Delayed Rupture of an Anterior Communicating Artery Pseudoaneurysm Caused by Distal Occlusion Thrombectomy Using a Stent Retriever: A Case Report and Mechanism of Injury / 신경중재치료의학

We report a case of delayed rupture of an anterior communicating artery (Acom) pseudoaneurysm following mechanical thrombectomy (MT) of a distal artery occlusion using a stent retriever. An elderly patient with right hemiparesis showed left proximal internal cerebral artery and middle cerebral artery occlusions. During MT, a fragmented thrombus moved to the anterior cerebral artery (ACA). A stent retriever was deployed to the occluded ACA, and the Acom and proximal ACA segment were significantly straightened. Additionally, we attempted a blind exchange mini-pinning (BEMP) technique, but a subarachnoid hemorrhage (SAH) occurred. Bleeding was almost entirely absorbed 9 days after the procedure, but the SAH recurred at 20 days, and computed tomography angiography revealed a new pseudoaneurysm formation in the Acom. We suggest that the proposed mechanism of pseudoaneurysm formation was likely due to the dislocation and avulsion of the Acom perforators when the ipsilateral ACA was pushed and pulled during MT.

Synergic Effects of Cranial Electrotherapy Stimulation with Sleep Hygiene in Patients with Chronic Insomnia

OBJECTIVES: To investigate the therapeutic effect of cranial electrotherapy stimulation (CES) with sleep hygiene in patients with chronic insomnia. METHODS: This study was designed as a prospective, double-blinded, and randomized controlled trial. Twenty-seven patients with chronic insomnia were recruited and randomly allocated to two groups; cranial microcurrent therapy (MC) group and sham group. All patients received sleep hygiene education. Pittsburgh Sleep Quality Index (PSQI) and Insomnia Severity Index (ISI) were measured at baseline (pre-treatment), and 2 weeks and 4 weeks of treatment. RESULTS: In MC group, the PSQI and ISI showed a tendency to decrease consistently until 4 weeks of treatment. In sham group, PSQI and ISI initially decreased during the first 2 weeks, but it increased after 2 weeks of treatment. CONCLUSIONS: This study showed that combination treatment of CES and sleep hygiene is more effective in treating chronic insomnia than sleep hygiene only as demonstrated by improvement and maintenance of sleep score for 1 month.

Comparison of Four Methods calculating Ankle Brachial Indexes for Coexistent Intracranial and Extracranial Artery Stenoses in the Patients with Ischemic Stroke

BACKGROUND: The ankle brachial index (ABI) is a useful screening tool for peripheral arterial disease. It has been documented that the cerebral atherosclerosis is more frequent in stroke patients with abnormal ABI than in those with normal ABI. The present study compared the different calculation methods of ABI for coexistent intracranial and extracranial arterial stenosis (IECAS) in ischemic stroke. METHODS: We reviewed the data of patients admitted for acute ischemic stroke or transient ischemic attack. The following four distinct ABIs were calculated: the ratio of the higher (ABI-H), lower (ABI-L), or either of the systolic blood pressures (SBPs) of the posterior tibial (ABI-PT) and dorsalis pedis (ABI-DP) arteries relative to the higher of the brachial SBP. We compared the values of these four ABI measures relative to the presence of any IECAS using receiver operating characteristic (ROC) curve analysis. RESULTS: ABI-H, ABI-L, ABI-PT, and ABI-DP were abnormal (≤ 0.9) in 19 (13.1%), 36 (24.8%), 29 (20%), and 30 (20.7%) of 145 patients, respectively. The area under the ROC curve was significantly larger for ABI-H, ABI-L, and ABI-DP than for ABI-PT for any type of IECAS. The extracranial stenosis was more frequent when any of the four ABIs was abnormal, while intracranial stenosis was not correlated with the four ABIs. The IECAS was more frequent for abnormal ABI-H and ABI-DP than for normal ABIs. CONCLUSIONS: Our studies suggested that ABIs based on a higher SBP of the PT or DP (i.e., ABI-H) are more strongly associated with the presence of IECAS than are those using the SBP of the PT (ABI-PT). Extracranial artery stenosis seems to be more strongly associated with ABI than is intracranial stenosis.

A Case of Hemichorea with Primary Somatosensory Cortical Infarction / 대한뇌졸중학회지

Hemichorea is caused by various diseases but stroke is the most common cause. The usual lesions of the stroke related hemichorea are the contralateral subthalamus or basal ganglia. Few cases with cortical lesion have been reported. But hemichorea with primary somatosensory cortical lesion has not yet been reported. We report a case with hemichorea after acute infarction of the contralateral primary somatosensory cortex.

