[The peak latency prolongation of the blink reflex in a patient with trigeminal neuralgia of Meckel's cave mass]. / A pislogási reflexcsúcs latenciájának megnyúlása egy Meckel-barlang-terime következtében kialakuló trigeminusneuralgia esetben.

The blink reflex test of the trigeminal nerve can provide valuable information about lesions site. However it may not find small compressive lesions. We observed peak latency prolongation of the blink reflex test in a patient with trigeminal neuralgia caused by a small Meckel's cave mass, in whom the onset latency was normal. Conclusion - We suggest peak latency of the blink reflex might be a valuable aid for discerning small mass in patients with trigeminal neuralgia. This is the first case report of compressive trigeminal neuralgia showing peak latency prolongation of the blink reflex test.

The moderating effect of religiosity on caregiving burden and depressive symptoms in caregivers of patients with dementia.

OBJECTIVES: This study explored whether religiosity/spirituality has a protective role against negative caregiving outcomes, in a large multicenter nationwide sample of caregivers of patients with dementia in South Korea. Additionally, this study was the first to examine whether religiosity/spirituality could affect caregiving outcomes according to the various religious affiliations of caregivers. METHODS: The study was conducted on a sample of 476 caregivers of patients with dementia participated in the Clinical Research Center for Dementia of South Korea (CREDOS). We examined the moderating effect of each of the three dimensions of religiosity/spirituality (organizational religious activity, ORA; non-organizational religious activity, NORA; intrinsic religiosity, IR) on the relationship between activities of daily living (ADL) of patients with dementia and caregiving burden and depressive symptoms of caregivers, using a series of hierarchical regression analyses. In addition, these analyses were conducted according to the religious affiliations of the caregivers. RESULTS: ORA, NORA, and IR of religiosity/spirituality alleviated the effect of ADL of patients on caregiving burden. ORA and IR moderated the relationship between ADL of patients and depressive symptoms of caregivers. These moderating effects of religiosity on caregiving outcomes were different according to various religious groups. CONCLUSION: We have identified religiosity/spirituality as a protective factor for caregivers of patients with dementia. The sub-dimensions of religiosity as moderators were different by religious affiliations of caregivers. Further studies are needed to investigate the specific religiosity-related factors which could positively impact the mental health of the caregivers of patients with dementia by religions.

Influence of personality on depression, burden, and health-related quality of life in family caregivers of persons with dementia.

BACKGROUND: Personality may predispose family caregivers to experience caregiving differently in similar situations and influence the outcomes of caregiving. A limited body of research has examined the role of some personality traits for health-related quality of life (HRQoL) among family caregivers of persons with dementia (PWD) in relation to burden and depression. METHODS: Data from a large clinic-based national study in South Korea, the Caregivers of Alzheimer's Disease Research (CARE), were analyzed (N = 476). Path analysis was performed to explore the association between family caregivers' personality traits and HRQoL. With depression and burden as mediating factors, direct and indirect associations between five personality traits and HRQoL of family caregivers were examined. RESULTS: Results demonstrated the mediating role of caregiver burden and depression in linking two personality traits (neuroticism and extraversion) and HRQoL. Neuroticism and extraversion directly and indirectly influenced the mental HRQoL of caregivers. Neuroticism and extraversion only indirectly influenced their physical HRQoL. Neuroticism increased the caregiver's depression, whereas extraversion decreased it. Neuroticism only was mediated by burden to influence depression and mental and physical HRQoL. CONCLUSIONS: Personality traits can influence caregiving outcomes and be viewed as an individual resource of the caregiver. A family caregiver's personality characteristics need to be assessed for tailoring support programs to get the optimal benefits from caregiver interventions.

Gender differences in risk factors for transition from mild cognitive impairment to Alzheimer's disease: A CREDOS study.

