Si Eun Kim

Clinical Significance of Fluid-Attenuated Inversion Recovery Vascular Hyperintensities in Borderzone Infarcts.

Background and Purpose— Fluid-attenuated inversion recovery vascular hyperintensities (FVHs) are seen in some cases with cerebral hemodynamic impairment and collateral flow. Because the worst outcomes of patients with borderzone infarcts were mainly correlated with impaired hemodynamics, the presence of FVH might provide another clue for predicting the prognosis of patients with borderzone infarcts. Methods— We reviewed 1377 consecutive patients with ischemic stroke. Cortical borderzone (CBZ) and internal borderzone infarcts were selected based on diffusion-weighted imaging. FVHs were defined as tubular- or serpentine-shaped hyperintensities in the subarachnoid space. We investigated the clinical significance of FVHs in borderzone-infarcted patients. Results— Among 87 patients with borderzone infarcts, the presence of FVH was observed in 30 (34.5%). We identified 62 patients with CBZ infarcts and 25 patients with internal borderzone infarcts. In the cases with CBZ infarcts, the initial National Institutes of Health Stroke Scale scores and the portions of nonfavorable outcome at 3 months in the FVH(+) group were significantly higher than in the FVH(−) group (P<0.05 and P<0.001, respectively). Unlike the cases with CBZ infarcts, there were no significant differences of these clinical features between the FVH(+) group and the FVH(−) group in the patients with internal borderzone infarcts. Conclusions— The findings of FVH are associated with relatively severe clinical presentation and nonfavorable prognosis in patients with CBZ infarcts, but not in patients with internal borderzone infarcts. The presence of FVH may help to identify CBZ-infarcted patients who require close observation and hemodynamic control.

Response to antiepileptic drugs in partial epilepsy with structural lesions on MRI.

OBJECTIVE Although partial epilepsy with structural lesions on MRI (lesional epilepsy) is less favorably responsive to antiepileptics than those without structural lesions on MRI, the response to antiepileptics in lesional epilepsy is a heterogeneous condition. There is growing evidence that the extent of epileptic network beyond the visible lesion on MRI may be related with the response to antiepileptics. The aims of this study are to clarify whether (1) the epilepsy network beyond the visible lesion on MRI, or (2) duration of lesional epilepsy on MRI are related with the response to antiepileptics or not. METHODS The inclusion criteria for this study were (1) having structural lesions on MRI, (2) taking antiepileptics for at least 1 year, and (3) age ≥13 years old. The definition for drug-resistance epilepsy was a failure of adequate trials of two tolerated, appropriately chosen and used antiepileptics to achieve sustained seizure freedom. The duration was defined as the interval between the start of antiepileptics and the last follow-up. We defined the lesion-plus group as the structural lesions on MRI that has wider spread of epileptic network beyond the visible lesions on MRI, such as hippocampal sclerosis and malformation of cortical development. Lesion-restriction group was defined as the epileptic network being believed to be limited on the structural lesions. RESULTS We found 234 patients with lesional epilepsy, who met the inclusion criteria. Of these 234 patients, 115 patients were male (49%) and 119 patients were female (51%). The median age was 22 years old (range 13-78 years old) and the median duration was 131 months (range 12-516 months). Forty percent (90/234 patients) were intractable to antiepileptics. Of the structural lesions on MRI, hippocampal sclerosis was most frequent (N=90). Other structural lesions were malformation of cortical development (N=38), cerebromalatic lesions related with trauma (N=34), tumor (N=19), cystic lesion (N=15), cerebral infarction (N=11), vascular malformation (N=10), and other miscellaneous lesion (N=24). Lesion-plus group had significantly higher drug-resistance epilepsy than cystic lesions on MRI (60/128 vs. 2/15, p=0.013 by Fishers exact test). There was a tendency of having more drug-resistance epilepsy in the lesion-plus group than the lesion-restriction group (56/121 vs. 30/89, p=0.09 by Chi-square test). The median duration in drug-resistance epilepsy was significantly longer than that of medically controlled epilepsy (178 months (range 23-516 months) vs 102 months (range 12-479 months), p<0.0001 by Mann-Whitney test). In addition, duration was only the significant variable associated with drug-resistance epilepsy in lesional epilepsy by multiple logistic regression analysis (p=0.02 for overall model fit). CONCLUSION In lesional epilepsy, hippocampal sclerosis and malformation of cortical development are more intractable to antiepileptics, reflecting wider epileptic network beyond the visible lesion. In addition, the response to antiepileptics may be expected to decrease when the duration is prolonged.

