Stroke in Young Adults

Stroke in young adults are not common and it is often hard to find their causes. We reviewed the medical records of 154 young adult patients aged 15-45 years who were admitted to the Seoul National Urliversity Hospital with a diagnosis of stroke between March 1989 and February 1991. These cases comprised 13.8% of 1115 patients of all ages admitted for stroke. The number of young adult patients with intracerebral hemorrhage was 47 (30.5%, N&154); the main causes were hypertension, arteriovenous malformation, and moyamoya disease. Subarachnoid hemorrhage was found in 25 young patients (l6.2%, N=154); the majority were due to aneurysms. The number of intraventricular hemorrhage cases was 17 (11.0%, N&154). The causes confirmed by angiography, were moyamoya disease in 7 cases and arteriovenous malformahon in 5 cases. The remaining 73 patients (47.4%, N&154) had cerebral infarction;the major causes were young-aged atherosclerosis (75.3%) and cardiogenic emboli (24.7%). Hypertension, history of transient ischemic attack, and hyperlipidemia were major risk factors of atherosclerotic cerebral infarction. Among the cerebral infarction patients whose risk factors had not been found by conventional diagnostic methods (l6 patients), there were 5 patients in whom the presence of cardiac embolic sources could be demonstrated only by transesophageal echocardiography (left atrial thrombus in two patients; patent foramen ovale in two; and atrial septal aneurvsm in one patient). The total number of all tvpes of young adult stroke patients whose causes (or risk factors) were unable to be classified in detail was 24 (15.6%, N&154). The transesophageal echocardiography and the angiography, in many occasions, were helpful in detecting the causes of young adult stroke of which risk factors had been undetermined.

Botulinum A Toxin Treatment of Hemifacial Spasm: The Dose-response Relationship in Orbicularis Oculi

Forty-one patients with hemifacial spasm received botulinum A toxin in total 73 visits. In 68 of 73 visits(93%), substantial improvement with peak effect(change in severity of hemifacial spasm 22 ) was obtained, with a mean total dose of 12.5 units. Mean severity of hemifacial spasm before and after treatrnent were 3.8 and 1.1 respectively on a 0-5 scale. Mean muscle dose of orbicularis oculi was 9.0 units There was a significant association between muscle dose and post-treatment weakness of orbicularis oculi(Spearman correlation coefficient, 0.42691). There was also a striking and significant association between post-treatment weakness of orbicularis oculi and peak effect(Spearman correlation coefficient, 0.74883). Lagophthalmos occurred only in 2 of 28 visits (7%) who received lesser than 10.0 units for orbicularis oculi as compard to 22% in the higher dose group. But peak effects showed no significant difference between the two groups(p =O.I30). We suggest that the occurrence of lagophthalmos can be reduced with the dose lesser than 10.0 units for orbicularis oculi, maintaining the significant effect.

Magnetic resonance imaging in brainstem ischemic stroke

To evaluate the efficacy of magnetic resonance imaging in brainstem stroke, we studied 21 cases of clinically definite brainstem ischemic stroke with brain magnetic resonance imaging (MRI) and conventional computed tomography (CT). MRI demonstrated brainstem lesions in 79% of the cases (16.5 out of 21), while CT revealed 33% (7 out of 21) when cases with suspicious lesions counted as 0.5. Although MRI was done a few days later than CT in most cases, MRI was superior to CT in detecting the number and the size of ischemic lesions, with clear delineation of anatomy and visualization of the status of the blood flow in the vertebral-basilar artery. Disappearance of the flow signal void in the basilar artery can be an important clue in diagnosing occlusion or thrombus of the basilar artery. By delineating the extent and the location of the infarction, MRI findings allowed an interpretation of whether the ischemic vessel is a small basilar branch or a large vessel vertebral or basilar artery.

