Yen-Chu Huang

Periictal magnetic resonance imaging in status epilepticus

PURPOSE To determine the changes of magnetic resonance imaging (MRI) during the periictal phase in status epilepticus (SE). PATIENTS AND METHODS We identified 15 patients diagnosed of status epilepticus with corresponding MRI changes, including 11 patients with generalized convulsive status epilepticus (GCSE), 2 with complex partial status epilepticus (CPSE), and 2 with simple partial status epilepticus (SPSE). All MRI changes, corresponding electroencephalogram, and prognosis were evaluated. RESULTS Regional cortical lesions were observed on MRI, including restricted diffusion in diffusion-weighted images (DWIs) (11 out of 15) and hyperintense signal change in fluid-attenuated inversion recovery (FLAIR) images (12 out of 15) with hypervascularity and parenchymal swelling. The remote lesions included crossed cerebellar diaschisis (3 patients), ipsilateral thalamic lesion (4 patients), and basal ganglia lesions (3 patients). Although the periictal MRI changes were usually reversible, irreversible changes were also found, especially in GCSE, such as focal brain atrophy, cortical laminar necrosis, and mesial temporal sclerosis. GCSE patients with periodic epileptic form discharges had higher possibilities of widespread MRI abnormalities and poor prognosis in the future. CONCLUSIONS In this study, DWIs and FLAIR images were proved useful in determining the extent and severity of early neuronal damage caused by epileptic discharges in SE patients. Seizure-induced long-term injuries were also observed in the follow-up MRI.

Increased prothrombin, apolipoprotein A-IV, and haptoglobin in the cerebrospinal fluid of patients with Huntington's disease.

Huntingtons disease (HD) is a progressive neurodegenerative disease caused by an unstable CAG trinucleotide repeat expansion. The need for biomarkers of onset and progression in HD is imperative, since currently reliable outcome measures are lacking. We used two-dimensional electrophoresis and mass spectrometry to analyze the proteome profiles in cerebrospinal fluid (CSF) of 6 pairs of HD patients and controls. Prothrombin, apolipoprotein A-IV (Apo A-IV) and haptoglobin were elevated in CSF of the HD patients in comparison with the controls. We used western blot as a semi-quantified measurement for prothrombin and Apo A-IV, as well as enzyme linked immunosorbent assay (ELISA) for measurement of haptoglobin, in 9 HD patients and 9 controls. The albumin quotient (Qalb), a marker of blood-brain barrier (BBB) function, was not different between the HD patients and the controls. The ratios of CSF prothrombin/albumin (prothrombin/Alb) and Apo A-IV/albumin (Apo A-IV/Alb), and haptoglobin level were significantly elevated in HD. The ratio of CSF prothrombin/Alb significantly correlated with the disease severity assessed by Unified Huntingtons Disease Rating Scale (UHDRS). The results implicate that increased CSF prothrombin, Apo A-IV, and haptoglobin may be involved in pathogenesis of HD and may serve as potential biomarkers for HD.

Decreased intrathecal synthesis of prostaglandin D2 synthase in the cerebrospinal fluid of patients with acute inflammatory demyelinating polyneuropathy.

Prostaglandin D(2) synthase (PGDS) is the most abundant brain protein in cerebrospinal fluid (CSF) and is tied closely with inflammatory processes. This study investigated whether CSF PGDS levels in patients with acute inflammatory demyelinating polyneuropathy (AIDP) are altered. The results suggest that PGDS concentration is significantly increased in the CSF of AIDP patients compared with the control patients (p<0.05) due to a blood-CSF barrier dysfunction, whereas the intrathecal synthesis of PGDS, reflected by the CSF PGDS/albumin ratio, is significantly decreased in AIDP compared with the control group (p<0.05). The changes of CSF PGDS/albumin ratio are only observed in AIDP patients, but not in Miller Fisher Syndrome (MFS), chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), or multiple sclerosis (MS) patients.

