R. T. F. Cheung

Cerebral infarcts complicating tuberculous meningitis.

Cerebral infarction (CI) is a serious complication of tuberculous meningitis (TBM). It can be asymptomatic or symptomatic, causing stroke. We studied 40 TBM patients. All had initial CT brain scan, CT/MRI brain scan 3 months later and urgent CT brain scan for deterioration. CI was classified into lacunar infarction (LI) or large artery infarction (LAI). Twelve (30%) had CI, in 9 (23%) it was symptomatic and in 3 (8%) silent. Seven (58%) had LAI ± LI. Eight (67%) had multiple CI. Two died from brainstem CI and 6 were dependent at 1 year. Patients with LAI might develop posterior circulation CI more frequently than those with LI only. CI is a common complication of TBM locally, with LAI and multiple CI being common. Two thirds of TBM patients complicated by CI had poor prognosis despite adjunctive dexamethasone treatment.

Postictal psychosis related regional cerebral hyperperfusion

Postictal psychosis is a known complication of complex partial seizure in particular temporal lobe epilepsy. It usually runs a benign and self limiting course. A postictal phenomenon with focal cerebral hypofunction (similar to Todds palsy), rather than ongoing seizure activity, has been postulated.1 2 Surface EEG is either normal or showing non-specific slow waves.3 Hence, antipsychotic medications are prescribed instead of antiepileptic drugs. Until recently, the pathogenic mechanisms have remained unknown. In this communication, we report on two patients with postictal psychosis, during which a cerebral SPECT study showed a hyperperfusion signal over the right temporal lobe and contralateral basal ganglion. As hyperperfusion in ictal cerebral SPECT is closely linked to epileptic activities,4 our findings support a contrary explanation for postictal psychosis. Interictal SPECT and SPECT performed during postictal psychosis. (Top) A SPECT study of patient 1 showing areas of relative hyperperfusion over the right temporal neocortex (red arrows) and the left basal ganglia (blue and yellow arrows) during postictal psychosis. (Bottom) SPECT study of patient 2 showing areas of hyperperfusion over the right temporal neocortex and the left basal ganglia. Arrows indicate areas of hyperperfusion. Prolonged video-EEG telemetry study was performed in patients who underwent presurgical evaluation for epilepsy surgery. Antiepileptic drugs were withdrawn …

Knowledge of Stroke in Hong Kong Chinese

A random telephone survey on knowledge of stroke was conducted in 1,238 Hong Kong Chinese. Most respondents realized that effective treatment was available, that stroke was preventable and that it could be fatal or disabling. Sudden unilateral limb weakness, sudden speech and language disturbances, and sudden vertigo and clumsiness were better recognized than other warning symptoms of stroke. A slightly better recognition of symptoms of stroke was seen in those with a belief of knowing about stroke, providing a correct description of stroke, those with a positive household history of stroke and those with a better knowledge of potential risk factors. Most respondents would choose desirable actions if stroke was suspected in their family members or themselves. Friends and relatives, newspapers and magazines, and mass media provided the major sources of their knowledge.

Idiopathic inflammatory demyelinating disorders after acute transverse myelitis

Acute transverse myelitis (ATM) is commonly para‐infectious. Recurrent ATM occurs in connective tissue diseases (CTD), infective myelitis and idiopathic inflammatory demyelinating disorders (IIDD) including multiple sclerosis (MS) and neuromyelitis optica (NMO). Previous studies might include NMO and idiopathic recurrent transverse myelitis (IRTM) as MS. The aim was to study the outcome of patients after a first attack of idiopathic ATM. Idiopathic ATM patients over a 6‐year period were retrospectively studied. Known causes of myelopathy were excluded. Among 32 patients studied, 20 (63%) had single ATM attack upon follow up for 39–93 months, three developed recurrent ATM related to CTD (two systemic lupus erythematosus and one anti‐Ro antibody positive) and nine (28.1%) developed recurrent neuroinflammation compatible with IIDD. Among IIDD patients, three had NMO, two restricted variant of NMO, three IRTM and one classical MS. NMO, its variant and IRTM had mean spinal MRI abnormality of 3.7, 2.1 and 3.9 vertebral segments respectively while non‐recurrent ATM had 1.6 vertebral segments. Four (80%) of the five patients with NMO or its variant had poor neurological prognosis versus only one (5%) of non‐recurrent ATM patients. IRTM patients had advanced mean onset age, 62 years vs. 43 years for non‐recurrent ATM patients. In IIDD patients presenting with ATM as first attack of neuroinflammation, NMO and its variant (56%) were most frequent, then IRTM (33%), with classical MS (11%) the rarest. As long‐term treatments for NMO are different from MS, early recognition of NMO and its variant is important for prevention of serious neurological deficits.

