Kessarin Panichpisal

Acute quadriplegia from hyperkalemia: a case report and literature review.

Background Hyperkalemia has been described as a rare and under recognized cause of acute quadriplegia. Case Report A 52-year-old man with end-stage renal disease presented with ascending quadriplegia and dyspnea for 2 days. He had life-threatening hyperkalemia (9.0 mEq/L). His electrocardiogram showed typical features of hyperkalemia. His symptoms improved in 30 minutes and completely resolved in 5 hours after emergent treatment of hyperkalemia. He admitted eating large amounts of high potassium foods and taking ibuprofen in uncertain quantities. We reviewed 62 articles and identified 73 patients with secondary hyperkalemic paralysis. Common presentations were diminished reflexes, quadriparesis/paralysis, respiratory involvement, and sensory loss. Almost half of all patients had potassium levels higher than 9 mEq/L. Complete recovery, achieved in 89% of patients, did not correlate either with the absolute potassium level or the degree to which it was corrected. Conclusions Hyperkalemia is a rare but treatable cause of acute flaccid paralysis that requires immediate treatment. Late diagnosis can delay appropriate treatment leading to cardiac arrhythmias and arrest.

The Management of Stroke in Antiphospholipid Syndrome

Ischemic stroke is one of the most common complications of the antiphospholipid syndrome (APS). Because of the relative lack of definitive prospective studies, there is still some debate as to whether the persistent presence of antiphospholipid antibodies (aPLs) increases the risk of recurrent stroke. There is more evidence for aPLs as a risk factor for first stroke. The mechanisms of ischemic stroke are considered to be thrombotic and embolic. APS patients with thrombotic stroke frequently have other, often conventional vascular risk factors. Transesophageal echocardiogram is strongly recommended in APS patients with ischemic stroke because of the high yield of valvular abnormalities. The appropriate management of thrombosis in patients with APS is still controversial because of limited randomized clinical trial data. This review discusses the current evidence for antithrombotic therapy in patients who are aPL positive but do not fulfill criteria for APS, and in APS patients. Alternative and emerging therapies including low molecular weight heparin, new oral anticoagulants (including direct thrombin inhibitors), hydroxychloroquine, statins, and rituximab, are also addressed.

Contrast-Induced Neurotoxicity following Cardiac Catheterization

We report a case of probable contrast-induced neurotoxicity that followed a technically challenging cardiac catheterization in a 69-year-old woman. The procedure had involved the administration of a large cumulative dose of an iodinated, nonionic contrast medium into the innominate artery: twelve hours following the catheterization, the patient developed a seizure followed by a left hemiplegia, and an initial computed tomography (CT) scan showed sulcal effacement in the right cerebral hemisphere due to cerebral swelling. The patients clinical symptoms resolved within 24 hours, and magnetic resonance imaging at 32 hours showed resolution of swelling. Contrast-induced neurotoxicity should be found in the differential diagnosis of acute neurological deficits occurring after radiological procedures involving iodinated contrast media, whether ionic or nonionic.

Gentamicin-induced myoclonus: a case report and literature review of antibiotics-induced myoclonus.

Introduction:Drug-induced myoclonus is a diagnosis of exclusion. Various drugs have been reported to induce myoclonus. Antibiotic-induced myoclonus (AIM) is very rare. We describe a case of multifocal myoclonus secondary to gentamicin toxicity and review the literature of AIM. Case Report:A 59-year-old woman with end-stage renal disease developed generalized multifocal myoclonus within 1 hour after receiving only 1 supratherapeutic dose of gentamicin for a potential hemodialysis catheter infection. Myoclonus was completely resolved after 2 sessions of hemodialysis. We identified 22 patients of AIM in the literature. The median age of patients was 63 years. More than half of patients (12/22, 55%) had underlying chronic kidney disease. Cephalosporins were the most common drug class associated with AIM (12/22 patients; 55%). About two third of patients (15/22, 68%) received overdoses of antibiotics. Fifteen patients (71%) completely recovered after discontinuing or decreasing the dose of antibiotics. Five patients (24%) died of underlying medical conditions or of unknown etiology. Only 1 had persistent myoclonus. The potential mechanisms of AIM are discussed. Conclusions:AIM, although rare, should be considered as a potential cause of multifocal myoclonus in patients with advanced age or renal insufficiency. The prognosis of AIM appears favorable, with several cases resolving after withdrawal of the antibiotic.

