Myoung C. Lee

The VITATOPS (Vitamins to Prevent Stroke) Trial: Rationale and Design of an International, Large, Simple, Randomised Trial of Homocysteine-Lowering Multivitamin Therapy in Patients with Recent Transient Ischaemic Attack or Stroke

Background: Epidemiological studies suggest that raised plasma concentrations of total homocysteine (tHcy) may be a common, causal and treatable risk factor for atherothromboembolic ischaemic stroke. Although tHcy can be lowered effectively with small doses of folic acid, vitamin B12 and vitamin B6, it is not known whether lowering tHcy, by means of multivitamin therapy, can prevent stroke and other major atherothromboembolic vascular events. Purpose: To determine whether vitamin supplements (folic acid 2 mg, B6 25 mg, B12 500 µg) reduce the risk of stroke, and other serious vascular events, in patients with recent stroke or transient ischaemic attacks of the brain or eye (TIA). Methods: An international, multi-centre, randomised, double-blind, placebo-controlled clinical trial. Results: As of November 2001, more than 1,400 patients have been randomised from 10 countries in four continents. Conclusion: VITATOPS aims to recruit and follow up 8,000 patients between 2000 and 2004, and provide a reliable estimate of the safety and effectiveness of dietary supplementation with folic acid, vitamin B12, and vitamin B6 in reducing recurrent serious vascular events among a wide range of patients with TIA and stroke.

Intracranial Dural Arteriovenous Fistulas: Analysis of 60 Patients

Objective: To analyze and update the clinical symptomatology, CT and MRI findings, angiographic features, and therapeutic outcomes of patients with dural arteriovenous fistulas (DAVFs). Background: Studies of DAVFs in a large number of patients have seldom appeared in neurology literature. Methods: The authors investigated 60 consecutive patients with DAVFs who were admitted between January 1991 and January 2001. The DAVFs were graded into five types according to the classification of Cognard et al. [Radiology 1995;194:671–680]. Presumable etiologies, clinical features, imaging findings and therapeutic outcomes were evaluated on the basis of the location and type of DAVFs. Results: Sinus thrombosis, previous trauma, craniotomy, cerebral infarction and acupuncture were detected as possible etiologic factors of DAVFs. The cavernous sinus (57%) was the most common location of DAVFs. Although the neurological symptoms were closely related to the location of the DAVFs, in some patients, there were also symptoms that did not reflect the location. Although the women outnumbered the men, the men presented with aggressive neurological manifestations more often (p < 0.05). Ten out of 12 patients (83%) with DAVFs involving locations other than the large sinuses presented with aggressive neurological manifestations. 70% of brain CTs and 81% of brain MRIs showed abnormal findings suggestive of DAVFs. Of 33 patients who underwent only endovascular embolization, 29 patients (88%) were cured or improved. Radiosurgery and surgical excision done in some patients provided fair results. Patients with DAVFs involving large sinuses showed a better therapeutic outcome than those in whom locations other than the large sinuses were involved, while patients without venous ectasia had more a favorable outcome than those with it (each, p < 0.01). Conclusions: DAVFs result from various etiologic factors, show diverse manifestations usually reflecting the location and can be treated successfully in most patients. Factors related to poor clinical outcome include male sex, the presence of venous ectasia and involved locations other than the large sinuses.

Syndromes of Pontine Base Infarction A Clinical-Radiological Correlation Study

BACKGROUND AND PURPOSEnAlthough there have been sporadic reports of lacunar syndromes due to pontine base infarction, studies of clinical-radiological correlation in sufficient numbers of patients have not yet been reported.nnnMETHODSnWe studied the clinical features of 37 patients with acute infarcts that mainly involved the base of the pons and correlated the clinical syndromes with the radiological findings.nnnRESULTSnThe clinical presentations included pure motor hemiparesis (PMH) in 17, sensorimotor stroke in 3, ataxic hemiparesis (AH) in 4, and dysarthria-clumsy hand (DA-CH) syndrome in 6 patients. Variants of AH included 1 patient with dysarthria-hemiataxia and 2 with quadrataxic hemiparesis, and in 4 patients dysarthria-facial paresis syndrome was considered a variant of DA-CH syndrome. Hypertension was the single most common and important risk factor, and the pathogenetic mechanisms of ischemia were likely to be small arterial (lacunar) occlusion or basilar atheromatous branch occlusion in most of the patients. Our clinical-radiological correlation study suggested that large lesions involving the paramedian caudal or middle pons correlate with severe hemiparesis (PMH), whereas lesions of similar size located in the paramedian rostral pons tended to produce DA-CH syndrome. Lesions producing AH were located variously but tended to spare the pyramidal tracts. The prognosis of these patients is fair or good, although residual hemiparesis remained in patients with initially severe hemiparesis.nnnCONCLUSIONSnOur data suggest that the various lacunar syndromes that follow pontine base infarcts reflect the balance of the involvement of the corticospinal, corticopontocerebellar, and corticobulbar tracts. Analysis of radiological findings aids in determining the clinical-anatomic correlation in patients with pontine base infarction.

Writing tremor after discrete cortical infarction.

