Cerebral venous thrombosis secondary to ovarian hyperstimulation syndrome.

We report a case of a woman who underwent in-vitro fertilisation embryo transfer treatment for infertility and developed an acute stroke (left hemiparesis and headache). The stroke was caused by cerebral venous thrombosis due to ovarian hyperstimulation syndrome. We review the current background about this uncommon disorder.

Prognosticating acute symptomatic seizures using two different seizure outcomes.

PURPOSE: This study examined the profiles and prognosis of first acute symptomatic seizure (ASS). Because seizure recurrences may occur in the setting of a persisting or reemerging acute symptomatic cause or in the setting of an unprovoked seizure, we documented the prognosis of ASS in terms of acute symptomatic seizure (AS) or unprovoked seizure (US) recurrence. METHODS: We conducted a prospective study of patients with suspected seizures between April 2004 and December 2005. Patients were classified according to medical history taking, routine clinical evaluation, and expert adjudication, and they were followed for a minimum of 2 years or until death. The Kaplan-Meier method and univariate/multivariate statistical analysis were used to determine prognosis. RESULTS: One hundred five patients with first-ever ASS were identified. For many, first ASS was associated with status epilepticus (29.5%), multiple-onset (>1 seizure within 24 h on day of presentation) (35.2%), and multiple etiologies (22.9%), with a mortality of 30% at 2 years (Kaplan-Meier method). Using AS as outcome, the risk of recurrence following an ASS was 32% at 2 years [mean time to recurrence 20.5 days with epileptiform electroencephalography (EEG) being an independent predictor; p = 0.005, odds ratio (OR) 16, 95% confidence interval (CI) 4.09-62.7]. Using US as outcome, the risk of recurrence following an ASS was 12% at 2 years. DISCUSSION: Although ASS did not associate with a high rate of US recurrence, we demonstrated that ASS was often followed by another AS. This may have implication for short- to medium-term antiepileptic agent therapy, especially when the acute symptomatic cause takes a long time to treat, is prone to reemergence, or is irreversible.

Effects of valproate or lamotrigine monotherapy on the reproductive endocrine and insulin-related metabolic profile in Chinese adults with epilepsy: a prospective randomized study.

Cross-sectional studies have suggested that valproate treatment may be associated with hyperinsulinemia and hyperandrogenism in women. Few prospective data are available. We evaluated the reproductive endocrine and insulin-related metabolic parameters in men and women with untreated epilepsy randomized to valproate (n=44) or lamotrigine (n=37) monotherapy for 12 months. On treatment, there was no significant difference in fasting serum insulin concentrations between the two groups. In women (n=40), there was no significant difference between the two groups in change from baseline in serum total testosterone, dehydroepiandrosterone sulfate, luteinizing hormone, or follicle-stimulating hormone. In men (n=41), follicle-stimulating hormone concentration significantly decreased in patients taking valproate compared with those on lamotrigine as early as 3 months after treatment. Greater attention should be paid to investigate the potential impact of valproate on reproductive function in men.

An epidemiological study of epilepsy in Hong Kong SAR, China.

BACKGROUND: Several specialist clinic-based epidemiology studies suggested low prevalence in Hong Kong Special Administrative Region (HKSAR) of China. Population-based epidemiological data for epilepsy is not available. We performed the first population-based epidemiological survey of epilepsy in this locality. METHOD: We conducted a territory-wide survey. We randomly selected 9547 households from fixed-line telephone directory. We successfully surveyed 17,783 persons of 5178 households by telephone interview. All positive respondents 685 (3.85%) were invited for clinical validation. 127 subjects were validated by board-certified neurologists. RESULTS: Seizure disorders were confirmed in 28 subjects. The crude prevalence of active epilepsy and seizure disorder were estimated to be 3.94/1000 (95% confidence interval (CI): 2.10-6.74/1000) and 8.49/1000 (95% CI: 5.64-12.27/1000), respectively. CONCLUSIONS: The prevalence of epilepsy in HKSAR is more common than previously thought. The data retrieved is useful for planning and allocation of health resources for patients with seizure disorders.

Herpes simplex virus (HSV) encephalitis in a young man: an unusual course.

We present a case of cerebral venous sinus thrombosis (CVST) as a rare complication of herpes simplex virus (HSV) encephalitis. A young man with no pertinent medical history was diagnosed with HSV encephalitis. After initial treatment, he showed improvement in symptomatology until day 6 when he acutely developed new neurological deficits. An urgent MRI brain showed changes in left temporal lobe consistent with HSV encephalitis and lack of flow void in superior sagittal sinus. Subsequent magnetic resonance venography confirmed the diagnosis of superior sagittal sinus thrombosis along with thrombosis of bilateral frontoparietal cortical draining veins. Anticoagulation was immediately initiated and oral anticoagulation was continued for 1 year. He made complete recovery subsequently. Our case serves as a reminder for the treating clinicians to consider CVST in patients with HSV encephalitis who develop an unexpected new neurological deficits during early phase of appropriate treatment.