Frovatriptan is Effective and Well Tolerated in Korean Migraineurs: A Double-Blind, Randomized, Placebo-Controlled Trial

BACKGROUND AND PURPOSE: Frovatriptan is a selective 5-HT1B/1D agonist with a long duration of action and a low incidence of side effects. Although several placebo-controlled trials have documented the clinical efficacy and safety of frovatriptan in adults with migraine, this drug has not previously been studied in Asian including Korean patients. METHODS: In this double-blind multicenter trial, 229 patients with migraine were randomized to receive frovatriptan 2.5 mg or placebo upon the occurrence of a moderate-to-severe migraine. The primary outcome was the 2-hour headache response rate. RESULTS: Frovatriptan significantly increased the 2-hour headache response rate compared with placebo (52.9% vs. 34.0%, p=0.004). The headache response rates at 4, 6, and 12 hours were significantly higher in the frovatriptan group than in the placebo group, as was the pain-free rate at 2 hours (19.0% vs. 5.7%, p=0.004), 4 hours (40.7% vs. 23.0%, p=0.006), and 6 hours (56.1% vs. 34.0%, p=0.002). The median time to a headache response was significantly shorter in the frovatriptan group than in the placebo group (2.00 hours vs. 3.50 hours, p<0.001). The use of rescue medications was more common in the placebo group (p=0.005). Chest tightness associated with triptan was infrequent (2.5%), mild, and transient. CONCLUSIONS: These results demonstrate that 2.5-mg frovatriptan is effective and well tolerated in Korean migraineurs for acute treatment of migraine attacks.

Generalized Actinic Granuloma with Ocular Involvement,Subsequent Development of Temporal Arteritis / 대한피부과학회지

A 63-year-old Korean man presented with generalized, asymptomatic, discrete papules and coalescent annular plaques for one year. Interestingly, the patient complained of conjunctival congestion, concurrently with aggravation of the skin lesion. Histopathologic findings of the skin lesion and conjunctiva revealed giant cells engulfing fragmented elastic fibers, and a diagnosis of actinic granuloma with ocular involvement was made. Ten months later, the patient revisited with a two-week history of bilateral temporal headache, neck pain, intermittent jaw claudication, and blurred vision. Biopsy of the temporal artery confirmed the clinical diagnosis of temporal arteritis. Both actinic granuloma and temporal arteritis show similar pathologic process, and this case supports the hypothesis that actinically degenerated elastic tissue is likely to be the antigenic basis of actinic granuloma of the skin and temporal arteritis.

Comparisons of Life Quality between Chronic and Episodic Migraine Patients

BACKGROUND: In this study, the quality of life of patients with chronic and episodic migraine was compared using quality of life assessments tools, which included the MIDAS (migraine disability assessment) questionnaire and MSQoL (migraine-specific quality of life) questionnaire. METHODS: The investigation occurred from November 2005 to April 2006 for patients who visited the neurology department of hospital in because of headache. The patients for the question investigation consisted of 34 patients with chronic migraine (CM) and 48 patients with episodic migraine (EM). The diagnosis of migraines was obtained by the migraine criteria of the International Headache Society (IHS). RESULTS: In the comparisons of the MIDAS score in patients with CM and EM, the second question (reduced effectiveness at work/school), the fourth question (reduced effectiveness in housework), total scores (28+/-19.7 versus 12.0+/-10.1, p<.01), and the question A were higher in CM patients (51.2+/-20.1 versus 15.5+/-13.1, p<.01). MIDAS grade of CM patients were also higher than EM patients. In MSQoL score comparisons of CM and EM patients, three parts of life qualities, which are role-function restrictive, role-function preventive, and emotional function due to headache, and total score (61.9+/-11.7 versus 73.7+/-13.9, p<.01) was less in CM patients than EM patients. CONCLUSIONS: The study shows that life qualities of the patients with CM were significantly lower than of the patients with EM.

A Case of Ocular Flutter after Right Posterolateral Medullary Infarction

No abstract available.

A Case of Bickerstaff's Brainstem Encephalitis with Guillain-Barre Syndrome Presenting Optic Neuropathy and Seizure

Bickerstaff's brainstem encephalitis (BBE), characterized by acute ophthalmoplegia and ataxia, often causes impaired consciousness and hyperreflexia. A 17-year-old man was admitted with an acute meningitic condition including high and neck stiffness. His condition rapidly deteriorated over 2 weeks, and he showed ophthalmoplegia, ataxia, seizure, tetraplegia, comatose mentality, and optic neuropathy. Electroencephalography showed diffuse slow waves. Visual evoked potentials showed no responses in the right eye. This is the first case of BBE with Guillain-Barre syndrome presenting with optic neuropathy and seizure.

