Tae Sung Lim

Galantamine administration in chronic post-stroke aphasia

Background To investigate the influence of galantamine on linguistic function, any associated factors in patients with chronic post-stroke aphasia were analysed. Methods 45 patients younger than 75 years with chronic aphasia (≥1 year since onset) were prospectively enrolled in the study. Language testing was performed at weeks 0 and 16. Initial galantamine dose was 8 mg/day for 4 weeks, and 16 mg/day for the following 12 weeks. Efficacy was evaluated by the sum of four domains (spontaneous speech, comprehension, repetition and naming) on the aphasia quotient (AQ) of the Western Aphasia Battery from baseline (AQ1) to endpoint (AQ2). Patients were considered as ‘responding’ if the increase in AQ was ≥20. Results Mean age was 60.4 years (22–74) and 14 patients were female. Mean duration of aphasia was 2.2±1.5 years. There was a significant increase in the total AQ score in the galantamine group (n=23, 48.5–57.0 percentile; p=0.007) but not in the control group (n=22, 54.3–54.9 percentile; p=0.308). The AQ2 score was independently associated with AQ1, galantamine administration and Mini-Mental State Examination (MMSE) score in multiple linear regression models. With the galantamine group, the good responders (vs poor responders) had a higher level of education (p=0.048), higher baseline MMSE score (p=0.009) and a subcortical dominant pattern (p=0.030). After adjusting for potential variables, subcortical dominant lesion was the independent determinant for galantamine responsiveness (OR 30.3; 95% CI 1.1 to 805.9, p=0.041). Conclusion Administration of galantamine had a beneficial effect on chronic post-stroke aphasia, and was more prominent in subcortical dominant lesions.

Serum cholesterol levels and the risk of multiple system atrophy: A case-control study†

Cholesterol in brain membranes may modulate the conformational state and accumulation of α‐synuclein in α‐synucleinopathies.We examined the association between serum cholesterol and the risk of multiple system atrophy (MSA), one of the α‐synucleinopathies. We enrolled 142 patients with probable MSA from two tertiary referral hospitals and 155 age‐ and gender‐matched healthy people with no neurological disease. The levels of total cholesterol, low‐density lipoprotein cholesterol (LDL‐C), and high‐density lipoprotein cholesterol (HDL‐C) were significantly lower in MSA patients than in controls (total cholesterol: 172.7 vs. 196.3 mg/dL, P < 0.001; LDL‐C: 104.0 vs. 115.3 mg/dL, P = 0.001; HDL‐C: 47.3 vs. 54.2 mg/dL, P < 0.001). After adjusting for age, gender, use of cholesterol‐lowering drugs, and histories of hypertension, diabetes mellitus, and smoking, the odds ratios was 5.9 (95% CI = 2.3–11.5, P < 0.001) for MSA patients in the lowest quartile of total cholesterol and 2.6 (95% CI = 1.2–5.5, P = 0.016) for those in the lowest quartile of HDL‐C, compared with the highest quartiles. Levels of serum cholesterol did not significantly correlate with disease duration or severity. Our data suggest that lower levels of total cholesterol and HDL may be associated with an increased risk of MSA.

Metabolite Investigation in Both Anterior and Posterior Cingulate Gyri in Alzheimer’s Disease Spectrum Using 3-Tesla MR Spectroscopy

Aims: In order to evaluate the metabolite changes of both anterior and posterior cingulate gyri during the progression of Alzheimer’s disease (AD) pathology, a 3-tesla MR spectroscopy study was performed. Methods: Thirty-six patients with AD, 19 patients with amnestic mild cognitive impairment (aMCI), and 23 cognitively normal (CN) subjects were recruited. MR spectroscopy was conducted within the anterior and posterior cingulate gyri. A one-way analysis of co-variance was used to compare the metabolite ratios of each group and correlation analysis was used to show the correlation between the metabolite ratios with the Mini-Mental State Examination (MMSE) and Neuropsychiatric Inventory (NPI). Results: The N-acetylaspartate/creatine (NAA/Cr) of the posterior cingulate gyrus was significantly higher in CN subjects than in aMCI and AD patients. On the other hand, the myoinositol/creatine (ml/Cr) of the anterior cingulate gyrus was significantly higher in AD patients than in CN subjects and aMCI patients. The ml/Cr of the posterior cingulate gyrus correlated with the MMSE and that of the anterior cingulate gyrus correlated with the NPI. Conclusion: Both the decreased NAA/Cr of the posterior cingulate gyrus and the increased ml/Cr of the anterior cingulate gyrus may reflect biochemical changes in AD according to the posterior-dominant progression of AD pathology.