Refractory epilepsy in a Chinese population.

OBJECTIVES: To investigate the proportion of Chinese patients with intractable seizures and the risk factors leading to refractory epilepsy. METHODS: Consecutive patients over 14 years of age attending a Neurology clinic were evaluated. Patients with epilepsy were classified into two groups according to their seizure control: refractory or seizure-free. Epilepsy was classified as idiopathic as defined by age-related onset and typical electroclinical characteristics, symptomatic if secondary to a structural abnormality and cryptogenic if the cause was unknown. Age, sex, epilepsy syndrome classification, aetiology, presence of mental retardation and the number of drugs used were compared between patients with refractory epilepsy and those in remission. RESULTS: Among 260 adolescent and adult patients with a mean age of 34 years (range 15-79), complete seizure control was achieved in 157 (60%) cases. Multivariate binomial logistic regression analysis showed that patients with mesial temporal sclerosis (OR=7.6, 95% CI 3.53-16.4, p<0.01) and the presence of mental retardation (OR=9.39, 95% CI 3.98-22.12, p<0.01) were more likely to develop pharmacoresistant epilepsy. CONCLUSION: In adults the underlying aetiology is an important factor as to whether patients develop intractable seizures. Poor control was also associated with the presence of mesial temporal sclerosis and mental retardation.

Diagnostic value and safety of long-term video-EEG monitoring.

This paper aimed to assess the usefulness and safety of video-EEG (video-electroencephalography) monitoring in patients with refractory epilepsy. We analysed the video-EEG recordings of consecutive patients over a 3-year period from 2002 to 2005. The pre-admission diagnosis, demographic information, number of ictal episodes, adverse events, and final diagnosis were recorded in all patients. The diagnostic labels before and after monitoring were compared in order to assess whether it had led to a change in diagnosis and management. Of the 100 patients who underwent video-EEG, 227 clinical events were recorded in 62 cases. The most common events were complex partial seizures followed by non-epileptic attacks. Video-EEG allowed a diagnosis to be made in 81 patients and the diagnosis at discharge was altered in 19 cases. Major injuries and status epilepticus did not occur during monitoring. In our experience video-EEG is safe and provides important clinical information in over 80% of patients.

Update on status epilepticus.

Status epilepticus is a medical emergency and is secondary to a range of insults to the central nervous system. The authors reviewed the current management of this disorder in light of the latest developments from recent trials and guidelines. Important principles in management include early recognition of status epilepticus, identification of the underlying cause and prompt treatment to terminate seizures and reduce complications. The role of electroencephalographic monitoring and different treatment regimens are examined.

Treatment of lateral epicondylitis with botulinum toxin: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Lateral epicondylitis is a common condition for which botulinum toxin has been reported to have a therapeutic role in uncontrolled studies. OBJECTIVE: To determine if an injection of botulinum toxin is more effective than placebo for reducing pain in adults with lateral epicondylitis. DESIGN: Randomized, double-blind, placebo-controlled trial conducted from September 2002 to December 2004. SETTING: Outpatient clinics at a university hospital and a district hospital in Hong Kong. PARTICIPANTS: 60 patients with lateral epicondylitis. MEASUREMENTS: The primary outcome was change in subjective pain as measured by a 100-mm visual analogue scale (VAS) ranging from 0 (no pain) to 10 (worst pain ever) at 4 weeks and 12 weeks. All patients completed post-treatment follow-up. INTERVENTIONS: A single injection of 60 units of botulinum toxin type A or normal saline placebo. RESULTS: Mean VAS scores for the botulinum group at baseline and at 4 weeks were 65.5 mm and 25.3 mm, respectively; respective scores for the placebo group were 66.2 mm and 50.5 mm (between-group difference of changes, 24.4 mm [95% CI, 13.0 to 35.8 mm]; P < 0.001). At week 12, mean VAS scores were 23.5 mm for the botulinum group and 43.5 mm for the placebo group (between-group difference of changes, 19.3 mm [CI, 5.6 to 32.9 mm]; P = 0.006). Grip strength was not statistically significantly different between groups at any time. Mild paresis of the fingers occurred in 4 patients in the botulinum group at 4 weeks. One patient's symptoms persisted until week 12, whereas none of the patients receiving placebo had the same complaint. At 4 weeks, 10 patients in the botulinum group and 6 patients in the placebo group experienced weak finger extension on the same side as the injection site. LIMITATIONS: The trial was small, and most participants were women. The blinding protocol may have been ineffective because the 4 participants who experienced paresis of the fingers could have correctly assumed that they received an active treatment. CONCLUSIONS: Botulinum toxin injection may improve pain over a 3-month period in some patients with lateral epicondylitis, but injections may be associated with digit paresis and weakness of finger extension.

