Ok-Joon Kim

Acute Spinal Subdural Hematoma Presenting with Spontaneously Resolving Hemiplegia

Although prompt diagnosis and emergent surgical intervention are important in acute spinal subdural hematoma (SSDH), some cases with spontaneous remission of symptom and hematoma without surgery have been reported. We present a case of acute nontraumatic SSDH presenting with transient left hemiplegia for 4 hours. A magnetic resonance imaging study of cervical spine confirmed SSDH with C3-6 cervical cord compression at the left side. The patient had conservative management without recurrence. Although hemiplegia is an unusual clinical manifestation of SSDH, it should be differentiated from that of cerebrovascular origin promptly. Conservative management may be an alternative therapeutic option for selective cases with transient neurological deficits.

The role of VEGF and KDR polymorphisms in moyamoya disease and collateral revascularization.

We conducted a case-control study to investigate whether vascular endothelial growth factor (VEGF −2578, −1154, −634, and 936) and kinase insert domain containing receptor (KDR −604, 1192, and 1719) polymorphisms are associated with moyamoya disease. Korean patients with moyamoya disease (n = 107, mean age, 20.9±15.9 years; 66.4% female) and 243 healthy control subjects (mean age, 23.0±16.1 years; 56.8% female) were included. The subjects were divided into pediatric and adult groups. Among the 64 surgical patients, we evaluated collateral vessel formation after 2 years and divided patients into good (collateral grade A) or poor (collateral grade B and C) groups. The frequencies and distributions of four VEGF (−2578, −1154, −634, and 936) and KDR (−604, 1192, and 1719) polymorphisms were assessed from patients with moyamoya disease and compared to the control group. No differences were observed in VEGF −2578, −1154, −634, and 936 or KDR −604, 1192, and 1719 polymorphisms between the control group and moyamoya disease group. However, we found the −634CC genotype occurred less frequently in the pediatric moyamoya group (p = 0.040) whereas the KDR −604C/1192A/1719T haplotype increased the risk of pediatric moyamoya (p = 0.024). Patients with the CC genotype of VEGF −634 had better collateral vessel formation after surgery. Our results suggest that the VEGF −634G allele is associated with pediatric moyamoya disease and poor collateral vessel formation.

Alteration of immunologic responses on peripheral blood in the acute phase of ischemic stroke: Blood genomic profiling study

OBJECTIVE Peripheral blood cells and inflammatory mediators have a detrimental effect on brain during cerebral ischemia. We investigated the immunologic changes on peripheral blood in the acute phase of ischemic stroke using RNA microarray. METHODS mRNA microarray and real time-polymerase chain reaction (RT-PCR) for genes of interest in microarray data were analyzed in 12 stroke patients and 12 controls. Plasma matrix metalloproteinase-9 (MMP-9) concentrations were measured in 120 stroke patients and 82 controls. RESULTS In microarray analysis, a total of 11 genes of interest showed different expression in patients with ischemic stroke. The three most highly expressed genes were C19orf59 (chromosome 19 open reading frame 59), MMP9 and IL18RAP (interleukin-18 receptor accessory protein), whereas gene with the lowest expression was GNLY (granulysin). The expression patterns of three selected genes (MMP9, IL18RAP and GNLY) were validated by RT-PCR. The plasma concentration of MMP-9 was significantly elevated in the stroke patients, and showed a weakly positive correlation with infarct volume. Gene set enrichment analysis (GSEA) showed that gene sets related to immunity and defense, signal transduction, transport and cell adhesion were significant in acute ischemic stroke. CONCLUSIONS In the peripheral blood, numerous genes of inflammatory mediators, including MMP9, IL18RAP and GNLY, are altered in the acute phase of ischemic stroke. This stroke-specific gene expression profiling provides valuable information about the role of peripheral inflammation to the pathophysiological mechanism of ischemic stroke.