Psychosocial Characteristics of Migraine and Tension-type Headache Sufferers

BACKGROUND: Psychosocial factors exert a significant influence on primary headaches. However, little has been known about the agreement concerning the extent and nature of psychological processes on migraine and tension-type headache (TTH). METHODS: Fifty-five patients with primary headache were enrolled to participate in the study and 33 headache-free control subjects. A depression scale (BDI), an anxiety scale (STAI), a psychopathology scale (SCL-90-R), a stress coping scale (MCS), and a quality-of-life scale (WHOQOL-BREF) were administered to all the participants. RESULTS: The headache sufferers turned out to have various emotional problems, used more inefficient stress coping strategies and lead poor quality of life compared with those who had no headache. No distinctive psychological symptom was found between the two diagnosis groups, but the migraine group showed higher obsessive-compulsive symptoms than the TTH group, and the latter group showed higher levels of trait anxiety than the former. CONCLUSIONS: This study shows that the primary headache sufferers have various psychosocial problems. Accordingly, individual treatment approach focusing on the psychological symptoms is needed for the efficient management of headache.

Complex Partial Seizure Like Symptoms Presented by a Patient with Insulinoma and Hyperproinsulinemia / 대한간질학회지

Insulinoma with hyperproinsulinemia and normal serum insulin level is a rare disease. Because of the neuroglycopenic symptoms, the initial diagnosis tends to be made as epilepsy or as psychosis. A 43-year-old man was admitted to our hospital because of recurrent confusional episodes. Symptoms are intermittent and consist of staring, confusion, amnesia, and bizarre behavior. Vital signs during the episode were normal but the serum glucose level was 27 mg/dl. The serum level of insulin during the episode was lower than normal and those of proinsulin and growth hormone were higher than normal. Solitary pancreatic mass was found by abdominal CT, measuring 15 mm in diameter. Pathologic evaluation showed islet cell tumor. This suggests that the serum level of proinsulin should be checked when insulinoma with neuroglycopenic symptom is suspected.

Two Cases of Wernicke Encephalopathy with Focal Cerebral Cortical Involvement and Convulsive Seizure

We report two cases of Wernicke encephalopathy presenting with convulsive seizures. The first patient had been supplied with total parenteral nutrition due to acute pancreatitis and presented with partial seizure evolving to generalized seizure. The second patient had been malnourished due to alcoholism and recent dyspepsia after a gastrectomy, who presented with generalized seizure. Brain MRI revealed high-signal lesions in the focal cerebral cortex on T2-weighted, FLAIR, and diffusion-weighted images. After a thiamine injection, the patients recovered and abnormalities on the MRIs disappeared.

Two Cases of Paroxysmal Hemicrania with Response to Rofecoxib

Paroxysmal hemicrania (PH) has been recently defined as an uncommon primary headache. PH is characterized by frequent attacks of severe unilateral pain associated with autonomic symptoms. The attack frequency usually ranges from 5 to 40 attacks per day. PH is characterized by its absolute responsiveness to indomethacin. However, indomethacin is not often well tolerated because of its gastric side effects. We report two patients with PH who could not tolerate indomethacin due to its severe gastric side effects but dramatically responded to rofecoxib.

Clinical Charateristics of Chronic Daily Headache Patients Visit to University Hospital

BACKGROUND: Chronic daily headache(CDH) could be included all of the primary headache disorders with daily or near-daily headache lasting more than 4 hours/day for 15 days/month. Several studies have shown that patients with CDH are difficult to classify using the currently published International Headache Society(HIS) system. Recently, some authors recommended that CDH could be subclassified into transformed migraine(TM), chronic tension-type headache(CTTH), new daily persistent headache(NDPH) and hemicrania continua(HC). METHODS: We analysed 100 patients with CDH who were diagnosed in Taegu-Hyosung Catholic University Hospital from February 1996 to May 1998. To describe clinical features of CDH, we used our CDH protocol. RESULTS: (1) Most of the patients were in their 5th-7th decades, and female was predominantly affected(female to male ratio, 7.3:1). (2) The subclassification of CDH were CTTH in 59 patients, TM in 33 patients, NDPH in 7 patients, and HC in 1 patient. (3) Clinical characteristics of CDH were mostly bilateral location, mild to moderate intensity and dull nature. The mean onset age of CDH was 47.7 years, the onset time of the day was in the afternoon or anytime, the duration was more than 4 hours or 12 hours in 90 patients, and the frequency was near-daily or daily in 80 patients. Common associated symptoms were nausea, dizziness, insomnia, fatigue, photophobia, blurred vision, and scalp tenderness. (4) Daily use of analgesics was reported in 66 patients. CDH was aggravated during premenstrual period in 10 patients. Positive family history was shown in 26 patients. CONCLUSIONS: We present this report because knowledge of clinical characteristics and adequate protocol for CDH in clinical practice is necessary.