BACKGROUND: Women are subject to a disproportionate burden from Alzheimer's disease (AD) and sex differences exist in treatment response and prognosis of the disease. Yet gender-specific risk factors have not been widely studied. We aimed to investigate gender-specific risk factors for AD in subjects with mild cognitive impairment (MCI). METHODS: Participants (n=294) with MCI were recruited from a nationwide, prospective cohort study of dementia and were followed for a median (range) of 13.8 (6.0-36.0) months. Sex-stratified associations of progression to AD with baseline characteristics were explored. RESULTS: Seventy-four individuals (25.2%) developed incident dementia (67 AD) during follow-up. Significant risk factors for probable AD differed by sex. In men, the significant risk factors were severe periventricular white matter hyperintensities, and poorer global cognitive function. In women, older age, clinically significant depressive symptoms at baseline, and positive APOE ε4 alleles were the significant risk factors. CONCLUSIONS: Risk factors for progression from MCI to probable AD differed in men and women. These results may translate to gender-specific preventative or therapeutic strategies for patients with MCI.

Effects of education on the progression of early- versus late-stage mild cognitive impairment.

BACKGROUND: Highly educated participants with normal cognition show lower incidence of Alzheimer's disease (AD) than poorly educated participants, whereas longitudinal studies involving AD have reported that higher education is associated with more rapid cognitive decline. We aimed to evaluate whether highly educated amnestic mild cognitive impairment (aMCI) participants show more rapid cognitive decline than those with lower levels of education. METHODS: A total of 249 aMCI patients enrolled from 31 memory clinics using the standard assessment and diagnostic processes were followed with neuropsychological evaluation (duration 17.2 ± 8.8 months). According to baseline performances on memory tests, participants were divided into early-stage aMCI (-1.5 to -1.0 standard deviation (SD)) and late-stage aMCI (below -1.5 SD) groups. Risk of AD conversion and changes in neuropsychological performances according to the level of education were evaluated. RESULTS: Sixty-two patients converted to AD over a mean follow-up of 1.43 years. The risk of AD conversion was higher in late-stage aMCI than early-stage aMCI. Cox proportional hazard models showed that aMCI participants, and late-stage aMCI participants in particular, with higher levels of education had a higher risk of AD conversion than those with lower levels of education. Late-stage aMCI participants with higher education showed faster cognitive decline in language, memory, and Clinical Dementia Rating Sum of Boxes (CDR-SOB) scores. On the contrary, early-stage aMCI participants with higher education showed slower cognitive decline in MMSE and CDR-SOB scores. CONCLUSIONS: Our findings suggest that the protective effects of education against cognitive decline remain in early-stage aMCI and disappear in late-stage aMCI.

A case of diphenhydramine intoxication showing prolonged false positive tricyclic antidepressant in the urine assay.

Background: The urine immunochromatographic assay is a useful screening tool for patients suspected of acute drug intoxication in emergency conditions. Diphenhydramine intoxication shows symptoms similar to those of tricyclic antidepressant (TCA) intoxication. Case presentation: We examined a case of diphenhydramine intoxication showing cerebellar ataxia and prolonged false positive results for TCA in the urine. The urine TCA test showed persistently positive results even 60 h after the patient's initial drug screening. We observed negative conversion 90 h after the initial drug screening. Discussion: Considering the similarities of clinical symptoms between diphenhydramine and TCA intoxication, emergency physicians should consider the possibility of cross-reactivity in the diagnosis of a patient with unknown acute drug intoxication showing positive results of TCA immunochromatographic assay in the urine. Conclusion: The present case suggests that diphenhydramine overdose may cause cerebellar ataxia and show prolonged cross-reactivity as TCA in the urine.

Varicella zoster virus meningoencephalitis accompanied by rhabdomyolysis without skin eruption.

We report a case of a 38-year-old man with a Varicella zoster virus (VZV) reactivation who manifested meningoencephalitis accompanied by rhabdomyolysis without a skin eruption. During the acute phase, VZV DNA was detected in serum and cerebrospinal fluid (CSF) by the polymerase chain reaction (PCR). After 16 days, all symptoms and signs resolved, and follow-up PCR studies revealed negative conversion of VZV in the serum and CSF. We discuss the possible underlying mechanism of VZV reactivation in our patient. This is the first case report of VZV reactivation meningoencephalitis accompanied by rhabdomyolysis without skin eruption demonstrated by viral DNA in the serum and CSF.

