Long-Term Care Hospital and the Role of Neurologist

Korea health care system and public welfare system have been changed slowly and developed step by step. It makes efforts to promote the welfare of the people, but does not provide good benefits for geriatric patients. In 2008, it was incompletely set up the long term care system in Korea. And the Law on Long-Term Care Insurance for Elderly was officially announced in Nov. 2011 and the law for dementia, Dementia Management Act, was drafted in Feb. 2012. Though there were many laws, the concept of long-term care hospital and geriatric care facility is still obscure. In long-term care hospital, there are big expansion of the number of beds and institutions in Korea. Over a half of the patients in long-term care hospitals are suffered from mixed neurological diseases. Especially, dementia is the comorbid state with other chronic geriatric diseases. In view of the aging population, the role of neurologist will continue to grow. So neurologists need more special training for the needed skills and competencies, and the specific care settings program in long-term care hospital. In this review, the history and current state of long-term care hospital, related laws, and the role of neurologist will be discussed.

Endothelin 1 protects HN33 cells from serum deprivation-induced neuronal apoptosis through Ca2+-PKCalpha-ERK pathway

Endothelins (ETs), which were originally found to be potent vasoactive transmitters, were known to be implicated in nervous system, but the mode of mechanism remains unclear. ETs (ET-1, ET-2, and ET-3) were added to HN33 (mouse hippocampal neuron chi neuroblastoma) cells. Among the three types of ET, only ET-1 increased the intracellular calcium levels in a PLC dependent manner with the induction of ERK 1/2 activation. As the result of ET-1 exposure, the survival rate of HN33 cells and the PKCalpha translocation into the plasma membrane were increased. We suggest that ET-1 participated in the neuroprotective effect involving the calcium-PKCalpha-ERK1/2 pathway.

Hepatic Myelopathy Involving the Posterior Column

Hepatic myelopathy is a rare neurological complication of chronic liver disease, and is characterized by a progressing spastic paraparesis without any sensory loss. However, a few recent reports suggest that involvement of the sensory system is also possible in hepatic myelopathy. We present a patient with hepatic myelopathy, who had impaired proprioception and a delayed cortical response of somatosensory evoked potentials. This supports the hypothesis that hepatic myelopathy may involve the sensory system as well as the motor system.

Dynamic Foot Pressure Measurement in Parkinson's Disease with Foot Scan System

BACKGROUND: Foot Scan System (RS scan international cooperation) measuring the plantar pressure distribution is simple and inexpensive tool for gait analysis. The analysis of plantar pressure distribution of the feet during gait maybe helps the assessment of motor symptoms or gait stability of Idiopathic Parkinson's disease (IPD). METHODS: We compared the parameters of foot scan system between 34 normal controls and 23 IPD patients before and after levodopa administration. Data of plantar force distribution and time of stance phase were collected using pressure-sensitive insoles as parts of the Foot Scan System. RESULTS:There were significant difference between normal controls and IPD patients in fore foot peak pressure/rear foot peak pressure ratio, time percentage of heel strike phase, mid stance phase, propulsion phase in stance phase. But in these parameters there were no significant difference between IPD patients before dopamine with after dopamine medication. CONCLUSIONS: Using the Foot Scan System (RS scan international cooperation) measuring the plantar pressure distribution, we showed that F/R ratio and time percentage of propulsion phase are reduced significantly in patients with IPD, which enables us to understand the features of gait in IPD patients more easily.

A Case of Meningoencephalitis Associated with Relapsing Polychondritis

Relapsing polychondritis (RP) is a rare multisystem autoimmune disease of unknown origin characterized by recurrent episodes of inflammation and progressive destruction of cartilaginous tissues. We present a patient diagnosed with meningoencephalitis associated with RP whose initial symptoms included chronic headache with memory disturbance and disorientation. After treatment of meningoencephalitis, the patient had frequent bilateral auricular swelling, polyarthralgia, and sensory neural hearing loss. Although RP is an extremely rare disease, it should be considered as a possible cause of chronic meningoencephalitis.