Isolated foot drop in acute infarction of the supplementary motor area.

Isolated monoparesis of any lower limb caused by acute schemic stroke is uncommon. Among cases of isolated monoaresis, reports of sudden isolated foot drop are rarely reported 1,2]. This symptom, which presents with a peroneal-like distriution, has been shown to be caused by small cortical lesions in he parasagital precentral gyrus. However, to our knowledge, there ave been no reports of isolated foot drop associated with a lesion n the supplementary motor area (SMA). We report a patient with solated foot drop after acute infarction of the SMA.

Can the adverse effects of antiepileptic drugs be detected in saccadic eye movements

PURPOSE The objective of this study was to determine whether the adverse effects of antiepileptic-drugs could be assessed by the eye movements of epilepsy patients. METHODS This study was performed prospectively in a single tertiary hospital. The inclusion criteria for this study were as follows: (1) consecutive patients with epilepsy taking antiepileptic-drugs regularly for at least 1 year, (2) the absence of structural lesions on MRI, (3) an age ≥16 years old, (4) not using medications that could influence eye movement, and (5) a normal neurological examination. The latency, peak velocity and accuracy of the saccades and the gain of the pursuits were recorded by video-based electro-oculography. We analyzed the differences in the parameters of the eye movements for 75 patients with epilepsy and 20 normal controls matched for age and sex. RESULTS The total latency (1017.7 ± 148.9 ms vs. 1150.7 ± 106.6 ms, p=0.0003) and accuracy [370.7% (95% CI 364.1-376.4%, range 306-408.2%), 92.7% as total accuracy normalized value vs. 383.6% (95% CI 378.8-398%, range 322.9-417.4%), 95.9% as total accuracy normalized value, p=0.0005] were significantly different between the patients with epilepsy and normal controls. For the detection of nystagmus with video-based electro-oculography, the clear cutoff values of total accuracy (≤388.7%, 97.2% as total accuracy normalized value) revealed 93.4% sensitivity and 28.6% specificity, and the clear cutoff values of total latency (≤1005.5 ms) showed 49.2% sensitivity and 78.6% specificity. CONCLUSIONS The total latency and accuracy of video-based electro-oculography may be screened to identify patients with a high risk of adverse effects with antiepileptic-drugs.

An elderly case of acute cerebellitis after alleged vaccination.

Acute cerebellitis (AC) is a benign and self-limiting inflammatory disease. It typically occurs as a primary infectious or postinfectious disorder. Although AC mostly presents in early childhood, it can appear in adult. A 66-year-old man admitted to our hospital because of limb and gait ataxia. Three weeks ago, he took an influenza vaccination. There was no abnormality on brain MRI with contrast enhancement, but Technetium-99m hexamethyl propylene amine oxime-single photon emission computed tomography (HMPAO-SPECT) showed markedly cerebellar asymmetry, suggesting hypoperfusion in the right cerebellum. Influenza vaccination can cause AC in the elderly and brain HMPAO-SPECT imaging is more useful than MRI in identifying patients with AC.

Orthostatic dizziness in Parkinson's disease is attributed to cerebral hypoperfusion: A transcranial doppler study

Orthostatic hypotension (OH) is controversially regarded as the cause of orthostatic dizziness in Parkinsons disease (PD). We sought to evaluate whether cerebral autoregulation is an alternative cause for orthostatic dizziness in PD patients, using transcranial Doppler monitoring during head‐up tilting.

Procalcitonin as a potential predicting factor for prognosis in bacterial meningitis

We investigated the potential role of serum procalcitonin in differentiating bacterial meningitis from viral meningitis, and in predicting the prognosis in patients with bacterial meningitis. This was a retrospective study of 80 patients with bacterial meningitis (13 patients died). In addition, 58 patients with viral meningitis were included as the disease control groups for comparison. The serum procalcitonin level was measured in all patients at admission. Differences in demographic and laboratory data, including the procalcitonin level, were analyzed between the groups. We used the mortality rate during hospitalization as a marker of prognosis in patients with bacterial meningitis. Multiple logistic regression analysis showed that high serum levels of procalcitonin (>0.12ng/mL) were an independently significant variable for differentiating bacterial meningitis from viral meningitis. The risk of having bacterial meningitis with high serum levels of procalcitonin was at least 6 times higher than the risk of having viral meningitis (OR=6.76, 95% CI: 1.84-24.90, p=0.004). In addition, we found that high levels of procalcitonin (>7.26ng/mL) in the blood were an independently significant predictor for death in patients with bacterial meningitis. The risk of death in patients with bacterial meningitis with high serum levels of procalcitonin may be at least 9 times higher than those without death (OR=9.09, 95% CI: 1.74-47.12, p=0.016). We found that serum procalcitonin is a useful marker for differentiating bacterial meningitis from viral meningitis, and it is also a potential predicting factor for prognosis in patients with bacterial meningitis.