Visit-to-visit systolic blood pressure variability predicts all-cause and cardiovascular mortality after lacunar infarct

Both blood pressure (BP) and its variability (BPV) are established risk factors for development of atherosclerotic disease and are associated with an increased risk for cardiovascular and all‐cause mortality. The prognostic implications of outpatient clinic visit‐to‐visit BPV amongst patients with lacunar infarction are nevertheless unknown.

Wilson’s disease with depression and parkinsonism

Wilsons disease (WD) is an autosomal recessive disorder with reduced biliary excretion of copper plus impaired formation of ceruloplasmin, leading to copper accumulation in the liver, brain, kidney, and cornea. Clinical manifestations include liver damage, psychiatric symptoms, and neurological features. We report a 35-year-old woman with a history of deranged liver functions who had severe depression several years later and eventually presented with parkinsonian features. The underlying diagnosis is WD and family screening revealed WD in 2 other siblings. She could not tolerate penicillamine because of fever and leucopenia. While taking trientine hydrochloride and zinc sulphate, her parkinsonism improved and her depression remained in remission. WD should be considered in patients with unexplained liver function derangement or psychiatric symptoms. Early diagnosis and initiation of specific treatment are crucial in minimising any further cerebral and hepatic damage as well as securing possible improvement in organ functions.

Warfarin associated intracerebral hemorrhage in Hong Kong Chinese

Abstract Objectives: Warfarin-associated intracerebral hemorrhage (WICH) is a serious neurological condition associated with significant mortality and morbidity. We aimed to study the clinical features and factors that predict clinical outcome of Chinese patients with WICH. Methods: Medical records of patients with spontaneous intracerebral hemorrhage (ICH) admitted to our hospital between July 2001 and June 2010 were reviewed and those with WICH were studied in detail retrospectively. Results: Fifty-one patients with WICH were studied. The mean age was 74·3 ± 10·5 years and 52·9% of the patients were female. The mean international normalized ratio (INR) on presentation was 2·9 ± 1·0. The median ICH volume was 23·3 (10·4–59·3) ml. The mortality rate at 3–6 months for WICH was 62·0%. Multivariate logistic analysis revealed that an initial ICH volume of > 20 ml (OR 34·4, P  =  0·037) and presence of intraventricular hemorrhage (OR 22·9, P  =  0·046) were independently associated with poor outcome. Supratherapeutic INR (INR > 3·0) on admission (P  =  0·724) and complete correction of INR within 24 hours after admission (P  =  0·486) were not independent predictors of poor outcome. The median ICH volumes did not differ between INR groups (18·2 (9·4–61·1) ml for INR ≤ 3 vs 27·3 (13·7–58·5) ml for INR > 3, P  =  0·718). Neurological deterioration (ND) was documented in 19 (63·3%) of the 30 patients included in a smaller sub-cohort, and was associated with poor neurological outcome (OR 20·7, P  =  0·027). Warfarin was resumed in 7 of the 20 survivors. There were two episodes of recurrent WICH and one episode of ischemic stroke during a mean follow-up duration of 5·4 years. In survivors who were not resumed on warfarin, there were two episodes of recurrent ICH and 12 episodes of ischemic vascular events (nine ischemic strokes) during a mean follow-up duration of 2·6 years. Conclusion: Warfarin-associated intracerebral hemorrhage is a very serious complication of warfarin therapy with high mortality and morbidity. Initial ICH volume, presence of intraventricular hemorrhage, and ND are independent predictors of clinical outcome.

Nonthymoma early-onset- and late-onset-generalized myasthenia gravis--a retrospective hospital-based study.