Gouty Arthritis in Acute Cerebrovascular Disease

Background: Gouty arthritis is a metabolic disorder associated with several medical diseases and is considered as a high-risk factor of acute myocardial infarction and cardiovascular mortality. Since no study has assessed the frequency of gout attack in acute-stroke patients, a retrospective analysis of gouty arthritis in stroke patients was performed to identify the frequency and characteristics of gouty arthritis in hospitalized stroke patients. Methods: We reviewed the data of 920 patients admitted to the neurology ward of the Chiayi Chang Gung Memorial Hospital between 2002 and 2005 with ischemic stroke. The frequency of gouty arthritis in these patients was evaluated. The severity of the risk factors was compared between the patients with gout and those without. Results: The frequency of gouty arthritis in the stroke patients was 6.5%. Most patients had an attack of gout within 9 days of admission. History of gout, uric acid level and hypercholesterolemia were independent risk factors of gout attack during acute stroke. The duration of acute-ward stay was longer in patients with gout than in those without (17.17 vs. 14.01 days, p = 0.016). Conclusions: Our retrospective study demonstrated that gout attack is not uncommon in acute-stroke patients and may result in longer duration of acute-ward stay.

Parkinsonism in a patient with antiphospholipid syndrome — Case report and literature review

Antiphospholipid syndrome (APS) is identified as the presence of antiphospholipid antibodies (aPLs) in patients with vascular thrombosis and/or pregnancy morbidity (including fetal death, premature birth and habitual abortion). Neurological manifestations in patients with APS are common, whereas movement disorders are rarely seen. We report an extremely rare case of APS presented with parkinsonism and review the literature to address the clinical profile and possible pathophysiologic mechanism of this disorder.

Gastrointestinal Hemorrhage after Acute Ischemic Stroke and Its Risk Factors in Asians

Background: The aim of this study was to examine the frequency and risk factors of gastrointestinal (GI) hemorrhage in acute ischemic stroke patients in Taiwan. Method: 920 patients admitted for acute ischemic stroke from January 2001 to October 2005 were included in the study. We reviewed the available medical records for any episode of GI hemorrhage, possible precipitating factors and administration of ulcer prophylaxis. Results: Seventy-two patients (7.8%) experienced GI hemorrhage; these patients were of an older age (74.7 vs. 69.0 years, p < 0.001), had a longer acute ward stay (30.4 vs. 12.9 days, p < 0.001) and higher mortality rate (odds ratio 9.61, CI 4.53–20.42) than patients without GI hemorrhage. In multivariate logistic regression analysis, the important risk factors of GI hemorrhage included sepsis, previous history of GI hemorrhage, severe stroke, renal insufficiency and abnormal liver function. Of the 779 patients who had a 0–1 risk factor, 26 (3.3%) experienced GI hemorrhage; of the 27 patients with more than 2 risk factors, 17 (63%) suffered GI hemorrhage. Conclusion: This study of Asians revealed a higher frequency of GI hemorrhage after acute ischemic stroke than that reported in previous studies, and the frequency of GI hemorrhage was positively correlated with the number of risk factors present. We suggest that identifying stroke patients with a high risk of hemorrhage may allow clinicians to set up ulcer prophylactic protocols for the patients most likely to benefit, especially in an Asian population.

Spontaneous intrapetrous internal carotid artery dissection: A case report and literature review

Although hemodynamic change has been identified as the main mechanism of infarcts in intracranial internal carotid artery dissection, no report has utilized computed tomography perfusion study to evaluate the cerebral flow change in such cases. This report presents a rare case of intrapetrous internal carotid artery dissection with watershed infarction. Additionally, a literature review addresses the clinical profiles and related neuroimaging findings of such patients.