Myopathic changes associated with severe acute respiratory syndrome: a postmortem case series.

BACKGROUND: The March 2003 outbreak of the severe acute respiratory syndrome (SARS) resulted in significant morbidity and mortality. Muscle weakness and elevated serum creatine kinase levels are commonly encountered in patients with SARS. However, the nature and cause of myopathy associated with a SARS infection are unknown because, to our knowledge, there has been no report of histological or postmortem examination of the skeletal muscle from SARS-infected patients. OBJECTIVE: To determine the exact nature of the myopathy associated with SARS. METHOD: Postmortem skeletal muscles from 8 consecutive patients who died of SARS in March 2003 were studied under light and electron microscopy as well as immunohistochemistry. RESULTS: Focal myofiber necrosis was identified in 4 of 8 cases. Macrophage infiltration and regenerative fiber were scanty. All 4 patients treated with a steroid had significant myofiber atrophy. In situ hybridization for coronavirus was negative in all subjects. Viral cultures for coronavirus and examination for viral particles under electron microscopy were performed in 2 patients. The viral culture yielded no organisms and there were no viral particles seen on electron microscopic examination. CONCLUSIONS: There is a spectrum of myopathic changes associated with a SARS infection. Focal myofiber necrosis is common and possibly is immune mediated. Critical illness myopathy and superimposed steroid myopathy may also play an important role in SARS.

Socio-economic status and patterns of care in lung cancer.

OBJECTIVE: This retrospective study aims to explore the associations between socio-economic factors and lung cancer management and outcomes in the Australian setting. METHODS: The study population consisted of patients who were living in the Northern Sydney Area Health Service (NSAHS) or South Western Sydney Area Health Service (SWSAHS) at the time of their lung cancer diagnosis in 1996. Data on patient demographics, tumour characteristics, management details, recurrence and survival were collected and compared between the two areas. Socio-economic status indicators of the two Area Health Services were obtained from the Australian Bureau of Statistics. RESULTS: There were 270 and 256 new cases of lung cancer identified in NSAHS and SWSAHS respectively. Patients in NSAHS were slightly older and there were more women. Based on the 1996 Census data, the population of NSAHS is more affluent, better educated and more likely to be employed compared with SWSAHS. The stage distributions and performance status of the two areas were similar. The utilisation rates of different treatment modalities in the two areas were similar except for chemotherapy. The five-year overall survival rate was 10.5% in NSAHS and 7.2% in SWSAHS (p=0.08). Comparison based on the SEIFA Index of Relative Socio-economic Disadvantage did not reveal significant differences. CONCLUSION: Patients with lung cancer had similar patterns of care and survival despite differences in socio-economic profiles between the two Area Health Services. IMPLICATION: There seems to be equity of access to lung cancer services between the two Area Health Services.

Generalized tonic-clonic status epilepticus in the elderly in China.

The proportion of elderly people in China is projected to increase rapidly but there is limited information on status epilepticus (SE) in this population. We evaluated retrospectively the etiology, response to treatment, outcome and predictors of mortality in a group of elderly patients with generalized tonic-clonic SE in Hong Kong, China. Factors for increased mortality were analyzed using a logistic regression model. Of the 80 acute admissions for SE from two large urban hospitals over a seven-year period, 1996-2002, the two leading causes were attributed to cerebral infarct (n=28, 35%) and cerebral haemorrhage (n=14, 17.5%). The mean age was 74.2 years (range 60-93 years). At six months from the onset of seizures, 26 patients (32.5%) had made a good recovery but another 28 (35%) had died. Results showed that mortality was associated with increasing age (OR 1.08, 95% CI 1.01-1.16) and SE due to an acute symptomatic disturbance (OR 4.90, 95% CI 1.17-13.67). SE is associated with significant morbidity and mortality in this age group.

Electrophysiological, clinical and epidemiological study of Guillain-Barre Syndrome in Hong Kong Chinese.

The authors reviewed the clinical and electrophysiological features in 20 consecutive adult patients with Guillain-Barre Syndrome (GBS) admitted to a regional hospital in Hong Kong from 1993 to 1998. The majority of cases in this locality consists of the demyelinating form of GBS; epidemic, acute motor axonal neuropathy is not the predominant form. The incidence of GBS in this region of China was 0.44 per 100,000.

Simple partial status epilepticus in Chinese adults.