Cognitive and behavioral effects of lamotrigine and carbamazepine monotherapy in patients with newly diagnosed or untreated partial epilepsy

PURPOSE In this prospective study, we compared the long-term cognitive and behavioral effects of lamotrigine (LTG) and carbamazepine (CBZ) in patients with newly diagnosed or untreated partial epilepsy. METHODS This was a multicenter, open-label, randomized study that compared monotherapy with LTG and CBZ in newly diagnosed or untreated patients with partial epilepsy. We employed an 8-week titration period and a 40-week maintenance period. Neuropsychological tests, Symptom Check List-90, and QOLIE-31 were assessed at baseline, 16 weeks, and 48 weeks after drug treatment. A group-by-time interaction was the primary outcome measure and was analyzed by use of the linear mixed model. RESULTS A total of 110 patients were eligible and 73 completed the 48-week study (LTG, n=39; CBZ, n=34). Among the cognitive tests, significant group-by-time interaction was identified only in phonemic fluency of Controlled Oral Word Association Task (p=0.0032) and Stroop Color-Word Interference (p=0.0283), with a significant better performance for LTG group. All other neuropsychological tests included did not show significant group-by-time interactions. Among the subscales of Symptom Check List-90, significant group-by-time interactions were identified in Obsessive-Compulsive (p=0.0005), Paranoid Ideation (p=0.0454), Global Severity Index (p=0.0194), and Positive Symptom Total (p=0.0197), with a significant improvement for CBZ group. QOLIE-31 did not show significant group-by-time interactions. CONCLUSION Our data suggest that epilepsy patients on LTG have better performance on phonemic fluency and the task of Stroop Color-Word Interference than do patients on CBZ, whereas patients on CBZ had more favorable behavioral effects on two subscales and two global scores of Symptom Check List-90 than did patients on LTG.

Kinetic tremor and cerebellar ataxia as initial manifestations of Kikuchi–Fujimoto's disease

Involvement of central nervous system occasionally occurs as a form of aseptic meningitis in Kikuchi-Fujimoto disease (KFD). However, acute cerebellar symptoms are very rare in KFD. We describe a 42 year-old woman presenting kinetic tremor and gait ataxia preceding cervical lymphadenopathy. The diagnosis of KFD was made based on pathology. Lymphocyte-dominant pleocytosis was observed in cerebrospinal fluid. Brain and spinal magnetic resonance imaging showed no structural abnormalities. Acute cerebellar symptoms and cervical lymphadenopathy disappeared spontaneously within 2 months. This case of KFD involved unusual acute cerebellar symptoms. Selective involvement of the cerebellar system by viral or immunologic response may be attributed to acute cerebellar symptoms in KFD.

Limited clinical value of multiple blood markers in the diagnosis of ischemic stroke.

OBJECTIVES No ideal blood marker exists for the diagnosis of ischemic stroke. Combined use of multiple blood markers would enhance the ability of clinical diagnosis of ischemic stroke. DESIGN AND METHODS Blood concentrations of neuronal markers (NSE, VSNL-1, hFABP, and Ngb), astroglial markers (S100B and GFAP), inflammatory markers (IL-6 and TNF-α), blood-brain barrier marker (MMP-9), and hemostatic markers (PAI-1) were measured within 6-24 h of stroke onset. The area under the receiver operator characteristic (AUROC) curve of patients with ischemic stroke and stroke-mimic was compared after adding individual or a combination of blood markers to the clinical diagnostic assessment (age, atrial fibrillation, and Face-Arm-Speech Test [FAST]). RESULTS Despite acute elevations of blood IL-6, S100B, MMP-9, hFABP, and PAI-1 in univariate analysis, only IL-6, S100B, and MMP-9 were independently associated with ischemic stroke in multivariate analysis. The addition of biomarkers (IL-6, S100B, and MMP-9) did not improve the diagnostic performance of baseline clinical models with added biomarkers versus baseline clinical models alone (AUROC, 0.865 vs. 0.837, p=0.069). CONCLUSIONS IL-6, S100B, and MMP-9 markers are elevated in the peripheral blood during the acute phase of ischemic stroke. However, the clinical usefulness of these biomarkers is limited due to low discriminating ability when compared to clinical parameters alone in diagnosis of ischemic stroke.

Multiple Fusiform Cerebral Aneurysms and Highly Elevated Serum Interleukin-6 in Cardiac Myxoma

Cerebral embolic infarction is the most common neurologic complication of cardiac myxoma (CM). Development of cerebral aneurysms in CM is very rare. We present a 64-year-old woman with acute cerebral infarction and multiple cerebral aneurysms complicated by CM. The aneurysms were multiple, fusiform-shaped, and located in distal branch of major cerebral arteries. The serum interleukin (IL)-6 was highly elevated, which was normalized after surgical resection of CM. There was no regression of aneurysms on follow-up neuroimaging. Multiple cerebral aneurysms in CM are rare condition. Highly elevated serum IL-6 may be associated with increased risk of cerebral aneurysmal formation.