Contralateral glossoplegia in a lower pontine infarction.

A 65-year old man developed sudden dysarthria, dysphagia, right-sided weakness, and sensory loss. The neurologic examination revealed left-sided tongue deviation caused by right glossoplegia. A magnetic resonance imaging scan revealed an elongated acute infarction from the left ventromedial portion of the lower pons extending to the dorsal pontine tegmentum area. The ipsilateral tongue deviation of the patient may result from interruption of the contralateral crossed corticohtpoglossal projection. This finding suggests that the possibility of the corticohypoglossal decussation may exist just above the pontomedullary junction, with individual variability.

Neuropsychological correlates of the proportional impact of white matter hyperintensities on mild to moderate dementia: the MRI 300 study.

BACKGROUND: White matter hyperintensities (WMH) increase cognitive impairment in patients with dementia. OBJECTIVE: We investigated the impact of WMH on the neuropsychological profiles in patients with mild to moderate dementia. METHODS: We consecutively recruited newly diagnosed patients with mild to moderate dementia across South Korea for 1 year. The participants completed neuropsychological tests, magnetic resonance imaging, and structured neurological evaluations. The patients were divided into 3 categories, i.e. minimal, moderate, and severe WMH groups, according to the proportional degree of WMH. RESULTS: 289 patients were recruited; 140 (48.3%) for the minimal WMH group, 99 (34.2%) for the moderate group, and 50 (17.5%) for the severe group. Both advanced age and low general cognitive level were significant contributors to WMH in patients with dementia. After adjusting for age, the neuropsychological correlates of the proportional impact of WMH were frontal executive, language, and attention profiles. However, the only significant neuropsychological correlate was the recognition memory profile after adjusting for both age and general cognitive level simultaneously. CONCLUSION: The results suggest that the most significant neuropsychological profile impacting the burden of WMH in patients with mild to moderate dementia was the recognition memory profile, regardless of age and general cognitive function.

Different associations of periventricular and deep white matter lesions with cognition, neuropsychiatric symptoms, and daily activities in dementia.

We investigated the associations of periventricular white matter hyperintensities (PWMHs) and deep white matter hyperintensities (DWMHs) with cognition, activities of daily living (ADLs), and neuropsychiatric symptoms in dementia. This was a hospital-based MRI300 study. We recruited patients newly diagnosed with mild-to-moderate dementia caused either by Alzheimer's disease or subcortical ischemic vascular dementia from 13 dementia clinics at university or general hospitals in South Korea. We enrolled 289 patients aged over 50 from August 2007 to March 2008. We compared cognition, ADLs, and neuropsychiatric symptoms among 3 groups according to the severities of PWMHs and DWMHs, respectively, by adjusting for age, vascular risk factors, and level of other WMHs. A higher severity of PWMHs was related to lower cognitive function and severer neuropsychiatric symptoms, whereas basic ADLs were associated with DWMH. Both PWMHs and DWMHs exhibited different associations with cognition, neuropsychiatric symptoms, and daily activities.

Impact of white matter changes on activities of daily living in mild to moderate dementia.

The association between white matter changes and activities of daily living (ADL) in a large, well-defined cohort of patients with mild-to-moderate dementia (either Alzheimer's disease or subcortical vascular dementia) were investigated. A total of 289 patients were divided into three groups (140 mild, 99 moderate, and 50 severe) depending on the degree of white matter changes as indicated on brain magnetic resonance image scans. Further, we analyzed the three groups' performances on basic and instrumental ADL. The degree of white matter changes was associated with greater age, hypertension, previous history of stroke, higher Hachinski Ischemic Score, worse global cognitive and functional status, and an increased impairment of basic ADL and instrumental ADL. The increased impairment with regard to the severe group's performance on both the basic and instrumental ADL remained significant after adjustment for age and hypertension. Tasks involving physical activities were most significant. This was the first study investigating the association between white matter changes and ADL in a large, well-defined dementia cohort. The present study suggests that severe white matter changes may be associated with higher impairment on both basic and instrumental ADL.

