Myoung-Chong Lee

Spectrum of lateral medullary syndrome. Correlation between clinical findings and magnetic resonance imaging in 33 subjects.

Background and Purpose Computed tomography is insufficient in evaluation of medullary lesions. Although lateral medullary infarction is a relatively common type of cerebrovascular disease, detailed correlation between clinical findings and magnetic resonance imaging (MRI) has not yet been reported. Methods We studied 33 consecutive patients with lateral medullary infarction who showed appropriate MRI lesions and correlated their clinical findings with the MRI results. Results Gait ataxia (88%), vertigo/dizziness (91%), nausea/vomiting (73%), dysphagia (61%), hoarseness (55%), Horner sign (73%), and facial (85%) and hemibody (94%) sensory changes were frequent clinical findings. MRI results showed that the lesions located in the rostral part of the medulla were usually diagonal band‐shaped and were associated with more severe dysphagia, hoarseness, and the presence of facial paresis, whereas the caudal lesions, situated usually in the lateral surface of the medulla, appeared to correlate with more marked vertigo, nystagmus, and gait ataxia. Nausea/vomiting and Horner sign were common regardless of the lesion location, and lesions extending ventromedially correlated with facial sensory change on the contralateral side of the lesion. Conclusions Analysis of MRI findings in rostrocaudal and dorsoventral aspects allows us, although not unequivocally, to make anatomicoclinical correlations in the evaluation of patients with lateral medullary stroke syndrome. (Stroke. 1994;25:1405‐1410.)

Ischemic stroke in Korean young adults.

Objectives– To evaluate the characteristics of ischemic stroke in Korean young adults. Material and methods– We prospectively studied 149 consecutive patients with acute ischemic stroke aged between 15 to 44 years who were admitted to Asan Medical Center. All patients underwent brain CT/MRI and the majority of them underwent cerebral angiogram, echocardiography and laboratory studies for coagulopathy and vasculitis. Stroke subtypes were classified according to TOAST criteria. Results– In our study, men (75.2%) significantly outnumbered women. Stroke subtypes were: large artery atherosclerosis 20.8%, small artery occlusive disease 17.4%, cardioembolism 18.1%, undetermined causes 16.8%, and other determined etiologies 26.8%. The prevalence of hypertension, cigarette smoking and habitual alcohol consumption was significantly higher in men than in women. Conclusions– Compared to the Western studies, the deviation of sex ratio and the relative proportion of large artery atherosclerosis/small artery occlusion was higher. Heavy exposure to risk factors such as hypertension and cigarette smoking in Korean young men may explain these differences.

Isolated or predominant ocular motor nerve palsy as a manifestation of brain stem stroke.

Background and Purpose: There have been few reports of strokes producing isolated or predominant ocular motor nerve palsies as a clinical manifestation. Methods: We studied seven patients with brain stem stroke who had ocular motor palsies as the only or the predominant neurological manifestation, and we correlated their clinical features with radiological findings. Results: Five patients had small strokes in the area of oculomotor nuclei or fascicles and showed various combinations of oculomotor disturbances. Three of these patients showed vertical gaze paresis of the opposite eye. One patient with a small hemorrhage near the aqueduct of Sylvius showed fourth nerve palsy on the contralateral side, and a patient with a small infarct in the pontine tegmentum showed isolated sixth nerve palsy. Nonocular minor neurological signs included trigeminal sensory changes in four patients and clumsy arm in two. Ocular and nonocular dysfunctions generally improved within several months. Radiological findings of the brain stem correlated well with the ocular signs. Conclusions: We conclude that acute brain stem stroke should be included in the differential diagnosis of isolated ocular motor nerve palsies and that appropriate diagnostic investigations should be performed in these cases. (Stroke 1993;24:581‐586)

Subdural hematoma in spontaneous CSF hypovolemia

Of 67 consecutive patients with spontaneous CSF hypovolemia (SCH), 11 (16.4%) had subdural hematoma (SDH). Patients with SDH were older (p = 0.005), more likely to be male (p = 0.035), and displayed longer time to diagnosis of SCH (p = 0.019) than those without SDH. All patients with SDH showed the findings of pseudo–subarachnoid hemorrhage on CT and responded favorably to epidural blood patches and neurosurgical drainage.

Small primary intracerebral hemorrhage. Clinical presentation of 28 cases.