Significance of chronic epilepsy in glial tumors and correlation with surgical strategies

PURPOSE This study was designed to compare the frequency of postoperative epilepsy in patients with acute and chronic pre-operative epilepsy and with frontal or temporal lobe glial tumors based on the hypothesis that patients with chronic epilepsy do worse. METHODS We compared the clinical and diagnostic characteristics of the patients (n = 73) who had seizures preoperatively with those of the patients (n = 153) who did not. Among those who have had seizures preoperatively, we compared those (n = 32, chronic seizure group) who had seizures a year or more prior to surgery with those (n = 41, acute seizure group) who had seizures less than a year prior to surgery. RESULTS Among the various factors, the frequency of benign pathology and favorable neurological state were higher in the seizure group than in the non-seizure group (p < 0.05). Complex partial seizures and low-grade tumors were frequent in the chronic seizure group, whereas simple partial seizures and high-grade tumors were frequent in the acute seizure group. Seizure-free rate was significantly higher in the acute seizure group than in the chronic group (p < 0.05). Also, the difference of seizure control rate between surgical strategies was statistically significant (p < 0.05). CONCLUSION This study indicates that preoperative seizure duration and frequency have a close relationship with the frequency of postoperative epilepsy in patients with glial tumors. A longer duration may allow the formation of epileptogenic foci, leading to chronic epilepsy, and eventually have a negative effect on the prognosis of the patients. Factors including histopathological characteristics of the tumor, its location, seizure duration/frequency, and symptomatology should be taken into account when deciding on surgical strategies.

Predictive value of circulating interleukin-6 and heart-type fatty acid binding protein for three months clinical outcome in acute cerebral infarction: multiple blood markers profiling study

IntroductionThere is no single blood marker for predicting the prognosis in ischemic stroke. A combination of multiple blood markers may enhance the ability to predict long-term outcome following ischemic stroke.MethodsBlood concentrations of neuronal markers (neuron-specific enolase, visinin-like protein 1, heart type fatty acid binding protein (hFABP) and neuroglobin), astroglial markers (S100B and glial fibrillary acidic protein), inflammatory markers (IL-6, TNF-α, and C-reactive protein), blood-brain barrier marker (matrix metalloproteinase 9), and haemostatic markers (D-dimer and PAI-1) were measured within 24 hours after stroke onset. The discrimination and reclassification for favorable and poor outcome were compared after adding individual or a combination of blood markers to the clinical model of stroke outcome.ResultsIn multivariate analysis, natural log-transformed (log) IL-6 (odds ratio (OR): 1.75, 95% CI: 1.25 to 2.25, P = 0.001) and loghFABP (OR: 3.23, 95% CI: 1.44 to 7.27, P = 0.005) were independently associated with poor outcome. The addition of a single blood marker to the clinical model did not improve the discriminating ability of the clinical model of stroke outcome. However, the addition of the combination of logIL-6 and loghFABP to the clinical model showed improved discrimination (area under receiver operating characteristic (AUROC) curve: 0.939 versus 0.910, P = 0.03) and reclassification performance (net reclassification improvement index: 0.18, P = 0.005).ConclusionsA combination of circulating IL-6 and hFABP level has an additive clinical value for the prediction of stroke outcome.

Different Risk Factor Profiles between Silent Brain Infarction and Symptomatic Lacunar Infarction

Background/Aims: It is generally assumed that silent brain infarction (SBI) and symptomatic lacunar infarction (sLAC) share common vascular risk factors and their pathogeneses are known to be similar. However, few studies have conducted a risk factor profile analysis of the two diseases in a single study design. Methods: This study included 64 subjects with SBI lesions, 140 patients with sLAC, and 342 controls by retrospective investigation of brain MRI. Topographic findings and vascular risk factor profiles were compared. Results and Conclusion: Compared to the controls, the SBI group was found to be associated with hypertension (p = 0.002) and elevated plasma total homocysteine level (p = 0.02). The sLAC group was found to be associated with hypertension (p = 0.001), diabetes (p = 0.004), smoking (p = 0.002), ischemic heart disease (p = 0.01) and hyperlipidemia (p = 0.04). In the present study, risk factor profiles of the SBI and sLAC were not exactly the same, indicating a different pathogenesis between the two diseases.