Induced-hypertension in progressing lacunar infarction

BACKGROUND Although an early neurological deterioration after lacunar infarction is not rare, its therapeutic options are still undetermined. We investigated the effect of induced-hypertension in lacunar infarction with motor progression. METHODS We reviewed 82 lacunar infarction patients who experienced motor progression [≥ 1-point increase of NIH stroke scale (NIHSS) during hospitalization]. Induced-hypertension using phenylephrine was applied to 52 patients and the others received conventional treatment. Target blood pressure (BP) was defined as a 20% increase of initial systolic BP and motor stabilization time as a period from motor progression to motor stabilization. Good outcome was designated as a modified Rankin disability scale 0-2 at discharge in phenylephrine group. RESULTS Phenylephrine group (vs. conventional group) had a lower NIHSS motor score after each treatment (p=0.022), a shorter motor stabilization time (p<0.001) and hospitalization period (p=0.047), although there were not significantly different from baseline clinical and laboratory findings (ie. age, sex, risk factors for stroke, initial BPs, and NIHSS motor score) in two groups. In multiple regression analysis, a history of hypertension (odds ratio, OR 7.11, 95% CI 1.43-35.31, p=0.016), achievement of target BP (OR 8.13, 95% CI 1.49-44.45, p=0.016) and motor stabilization time (OR 0.51 per 1-day increase, 95% CI 0.29-0.87, p=0.015) were independent predictors for good outcome in the phenyephrine group. Side effects of phenylephrine treatment were transient chest tightness (n=3) and dysuria (n=2). CONCLUSION The present study suggests that phenylephrine induced-hypertension can result in early motor restoration without serious side effects in progressing lacunar infarction.

Evaluation of coexistence of Alzheimer’s disease in idiopathic normal pressure hydrocephalus using ELISA analyses for CSF biomarkers

BackgroundWe investigated levels of the β-amyloid 1–42 (Aβ42), total tau protein (T-tau) and tau phosphorylated at position threonine 181 (P-tau) in cerebrospinal fluid (CSF) of idiopathic normal pressure hydrocephalus (iNPH) patients and tried to find their clinical implications in the evaluation and treatment of iNPH.MethodTwenty-five possible iNPH patients were prospectively enrolled and their CSF was collected to analyze levels of Aβ42, T-tau and P-tau using ELISA method. Gait disturbance, urinary incontinence, and cognitive impairment were semi-quantified and detailed neuropsychological (NP) test was performed.ResultEight iNPH patients were classified into the lower CSF Aβ42 group and 17 patients were classified into the higher CSF Aβ42 group. There was no difference in the iNPH grading score and its improvement after LP between the two groups. The lower CSF Aβ42 group showed more deficits in attention, visuospatial function and verbal memory in the baseline NP test and less improvement in phonemic categorical naming and frontal inhibitory function after LP.ConclusionsOur study suggested that concomitant AD in iNPH patients might contribute to lumbar puncture or shunt unresponsiveness, especially in the field of cognitive dysfunction.

Functional investigation of bilateral posterior cingulate gyri using multivoxel MR spectroscopy.

The exact functional correlation of each hemisphere’s posterior cingulate gyrus with the symptoms of Alzheimer’s disease (AD) remains unknown. We attempted to evaluate the relationship between metabolite ratios in each hemisphere’s posterior cingulate gyrus and cognitive deficits, using multivoxel magnetic resonance spectroscopy (MRS). We recruited 23 patients with AD, 16 patients with amnestic mild cognitive impairment and 22 cognitively normal subjects. All patients underwent multivoxel MRS in the bilateral posterior cingulate gyri. We statistically analyzed correlations between the N-acetylaspartate/creatine ratio (NAA/Cr) in each posterior cingulate gyrus and patients’ raw scores on neuropsychological tests. The NAA/Cr of each posterior cingulate gyrus correlated well with the verbal learning test scores on immediate recall and delayed recall tasks. We found that the only cognitive domain to correlate with the NAA/Cr of each posterior cingulate gyrus was verbal memory. Our results did not show any significant functional difference between right and left posterior cingulate gyri.

