Hyung Chan Kim

Clinical Significance of Fluid-Attenuated Inversion Recovery Vascular Hyperintensities in Borderzone Infarcts.

Background and Purpose— Fluid-attenuated inversion recovery vascular hyperintensities (FVHs) are seen in some cases with cerebral hemodynamic impairment and collateral flow. Because the worst outcomes of patients with borderzone infarcts were mainly correlated with impaired hemodynamics, the presence of FVH might provide another clue for predicting the prognosis of patients with borderzone infarcts. Methods— We reviewed 1377 consecutive patients with ischemic stroke. Cortical borderzone (CBZ) and internal borderzone infarcts were selected based on diffusion-weighted imaging. FVHs were defined as tubular- or serpentine-shaped hyperintensities in the subarachnoid space. We investigated the clinical significance of FVHs in borderzone-infarcted patients. Results— Among 87 patients with borderzone infarcts, the presence of FVH was observed in 30 (34.5%). We identified 62 patients with CBZ infarcts and 25 patients with internal borderzone infarcts. In the cases with CBZ infarcts, the initial National Institutes of Health Stroke Scale scores and the portions of nonfavorable outcome at 3 months in the FVH(+) group were significantly higher than in the FVH(−) group (P<0.05 and P<0.001, respectively). Unlike the cases with CBZ infarcts, there were no significant differences of these clinical features between the FVH(+) group and the FVH(−) group in the patients with internal borderzone infarcts. Conclusions— The findings of FVH are associated with relatively severe clinical presentation and nonfavorable prognosis in patients with CBZ infarcts, but not in patients with internal borderzone infarcts. The presence of FVH may help to identify CBZ-infarcted patients who require close observation and hemodynamic control.

Isolated foot drop in acute infarction of the supplementary motor area.

Isolated monoparesis of any lower limb caused by acute schemic stroke is uncommon. Among cases of isolated monoaresis, reports of sudden isolated foot drop are rarely reported 1,2]. This symptom, which presents with a peroneal-like distriution, has been shown to be caused by small cortical lesions in he parasagital precentral gyrus. However, to our knowledge, there ave been no reports of isolated foot drop associated with a lesion n the supplementary motor area (SMA). We report a patient with solated foot drop after acute infarction of the SMA.

Can the adverse effects of antiepileptic drugs be detected in saccadic eye movements

PURPOSE The objective of this study was to determine whether the adverse effects of antiepileptic-drugs could be assessed by the eye movements of epilepsy patients. METHODS This study was performed prospectively in a single tertiary hospital. The inclusion criteria for this study were as follows: (1) consecutive patients with epilepsy taking antiepileptic-drugs regularly for at least 1 year, (2) the absence of structural lesions on MRI, (3) an age ≥16 years old, (4) not using medications that could influence eye movement, and (5) a normal neurological examination. The latency, peak velocity and accuracy of the saccades and the gain of the pursuits were recorded by video-based electro-oculography. We analyzed the differences in the parameters of the eye movements for 75 patients with epilepsy and 20 normal controls matched for age and sex. RESULTS The total latency (1017.7 ± 148.9 ms vs. 1150.7 ± 106.6 ms, p=0.0003) and accuracy [370.7% (95% CI 364.1-376.4%, range 306-408.2%), 92.7% as total accuracy normalized value vs. 383.6% (95% CI 378.8-398%, range 322.9-417.4%), 95.9% as total accuracy normalized value, p=0.0005] were significantly different between the patients with epilepsy and normal controls. For the detection of nystagmus with video-based electro-oculography, the clear cutoff values of total accuracy (≤388.7%, 97.2% as total accuracy normalized value) revealed 93.4% sensitivity and 28.6% specificity, and the clear cutoff values of total latency (≤1005.5 ms) showed 49.2% sensitivity and 78.6% specificity. CONCLUSIONS The total latency and accuracy of video-based electro-oculography may be screened to identify patients with a high risk of adverse effects with antiepileptic-drugs.

