Which Vestibulopathy is Vertebral Artery Hypoplasia Related with in Vestibular Migraine?

PURPOSE: A possible relationship between vertebral artery hypoplasia (VAH) and vestibular migraine (VM) has been suggested at some medical conferences, few studies of this condition have elucidated which vestibulopathy is VAH associated with during the vestibular episodes of VM. METHODS: We performed a retrospective case-series control study to elucidate the above issue. From 2008 January to May 2010, 18 VM patients received magnetic resonance imaging. Of them, 44.4% (n=8) were the VAH subgroup and 55.6% (n=10) were the non-VAH subgroup. We reviewed the ictal electronystagmogram battery of the two subgroups. A Fisher's exact test was used with alpha of 0.01. RESULTS: VAH was not more significantly prevalent in the VM patients than the non-VM ones. In the VM group, there was a significant difference in the 4 sub-divisions of vestibulopathy between the VAH and non-VAH subgroups (p=0.0096). CONCLUSION: In this small neurotological study, VAH was closely related with central vestibulopathy rather than peripheral or mixed vestibulopathy so the topographic factor of VAH little influenced the ipsilateral peripheral vestibular labyrinth in the vestibular episodes of VM.

Infectious Mononucleosis Complicated with Acute Cerebral Infarction: A Case Report.

PURPOSE: Infectious mononucleosis (IM) complicated with a neurological manifestation, including acute cerebellar ataxia, Guillain-Barre syndrome, meningitis, encephalitis, cranial nerve palsies, optic neuritis or transverse myelitis, has been rarely reported; however, IM complicated with acute cerebral infarction has never been reported in the literature. CASE REPORT: A 49-year-old man with diabetic mellitus suffered from IM with fever, pharyngitis, parotiditis with lymphadenopathies, thrombocytopenia and splenomegaly. After two weeks of conservative treatment, left upper limb paresis and left hemihypesthesia occurred. Neuroimaging demonstrated acute ischemic stroke involving the right frontal lobe. In view of the underlying infection, immediate intravenous rt-PA was not recommended; hence, oral aspirin 100 mg daily was prescribed and he received regular rehabilitation in the subsequent follow up. CONCLUSION: Although IM is known to be self-limited, it could contribute to acute cerebral infarction, which is a rare IM neurological complication.

Anton-Babinski syndrome in an old patient: a case report and literature review.

Anton-Babinski syndrome is a rare disease featuring bilateral cortical blindness and anosognosia with visual confabulation, but without dementia or any memory impairment. It has a unique neuropsychiatric presentation and should be highly suspected in those with odd visual loss and imaging evidence of occipital lobe injury. In the case discussed herein, a 90-year-old man presented with bilateral blindness, obvious anosognosia, and vivid visual confabulation, which he had had for 3 days. Brain computed tomography demonstrated recent hypodense infarctions at the bilateral occipital lobes. Thus, the patient was diagnosed with Anton-Babinski syndrome. Because of his age and the thrombolytic therapy during the golden 3 hours after ischemic stroke, the patient received aspirin therapy rather than tissue plasminogen activator or warfarin. He gradually realized he was blind during the following week, but died of pneumonia 1 month later. In the literature, it is difficult to establish awareness of blindness in patients with Anton-Babinski syndrome, but optimistically, in one report, a patient was aware of blindness within 2 weeks, without vision improvement. Our case illustrates that elderly patients with Anton-Babinski syndrome can partially recover and that 1 week is the shortest time for the establishment of awareness of blindness for sufferers without vision improvement.

Prevalence of cavum septum pellucidum and/or cavum Vergae in brain computed tomographies of Taiwanese.