Multimodality Evoked Potentials in Amyotrophic Lateral Sclerosis

Twenty-one patients with amyotrophic lateral sclerosis were studied with visual, brain stern auditory and sornatosensory evoked potentials. Median nerve sensory evoked poten tials were recorded in 18 patients, showing prolonged absolute or interwave latencies in 5 pafients and no consistent wave forrnation in a patient. Posterior tibial nerve sensory evoked potentials were recorded in 16 patients, showing prolonged absolute or interwave latencies in 4 patients and no consistent wave formation in a patient. P1 absolute latency and arnplitude of VEP, I-III, III-V and I-V interpeak latencies of BAEP were withi normal lirnits in all ALS patients. These results suggest a pathological slovwing of conduction along the central sensory pathways in amyotrophic lateral sclerosis.

Two Cases with Bilateral Adie's Pupils

Adie's tonic pupil usually consists of mydriasis, defect in accommodation. Poor or absent light reflex, and tonic near reflex, It is usually unilateral, but rarelY observed bilaterally. The pupillary abnormalities often accompany areflexia, which is called Adie syndrome collechvely, Other autonomic dysfunction especially hypohidrosis. Are rarely reported in association with Adie syndrome. We recently experienced 2 cases of bilateral Adie's pupils in 2 women, one of whom had hypohidrosis, and the other had areflexia. So we report 2 cases with bilateral Adie's pupils with a review of literature.

Two Cases of Juvenile Myoclonic Epilepsy of Janz

Juvenile myoclonic epilepsy(JME) of Janz is a syndrome of generalized age related epilepsy with increasing incidence and probable autosomal recessive trait. We have experienced 2 female patients who had awakening myoclonus in both arms, which had started in their early 10th. The patterns of seirures and electroencephalographic findings were consistent with those of JME which had been first described as impulsive petit mal by Janz. We report these cases with brief review of literatures.

A Case of Paraplegia Following Intrathecal Methotrexate Instillation

Paraplegia following intrathecal methotrexate(MTX) instillation is a rare complication and 18 cases have been reported in the literature. It has not been reported m Korea. We recenty experienced a 56 year-old female with quadriplegia following intrathecal MTX instillation. So we report a case of paraplegia following intrathecal MTX instillation with review of the literature.

MR demonstration of cryptic vascular malformation producing a palatal myoclonus: a case report

A 47-year-old man had suffered oscillopsia associated with palatal myoclonus for 10 years. High-field magnetic resonance imaging (MRI) revealed a cryptic vascular malformation within the "Guillain-Mollaret triangle" which was thought to be the responsible lesion.

A Case of Down Syndrome with Atlanto-axial Dislocation

Atlanto-axial instability in children with Down syndrome(trisomy 21) has become a wel! Known entity and it has been reported frequently since it was first reported over 25 years ago. However, symtomatic atlanto-axial dislocation associated with cord compression is relatively rare and it had seldom been reported. We recently experienced a 14-year-old mongoloid female with progressive quadriparesis, who have no prior cervical inflammation and we detected atlanto-axial dislocation with ossculum terminale and cord compression through radiological evaluations. We report a case of symptomatic atlanto-axial dislocation in Down syndrome with review.

Correlation of Cognitive Evoked Potentials with Memory Tests in Patients with Memory Disturbance

We performed 3 kinds of memory tests and cognitive evoked potential study, P300, in 13 patients with memory disturbance and 19 control free of neurologic symptoms or history of neurological impairment; to determine correlation of each memory test with P300 and possibility of clinical application of P300 as a quantitative test of cognitive function. Patients and control younger than 40 years of age were selected to minimize the aging effect on the cognitive function tests. Those who marked 30 points in Mini-mental state examination were chosen as control. 11 of 13 patients had brrain lesions including temporal lobe. Comparing with tests in control group, the declarative ant the procedural memory of patients were significantly impaired (p<0.05, p<0.025, respectively), and P300 latency was significantly prolonged (p<0.001). In control group, among declarative memory tests Rey-Osterreith complex figure test and enhanced cued recall had significant correlation with P300 latency (p<0.05, p<0.05, respectively), while the Tower of Toronto test which was known to evaluate precedural memory did not. In patient group there was no significant correlation between any kind of memory test and P300 latency. These results not only are consistent with previous studies which detected temporal lobe as the origin of P300 wave, but implicate that brain loci other than temporal lobe might originate P300 wave. To apply P300 as a quantitative test of cognitive function, further extensive studies using age and IQ matched control will be needed.