Effects of medial temporal atrophy and white matter hyperintensities on the cognitive functions in patients with Alzheimer's disease.

AIMS: We conducted this study to investigate the independent association of medial temporal atrophy (MTA) and white matter hyperintensities (WMH) with cognitive impairments of Alzheimer's disease (AD) patients and the interaction between MTA and WMH. METHODS: From 13 centers, a total of 216 AD patients were consecutively recruited and their MTA and WMH were visually rated. We evaluated the association of MTA and WMH with the various cognitive domains, and the interaction between MTA and WMH. RESULTS: MTA independently correlated with scores of the Mini-Mental State Examination (MMSE), Clinical Dementia Rating scale (CDR), delayed recalls of the Seoul Verbal Learning Test (SVLT), the Boston Naming Test (BNT), and Word Fluency. WMH independently correlated with MMSE, CDR, Digit Span, and Stroop word reading, but not with delayed recall. There were interactions of WMH and MTA on CDR (p = 0.004), SVLT (p = 0.023), BNT (p = 0.002) and the semantic Word Fluency (p = 0.007). CONCLUSION: MTA and WMH independently affected cognitive deficits in AD patients, with somewhat different patterns where MTA was associated mostly with memory and language, while WMH were associated with attention and frontal executive functions. This study also showed interactions between MTA and WMH on some cognitive deficits and dementia severity, suggesting that they synergistically contribute to cognitive impairment in AD.

Clinical characteristics of a nationwide hospital-based registry of mild-to-moderate Alzheimer's disease patients in Korea: a CREDOS (Clinical Research Center for Dementia of South Korea) study.

With rapid population aging, the socioeconomic burden caused by dementia care is snowballing. Although a few community-based studies of Alzheimer's disease (AD) have been performed in Korea, there has never been a nationwide hospital-based study thereof. We aimed to identify the demographics and clinical characteristics of mild-to-moderate AD patients from the Clinical Research Center for Dementia of Korea (CREDOS) registry. A total of 1,786 patients were consecutively included from September 2005 to June 2010. Each patient underwent comprehensive neurological examination, interview for caregivers, laboratory investigations, neuropsychological tests, and brain MRI. The mean age was 74.0 yr and the female percentage 67.0%. The mean period of education was 7.1 yr and the frequency of early-onset AD (< 65 yr old) was 18.8%. Among the vascular risk factors, hypertension (48.9%) and diabetes mellitus (22.3%) were the most frequent. The mean score of the Korean version of Mini-Mental State Examination (K-MMSE) was 19.2 and the mean sum of box scores of Clinical Dementia Rating (CDR-SB) 5.1. Based on the well-structured, nationwide, and hospital-based registry, this study provides the unique clinical characteristics of AD and emphasizes the importance of vascular factors in AD in Korea.

Patients with scans without evidence of dopaminergic deficit (SWEDD) do not have early Parkinson's disease: Analysis of the PPMI data.

BACKGROUND: To evaluate whether patients with scans without evidence of dopaminergic deficit (SWEDD) have early Parkinson's disease (PD). METHODS: The clinical characteristics, striatal specific binding ratios (SBRs), and the indices of I-123 FP-CIT SPECT images of 50 SWEDD patients, 304 PD patients, and 141 healthy controls were acquired from the Parkinson's Progression Markers Initiative (PPMI) data and evaluated during a 2-year clinical follow-up period. RESULTS: Of the 50 subjects with SWEDD, PD was confirmed in 13 subjects (the PD-SWEDD group), while the remaining 37 subjects had other diseases (the Other-SWEDD group). Striatal SBR values and striatal asymmetry indices of the PD group were significantly different with those of the PD-SWEDD and Other-SWEDD groups at both baseline and after 2 years (p < 0.001). Putaminal SBR values of the PD-SWEDD group were significantly decreased after 2 years (p < 0.05). There was no difference of the SBR values between baseline and after 2 years in the Other-SWEDD group. A baseline MDS-UPDRS III score matched comparison of the PD and PD-SWEDD group was done due to the large difference of the subject numbers. Striatal SBR values and striatal asymmetry indices were significantly different (p < 0.001) between the two groups at both baseline and after 2 years, but there were no significant difference with respect to the MDS-UPDRS III scores after 2 years between the two groups. CONCLUSION: The different SBR values and asymmetry indices between the PD and PD-SWEDD groups at baseline and after 2 years indicate that SWEDD may not be early PD, but rather a different disease entity.