The Analysis of Treatment with Acyclovir and Prognostic Factors on Idiopathic Facial Mononeuropathy Using Sunnybrook Scale

BACKGROUND: Based on a recent study showing that the reactivation of HSV-1 may be one of the possible pathogenesis of idiopathic facial mononeuropathy, antiviral therapy has been suggested as a good treatment modality. However, the efficacy of antiviral therapy is still controversial. This argument may be caused by the absence of a reliable system of grading facial nerve paralysis. We performed this study to investigate the therapeutic effects of an antiviral agent and possible prognostic factors using the Sunnybrook scale. METHODS: Patients with idiopathic facial mononeuropathy were divided as two groups according to the treatment regimens (Acyclovir & Steroid vs. Steroid only). Clinical efficacy was evaluated using the House-Brackmann grading system and Sunnybrook scale. Electrodiagnostic studies including the blink reflex, facial nerve conduction study, and facial nerve excitability test were performed. The clinical improvement rate between the two groups and the usefulness of the electrodiagnostic studies as prognostic factors were analyzed. RESULTS: No significant differences of the clinical improvement rate was revealed with a 70% improvement rate for the Acyclovir treatment group and 84% for the steroid only group. Among electrodiagnostic studies, the compound muscle gamma action potential (CMAP) amplitude (=0.637, p=0.000) and nerve excitability =0.688, gamma test (p=0.000) on 2 weeks showed significant correlations to the final Sunnybrook score. There is good correlation between the two facial nerve grading systems. CONCLUSIONS: Acyclovir may not be effective in the recovery of idiopathic facial mononeuropathy. CMAP amplitude and nerve excitability tests on 2 weeks may provide valuable prognostic factors. The Sunnybrook scale may be useful as a facial grading system.

A Case of Dopamine Dysregulation Syndrome with Concurrent Parkinsonism Hyperpyrexia Syndrome

A few patients with Parkinson's disease (PD) crave large amounts of levodopa therapy far beyond those needed to alleviate their symptoms, even in the state of overdose complication. Such harmful pattern of compulsive dopaminergic drug use is called as dopamine dysregulation syndrome (DDS). We report a chronic stage PD patient presenting with high fever and altered mentality, who had the DDS as well as the Parkinsonism hyperpyrexia syndrome (PHS).

Craniocervical Segmental Dystonia in the Spinocerebellar Ataxia Type 2

The spinocerebellar ataxia type 2 (SCA 2) is an autosomal dominant cerebellar ataxia that commonly presents with cerebellar ataxia, hyporeflexia, and slow saccades. Recent clinical series described movement disorder in the SCA 2 such as Parkinsonism or dystonia. Dystonia can be observed in and even be the presenting feature of the SCA 2. We report two patients with genetically confirmed SCA 2 displaying a slowly progressive syndrome combined with cerebellar ataxia and craniocervical segmental dystonia.

Bitemporal Hemianopia Associated with Anti-Tuberculosis Medication

No abstract available.

Analysis of 10,811 Cases with Acute Ischemic Stroke from Korean Stroke Registry: Hospital-Based Multicenter Prospective Registration Study

BACKGROUND: Although several hospital-based stroke studies were published, there has not been any reliable data representing the clinical characteristics of stroke in Korea. We analyzed the clinical characteristics of patients with ischemic stroke registered in the Korean Stroke Registry (KSR), which is the largest prospective hospital-based nation-wide stroke registry in Korea. METHODS: The KSR provided standardized protocols for collecting data, which includes the data of demographics, subtypes of stroke, risk factors, and neurological outcome at discharge. The brain imaging studies, including CT or MRI, were performed in all cases. RESULTS: KSR registered 10,811 patients of acute ischemic stroke between Nov. 2002 and Jun. 2004. The large-artery atherosclerosis was the most common subtype (37.3%), followed by small vessel occlusion (30.8%). Hypertension (65.4%) was the most common risk factor, followed by smoking (34.5%) and diabetes (28.3%). Although most of the hypertensive and diabetic patients had been diagnosed before the stroke, less than 45.4% and 32.5% of them were under regular control. The steno-occlusive lesion of extracranial carotid artery was only 29.3% and the ratio of intra- to extracranial artery disease was more than 2 in KSR. Only 20.5% of patients were admitted within 3 hours after stroke onset and 2.1% were treated with intravenous thrombolysis. In-hospital case-fatality was 5.2%, which is relatively comparable to those of previous studies. CONCLUSIONS: The KSR provided informative data in understanding the clinical characteristics of ischemic stroke in Korea. Further analysis of KSR will facilitate clinical trials and development of guidelines for the management of stroke patients.