Amplitude and Latency Difference Between Right and Left Half-Field Visual Evoked Potentials in Normal Subjects

The amplitude and latency of visual evoked potentials to pattern-reversal half-field stimulation were measured in 20 normal right-handed subjects to determine whether the individual contribution of right and left cerebral hemispheres is different as related to the generation of pattern-evoked potentials. The amplitude and latency of P1 from a lateral occipital electrode ipsilateral to the halffield stimulation were significantly greater with right half-field wtimulation. The amplitude and latency difference between both sides probably reflects asymmetries of human striate cortex.

Brainstem Auditory Evoked Potentials in Tuberculous Meningitis

Brainstem auditory evoked potentials (BAEPs) were evaluated in 22 patients with tuberculous meningitis to determine the incidence of abnormal BAEPs in tuberculous meningitis and the possible effect of variable factors on the incidence of abnormal BAEPs. Of 22 patients tested, 19 (86.4%) had abnormal interpeak latencies in one or both ears. I-III interpeak latenies were increased in 14 patients (63.6%) and III-V interpeak latencies in 7 patients (31.8%). Meningeal enhancement in brain CT or MRI was significantly correlated with abnormal BAEPs, especially with I-III interpeak latencies.

Brain Magnetic Resonance Imaging in the Evaluation of Patients with Lacunar Syndrome Compared with CT

The purpose of this study was to evaluate the efficiency of Magnetic Resonance Imaging (MRI) in the evaluation of patients with lacunar syndrome, to compare the sensitivity of MRI and that of brain Computed Tomography(CT) in the lacunar lesions. Thirty-nine cases of lacunar syndrome were pure sensory stroke(1 case), pure motor hemiparesis (12 cases), ataxic hemiparesis (5 cases), pure motor hemiparesis sparing face (2 case), pure motor hemiparesis with confusion (1 case), cerebellar ataxia with crossed 3rd nerve palsy (1 case), sensory-motor stroke(4 cases), lower basilar branch syndrome (6 cases), lateral medullary syndrome (3 cases), lateral pontomedullary syndrome (2 cases), locked-in syndrome (1 case), and miscellaneous (1 case). MRI detected small, deep lesions appropriate to lacunar syndrome in 34 cases (medulla, 3 cases; pons, 16 cases; midbrain, 3 cases : thalamus-internal capsule, 2 cases : internal capsule-basal ganglia, 6 cases; periventricular white matter, 3 cases) of the patients (34/39, 87.1%), and was diagnostically superior to CT in those cases (especially in brainstem lacunar lesions), where both studies were obtained concommitantly (MRI : CT=84.3% : 37.5%). MRI, when evailable, should replace CT as the diagnostic imaging procedure of choice in evaluation of lacunar syndrome.

Capsular Infarcts (Clinical and Computed Tomographic Correlations)

Twenty patient's capsular lesions were detected by high resolution brain computed tomograhpy (CT). Eighteen of them had systemic hypertension. Two patients had prior stroke episodes that were of the same nature. All of the patients had sudden onset of neurologic deficits. Their neurologic syndromes were pure motor stoke (10 cases), ataxic hemiparesis (3 cases), pure motor stroke with dysphasia (1 cases), pure sensory-motor stroke (3 cases), pure motor stroke with tremor, locked-in syndrome, and hemiparesis with latered consciousness, each 1 case respectively. The CT showed capsular infarcts of ovolid or round hypodense lesion that was smaller than 20mm in diameter and that was seen on only two scan sections. The sites of capsular infarcts were genu(5 cases), posterior limb (9 cases), genu-posterior limb (3 cases), genu-anterior limb (3 cases), and anterior limb (4 cases) respectively. Large capsulo-putamino-caudate infarcts, or giants lacunes (type 1 of Rascol et al ) are seen in 3 cases only in pure motor stroke ; Posterior limb capsular Iacunes (type 2 of Rascol et al), 6 cases in pure motor stroke, 3 cases in ataxic hemiparesis, 2 cases in pure sensory-motor stroke, 1 case in modified pure motor stroke with tremor : Anterior capsular lacunes (type 3 of Rascol et al), 1 case in pure motor stroke, 1 case in modified pure motor stroke with dysphasia, 1 case in modified pure motor stroke with memory and cognitive dysfunction. None of the capsular infarct caused mass effect. In five cases there was a relatively complete neurologic improvement, in 14 cases did the patients show mild residual neurologic deficit, and one patient expired. With the use of CT, the diagnosis of capsular infarcts has moderately increased.