Simple partial status epilepticus (SPSE) is uncommon compared with generalized tonic-clonic status epilepticus. We evaluated the clinical profile and predictors of poor outcome in a group of Chinese patients with this condition. We identified 32 patients above the age of 14 years with SPSE from a large urban hospital over an eleven-year period. Factors for poor outcome, defined as death or morbidity, were analyzed. The most common underlying causes were due to cerebrovascular disease (46.9%), CNS infection (15.6%), metabolic derangement (12.5%) and tumor (12.5%). At 30 days from the onset of seizures, 13(40.5%) patients had recovered fully and seven (21.9%) had died. Poor outcome was associated with the presence of an acute symptomatic injury.

Cerebral microbleeds and white matter changes in patients hospitalized with lacunar infarcts.

Microbleeds (MBs) detected by gradient-echo T2*-weighted MRI (GRE-T2*),white matter changes and lacunar infarcts may be regarded as manifestations of microangiopathy. The establishment of a quantitative relationship among them would further strengthen this hypothesis. We aimed to investigate the frequency and the number of MBs in patients hospitalized with lacunar infarcts and their quantitative relationship with the severity of white matter changes (WMC) and the number of old lacunar infarcts. We performed a hospital-based survey of patients with acute lacunar infarct. Eighty-two consecutive Chinese patients with acute lacunar infarcts on diffusion-weighted imaging were recruited in 2002. The number of MBs, number of old lacunar infarcts on T2-weighted imaging and the severity of WMC on MRI on admission were recorded. MBs were detected in 22 (27%) patients. The number of MBs ranged from 1 to 42 (mean 6.59, median 3). Advancing age and previous transient ischemic attacks or cerebrovascular accidents (TIA/CVA) were more common in patients with MBs than those without. There were significant correlations among the number of MBs, extent of WMC and number of lacunar infarcts: lacunar infarcts and MBs (r = 0.297, p = 0.007); lacunar infarct and WMC (r = 0.331, p = 0.002); WMC and MBs (r = 0.522, p < 0.0001). In conclusion, linear associations exist among MBs, WMC and lacunar infarcts. Our results suggest that all three may have a shared pathogenesis such as advanced microangiopathy.

Small subcortical infarct and intracranial large artery disease in Chinese.

BACKGROUND: Small subcortical infarct (SSI) occurs more frequently among Chinese than Caucasians. Apart from small vessel disease, SSI is also associated with intracranial large artery disease. We aimed to study the frequency of SSI with and without intracranial large artery disease among Chinese stroke patients. METHODS: Magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and diffusion weighted imaging (DWI) were performed among consecutive Chinese stroke patients admitted to our acute stroke unit over a 6-month period. RESULTS: Among the 257 patients with ischemic stroke, 71 patients (27.6%) had SSI. Twelve patients (16.9%) had relevant intracranial large artery disease and three patients (4.2%) had lone relevant extracranial carotid artery disease. No patient had an identifiable cardiac embolic source or other miscellaneous cause. Excluding patients with relevant intracranial large artery disease and extracranial carotid artery disease, the frequency of SSI associated with presumed small vessel disease among patients with ischemic stroke was 21.7%. Patients with SSI associated with intracranial large artery disease had greater number of acute infarcts and slightly greater stroke severity and cognitive impairment than those with presumed small vessel disease. CONCLUSION: Our present study suggests that the higher frequency of SSI among Chinese may be in part related to a higher frequency of intracranial large artery disease rather than to a higher frequency of small vessel disease.

Epidemiology and management of epilepsy in Hong Kong: an overview.

Over half of the estimated 50 million people with epilepsy live in Asia, but there has been limited information on the epidemiology, aetiology and management of epilepsy from this region. In this article, we summarise some of the main problems faced by patients and the current treatment options available in an urban area of China.

Status epilepticus in Hong Kong Chinese: aetiology, outcome and predictors of death and morbidity.

The majority of patients with epilepsy live in developing countries but there is limited information on status epilepticus (SE) from these regions. We evaluated the clinical profile and predictors of poor outcome in a group of Chinese patients with SE. Patients with SE were ascertained from the medical, intensive care and emergency departments of a large urban hospital from 1996 to 2001. Factors for poor outcome, defined as death or morbidity as measured by deterioration in functional status using the Glasgow Outcome Score were analysed in a multivariate logistic regression model. A total of 107 episodes of SE occurring in Chinese patients were studied. The three most common underlying causes were cerebrovascular disease, metabolic derangement and anti-convulsant withdrawal but alcohol-related SE was infrequent. Twenty-six percent had worsened functional ability and the mortality rate was 16%. Predictors of poor outcome were older age (odds ratio (OR)=1.04, 95% CI 1.01-1.07), delay in treatment (OR=3.52, 95%CI 1.01-12.18), SE due to cerebrovascular disease (OR=9.73, 95% CI 1.58-59.96) and CNS infection (OR=30.27, 95% CI 3.14-292.19).