Pomona Large Vessel Occlusion Screening Tool for Prehospital and Emergency Room Settings

Background: Early identification of patients with acute ischemic strokes due to large vessel occlusions (LVO) is critical. We propose a simple risk score model to predict LVO. Method: The proposed scale (Pomona Scale) ranges from 0 to 3 and includes 3 items: gaze deviation, expressive aphasia, and neglect. We reviewed a cohort of all acute stroke activation patients between February 2014 and January 2016. The predictive performance of the Pomona Scale was determined and compared with several National Institutes of Health Stroke Scale (NIHSS) cutoffs (≥4, ≥6, ≥8, and ≥10), the Los Angeles Motor Scale (LAMS), the Cincinnati Prehospital Stroke Severity (CPSS) scale, the Vision Aphasia and Neglect Scale (VAN), and the Prehospital Acute Stroke Severity Scale (PASS). Results: LVO was detected in 94 of 776 acute stroke activations (12%). A Pomona Scale ≥2 had comparable accuracy to predict LVO as the VAN and CPSS scales and higher accuracy than Pomona Scale ≥1, LAMS, PASS, and NIHSS. A Pomona Scale ≥2 had an accuracy (area under the curve) of 0.79, a sensitivity of 0.86, a specificity of 0.70, a positive predictive value of 0.71, and a negative predictive value of 0.97 for the detection of LVO. We also found that the presence of either neglect or gaze deviation alone had comparable accuracy of 0.79 as Pomona Scale ≥2 to detect LVO. Conclusion: The Pomona Scale is a simple and accurate scale to predict LVO. In addition, the presence of either gaze deviation or neglect also suggests the possibility of LVO.

Hemorrhages From Cerebral Amyloid Angiopathy

CLINICAL PRESENTATION A 77-year-old man presented with transient left leg weakness lasting for 10 minutes. He had no history of prior medical problems or history of trauma. Magnetic resonance imaging of the brain showed subarachnoid hemorrhage (SAH) and multiple low-signal round foci compatible with hemosiderin at cortical and subcortical regions in both cerebral hemispheres but predominantly on the right side. Cerebral angiogram was unremarkable. He was diagnosed with probable cerebral amyloid angiopathy (CAA). Eight months after initial presentation, he was found on the floor with left leg weakness. Axial computer tomography brain demonstrated intraparenchymal hemorrhage (arrow) in the right frontal lobe with vasogenic edema (arrowhead) and mass effect and small intraventricular hemorrhage in the right front lobe (Figure 1). CAA is the most common cause of nontraumatic convexal SAH (cSAH) in patients older than 60 years. It is characterized by the progressive deposition of b-amyloid protein in the walls of smallto medium-sized arteries (up to about 2 mm in diameter), arterioles and capillaries in the cerebral cortex and overlying leptomeninges. The clinical diagnosis of CAA is based on characteristic neuroimaging findings. The diagnosis of probable CAA requires the following: age .55 years, detection of multiple hemorrhagic cerebral lesions, hemorrhages confined to cortical or cortical-subcortical (lobar) brain regions and exclusion of secondary causes of intracerebral hemorrhage. Note that SAH is not considered in the diagnostic criteria. GRE T2 (T2*) magnetic resonance imaging sequence increases the chance of detecting the additional lobar hemorrhage. A restricted cSAH is a marker of poor prognosis. One study found that 64% of patients with cSAH had modified Rankin scale of 3 to 6 and had a higher rate of subsequent ischemic infarctions and intracerebral hemorrhage contributed to unfavorable outcome.