ALOX5AP genetic variants and risk of atherothrombotic stroke in the Taiwanese population

We explored the role of variants of the arachidonate 5-lipoxygenase-activating protein (ALOX5AP) gene as factors for atherothrombotic stroke (ATS). A HapMap-based haplotype-tagging single nucleotide polymorphism (htSNP) association study was conducted in an isolated Taiwanese population. Multivariate logistic regression analyses revealed that patients with the GG/CG genotype of rs4293222 and the AA/AG genotype of rs4360791 had a 1.61-fold (odds ratio [OR]=1.61; 95% confidence interval [CI]=1.02-2.56, p=0.042) and a 1.69-fold (OR=1.69; 95% CI=1.00-2.86, p=0.047) increased risk of ATS, compared with patients with the CC/GG genotype, respectively. The most common haplotype allele, GTA, was used as a reference when analyzing the association between the haplotypes related to rs4293222, rs10507391, rs12429692 and ATS. The combined frequencies of all minor variant alleles of the three selected htSNP were associated with a 44% decreased risk of ATS (OR=0.56; 95% CI=0.37-0.84, p=0.005). This study provides preliminary evidence suggesting that genetic polymorphisms of ALOX5AP are associated with ATS.

Fate of Diffusion Restricted Lesions in Acute Intracerebral Hemorrhage

Background Diffusion-restricted lesions on diffusion-weighted imaging (DWI) are detected in patients with intracerebral hemorrhage (ICH). In this study, we aimed to determine the fate of DWI lesions in ICH patients and whether the presence of DWI lesions is associated with functional outcome in patients with ICH. Methods This prospective study enrolled 153 patients with acute ICH. Baseline MRI scans were performed within 2 weeks after ICH to detect DWI lesions and imaging markers for small vessel disease (SVD). Follow-up MRI scans were performed at 3 months after ICH to assess the fate of the DWI lesions. We analyzed the associations between the characteristics of DWI lesions with clinical features and functional outcome. Results Seventeen of the 153 patients (11.1%) had a total of 25 DWI lesions. Factors associated with DWI lesions were high initial systolic and mean arterial blood pressure (MAP) at the emergency room, additional lowering of MAP within 24 hours, and the presence of white matter hyperintensity and cerebral microbleeds. Thirteen of the 25 DWI lesions (52%) were not visible on follow-up T2-weighted or fluid-attenuated inversion recovery images and were associated with high apparent diffusion coefficient value and a sharper decease in MAP. The regression of DWI lesions was associated with good functional outcome. Conclusions More than half of the DWI lesions in the ICH patients did not transition to visible, long-term infarction. Only if the DWI lesion finally transitioned to final infarction was a poor functional outcome predicted. A DWI lesion may be regarded as an ischemic change of SVD and does not always indicate certain cerebral infarction or permanent tissue injury.

Polymorphisms at the LDLR locus may be associated with ischemic cerebrovascular disease independent of lipid profile.

The low-density lipoprotein receptor (LDLR) gene has been reported to be associated with cerebral infarction. This study aimed to explore 2 genetic LDLR variants, rs688 and rs5925, for their potential roles in cerebral infarction. This genetic association study was conducted within an isolated Taiwanese population; 815 ischemic stroke patients (431 with atherothrombotic stroke and 384 with lacunar infarction) and 430 normal controls were enrolled. There was no significant difference in the genetic frequency of rs688 and rs5925 between the control group and overall ischemic stroke, atherothrombotic stroke, or lacunar infarct groups. However, when analyzing the association between the haplotypes related to rs688 and rs5925 and cerebral ischemic stroke, the most common haplotype allele CT was used as the reference allele, and the haplotype TC associated with a 65% increased risk of overall ischemic stroke, 72% increased risk of atherothrombotic stroke, and 70% increased risk of lacunar infarction; this indicated a synergistic effect between these 2 single-nucleotide polymorphisms. The LDLR analysis based on the haplotypes rs688 and rs5925 was conducted in a Taiwanese population and provided preliminary evidence suggesting that genetic polymorphisms of LDLR are associated with cerebral infarction.