux. The lesion showed homogeneously low signal intensity on T1-weighted images and high signal intensity on T2-weighted images; these findings were consistent with a ganglion cyst. His symptoms and electrophysiologic findings gradually improved after surgical excision of the ganglion cyst. The MPPDN is the terminal sensory branch arising from the medial plantar nerve, and it subserves sensation to the medial aspect of the great toe. Its superficial position renders it susceptible to chronic compression, which results in MPPDN neuropathy. In our case, the cause of MPPDN neuropathy was initially thought to be chronic compression from ill-fitting shoes, but conservative treatment did not relieve the patient’s symptoms. Further examination indicated the presence of the ganglion cyst. We suggest that foot imaging be considered in patients with MPPDN neuropathy to exclude the possibility of a space-occupying lesion, especially when conservative treatment is unsuccessful.

Joubert Syndrome Presenting With Young-age Onset Ischemic Stroke: A Possible Etiologic Association

Joubert syndrome is a rare genetic disorder of childhood that is characterized by hypoplasia or agenesis of the cerebellar vermis in addition to brainstem malformations. Ataxia, hypotonia, developmental delay, and apnea-hyperpnea are the most prominent clinical symptoms of Joubert syndrome, but this condition can also affect multiple organs, making the clinical phenomenology of Joubert syndrome quite diverse. Seizures are the most common neurological complications of Joubert syndrome, but its neurological sequelae are poorly described because Joubert syndrome is very rare. Here we report an acute ischemic stroke in a 21-year-old woman with Joubert syndrome who had no conventional risk factors for early onset cerebrovascular disease. To date, this is the first report of an ischemic stroke in a patient with Joubert syndrome, and we believe this case may suggest an association between Joubert syndrome and extremely early onset cerebrovascular disease.