Sung-Sang Yoon

Plaque Rupture is a Determinant of Vascular Events in Carotid Artery Atherosclerotic Disease: Involvement of Matrix Metalloproteinases 2 and 9

Background and Purpose Unstable carotid atherosclerotic plaques are characterized by cap rupture, leading to thromboembolism and stroke. Matrix metalloproteinases (MMPs) have been implicated in the progression of atherosclerosis and plaque rupture. The aim of this study was to assess the relationship between the expressions of MMP-2 and MMP-9 and carotid plaque instability. Methods Eighty atherosclerotic plaques were collected from 74 patients undergoing carotid endarterectomy. Clinical information was obtained from each patient, and plaque morphology was examined at the macroscopic and microscopic levels. The immunohistochemical expressions of MMPs were graded using semiquantitative scales. Results Macroscopic ulceration (84.6% versus 63.4%, p=0.042) and microscopic cap rupture (79.5% versus 51.2%, p=0.010) were more common in symptomatic than in asymptomatic patients. Immunoreactivities of MMP-2 and MMP-9 were increased in 40 and 36 atheromatous plaques, respectively. Macroscopic ulceration was strongly correlated with the expressions of MMP-2 (p<0.001) and MMP-9 (p=0.001). There were significant correlations between increased MMP-2 expression and cap rupture (p=0.002), intraplaque hemorrhage (p=0.039), and a thin fibrous cap (p=0.002), and between increased MMP-9 expression and cap rupture (p=0.010) and a large lipid core (p=0.013). Conclusions Plaque rupture was significantly associated with the development of vascular events in carotid atherosclerotic disease. MMP-2 and MMP-9 are strongly correlated with plaque instability.

Relationship between clinical course and Diffusion-weighted MRI findings in sporadic Creutzfeldt-Jakob Disease

The aim of this study was to investigate the relationship between clinical course and diffusion-weighted MRI (DWI) findings in sporadic Creutzfeldt-Jakob Disease (sCJD). We reviewed clinical records and MRI examination in nine probable sCJD. According to hyperintense signal distribution on DWI, the patients were classified into two groups with cortical ribbon plus basal ganglia hyperintensity (6/9) and with only increased cortical signals (3/9). Clinical features including quadriparesis (3/6), akinetic mutism (2/6), and dysphasia (2/6), which were usually observed in the more advanced stage of CJD, were noted only in patients with cortical ribbon plus basal ganglia hyperintensity at the time of initial DWI examination. The patients with the cortical plus basal ganglia hyperintensity (6.4±1.7 weeks) had a shorter interval from symptom onset to akinetic mutism than those with only cortical ribbon hyperintensity (26.0±22.5 weeks) (p=0.02). These findings suggest that DWI may predict the clinical course of CJD.

Executive dysfunction associated with stroke in the posterior cerebral artery territory

Cognitive decline following posterior cerebral artery infarction (PCAI) is associated with lesions in the occipital lobe that extend into the parahippocampus or the splenium. We investigated patterns of neuropsychological deficits, including those causing executive dysfunction, associated with isolated lesions of the occipital lobe and with extensive lesions of the occipital lobe that extended into the splenium or the posterior ventral temporal lobes including the parahippocampus and fusiform gyrus. Eleven patients with unilateral PCAI involving the cerebral cortex and one patient with an occipital hemorrhage were selected for inclusion in this study. The mean age of the patients was 68.50 ± 7.94 years and their mean level of education was 8.58 ± 4.12 years. Four patients had isolated occipital lobe lesions and eight had lesions in either the splenium or the posterior ventral temporal lobe in addition to the occipital lobe. Whereas three of four patients with isolated occipital lobe lesions had left-sided lesions, only three of the eight patients with extended occipital lesions had left-sided lesions. The patients underwent a standardized battery of neuropsychological tests. The patients with occipital injuries in addition to splenial or posterior ventral temporal lobe injuries demonstrated performance decline across diverse cognitive domains, including memory (eight of eight), visuospatial function (eight of eight), executive function (seven of eight), language-related function (four of eight) and attention (one of eight). In contrast, memory impairment (three of four patients) was the only area in which patients with isolated occipital lobe lesions demonstrated decline in performance. Our findings suggest that strokes in the territory of the posterior cerebral artery are frequently associated with executive dysfunction. Injuries involving the splenium or posterior ventral temporal lobe in addition to the occipital lobe lead to more diverse neuropsychological impairments than do isolated occipital lobe injuries alone.

Amnesic syndrome in a mammillothalamic tract infarction.

It is controversial whether isolated lesions of mammillothalamic tract (MTT) produce significant amnesia. Since the MTT is small and adjacent to several important structures for memory, amnesia associated with isolated MTT infarction has been rarely reported. We report a patient who developed amnesia following an infarction of the left MTT that spared adjacent memory-related structures including the anterior thalamic nucleus. The patients memory deficit was characterized by a severe anterograde encoding deficit and retrograde amnesia with a temporal gradient. In contrast, he did not show either frontal executive dysfunction or personality change that is frequently recognized in the anterior or medial thalamic lesion. We postulate that an amnesic syndrome can develop following discrete lesions of the MTT.

A Case of Herpes Zoster Ophthalmicus with Isolated Trochlear Nerve Involvement

Background Herpes zoster ophthalmicus (HZO) can involve the oculomotor nerve; however, isolated trochlear nerve palsy has rarely been reported. Case Report An 83-year-old man who suffered from HZO in the right frontal area and scalp subsequently developed vertical diplopia and severe pain. Cerebrospinal fluid examination and brain MRI revealed no abnormalities. Isolated right trochlear nerve palsy was diagnosed based on the findings of neuro-ophthalmological tests. Conclusions Isolated trochlear nerve involvement associated with HZO is very rare and may be easily overlooked. Physicians should carefully examine oculomotor involvement in HZO.