OBJECTIVE Acquired myasthenia gravis (MG) is predominantly due to nicotinic acetylcholine receptor (AChR) autoantibodies (Ab). Differences between nonthymoma early-onset and late-onset MG were reported. We studied the clinical and serological characteristics of nonthymoma AChR Ab-positive-generalized MG patients. PATIENTS AND METHODS Chinese AChR Ab-positive-generalized MG patients who had generalized disease for 3 years or longer were studied. RESULTS Among 41 such patients, 25 (61%) were female. The mean onset age was 43.5 years (range 9-78 years) and the mean follow-up duration was 7.8 years (range 3-20 years). Sixteen (39%) patients had late-onset disease (onset age >or=50 years). Compared to early-onset patients (onset age <50 years), late-onset patients were characterized by male predominance (p=0.002), absence of thymic lymphofollicular hyperplasia (p=0.036), and a higher striated muscle Ab seropositivity rate (94% versus 4%, p<0.001). Although there was no statistically significant difference in clinical severity and outcome or response to treatment between late-onset and early-onset patients, 50% and 75% of late-onset patients had moderate or severe disease at onset and worst status, respectively, compared to 28% and 52% for early-onset patients at onset and worst status, respectively. Also 63% of late-onset patients had disease progressed within first 3 years compared to only 40% of early-onset patients did. CONCLUSION Nonthymoma late-onset-generalized MG patients were common among Hong Kong Chinese, with a statistically non-significant trend that it was clinically more severe than early-onset MG but with similar clinical outcome or response to treatment; >90% of these patients were seropositive for striated muscle Ab.

Hypertensive encephalopathy: BP lowering complicated by posterior circulation ischemic stroke

In hypertensive encephalopathy (HTE), prompt reduction of blood pressure (BP) is essential to prevent permanent neurologic and other damages. Radiologically, HTE is characterized by white-matter edema affecting preferentially the occipital lobes and other posterior structures.1 The clinical and radiologic manifestations of HTE usually resolve completely after correction of hypertension.1,2⇓ We report two patients in whom neurologic deterioration occurred paradoxically with treatment of HTE. ### Patient 1. A previously healthy 36-year-old Filipino man presented with acute headache, confusion, bilateral visual loss, and BP of 260/130. There was no other focal neurologic deficit on admission. Retinal examination was unremarkable. Brain CT revealed white-matter edema at the occipital lobes. After 50 mg bolus of IV labetalol, BP was reduced with the lowest reading at 140/110. Two hours later, he developed acute pulmonary edema and generalized seizures. He was transferred to the Intensive Care Unit (ICU) and was ventilated under sedation. EKG showed no evidence of myocardial ischemia. His condition was stabilized, and he was extubated 40 hours later. Physical …

Sexual dysfunction after stroke: A need for more study

Our brain controls the central and peripheral nervous systems and regulates virtually all bodily functions both voluntarily and involuntarily. Stroke is not only the world s second leading cause of death but also the leading cause of adult disability [1]. Assessment of stroke impact has been standardized [2]. The National Institutes of Health Stroke Scale contains 13 items and measures severity of impairment in consciousness, orientation, gaze, motor function, sensation, language, speech and inattention. The Barthel Index is a measure of disability in 10 functional items. The modified Rankin Scale measures handicap or death on a scale of 1–6. Whilst physical impairment, disability and handicap are well studied, there have been few studies on sexual dysfunction after stroke [3]. Stroke has profound and negative impacts on the patient s life, including sexual functions and relationships with the spouse or partner. Physical impairments may be important. Hemiplegia may prevent a person or a couple from achieving the sexual positions. Aphasia and dysarthria would affect communication between spouses or partners. Depression after stroke, a relatively neglected area, as well as emotional incontinence could dampen libido [4,5]. On the other hand, decreased libido is a common side effect of antidepressant medications. Similarly, antihypertensive medications such as b-blockers can reduce libido [6,7]. Coexisting diabetes mellitus may be an important factor [7]. In addition, stroke can damage areas of the brain important for sexual functions such as the insula or other areas involved in production of sexual hormones such as the hypothalamus [8]. Rarely, hypersexuality has been reported following thalamic infarction [9]. Of the few studies available, sexual dysfunction after stroke is found to be associated with a variety of psychosocial factors and coexisting medical conditions rather than the direct effect of stroke [4–7,10–12]. These factors include sexuality being regarded as unimportant, inability to discuss sexuality with the partner, unwillingness for sexual activity and fear of another stroke. Tamam et al. assessed the sexual function in 103 Turkish stroke patients with no or mild disability [13]. Their results have shown a significant post-stroke decline in frequency of sexual activity in both males and females. Female patients have a significant decline in vaginal lubrication, orgasm and satisfaction. Erection and ejaculation are affected in male patients. The overall results are in agreement with those reported in the literature, confirming the importance of post-stroke sexual dysfunction in different racial and ethnic groups [4–7,10–12]. To date, we know very little about the best treatment for sexual dysfunction after stroke. Physicians should encourage patients to discuss their sex life after stroke with their partners. Both physicians and nurses should be able to provide practical advice for sex after stroke [14]. When sexual dysfunction exists, medications and coexisting medical conditions should be reviewed. Professional advice and sex therapy may be useful. In conclusion, there is a need for more study on sexual dysfunction after stroke.