Keng-He Kong

Functional outcome in brain stem stroke patients after rehabilitation

OBJECTIVE To document functional outcome before and after rehabilitation in a group of brain stem stroke patients and to analyze possible factors influencing outcome. DESIGN AND SETTING A case series of 53 consecutive inpatients admitted to a rehabilitation facility with confirmed brain stem strokes over a period of 6 years. PATIENTS AND OUTCOME MEASURES Patients were selected by physiatrists for admission into the rehabilitation program. Outcome was measured by the Modified Barthel Index (MBI) for mobility and activities of daily living. RESULTS The mean age of this cohort was 57.9 +/- 11.9 years and the pons was involved in 55% of cases. Ataxia (68%) and hemiplegia (70%) were the most frequent neurological deficits. Twenty-one patients (40%) had significant dysphagia with risk of aspirin and 16 patients (30%) were incontinent of urine. Aspiration pneumonia and urinary tract infection were present in 8 (15%) and 13 (25%) patients, respectively. Significant improvements in functional status, motor strength, swallowing, and continence status were documented on discharge (p < .05). The total admission MBI was the only significant factor influencing total discharge Barthel Index ( Beta = .597, adjusted R2 = .476, p < .0001). Fifty-one (96%) were discharged home after rehabilitation. CONCLUSIONS Despite multiple physical deficits, this cohort of brain stem stroke patients made functional gains during rehabilitation with significant improvements in mobility and self-care skills, motor strength, severity of ataxia, continence and swallowing status.

Clinical characteristics and functional outcome of stroke patients 75 years old and older

OBJECTIVE To examine the demographic and clinical characteristics of stroke patients 75 years old and older admitted for rehabilitation, to study medical complications that occurred during rehabilitation, and to document functional outcome and possible factors influencing outcome. DESIGN AND SETTING A case series of 59 consecutive inpatients admitted to a rehabilitation facility with confirmed strokes over a 2-year period. MEASURES Patients were selected by rehabilitation physicians for admission into the rehabilitation program. Measures for outcome include the Modified Barthel Index (MBI) and the patients discharge disposition. RESULTS The mean age of this cohort was 80.4+/-3.2 years, and mean lengths of stay in the acute and rehabilitation facilities were 15.2 and 37.4 days. Twelve patients had three or more medical illnesses; hypertension and diabetes were the most common. Cognitive impairment, urinary incontinence, and dysphagia requiring tube feeding were present in 45.1%, 33.9%, and 11.9% of patients, respectively. Nineteen patients (32.2%) developed medical complications, and urinary tract infection was the most common. Improvements in functional status, motor power, continence, and dysphagia were noted after rehabilitation. Fifty-three patients (89.8%) were successfully discharged home, 28.8% of whom employed domestic maids as caregivers. The discharge MBI score was strongly predicted by the admission MBI and cognition scores. CONCLUSION Despite their age, significant functional improvements were documented in this cohort of aged stroke patients, and the majority were discharged home. Admission MBI and cognition scores strongly predicted functional outcome.

Neurolysis of the musculocutaneous nerve with alcohol to treat poststroke elbow flexor spasticity

OBJECTIVE To evaluate the effectiveness of alcohol in neurolysis of the musculocutaneous nerve for the treatment of elbow flexor spasticity in individuals with a stroke. DESIGN Case series. SETTING Outpatient clinic of a tertiary rehabilitation facility. PARTICIPANTS Twenty patients with a mean age of 62.8 years and poststroke duration of 12.3 months with elbow flexor spasticity. INTERVENTION Musculocutaneous nerve block of the hemiplegic upper extremity with 50% ethyl alcohol. OUTCOME MEASURES The severity of spasticity as assessed by the modified Ashworth scale (MAS) score and the elbow passive range of motion (PROM). RESULTS The mean baseline MAS score was 3.7 +/- 0.6, and this improved to 1.7 +/- 1.0, 2.0 +/- 0.8, and 2.1 +/- 0.8 at 4 weeks, 3 months, and 6 months postneurolysis, respectively. The elbow PROM was 87.3 degrees +/- 20.2 degrees, 104.3 degrees +/- 20.1 degrees, 103.8 degrees +/- 18.9 degrees, and 101.6 degrees +/- 19.7 degrees, respectively. These improvements were statistically significant (p < .05). Four subjects had concomitant improvement of finger flexor spasticity and another four had relief of shoulder pain. Three subjects developed temporary dysesthetic pain over the lateral forearm. CONCLUSION Neurolysis of the musculocutaneous nerve with alcohol provides good relief of elbow flexion spasticity in hemiplegic individuals.

Ruptured Intracranial Mycotic Aneurysm: A Rare Cause of Intracranial Hemorrhage

Intracranial mycotic aneurysm is a rare complication in patients with infective endocarditis occurring in about 2% to 10% of cases. Although the risk of rupture is about 1.7%, it is usually a catastrophic event with a fatality rate of 80%. Neurological deficits secondary to cortical involvement are common, given the frequency of intralobar hemorrhage. We report two cases of intracerebral hemorrhage caused by ruptured intracranial mycotic aneurysms. Both had involvement of the right frontoparietal lobes with resultant left hemiparesis, left homonymous hemianopia, and impairments of cognition and perceptual function. Despite intensive rehabilitation, their functional outcomes were less than satisfactory as they needed assistance in self-care activities and mobility on discharge.

“Great mimicry” in a patient with tetraparesis: A case report

The patient is a 63-year-old Chinese man who presented with tetraparesis and urinary incontinence. The initial diagnosis was cord compression from cervical spondylosis. The patient relapsed 3 months after cervical laminectomy. The transverse myelitis picture, left optic atrophy and suggestive brainstem evoked potentials led to treatment of a presumptive demyelinating process. The presence of vitiligo, however, led to detection of high titers of antinuclear antibodies (ANA) and presence of anti-nonhistone antibodies. The patient was then diagnosed to have a lupus (SLE)-like disease, which has not fully evolved. He was prescribed pulsed cyclophosphamide and prednisolone with significant gains both neurologically and functionally up to 1 year of follow-up. This report highlights the befuddling impact the disease process have on the clinicians in terms of diagnosis, treatment, and prognosis. That it can occur in men in the seventh decade of life heightens the need for awareness in our approach to the myelopathic patient.

Carbamazepine-Induced Hepatitis in a Patient With Cervical Myelopathy

Carbamazepine is a drug commonly used in the treatment of neuropathic pain. It is an iminostilbene derivative that is extensively metabolized by the liver. We describe a 66-year-old man with dysesthetic pain from cervical myelopathy who developed cholestatic hepatitis, skin rash, and eosinophilia after carbamazepine was administered for 5 weeks (total dose of 18.9gm). Withdrawal of carbamazepine led to complete resolution of both clinical and biochemical abnormalities within 3 weeks. Clinicians should be alert to this rare complication because it can be confused clinically with biliary tract sepsis and viral hepatitis.