Kammant Phanthumchinda

Magnetic resonance spectroscopy of the brain in neurologically asymptomatic HIV-infected patients

The CNS involvement is frequently found in human immunodeficiency virus (HIV) infection. The purpose of our study was to determine whether proton magnetic resonance spectroscopy (MRS) could detect early brain involvement in neurologically asymptomatic HIV-infected patients with normal MR imagings and to find the correlation between MRS and the immune status. We performed MRS in 30 HIV seropositive neurologically asymptomatic patients with normal MRI and compared the MRS findings with 13 controls. A statistically significant reduction in N-acetylaspartate (NAA)/creatine (Cr) and N-acetylaspartate (NAA)/choline (Cho) in both centrum semiovale (p < 0.005) and thalamic areas (p < 0.05) was found. There is no statistically significant difference as to choline (Cho)/creatine (Cr) and myoinositol (mI)/creatine (Cr) ratios in both regions. The difference of NAA/Cr was more pronounced in the white matter than in the gray matter. As for the immune status, there was a trend towards correlation between CD4 counts and NAA/Cr but devoid of statistical significance. Our results suggest that MRS is more sensitive than conventional MR imaging in detecting CNS involvement in neurologically asymptomatic HIV patients and may, therefore, be used for early detection of brain damage induced by HIV.

Thrombolytic therapy in acute ischemic stroke in Asia: The first prospective evaluation

OBJECTIVE Intravenous thrombolytic therapy has been widely recommended as a standard treatment for acute ischemic stroke in most clinical practice guidelines. However, the experience in Asia is still limited. We report the first prospective case series of thrombolytic therapy in a developing Asian country. PATIENTS AND METHODS Consecutive patients with acute ischemic stroke who presented within 3 h of onset were screened under stroke fast track program. Those who were eligible were treated with intravenous recombinant tissue plasminogen activator (rt-PA). General and neurological examinations together with the National Institute of Health stroke scale (NHISS) and modified Rankin scale (MRS) were recorded prior to and after the treatment at 1 h, 24 h, on discharge and at 3 months. Hemorrhagic brain lesion and death within 3 months were also recorded. RESULTS Thirty-four patients or 2.1% of patients with acute stroke received intravenous thrombolysis. The mean pretreatment NIHSS was 18.8 and the majority of patients had stroke in the middle cerebral artery territory. The mean door-to-needle time was 72.6 min (ranged 20-150 min). Major neurological improvement, defined as improving of the NIHSS >8 points or NIHSS of 0 points at 24 h, was observed in 17 patients (50%). Intracerebral hemorrhage was detected in four cases (11.8%), two of them were symptomatic (5.9%) and one was fatal. CONCLUSION Intravenous thrombolysis can be given in patients with acute stroke in our population. Our cases were more severe than other studies. However, half of them experienced major neurological improvement. The risk of hemorrhagic brain lesion is not much higher than previously reported.

Regional distribution of rabies viral antigen in central nervous system of human encephalitic and paralytic rabies

We studied the distribution of rabies viral antigen in the brain and spinal cord of 7 patients with rabies by immunohistochemical techniques. Four patients presented with encephalitis, the remaining 3 had paralysis. Neither the rabies viral antigen distribution nor inflammation paralleled clinical presentations. Patients who had survival times of 7 days or less (4/7) had a greater amount of antigen-positive neurons in brainstem and spinal cord regardless of the clinical type. Neuroglial cells were also found to contain rabies antigen. Our findings suggest that virus localization may not account for the difference in clinical manifestations.

Immunologic study of human encephalitic and paralytic rabies: Preliminary report of 16 patients

Lymphocyte proliferation tests to rabies antigen and myelin basic protein were performed on peripheral blood lymphocytes from nine patients with the encephalitic form and on seven with the paralytic form of human rabies. Six of the nine patients with encephalitis had proliferative responses to rabies antigen, whereas all of the patients with paralysis had no response. Two patients in each group also had a proliferative response to myelin basic protein. The myelin basic protein-reactive patients had a more rapidly fatal disease than the non-reactive patients. This preliminary study suggests that host immune responses may influence the clinical manifestations and course in human rabies.

Idiopathic hypertrophic cranial pachymeningitis: an unusual cause of subacute and chronic headache.

Three cases of idiopathic hypertrophic cranial pachymeningitis are presented. The diagnosis was based on the CT scan or MRI findings (or both) of thickened enhancing dura. In all cases, meningeal biopsies were performed and microscopic findings were compatible with non‐specific inflammation. All cases presented with subacute and chronic localized headache. Two cases had associated chronic meningitis. One case presented with a syndrome of multiple cranial nerve involvement (polyneuritis cranialis). Corticosteroids, in the form of prednisolone 60 mg/day, were effective in all cases. Two cases with less severe pachymeningitis received corticosteroids for 2 weeks, then were tapered off in 4 to 6 weeks. A case with extensive lesions needed a long‐term low dosage of prednisolone, 5 to 10 mg/day for maintenance therapy. Idiopathic hypertrophic cranial pachymeningitis may be related to the Tolosa‐Hunt syndrome, the syndrome of polyneuritis cranialis, and multifocal fibrosclerosis.

Recurrent reversible posterior leukoencephalopathy in a patient with systemic lupus erythematosus.