A NOMOGRAM FOR PREDICTING AMYLOID PET POSITIVITY IN AMNESTIC MILD COGNITIVE IMPAIRMENT

load (participants with positive versus negative brain amyloid load) will be determined. Results:Hyperspectral retinal imaging will be completed for the remaining n1⁄440 participants, aged 60 years and above. Data will be analysed via image processing and preliminary findings presented at the conference. Conclusions:Successful validation of hyperspectral retinal imaging will serve as an early, non-invasive and economical diagnostic tool for preclinical AD.

ALZHEIMER’S DEMENTIA CONVERSION IN AMNESTIC MCI ACCORDING TO NEUROPSYCHOLOGICAL PROFILE

annualized change in SUVR were compared between DLB and CN using generalized additive models accounting for matching. Associations between annualized global measures of clinical progression and b-amyloid accumulation were assessed in DLB. Results: The trajectories of longitudinal b-amyloid accumulation were similar between DLB and CN (p1⁄40.425 for difference in trajectory shape; p1⁄40.22 for difference in vertical shift; Figure 1). Rates of b-amyloid accumulation increased up to 1.8 baseline SUVR and then decreased. Increasing changes in clinical dementia rating -sum of boxes were independently associated with higher baseline SUVR (p1⁄40.023) and a greater change in SUVR (p1⁄40.025) until reaching 1.8 baseline SUVR; no relationship was present for >1.8 baseline SUVR (Figure 2). Conclusions: In DLB, b-amyloid accumulation accelerates and is associated with clinical decline up to 1.8 baseline SUVR. At >1.8 baseline SUVR, the accumulation decelerates and dissociates from the clinical progression. Acceleration–deceleration denotes a sigmoid-shaped functional form which is the same in unimpaired, clinical AD dementia, and as we have shown in DLB. Baseline PiB SUVR should be considered in designing clinical trials targeting b-amyloid pathology in DLB.

DISEASE COURSE MODELING OF ALZHEIMER’S DISEASE DEPENDING ON AMYLOID DEPOSITION: AN ACCELERATED LONGITUDINAL DESIGN

Background: Patients with dementia, particularly Alzheimer’s disease (AD), are at an increased risk of developing epilepsy. However, the extent of this increased risk has been disputed and remains unclear. We measured the prevalence of epilepsy in a cohort of patients with AD recruited from a memory clinic in secondary care to identify which patients are at a risk of epilepsy, the clinical features of these seizures and the stage of disease at which seizures occur Methods:Patients with a diagnosis of probable AD dementia were recruited from a regional memory clinic. Interviews were conducted with the patient and a reliable informant using a structured proforma designed for this purpose. Using their responses to questions regarding clinical features of epilepsy, patients were categorised into three groups: epilepsy probable, epilepsy possible, or no clinical suspicion of epilepsy. Dementia diagnoses were confirmed using established research criteria. Cognitive function was measured using the Addenbrooke’s Cognitive Examination Version-III (ACE-III). Results: 102 patients were recruited to the study. 12 patients (11.7%) were categorised to the epilepsy probable group and 16 (15.7%) patients to the epilepsy possible group. This group was not significantly different to those in whom there was no suspicion of epilepsy, in terms of age, gender, or duration of memory symptoms. However, there was a significant difference in the Clinical Dementia Rating (CDR) sum of boxes score between those with epilepsy and thosewithout. In the epilepsy probable group, 9 patients (75%) experienced focal impaired awareness / focal behavioural arrest seizures; 2 patients (16.67%) experienced generalised tonicclonic seizures. A range of further seizure features were also seen. The mean duration from onset of memory impairment to seizure onset in this group was 16.4 months (range 0 to 36). Conclusions:Patientswho experience epilepsy as a result of their dementia are demographically and cognitively similar to those that do not have epilepsy, but may experience a broader range of cognitive impairments and increased care needs as evidenced by elevated CDR scores. In our cohort, patients with epilepsy were likely to have experienced a first seizure within 18 months of developing memory symptoms.