Ischemic Infarctions in Young Men Secondary to Traumatic and Spontaneous Intracranial Arteries Dissection

Arterial dissection begins with spontaneous or traumatic rent of intima, which sometimes allows blood to penetrate the layers of the arterial wall. Dissections of the craniocervical arteries are separated according to whether they are extracranial or intracranial, spontaneous or traumatic. Dissection of intracranial portions of the carotid system is rare, but it may be one of the important causes of ischemic stroke in the young adults. Cerebral angiography, MRI, and Doppler sonography are important diagnostic methods in this case. Initial treatment with anticoagulants or antiplatelet agents are effective in many cases, but sometimes surgical method is recommended. We presented ischemic infarctions in young men secondary to traumatic and spontaneous intracranial arteries dissection

A case of acute disseminated encephalomyelitis

Acute disseminated encephalomyelitis(ADEM) is an uncommon acute inflammatory disease of the CNS which follows viral infections or Vaccination. ADEM is thought to be an immune mediated disease. The classic featues of ADEM include an antecedent event, commonly a viral illness, followed after a latent period by acute onset of multifocal or diffuse CNS signs, the potential for extensive or even complete recovery, and pathologic evidence of perivascular inflammation and demyelination. We experienced a 43-year-old patient with ADEM and reviewed literatures.

A case of aseptic meningitis following intrathecal administration of methotrexate

Methotrexate(MTX) is currently one of the most important antineoplastic drugs used in chemotherapy. Intrathecal(IT) MTX is widely used to treat or prevent meningeal leukemia and lymphoma. Aseptic meningitis following IT MTX is not uncommon, but not reported frequently in neurological field. We report a case of aseptic meningitis following IT MTX in acute lymphocytic leukemia.

A case of idiopathic exercise-induced axial dystonia with ipsilateral upper extremity atrophy

Torsion dystonia (TD) is a clinical syndrome characterized by prolonged spasms of muscle contraction, which distort the body into typical dystonic posture. The pathological or biochemical basis of either the familial types or of most sporadic forms of idiopathic or primary TD is unknown. We present a 40-year old man who showed a kinesigenic axial dystonia with ipsilateral upper extremity atrophy for 14 years. The symptoms and signs were spontaneous onset, nonprogrwsive course, and induced by voluntary activity but relieved by rest and sleep and responded to trihexyphenidyl medication.

Herpes zoster with multiple cranial and upper cervical nerves involvement

Herpes zoster is a viral disease that produces inflammatory lesions in the posterior root ganglia and is characterized clinically by pain and a skin eruption in the distribution of the affected ganglia. Involvement of motor roots or the CNS occurs in a small percentage of the patients. There are few reports about multiple cranial and upper cervical nerve involvement. We report a herpes zoster with multiple cranial(VI, VII, VIII, XII) and upper cervical(C2,3) nerves involvement. The patient was a 79-year-old woman who presented with painful vesicular eruption on left side of face and neck. She complained of decreased hearing and hyperacusis of left ear. Neurologic examination showed decreased taste sensation of left anterior tongue, left facial palsy, and tongue deviation to the left side.

A Case of Acute Onset Progressive Dementia Suggestive of a Creutzfeldt-Jakob disease

Creutzfeldt-Jakob disease (CJD) is a rare dementing illness that usually affects older adults and is characterized by a rapidly progressive dementia, ataxia, and myoclonus. The disease is due to an unusual transmissible protein called a prion. The diagnosis is often suspected on the basis of electroencephalographic (EEG) and clinical findings. Our case was 62-year-old woman, who presented acute onset rapid progressive dementia, myoclonus, heightened startle reaction, extrapyramidal symptoms, and died about 2.5 months after onset of disease. We diagnosed this case as CJD with typical EEG pattern and clinical features.