Background Although there have been sporadic reports of patients with small intracerebral hemorrhages presenting with discrete clinical features, the clinical and distributional characteristics of these hemorrhages have not been adequately investigated. Case Descriptions We studied 28 patients who had primary intracerebral hemorrhage of a longest diameter ≤1.5 cm as seen in computed tomographic scan and/or magnetic resonance imaging. Small primary intracerebral hemorrhages were found in the basal ganglia in 8 patients (2 with intraventricular hemorrhage), the posterior limb of the internal capsule in 8, the area of the fourth ventricle of the cerebellum in 7 (5 with intraventricular hemorrhage), the pontine tegmentum in 4, and the thalamomesencephalic area in 1. All patients except 3 were hypertensive, suggesting that most of the hemorrhages may have occurred because of rupture of small end arteries secondary to long‐standing hypertension. Depending on their location, the hemorrhages clinically manifested as pure motor stroke in 7, pure sensory stroke in 6, vertigo/ataxia in 7, sensorimotor stroke in 4, and ataxic hemiparesis in 2 patients. One patient with thalamomesencephalic hemorrhage showed vertical gaze disturbance, and 1 with basal ganglionic hemorrhage presented with symptoms of acute hydrocephalus secondary to a relatively large amount of intraventricular hemorrhage. The prognosis of small intracerebral hemorrhage was generally excellent except for when patients were very old or when there was a significant amount of intraventricular bleeding. Conclusions Small primary intracerebral hemorrhage has its predilection sites: basal ganglia, posterior limb of the internal capsule, area of the fourth ventricle of the cerebellum, and pontine tegmentum. Most of the hemorrhages are probably caused by rupturing of the small end arteries in the setting of chronic hypertension. They produce discrete clinical syndromes often mimicking classic lacunar syndrome, of which pure sensory stroke is relatively common. (Stroke. 1994;25:1500‐1506.)

Micrographia after thalamo-mesencephalic infarction: Evidence of striatal dopaminergic hypofunction

A patient with left thalamo-mesencephalic infarction presented with micrographia in the right hand as the only motor sign. Brain MRI and99m Tc ethyl cysteinate dimer (ECD) perfusion SPECT revealed ischemic lesions in the left midbrain and the anterior thalamus, but not in the basal ganglia, whereas [123I]-IPT SPECT demonstrated decreased activity of the [123I]-IPT in the left striatum. The patients micrographia may be related to a dysfunctional nigrostriatal dopaminergic system secondary to ischemic damage to the substantia nigra.

Coxiella (Q fever)‐associated myelopathy

We describe six men with a slowly progressive myelopathy characterized by asymmetric, incomplete spinal cord syndrome manifested with a thoracic sensory level, mild spastic paraparesis, and urinary incontinence. The spinal cord lesions were evident by MRI in four of them. Coxiella burnetii infection was confirmed in the blood of all patients by immunofluorescence microscopic assay (IFA) and transmission electron microscopy (TEM). In two patients, we detected C burnetii by TEM and IFA using CSF from the patients inoculated onto fresh peripheral blood lymphocyte. Four patients, treated with appropriate antibiotics, responded either with partial resolution of symptoms or arrest of further neurologic progression. In three, the MRI lesions decreased in size.

Disapperance of essential tremor after small thalamic hemorrhage

Stereotactic thalamotomy has been reported to be effective in the control of various tremors, including essential tremor. We report a 69-year-old female who experienced spontaneous thalamotomy with a small thalamic hemorrhage, resulting in disappearance of essential tremor on the contralateral side to the hematoma, which involved the nucleus ventralis intermedius (Vim) of the thalamus and a portion of the posterior limb of the internal capsule.

Orthostatic hypacusis in a patient with CSF hypovolaemia

The syndrome of CSF hypovolaemia has been a recognized cause of orthostatic headache (a headache in the upright position relieved by recumbancy) (1– 3). Among other clinical manifestations, a change in hearing has also been described in this syndrome (1, 2, 4, 5). However, the pathogenesis of hearing changes in CSF hypovolaemia is unclear. We report a patient with CSF hypovolaemia who had orthostatic hypacusis (hearing impairment in the upright position relieved by recumbancy) that was clearly demonstrated by pure tone audiometry. The anatomical and physiological relationship between CSF space and inner ear structure may explain the pathogenesis of orthostatic hypacusis in CSF hypovolaemia.

Determining factors related to pachymeningeal enhancement on brain MRI in CSF hypovolaemia

CSF hypovolaemia has been well recognized as a cause of orthostatic headache (1–3). On brain MRI, it has several typical MRI features, including diffuse pachymeningeal gadolinium enhancement (DPMGE), subdural fluid collection, and descent of the brain (1, 2, 4). In addition, cases with typical clinical features and CSF leaks, but without DPMGE on brain MRI have been reported (1, 2, 5). However, the causative factors related to the development of typical MRI changes in CSF hypovolaemia, particularly DPMGE, are still unclear. To determine these factors, we have compared the clinical and imaging features of CSF hypovolaemia with and without DPMGE on brain MRI.