Top 100 cited articles on epilepsy and status epilepticus: A bibliometric analysis

The purpose of this study is to identify the top 100-cited articles dedicated to epilepsy and status epilepticus published in journals from January, 1950 through February, 2016 that have made key contributions in the field. We performed a search of journals and selected the top 100-cited articles on epilepsy and status epilepticus, respectively, by utilizing the Institute for Scientific Information database available under the banner of the Web of Science. The top-cited articles on epilepsy and status epilepticus were all published in 24 journals, respectively. In both fields of epilepsy and status epilepticus, the most frequently cited journal was Epilepsia (26 articles on epilepsy and 19 articles on status epilepticus). The 100 most-cited articles in the field of both epilepsy and status epilepticus mainly originated from institutions in the United States of America. The articles on epilepsy included 25 laboratory studies, 15 pharmacotherapy studies, 13 general review studies, 12 surgery studies, 11 neuroimaging studies, eight epidemiology studies, eight neuropsychiatry studies, six genetic studies, and two electrophysiology studies, whereas 41 laboratory studies, 21 epidemiology studies, 16 pharmacotherapy studies, nine electrophysiology studies, nine general review studies, and four neuroimaging studies were included in the field of status epilepticus. We demonstrate that neuroimaging, genetics, and surgery are emerging topics in the field of epilepsy over the past decades. Moreover, we found that the majority of top-cited articles on epilepsy and status epilepticus originated from institutions in the United States of America and most were published in Epilepsia.

Can we predict drug response by volumes of the corpus callosum in newly diagnosed focal epilepsy

The aim of this study was to investigate whether volumes of the corpus callosum could predict a response to antiepileptic drugs in patients with newly diagnosed focal epilepsy.

Characteristics of seizure-induced signal changes on MRI in patients with first seizures

PURPOSE The aim of this study was to investigate the predictive factors and identify the characteristics of the seizure-induced signal changes on MRI (SCM) in patients with first seizures. METHODS We conducted a retrospective study of patients with first seizures from March 2010 to August 2014. The inclusion criteria for this study were patients with 1) first seizures, and 2) MRI and EEG performed within 24h of the first seizures. The definition of SCM was hyper-intensities in the brain not applying to cerebral arterial territories. Multivariate logistic regression was performed with or without SCM as a dependent variable. RESULTS Of 431 patients with seizures visiting the ER, 69 patients met the inclusion criteria. Of 69 patients, 11 patients (15.9%) had SCM. Epileptiform discharge on EEG (OR 29.7, 95% CI 1.79-493.37, p=0.018) was an independently significant variable predicting the presence of SCM in patients with first seizures. In addition, the topography of SCM was as follows; i) ipsilateral hippocampus, thalamus and cerebral cortex (5/11), ii) unilateral cortex (4/11), iii) ipsilateral thalamus and cerebral cortex (1/11), iv) bilateral hippocampus (1/11). Moreover, 6 out of 7 patients who underwent both perfusion CT and MRI exhibited unilateral cortical hyperperfusion with ipsilateral thalamic involvement reflecting unrestricted vascular territories. CONCLUSION There is an association between epileptiform discharges and SCM. Additionally, the involvement of the unilateral cortex and ipsilateral thalamus in SCM and its hyperperfusion state could be helpful in differentiating the consequences of epileptic seizures from other pathologies.

Juvenile myoclonic epilepsy may be a disorder of cortex rather than thalamus: An effective connectivity analysis