Poster 467 Dramatic Recovery of a Stroke Patient With Mirror Movements of the Affected Hand: A Case Report

Objective: To investigate the effects of additional inpatient rehabilitation therapy after conventional rehabilitation for early stage in subacute stroke patients. Design: Prospective follow-up study. Setting: Inpatient and outpatient rehabilitation clinic. Participants: We enrolled 104 subacute stroke patients who had already received 3 months poststroke rehabilitation therapy and could walk more than 10 m with or without any assist device. Interventions: 58 stroke patients received additional inpatient rehabilitation therapy for 3 months, and 46 control patients received only home-based self-care for the same periods. Rehabilitation therapy included physical therapy, such as Bobath neurodevelopmental techniques, gait training, balance training, and functional electrical stimulation, and occupational therapy, such as activity of daily living training and hand function training. Main Outcome Measures: The evaluation was measured before and after additional rehabilitation therapy. Functional improvement was measured by using modified motor assessment scale, timed up and go test, 10-m walking time, Berg balance scale, and the Korean-modified Barthel index. The health-related quality of life was evaluated by using medical outcome study 36-item Short Form survey. Results: There was no significant difference between 2 groups in age, gender, and assessment, such as modified motor assessment scale, timed up and go test, 10-m walking time, Berg balance scale, Korean-modified Barthel index, and 36-item Short Form survey before additional rehabilitation therapy. In experimental group, significant improvements were observed in all parameters at 3 months after additional rehabilitation (P .05). However, significant improvements were observed only in modified motor assessment scale, Berg balance scale, and Korean-modified Barthel index in the control group (P .05). In a comparison between the 2 groups, significant differences were observed in all parameters (P .05) except 10-m walking time. The improvement in 36-item Short Form survey was also meaningfully higher in experimental group compared to control group. Conclusions: This study demonstrates that additional inpatient rehabilitation therapy after conventional rehabilitation can provide functional improvements and enhance quality of life more effectively compared with home-based self-care in subacute stroke patients.

Clinical Reasoning: A rare cause of subarachnoid hemorrhage

A 48-year-old woman presented with severe headache radiating to her neck and chest, followed by a brief period of loss of consciousness in the emergency department. After she regained consciousness, the patient described a 2-year history of right-sided pulsatile tinnitus and hearing loss. She also had a history of poorly controlled hypertension and of noncompliance with her medication. On examination her blood pressure was 239/90 mm Hg. Results of a neurologic examination were unremarkable. Brain CT showed a subarachnoid hemorrhage (figure 1, A and B). Figure 1 Initial head CT scan revealing subarachnoid hemorrhage (A) Noncontrast brain CT scan demonstrates a posterior fossa mass and subarachnoid hemorrhage. (B) Intraventricular hemorrhage is also demonstrated. ### Questions for consideration: 1. What are the possible etiologies of her subarachnoid hemorrhage? 2. What additional diagnostic testing would you consider at this point? CT angiography of the head and neck did not reveal any intracranial aneurysm or vascular malformation (figure 2, A and B). However, a large mass was present in the right jugular foramen with erosion of temporal bone and encroachment of the right internal acoustic canal. MRI confirmed a hypervascular mass that contained numerous flow voids. The mass was located lateral to the medulla and extended superiorly into the cerebellopontine angle cistern. It extended inferiorly to the superior aspect of the right parapharyngeal space and displaced the right internal carotid artery (figure 2C). Figure 2 Radiologic imaging study revealing a jugular foramen mass (A) CT angiogram showing an enhancing jugular foramen mass extending into the posterior fossa. (B) Enhancing tumor mass at the skull base

Acute Massive Cerebral Infarctions Treated with Hemodialysis

We report here a 19-year-old woman with Down syndrome and end-stage renal disease who presented with left-sided weakness and fever. She had a massive pericardial effusion of unclear origin that required daily hemodialysis (HD) and cardiac intervention. She developed an acute right middle cerebral artery infarction with severe edema; her cerebral edema significantly improved with daily HD. Later in her hospitalization, she developed seizures and new onset of multiple acute embolic infarctions in left middle cerebral artery, left anterior cerebral artery (ACA), and right posterior cerebral artery (PCA) distributions with midline shift. However, we again noticed a dramatic decrease in cerebral edema with frequent HD. Although there is controversy about the use of dialysis in patients with stroke, our case suggests that daily HD may provide an alternate strategy for treating massive cerebral infarction. More studies are needed in these patients.