Movement disorders at a university hospital emergency room. An analysis of clinical pattern and etiology.

We prospectively evaluated the clinical features and etiologies of all common categories of movement disorder seen in the emergency room (ER) of an urban university hospital over a period of 12 months. We divided movement disorders according to the presenting phenomenology likely to dominate the clinical presentation, that is, gait disorder, tremor, dystonia, myoclonus, and acute akinetic crisis and classified a specific etiology in the individual phenomenology. In one year, there were 60,002 ER visits; of these, 58 (0.09 %) were diagnosed as a primary movement disorder. The most common clinical presentation was gait disorder (n = 21, 36.2 %), followed by myoclonus (n = 16, 27.6 %), dystonia (n = 10, 17.2 %), tremor (n = 8, 13.8 %), and acute akinetic crisis (n = 3, 5.2 %). Comparing the movement disorders, the mean age of the patients with dystonia was significantly lower than that of patients with other movement disorders (P < 0.001). Of the patients, 37 (63.8 %) had drug-related movement disorders. The contribution of drugs was significantly higher in patients with dystonia compared with the other movement disorders (P < 0.01). Our study showed that a large proportion of the movement disorders seen in the ER are drugrelated. Careful selection of drugs while prescribing would decrease movement disorder-related visits to the ER.

Posterior circulation embolism as a potential mechanism for migraine with aura

Background: Although the mechanism of migraine is regarded as a functional disorder of the brain, numerous studies have reported that migraine is closely associated with vascular system abnormalities. Case reports: We describe a 19-year-old female with recurrent migraine attacks and typical aura for 7 years. MRI showed multiple stroke lesions in the posterior circulation. Moreover, a pseudoaneurysm (1.9 ×  1.4 cm) originating from the left vertebral artery was observed on four-vessel angiography. Multiple microembolic signals (MES) were repeatedly observed in the basilar artery using 30-minute transcranial Doppler monitoring. Interestingly, MES and her typical migrainous symptoms disappeared simultaneously with removal of the pseudoaneurysm. Discussion: This case supports the fact that microemboli play a pivotal role in the development of migraine attacks.

Profile of memory impairment as a prognostic marker in amnestic mild cognitive impairment

We aimed to evaluate whether recognition memory can be used to identify patients with amnestic mild cognitive impairment (aMCI) at greater risk for converting to dementia. We recruited 2172 aMCI patients. They were divided into two groups: aMCI with impaired recall but normal recognition (aMCI-IRNR) vs aMCI with impaired recall and impaired recognition (aMCI-IRIR). We compared demographic findings and neuropsychological performance and illustrated the difference in converting to dementia between the two groups. Study subjects consisted of 1022 (47.0%) patients with aMCI-IRNR and 1150 (53.0%) patients with aMCI-IRIR. In most neuropsychological tests except for digit span forward, patients with aMCI-IRIR were more impaired than patients with aMCI-IRNR even after adjustment of their age and sex. Cox analysis adjusting age and gender revealed that the risk of dementia conversion was higher in patients with aMCI-IRIR than in patients with aMCI-IRNR [hazard ratio (HR)=1.400, 95% CI 1.009-1.943; P=0.044]. This study showed that recognition memory can be used to identify patients with amnestic mild cognitive impairment (aMCI) at greater risk for converting to dementia.

Migrating Calcification on CT Angiography: Another Sign of an Embolic Stroke

A 54-year-old male developed sudden right hemiparesis and motor aphasia. Computed tomography (CT) angiography showed calcifications on the distal middle cerebral artery ( fig. 1 a, b), an unusual place for intracranial calcifications [1] . CT scan taken 6 days later shows that one of the calcified plaques had migrated distally ( fig. 1 c, d). Transesophageal echocardiography revealed a heavily calcified aortic valve and a 5-mm-thick atheromatous plaque on the ascending aorta. Migrating calcification is a sign that highly suggests an embolic origin in a stroke patient. Received: September 3, 2009 Accepted: September 15, 2009 Published online: January 26, 2010