Chronic Inflammatory Demyelinating Polyneuropathy Developed during Interferon-beta Therapy in a Patient with Multiple Sclerosis

Preliminary studies have evaluated the effects of interferon beta formulations in the treatment of chronic inflammatory demyelinating polyneuropathy (CIDP) because of pathogenic similarities between CIDP and multiple sclerosis (MS). However, the efficacy of Interferon, which has been widely used for relapsing-remitting MS, is controversial in CIDP. We report here a 31year old woman with relapsing-remitting type MS treated with IFN beta-1b over 2 years who developed overt CIDP. She responded favorably to steroids. This case suggests that IFN beta-1b treatment may not prevent development of CIDP.

Analysis of Dynamics of Gait in Parkinson's Disease with 3-Demensional Gait Analysis System

BACKGROUND: Gait disturbance is one of the most disabling symptoms of Parkinson's disease (PD). To better understand of the dynamics of gait in PD, we quantitatively evaluated the spatiotemporal and kinematic parameters of gait in PD patients and normal controls with 3-demensional gait analysis system. METHODS: The diagnosis of PD was based on UK Brain Bank criteria. Subjects with PD were recruited from Parkinson disease clinic of Korea University Medical Center. The severity was indicated by Hoehn and Yahr stage and Unified Parkinson disease rating scale (UPDRS). The gait analysis and assessment was performed in the off condition. RESULTS: Thirty PD patients and thirty normal controls were included. The statistical significant results of gait analysis between PD and control groups were as followings; reduced walking velocity, reduced stride length, increased double supporting time, reduced pelvic oblique movement with preserved pelvic tilting, reduced maximal flexion and extension of hip joint, reduced flexion angle of knee joint especially in terminal stance phase and swing phase, and reduced plantar flexion of ankle. But there were no significant difference between PD and control groups in cadence. And these parameters except cadence had significant correlation with clinical disability in PD patients. The cadence did not correlated significantly with clinical disability. CONCLUSIONS: The PD patients showed statistically gait cycle change with preserved cadence, reduced range of motion in hip, knee, and ankle joint with preserved ankle dorsiflexion in the profiles. These features were aggravated in advanced stage.

Treatment with Repeated Lumbar Epidural Blood Patches for a Patient with Orthostatic Headache after Suboccpital Craniectomy

Orthostatic headache after suboccipital craniectomy has been rarely reported. A 32-year-old man underwent emergent suboccipital craniectomy due to acute bilateral cerebellar infarctions with massive brain edema. Although his neurological deterioration halted after the craniectomy, he still suffered from a severe disabling orthostatic headache. We performed two epidural blood patches at the levels of the lumbar and thoracic spine. He improved considerably a few days after the repetitive epidural blood patches. Epidural blood patches may be a useful treatment modality for post-craniectomy postural headaches.

A Case of Severe Obesity-Hypoventilation Syndrome Treated by Bilevel Positive Airway Pressure Therapy

Obesity-Hypoventilation syndrome (OHS) is characterized by morbid obesity, hypoxia, and hypercapnea during wakefulness without parechymal lung disease or severe obstructive sleep apnea. A woman was admitted because of mental deterioration and diagnosed as OHS on the basis of obesity and hypoventilation, while awake, after ruling out other causes. By bilevel positive airway pressure (BiPAP) therapy, hypercapnea and hypoxia were resolved. We report that BiPAP can be an effective treatment for severe hypercapnea and hypoxia in OHS, which obviate the need for invasive endotracheal intubation.

Jerky Seesaw Nystagmus in Isolated Internuclear Ophthalmoplegia

The authors report jerky seesaw nystagmus, extorsional downbeating in the right eye and intorsional upbeating in the left eye, in a patient with right internuclear ophthalmoplegia (INO). This pattern of nystagmus may occur by disrupting pathways from contralateral posterior and anterior semicircular canals by a lesion in the medial longitudinal fasciculus. Depending on damage to the pathways from contralateral vertical canals, various patterns of dissociated torsional-vertical nystagmus may accompany INO.

Gender Difference on Corpus Callosum in Korean Adults / 체질인류학회지

Corpus callsoum (CC) is the largest commissural fiber connecting the cerebral hemispheres. The gender difference in the size or the shape of CC is a long standing dispute. Some reported that adult female CC had more bulbous splenium and larger area considering brain size, but others failed to replicate this findings. There is no definite consensus on sexual dimorphism of CC yet, although extensive studies on sexual dimorphism has been expected to provide a clue to explain sociopsychological differences between male and female. This variable results are attributed to limited number of subjects, measured parameters, and method of measurement. We have employed comprehensive analytic parameters with large subjects to understand gender differences on CC of healthy Korean adults. We have analyzed the magnetic resonance image (MRI) in adults free from neurological disorders. The subjects were composed of 108 young people (3rd decade; male : 51, female : 57). Total area, its 5 sub-areas, linear parameters including height, length, and width and five specific angles of the CC were measured on the midsagittal MR images with NIH Image program (R) (Ver 1.6). The gender differences were observed in the area of splenium and length in the group. The male CC have larger splenium and longer length than female. The angle between neural axis and base of corpus callosum in female was significantly larger than that of male. This study reports not only gender difference of adult CC, but Korean adult standard morphometric data of CC research. These results might serve a useful basic data for various research in the fields of neuroanatomy, neuroradiology, and neuropsychiatry.