Methodological considerations of evaluating the rate of presynaptic dopaminergic denervation in Parkinson disease with radiotracers: Analysis of the PPMI data.

ABSTRACT: Many previous studies have estimated the rate of dopaminergic denervation in Parkinson disease (PD) via imaging studies. However, they lack the considerations of onset age, disease duration at onset, gender, and dopaminergic denervation due to normal aging. Herein, using a large prospective cohort, we estimated the rate of dopaminergic denervation in PD patients, compared with an age- and gender-matched normal control group.One hundred forty-one normal controls and 301 PD patients were enrolled. Striatal specific binding ratios (SBRs) of I-123 FP-CIT single positron emission tomography images were analyzed according to the age of onset, gender, and the duration of motor symptoms.In the PD group, symptom duration was significantly correlated with caudate SBRs, but with putamen SBRs (P  < .05, R2 = 0.02). Moreover, was significantly inversely related to caudate SBRs, but not with putamen SBRs (P  < .05, R2 = 0.02). Patients of different age onsets did not show any significant correlation between symptom durations and striatal SBRs. In the age-matched group, no significant relationship was observed between symptom duration and percent decrease of caudate SBRs, but there was a significant relationship between symptom duration and percent decrease of the putamen SBRs (P  < .01, R2 = 0.06). There was no significant relationship between the symptom duration and the percent decrease of striatal SBRs in the age- and gender-matched group.The significance and R2 values from the regression analysis between symptom duration, age, and dopaminergic denervation are low. This suggests that, contrary to previous knowledge, there is a relatively weak association between dopaminergic denervation and age or symptom duration.

Cognitive decline according to amyloid uptake in patients with poststroke cognitive impairment.

BACKGROUND AND PURPOSE: Poststroke cognitive impairment (PSCI) is common, but the impact of ß-amyloid (Aß) on PSCI is uncertain. The proposed study will investigate amyloid pathology in participants with PSCI and how differently their cognition progress according to the amyloid pathology. METHODS: This multicenter study was designed to be prospective and observational based on a projected cohort size of 196 participants with either newly developed cognitive impairment, or rapidly aggravated CI, within 3 months after acute cerebral infarction. They will undergo 18F-flutemetamol positron emission tomography at baseline and will be categorized as either amyloid-positive (A+) or amyloid-negative (A-) by visual rating. The primary outcome measures will be based on Korean Mini-Mental State Examination changes (baseline to 12 months) between the A+ and A- groups. The secondary outcome measures will be the dementia-conversion rate and changes in the Korean version of the Montreal Cognitive Assessment (baseline to 12 months) between the A+ and A- groups. CONCLUSIONS: This study will provide a broadened perspective on the impact of Aß on the cause and outcomes of PSCI in clinical practice. Identifying amyloid pathology in patients with PSCI will help select patients who need more focused treatments such as acetylcholinesterase inhibitors. TRIAL REGISTRATION: Clinical Research Information Service identifier: KCT0005086.

Comparison of Urinary Alzheimer-Associated Neural Thread Protein (AD7c-NTP) Levels Between Patients With Amnestic and Nonamnestic Mild Cognitive Impairment.