Although juvenile myoclonic epilepsy has been considered as a disorder of thalamo-cortical circuit, it is not determined the causality relationship between thalamus and cortex. The aim of this study was to evaluate whether juvenile myoclonic epilepsy is a disorder of thalamus or cortex. Twenty-nine patients with juvenile myoclonic epilepsy and 20 normal controls were enrolled in this study. In addition, we included 10 patients with childhood absence epilepsy as a disease control group. Using whole-brain T1-weighted MRIs, we analyzed the volumes of the structures, including hippocampus, thalamus, and total cortex, with FreeSurfer 5.1. We also investigated the effective connectivity among these structures using SPSS Amos 21 based on these volumetric measures. The structural volumes in juvenile myoclonic epilepsy were not different from those in normal controls. There was a statistically significant effective connectivity from the total cortex to the thalamus in the patients with juvenile myoclonic epilepsy. In addition, a significant effective connectivity from the hippocampus to the ipsilateral thalamus was revealed. Unlike the patients with juvenile myoclonic epilepsy, neither the patients with childhood absence epilepsy nor normal controls had a significant effective connectivity from the total cortex to the thalamus or from the thalamus to the cortex. The connectivity of brain in patients with juvenile myoclonic epilepsy could be different from that in patients with childhood absence epilepsy, and the cortex rather than the thalamus might play a critical role in the pathogenesis of juvenile myoclonic epilepsy.

Vasculitis Findings for the Anterior Choroidal Artery in 3D-Time-of-Flight Magnetic Resonance Angiography

Dear Editor, A 29-year-old female who had been treated in another hospital and who had a history of two stroke attacks was admitted with newly developed dysarthria. The two previous stroke attacks were lacunar syndromes caused by a right anterior thalamic infarction and a left lateral medullary infarction at 11 and 8 months prior to admission to our hospital, respectively. She denied having any conventional risk factors. On examination she was found to have moderately decreased sensation in the left side without any sequelae from the previous attacks. She was taking clopidogrel, warfarin, and rosuvastatin. Her initial international normalized ratio value for the prothrombin time was 2.38. Diffusion-weighted images obtained on her admission day showed an acute infarction in the right internal capsule (Fig. 1A). Her 3D and source images of time-of-flight magnetic resonance angiography (MRA) revealed abnormal dilatation and narrowing in a branch of the right distal internal carotid artery (Fig. 1B and C). We performed a lumbar puncture on the fifth day after admission. The findings for the cerebrospinal fluid, including the cell count, were normal. Conventional angiography revealed a characteristic beading pattern, consistent with vasculitis in the right anterior choroidal artery (Fig. 1D). The results of the laboratory tests for vasculitis can be summarized as positivity for antinuclear antibody (ANA) at a dilution of 1:640 with a homogeneous and speckled pattern, and for anti-double-stranded DNA (anti-dsDNA) at a dilution of 1:80. She was diagnosed with systemic lupus erythematosus (SLE) based on oral ulcers, proteinuria of 3+, positive ANA, and positive anti-dsDNA in accordance with the 2015 revised criteria of the American College of Rheumatology/Systemic Lupus International Collaborating Clinics. The immunosuppressant of hydroxychloroquine was added to her steroid therapy for treating the central nervous system (CNS) lupus for several weeks after admission. The abnormal findings for the right anterior choroidal artery had disappeared at follow-up MRA performed 1 year after starting steroid and immunosuppressive therapy (Fig. 1E). The follow-up fluid-attenuated inversion recovery image showed only a subtle old lesion in the right internal capsule (Fig. 1F). Ischemic stroke caused by lupus vasculitis is rare. Although magnetic resonance (MR) imaging is sensitive for CNS vasculitis,1 the findings of MRA evaluating vasculitis caused by SLE may be mostly normal since mainly small vessels are affected by lupus.2 Our case of lupus vasculitis shows two rare features: 1) vasculitis with a beading pattern appearing as narrowing and ectasia in the anterior choroidal artery and 2) abnormal findings for the anterior choroidal artery were detected in 3D-reconstructed MRA images as well as in conventional angiography. The main pathology of arteritis caused by collagen disease is fibrinoid degeneration in the arterial walls.3 While endothelial proliferations with destroyed muscular and elastic tissue are associated with arterial narrowing, weakening of the walls with smaller extents of endothelial hyperplasia may produce ectasias.3 This beading pattern of arteritis is easiest to detect usHyung Chan Kim Soo Young Bae Joon Won Lee Si Eun Kim Byung In Lee Sung Eun Kim Kyong Jin Shin JinSe Park Kang Min Park Sam Yeol Ha

Cortical morphology in patients with transient global amnesia

This study evaluated alterations in cortical morphology in patients with transient global amnesia (TGA).