Current Status of Cerebrovascular Disease in Korea

To evaluate the current status of cerebrovascular disease in Korea, we performed a retrospective study on 1260 cases of stroke who had been admitted to or had visited Seoul National University Hospital, Choongnam National University Hospital, Hanyang University Hosipital, and Chung Ang University Hospital in the period from Jul 1, 1986 to Jun 30, 1987. The incidence was highest in sixth and seventh decades. Ischemic stroke (51.1%) was more common thar, hemorrhagic stroke (47.6%), and thrombotic infarction was the leading type (37.7%) of all kinds of strokes. Middle cerebral arterial territory was the most commonly involved site in thrombotic and embolic stroke. Among intracerebral hemorrhage, basal ganglia hemorrhage was found in 47.7%, and was followed by thalamic(23.8%), lobar (15.3%) and pontine hemorrhage (9.4%). Primary intraventricular hemorrhage (IVH) was relatively rare (8 cases, 7.5% of all IVH), and hemorrhages in basal ganglia or thalamus frequently induced secondary IVH. 16 cases (10.7%) of subarachnoid hamorrhage were accompanied by secondary IVH. This study suggests changing trends of stroke in Korea, and multicenter prospective study using stroke registry is requird for confirmation.

Magnetic Resonance Imaging in Neurologic Diseases

Magrjetic resonance (MR) imagings with 0.15 Tesla resistive magnet developed by Korea Advanced Institute of 5cience were performed in 27 patients with various neurologic diseases and compared with X-ray computed tomography (CT). The purpose óf the paper is to evaluate the image quality, the diagnostic value and limitation, and the optimal pulse sequence of MR imagings with a resistive magnet. The MR images were obtained by using a variety of pulse sequence with spin echo technique includïng saturation recovery, T2-weighted spin echo, and/or inversion recovery with various pulse repetition(TR) and echo delay (TE) times. The M R imaging demonstrated the capability of detecting the lesions shown on CT in all cases and also detected an additional finding in one case (multiple sclerosis) which was not seen on CT. The MR imaging appeared to be more useful than CT in the evaluation of syringomyelia of spinal cord and white matter disease, while it failed to demonstrate small calcific lesion or inflammatory nodule (less than 1 cm) shown on CT and has shown somewhat poor contrast resolution in the case of meningioma. The spatial resolution of saturation recovery images was similar or superior to CT, whereas the contrast resolution of saturation recovery was inferior to CT. While the saturation recovery images have shown false negative findings in 5 patients (19%), the inversion recovery and T2-weighted spin echo have shown consistently positive findings. The inversion recovery and T2-weighted spin echo images demonstrated better contrast discrimination between normal and pathologic conditions than the saturation recovery images, but somewhat poorer spatial resolution. Authors suggest that the MR images of both the saturation recovery with 300/30 and T2-weighted spin echo with 1000/90 be used as a routine procedure and additional iversion recovery of 1300/300/30 sequence as a option if white matter disease is suspected.

Electrodiagnostic Studies in Neurological Complications of Acute Hemorrhagic Conjunctivitis

Electrodiagnostic studies were carried out in 31 patients with neurological complications of AHC, who were seen at Seoul National University Hospital from August 1981 to February 1982. Age of the patients ranged from 14 to 62 years. Both velocity and distal latency of motor and sensory conduction were normal in the nerves innervating the affected muscles. During the acute phase of motor paralysis, there was an absence of electrical activity in completely paralysed muscles. In partially denervated muscles, there were polyphasic motor unit potentials of normal duration and amplitrde on weak contraction and reduced interference on maximal effort. From the third or fourth week onwards, fibrillation potentials and positive sharp waves at rest were observed in paraspinal muscles in most cases. All the above findings were supporting the view that the principal site of involvement for the paralytic phenomena is at the level of the anterior horn cells or anterior roots.