Urinary Alzheimer-associated neural thread protein (AD7c-NTP) is a potential biomarker of Alzheimer disease (AD) or mild cognitive impairment (MCI). It is still unclear whether the urinary levels of AD7c-NTP are different between patients with amnestic MCI (aMCI) and nonamnestic MCI (naMCI). The present study aimed to explore the differences in urinary levels of AD7c-NTP between patients with aMCI and naMCI. Forty-six patients with MCI were divided into aMCI group (n = 23) and naMCI group (n = 23). The mean level of urinary AD7c-NTP in the aMCI group (32.75 ± 10.0 µg/mL) was significantly higher than that in the naMCI group (25.34 ± 9.0 µg/mL; P = .011). As far as we know, the present study is the first to show that individuals with aMCI have higher levels of urinary AD7c-NTP than those with naMCI, suggesting that urinary AD7c-NTP may be a potential biomarker to help identify patients with aMCI and naMCI.

Consecutive versus return motor perseveration during line cancellation task in hemispatial neglect.

BACKGROUND: Patients with neglect often repeatedly cancel the same targets, a form of motor perseveration (MP). There seems to be 2 types of MP, making uninterrupted multiple strokes for each target, consecutive MP (CMP) or return MP (RMP) where patients return to previously canceled targets and remark them. OBJECTIVE: The purpose of this study is to learn whether these 2 forms of MP are dissociable. METHODS: We studied 3 patients, 1 with primarily CMP, another with primarily RMP and a third with mixed CMP and RMP by having them perform the cancellation task with and without background movement. RESULTS: In the patient with primarily RMPs (patient 1), leftward background movement decreased the severity of the neglect and the perseveration. Rightward background movement increased both. In contrast to patient 1, who showed the correspondence between the severity of neglect and perseveration, the patient with both CMP and RMP (patient 2) and the patient with primarily CMPs (patient 3) did not show such correspondence. CONCLUSIONS: The different responses of CMP and RMP to the treatment of neglect suggest that different mechanisms account for these 2 forms of MP. Although RMP might be related to neglect induced aberrant approach behaviors, CMP seems to be related to a disengagement disorder.

Alteration of Tremor Dominant and Postural Instability Gait Difficulty Subtypes During the Progression of Parkinson's Disease: Analysis of the PPMI Cohort.

Background: Classifying PD into tremor dominant (TD) and postural instability gait difficulty (PIGD) subtypes may have several limitations, such as its diagnostic inconsistency and inability to reflect disease stage. In this study, we investigated the patterns of progression and dopaminergic denervation, by prospective evaluation at regular time intervals. Methods: 325 PD dopamine replacement drug-naïve patients (age 61.2 ± 9.7, M:F = 215:110) were enrolled. Patients were grouped into TD, indeterminant, and PIGD subtypes. Clinical parameters and I-123 FP-CIT SPECT images of each groups were analyzed and compared at baseline, 1, 2, and 4 years of follow up periods. Results: Baseline I-123 FP-CIT uptakes of the striatum were significantly higher in the TD group compared with the indeterminant group and PIGD group (p < 0.01). H & Y stage and MDS-UPDRS part III scores of the indeterminant group were significantly worse at baseline, compared with the TD and PIGD groups (p < 0.001 and p < 0.01, respectively), and MDS-UPDRS part II scores of the indeterminant group were significantly worse than the PIGD group (p < 0.001). There were no other significant differences of age, gender, weight, duration of PD, SCOPA-AUT, MOCA, usage of dopamine agonists, and levodopa equivalent daily doses at baseline. After 4 years of follow up, there were no differences of I-123 FP-CIT uptakes or clinical parameters, except for the MDS-UPDRS part II between the TD and indeterminant group (p < 0.05). The motor-subtypes were reevaluated at the 4 years period, and the proportion of patients grouped to the PIGD subtype increased. In the reevaluated PIGD group, MDS-UPDRS part II score (p < 0.001), SCOPA-AUT (p < 0.001), the proportion of patients who developed levodopa induced dyskinesia were higher than the reevaluated TD group, and the striatal I-123 FP-CIT uptakes were significantly lower (p < 0.01). Conclusion: There are no significant differences of symptoms and dopaminergic innervation between the TD and PIGD group after a certain period of follow up. Significant portion of patients switched from the TD subtype to the PIGD subtype during disease progression, and had a worse clinical prognosis.