Hand tremor is a rare manifestation of stroke, and writing tremor has not been reported to be produced by stroke. We describe a patient who developed a unilateral hand tremor mimicking primary writing tremor after discrete cerebral cortical infarction. Case Description A 67-year-old man developed mild right hemiparesis. Brain magnetic resonance imaging showed a discrete cortical infarct in the left frontal area. After recovery of motor power, the patient showed significant right hand tremor exclusively during writing or similar motor activities including tooth brushing or shaving. The tremor was temporarity alleviated by clonazepam but persisted until 7 months of follow-up. Medical history suggested that the patient had mild essential tremor, but he did not experience tremor on writing before the onset of stroke. Conclusions This observation suggests that unilateral hand tremor mimicking primary writing tremor may be produced by cortical infarction. It remains unclear whether the patients previous essential tremor played an additional role in the development of this symptom.

Stuttering and gait disturbance after supplementary motor area seizure

Acquired stuttering is an uncommon speech disorder. Supplementary motor area (SMA) lesions have been reported to be directly or indirectly related to acquired stuttering and various types of motor dysfunction. We report on a patient who presented with both acquired stuttering and long‐lasting gait disturbance after SMA seizure.

Gait freezing and speech disturbance in Parkinson’s disease

AbstractGait freezing and speech disturbance are disabling axial features of Parkinson’s disease (PD). However, the pathogenesis of these features remains unclear. We investigated the relation between changes in gait freezing and speech disturbance using visual and auditory cues in PD. 18 PD patients, comprising of 9 patients with freezing (PDGF) and 9 without gait freezing were studied. Patients performed a 7-m back-and-forth walk nin a baseline state and with visual and auditory cues. Gait velocity, stride length and cadence were evaluated using a three-dimensional gait analysis system. For speech evaluation, patients read ten sentences in a baseline state and with visual and auditory cues. The time delay of speech initiation, speech rate and the number of repetitions per sentence were quantified. In PDGF patients, the increase in gait velocity positively correlated with the decrease in the time delay of the speech initiation. Also, the increase in the gait velocity and cadence positively correlated with the decrease in the number of repetitions per sentence. The increase in the stride length positively correlated with the increase in speech rate. Lastly, the increase in stride length positively correlated with the decrease in the number of repetitions per sentence. These findings suggest that there is a common pathomechanism of gait freezing and speech disturbance in PD.

Isolated tongue tremor after gamma knife radiosurgery for acoustic schwannoma

We describe a patient who had an isolated tongue tremor with an audible click after gamma knife radiosurgery for acoustic schwannoma. The nature of the tongue tremor was clearly demonstrated by videofluoroscopy. The possible pathogenic mechanisms are discussed.

Isolated trigeminal sensory change due to pontine hemorrhage

Isolated trigeminal sensory change has been rarely described as a manifestation of pontine hemorrhage. We report a 31-year-old man who developed sudden and long-lasting trigeminal sensory disturbances. Brain magnetic resonance imaging showed a hemorrhage in the right lateral pontine tegmentum corresponding to the trigeminal sensory nucleus, and the venous phase angiogram demonstrated abnormal vascular structures. Pontine hemorrhage secondary to venous malformation can be one of the causes of isolated trigeminal sensory change.

Sensory Changes in the Ipsilateral Extremity A Clinical Variant of Lateral Medullary Infarction

BACKGROUNDnClassically, patients with unilateral lateral medullary infarction exhibit sensory abnormalities over the ipsilateral face and contralateral hemibody. As a variant, bilateral or contralateral facial sensory changes can be seen. However, sensory changes in the ipsilateral extremities are extremely rare.nnnCASE DESCRIPTIONSnWe describe three patients with lateral medullary syndrome in whom impaired deep sensation in the ipsilateral limbs was found. MRI results showed that the infarcts were located superficially in the lateral (case 1) and dorsal (cases 2 and 3) areas of the lower medulla, which probably involved the ascending or crossing dorsal column sensory tracts.nnnCONCLUSIONSnAlthough rare, impaired ipsilateral deep sensation is encountered in patients with lateral medullary infarction syndrome.

One-year open-label study of entacapone in patients with advanced Parkinson disease.

Background and purpose A carboxy-O-methyl transferase inhibitor entacapone has been introduced as an adjuvant drug for Parkinson disease (PD) patients. Although clinical trials reported beneficial role of entacapone, a long-term trial over 3 years failed to show significant effect. The goals of this study were to evaluate the clinical benefit and the efficacy of entacapone in an open clinical practice. Methods After the completion of a double-blind placebo-controlled entacapone study, 149 patients from 4 centers were included. Antiparkinsonian medications were optimized by the judgment of the neurologists in charge. The clinical global impression (CGI) scale was obtained at 6 months and 1 year after the initiation of entacapone treatment. Results Of the 149 patients, 117 patients chose to try entacapone in an open-label fashion. Sixty-nine (59%) patients completed the 1-year trial. Twenty-nine patients discontinued entacpaone before 6 months, and 19 between 6 months and 1 year during trial. Twelve patients out of 48 patients discontinued entacapone because of its poor efficacy. The CGI scale was 3.9 (±1.5) at the beginning of the trial, 4.3 (±1.1) at 6 month, and 3.8 (±1.3) at 1 year, respectively. The CGI scale of those who discontinued between 6 month and 1 year was 3.4 (±1.7), which was worse, but insignificantly, than that of the continuer. Conclusions The dropout at 1 year of our study was very high at 41%. Even though entacapone is indicated for advanced PD patients with motor fluctuation, the fluctuators commonly have dyskinesia and mental symptoms, which can become more troublesome with entacapone. In the patients with advanced PD, the clinical efficacy and side effects should be carefully considered in a long-term use of entacapone.