Possible Mechanism of Seesaw Nystagmus in Internuclear Ophthalmoplegia

The authors report jerky seesaw nystagmus, extorsional downbeating in the ipsilesional eye and intorsional upbeating in the contralesional eye, in a patient with internuclear ophthalmoplegia (INO) from focal pontine lesion. This pattern of nystagmus may occur by disrupting pathways from contralateral posterior and anterior semicircular canals by a lesion in the medial longitudinal fasciculus. Depending on the pathways involved, various patterns of dissociated torsional-vertical nystagmus may accompany INO.

A Study on Headache in an Island Area of Korea

BACKGROUND: Headache is one of the most common disorders, and shows ethnic or geographic diversities. Moreover, the prevalence and epidemiologic characteristics of headache, especially in people living in an island area, is lacking. Therefore, we investigated the prevalence and subtypes of headache in an island area of Korea. METHODS: We collected the demographic and clinical data of all residents living in the survey island area. A neurologist interviewed 352 respondents in a face-to-face method. The specific headache diagnosis was based on the diagnostic criteria of the International Headache Society. RESULTS: The survey island area represented a typical aging society like that of a rural area in Korea. Tension-type headache was the most common type. The prevalence of migraine, tension-type headache, and other headache were 4.0%, 7.1%, and 1.7%, respectively. Migraine with aura occupied 1.7% and migraine without aura occupied 2.3%. Episodic tension-type headache occupied 6.5% and chronic tension-type headache occupied 0.6%. Migraine showed a peak prevalence below the third decade of age and tension-type headache showed a peak prevalence above the sixth decade. CONCLUSIONS: This study showed a characteristic pattern of the prevalence of headache in an island area of Korea. We thought this low prevalence of headache might be due to not only subject age but also social-environmental factors. This study may be helpful in understanding headaches and can provide some basic information for future studies.

Left Hand Mirror Writing Following a Left Temporo-Parietal Lobe Infarction

Mirror writing is the simultaneous process of reversing individual letters and composing word strings in the reverse direction. This phenomenon appears rarely only after brain damage. We present the case of a 65-year-old, right-handed man with mirror writing following a left temporo-parietal lobe infarction. He preferred to write in the mirror direction with his left hand, but he did not show any visual-spatial disturbance and allochria. We think that damage to the dominant writing program of the brain, releases the normally suppressed contralesional writing program and this uninhibited program induces the mirror writing.

Cerebrovascular Complication in Tuberculous Meningitis

BACKGROUND: Cerebral infarction as a complication of tuberculous meningitis (TBM) is not uncommon, but has been rarely reported. The purposes of this study were to evaluate the clinical characteristics of cerebral infarction secondary to TBM and investigate the predictive values for cerebral infarction in patients with TBM. METHODS: We prospectively collected patients with TBM for 24 months. Patients were divided into two groups, either patients with stroke or without stroke. We compared the demographic features, clinical, laboratory, and neuroradiologic findings between the two groups. We classified the stroke subtype with neuroimaging findings. RESULTS: The 26 patients were diagnosed as TBM, and 6 patients had complications with cerebral infarction. The neutrophil percentage in the cerebrospinal fluid (CSF) leukocyte were significantly higher in patients with stroke than in patients without stroke (p=0.0098). On initial CT scan, meningeal enhancement was found in 9 patients, and 4 of them complicated with stroke. However, there were no significant differences in the other clinical and laboratory features such as demographic features, interval between meningitis onset time and treatment initiation time, peripheral white blood cell count, and CSF findings. In six patients with stroke, lacunar infarctions and non-lacunar territorial infarctions were found in 3 patients, respectively. In territorial non-lacunar infarction patients, one patient died due to herniation. CONCLUSIONS: We suggest that the possibility of cerebral infarction under the treatment of TBM should be considered, when the patient shows focal neurologic signs, meningeal enhancement on the CT scan and sustained polymorphic CSF pleocytosis.