Sirs: We describe a patient with multiple attacks of reversible posterior leukoencephalopathy syndrome associated with active lupus nephritis. A 20-year-old woman had been diagnosed as a case of systemic lupus erythematosus (SLE) since the age of 12 years. During the last three years, she had been admitted to hospital three times with active glomerulonephritis accompanied by seizures. Two weeks before the first admission, she had headache and blurring of vision. One day prior to admission, she had 5 episodes of seizure. Her blood pressure was 190/120 mmHg. Neurological examination was normal. Investigations showed a BUN of 28 mg/dl and creatinine of 2.2 mg/dl, active urine sediment and 4+ proteinuria. Cranial MRI was performed 6 days later, T2weighted and FLAIR images showed bilateral symmetrical hyperintensity lesions in occipital, parietal, frontal and temporal subcortical white matter as well as cerebellar white matter. She was treated with phenytoin, high dose prednisolone and antihypertensive drugs. Her blood pressure was controlled. One month later, she had headache, six episodes of tonicclonic seizures and confusion one day before the admission. Her blood pressure was 200/100 mmHg. The second cranial MRI showed T2-weighted hyperintensity with the same distributions as the previous MRI and also in the right thalamus. Diffusion-weighted images were normal. MRA demonstrated a narrowing segment of right M1 and the left A2 (Fig. 1). Beaded appearance was observed in the peripheral branches of both MCA and both PCA. Those findings represented either vasospasm or vasculitis. Intravenous methylprednisolone followed by oral azathioprine, moderate doses of prednisolone and antihypertensive drugs were given. After poor compliance, she discontinued follow-up with no medication. Two years later, she had acute glomerulonephritis. Blood pressure was normal during the first few days but increased to 180/ 116 mmHg on the third day. Three episodes of seizure and blurring of vision occurred. Intravenous phenytoin and dexamethasone were given. The third MRI/MRA was performed two weeks later but did not show significant abnormality. Seizures disappeared and blood pressure decreased. Prednisolone phenytoin and antihypertensive drugs were continuously prescribed after this episode. Two months later, she had severe headache with multiple episodes of seizures. Her blood pressure was 220/150 mm Hg. The forth cranial MRI showed similar features to those in the previous studies. Diffusion-weighted images and MRA were normal. Blood pressure was controlled. Follow-up MRI 2 weeks later showed nearly complete resolution of the abnormalities (Fig .2A, B). Phenytoin was continued and seizures did not occur within the 4 months follow up. Reversible posterior leukoencephalopathy syndrome (RPLS) is characterized by headache, altered mental function, seizures, and LETTER TO THE EDITORS

Comparison of Short (3-Day) Hospitalization followed by Home Care Treatment and Conventional (10-Day) Hospitalization for Acute Ischemic Stroke

This prospective randomized controlled study was designed to compare the treatment efficacy, safety and quality of life of ischemic stroke patients treated with conventional (10-day) hospitalization or short (3-day) hospitalization followed by home care treatment. One hundred and two patients with acute ischemic stroke who arrived within 48 h after symptom onset and met the inclusion criteria were studied. Patients were randomly assigned to either of two groups of treatment. Patients in the ‘hospitalization’ group were hospitalized for 10 days, whereas those in the ‘home care’ group were admitted only for the first 3 days and were followed at home under the home care program. The baseline characteristics were similar in the two groups. There was no difference in the number of deaths or dependency defined by the Modified Rankin scale more than or equal to 3 between the two groups at 6 months. The relative risk was 0.85 with a 95% confidence interval between 0.35 and 2.04. There was also no difference in the number of patients who had good outcome (NIHSS between 0 and 2 and Barthel index between 75 and 100) at 6 months. One patient in the home care group died due to massive intracerebral hemorrhage. Seventy-nine percent of patients in the home care group were satisfied with the home treatment program.

Prevalence and risk factors of Parkinson's disease in retired Thai traditional boxers

Boxing is often believed to be a frequent cause for parkinsonism caused by chronic repetitive head injury, with Muhammad Ali frequently cited as an example. The purpose of this study is to determine the prevalence of Parkinsons disease (PD) in retired Thai traditional boxers. Two standardized screening questionnaires were sent to all registered Thai traditional boxers. Subjects who screened positive for parkinsonism were invited for clinical examinations by two independent neurologists. Among 704 boxers (70%) who completed the questionnaires, 8 boxers (1.14%) had parkinsonism: 5 with PD, 1 with progressive supranuclear palsy and 2 with vascular parkinsonism. Boxers with PD were found to have an older mean age than those without PD (P = 0.003). The analysis of probable risk factors disclosed an association between the number of professional bouts (>100 times) and PD (P = 0.01). The crude prevalence of PD in Thai boxers was 0.71% (95% CI: 0.09–1.33), with a significant increase with age. The prevalence rate of PD in those aged 50 and above was 0.17% (95% CI: 0.15–0.20), age‐adjusted to the USA 1970 census, which is comparable to that of the general populations. The analysis determined that the number of professional bouts is a risk factor among these boxers, supporting the notion that repetitive head trauma may pose an additional risk to certain individuals who are already susceptible to PD.

Migraine disability awareness campaign in Asia: migraine assessment for prophylaxis.

Objectives.— This study aimed to survey the headache diagnoses and consequences among outpatients attending neurological services in 8 Asian countries.

The Montreal Cognitive Assessment-Basic: A Screening Tool for Mild Cognitive Impairment in Illiterate and Low-Educated Elderly Adults.

To assess the validity of a newly developed cognitive screening tool, the Montreal Cognitive Assessment—Basic (MoCA‐B), in screening for mild cognitive impairment (MCI) in elderly adults with low education and varying literacy.