Sleep Disturbances and Predictive Factors in Caregivers of Patients with Mild Cognitive Impairment and Dementia

Background and Purpose We examined the characteristics of sleep disturbances and sleep patterns in the caregivers of patients with amnestic mild cognitive impairment (aMCI) and dementia. Methods We prospectively studied 132 patients (60 with aMCI and 72 with dementia) and their caregivers, and 52 noncaregiver controls. All caregivers and controls completed several sleep questionnaires, including the Pittsburgh Sleep Quality Index (PSQI). The patients were administered neuropsychological tests and the neuropsychiatric inventory to evaluate their behavioral and neuropsychiatric symptoms of dementia (BPSD). Results The PSQI global score was 6.25±3.88 (mean±SD) for the dementia caregivers and 5.47±3.53 for the aMCI caregivers. The Insomnia Severity Index (ISI) and short form of the Geriatric Depression Scale (GDS-S) predicted higher PSQI global scores in aMCI caregivers, and higher scores for the ISI, Epworth Sleepiness Scale (ESS), and GDS-S in dementia caregivers. BPSD, including not only agitation, depression, and appetite change in dementia patients, but also depression, apathy, and disinhibition in aMCI patients, was related to impaired sleep quality of caregivers, but nighttime behavior was not. Age and gender were not risk factors for disturbed sleep quality. Conclusions Dementia and aMCI caregivers exhibit impaired quality of sleep versus non-caregivers. ISI, GDS-S, and ESS scores are strong indicators of poor sleep in dementia caregivers. In addition, some BPSD and parts of the neuropsychological tests may be predictive factors of sleep disturbance in dementia caregivers.

Takayasu’s disease presenting with atherothrombotic ischaemic stroke

Takayasu’s arteritis is a chronic inflammatory disease of the aorta and its main branches, and a well known cause of stroke. Pathogenesis of ischaemic stroke has been attributed to intracranial vasculitic involvement or emboli from either stenoocclusive extracranial vessels or cardiac disease such as aortic regurgitation. We present a patient with Takayasu’s arteritis and recurrent cerebral infarctions associated with intracranial atherosclerosis. We postulate that the intracranial atherosclerotic process is an important mechanism in Takayasu’s arteritis-related ischaemic stroke.

Splenium or parahippocampus involvement and its relationship to cognitive decline in posterior cerebral artery infarction

Although cognitive impairment after a posterior cerebral artery (PCA) infarct is frequently observed, the important functional areas associated with cognitive decline, other than the thalamus, have not been determined. We investigated the locus or loci that might induce cognitive decline after a PCA infarct. Forty-one patients with unilateral PCA infarctions involving only the occipital lobe or the occipital lobe plus other PCA areas were included. All subjects received a mini-mental status examination (MMSE) within 2 months of onset; 43.9% had cognitive impairment. The severity of cognitive impairment was not associated with left hemisphere lesion location, sex, age, education level, or the time between stroke and the MMSE assessment. Only the lesion volume was negatively correlated with MMSE score. Lesion location analysis revealed that an occipital plus splenial or parahippocampal lesion contributed to a decline in MMSE, which suggests that parahippocampal or splenial involvement with an occipital lesion is associated with the cognitive decline seen after PCA infarction.

Retrograde amnesia associated with fornix lymphoma.

petitively, often forgetting orders from customers, and would have his employees to roast sesame too much without considering the size of the order. The family thought he seemed strange because he showed no anger when one of his employees, who had worked for him for more than 10 years, moved to a neighboring mill without telling him. His medical history was remarkable for a small infarction of the posterior limb of the right internal capsule with consequent mild left lower extremity weakness 17 years previously as well as for medication-controlled diabetes mellitus arising 3 years earlier. On examination, the patient appeared alert and cooperative but unaware of his memory deficits. He correctly answered questions on personal information, such as his social security number, telephone number, and home address. However, he could not remember recent events, such as how he had visited the clinic and what he had eaten for lunch 1 h before. On MiniMental Status examination, he could not recall 3 words that he had registered only a few minutes before, scoring 20/30 due to additional problems with orientation in time and place and the last step of the Serial Seven Test. The severity and content of cognitive decline were investigated by detailed neuropsychological tests using a standardized battery called the Seoul Neuropsychological Screening Battery [5] . The patient’s Dear Sir, Fornix is a principal tract of the Papez circuit, interconnecting the hippocampus with the anterior thalamic nuclei directly or via the mammillary body. A fornix lesion disconnects the memory circuit that runs from the temporal to the frontal lobe, causing severe anterograde amnesia [1–3] . Memory impairment in those patients was characterized by anterograde amnesia, recognition better than recall and preserved procedural memory. To our knowledge, of 4 reported cases with a localized fornix lesion [1–4] , only 1 patient was described having memory deficits for a retrograde event [4] . However, the patient retained the ability to recall past events, while only confusing their temporal order. We evaluated a patient who suddenly developed a profound retrograde amnesia and anterograde memory impairment associated with an isolated fornix lesion.

Glossoplegia in a small cortical infarction

We recently observed a patient with obvious contralateral tongue deviation with minimal lower facial paresis caused by a small cortical infarction confirmed by MRI. The small cortical lesion, causing obvious tongue deviation in our patient, was located lateral to the precentral knob which is known as a reliable anatomical landmark for the motor hand area. We were able to localise the cortical area for tongue movement to the most lateral part of the precentral gyrus lateral to the precentral knob. A 63-year-old, right-handed man with a 1 year history of hypertension suddenly developed dysarthria. He was alert, …