OBJECTIVE: The reported prevalence of cavum septum pellucidum (CSP) and cavum Vergae (CV) in brain computed tomography (CT) is 5.5% in Great Britain and 1.24% in China but unknown in Taiwan. Moreover, CSP and/or CV has generally been thought to decrease as age progresses, but the evidence of actual prevalence at different age levels is still limited in the literature. METHODS: A total of 19,031 patients with brain CT at a regional hospital in northern Taiwan from July 2008 to August 2010 were included in this study. Their radiological official reports were retrospectively reviewed to check for CSP and/or CV. An X2 test was used for statistical analysis (α = .05). RESULTS: The prevalence of CSP and/or CV in all brain CT was 0.93% (n = 177), which was lower. than that in the Chinese and British studies. Among them, 2.8% (n = 5) had only CSP, 1.7% (n = 3) had only CV, and 95.5% (n = 169) had coexistent CSP and CV. There is a significant difference in prevalence between the age groups (p = .009), and the prevalence is the highest in the group aged 20-29 years (1.56%) and lowest in the group aged above 80. After age 20-29, the prevalence tends to decrease with increasing age. CONCLUSION: This is not only the first study of CSP and CV in the Taiwanese population but the study population is also larger than those in the literature. The prevalence was found to approximately decrease as age progresses, but would reach the peak in the young adult group rather than the children or adolescent group.

Moyamoya disease in an extremely old patient.

PURPOSE: The oldest patients diagnosed with moyamoya disease (MMD) in the USA may have been as old as 85+ years, and 68 years in Taiwan; therefore, MMD is generally thought not to occur in extremely old patients in Taiwan. Herein, we report this case to revise the common thinking. CASE REPORT: An 82-year-old woman had suffered twice from a right cerebral infarction. A digital subtraction angiogram demonstrated abundant collateral arterial networks from the bilateral proximal middle cerebral arteries despite the absence of arteriosclerotic stenosis of the bilateral extracranial internal carotid arteries. Aspirin has effectively controlled her symptom since diagnosis and, as a result, a direct or indirect revascularization procedure is unnecessary. CONCLUSION: MMD does occur in extremely old Taiwanese, as old as over 80 years old, and thus should be a differential diagnosis of cerebral infarction in an extremely old patient. Digital subtraction angiography is the gold standard for the diagnosis.

Bruns-Cushing nystagmus due to hypertensive unilateral paramedian pontine base infarction.

Bruns-Cushing nystagmus is unusually rare and is known to be related with cerebellopontine angle tumor. A 32-year-old male patient came to our emergency department 3 times because of dizziness, right upper limb ataxia, hypertension, and Bruns-Cushing nystagmus. Magnetic resonance imaging demonstrated left paramedian pontine infarction. In conclusion, Bruns-Cushing nystagmus not only indicates a cerebellopontine angle tumor but may also be associated with pontine infarction.

Reverse Lhermitte's phenomenon provoked by cervical cord compression.

PURPOSE: Lhermitte's phenomenon (LP) is a rare manifestation, which is defined when a sudden electric-shock sensation transmitted down the spine induced by neck flexion; however, the reverse LP is defined when symptoms are induced by neck extension, not flexion. Because reports of LP are limited in the Taiwan literature, we report this case. CASE REPORT: A 74-year-old woman presented to our emergency department with sudden onset of right neck pain when extending the neck. The pain mimicked an electric shock and radiated to the left shoulder. Imaging showed spondylosis and spondylolisthesis without any spinal canal stenosis. A neck collar was recommended, and the strange phenomenon did not recur over the following year. However, long-term follow-up and aggressive workup are recommended to rule in or rule out the possibility of multiple sclerosis in the future. CONCLUSION: Although LP represents spinal demyelination disorders, reverse LP is induced by extrinsic compression of the cervical cord, and neck collar immobilization rather than intravenous or oral medication is recommended.

Pure menstrual migraine with sensory aura: a case report.

Hormonal changes related to the menstrual cycle have a great impact on migraines in women. Menstrual migraine attacks are almost invariably without aura. Categorizing migraines into menstrual or non-menstrual types is one way to stratify migraines without aura according to the appendix criteria of the International Classification of Headache Disorders. We report a peri-menopausal woman whose sensory aura exclusively heralded menstrual migraine. A 51-year-old woman had suffered from monthly episodic headaches since the age of 46. Before a headache, and within 1 h on the first day of her menstruation, she always experienced numbness in her entire left upper limb. After the sensory aura, migrainous headaches occurred with nausea and photophobia. In the postmenopausal period, she no longer had sensory aura, and her headache pattern changed and became less severe. Her physical and neurologic exams as well as electroencephalography, brain magnetic resonance imaging, and conventional angiography were all normal. She fulfilled the diagnosis of pure menstrual migraine with typical sensory aura. To our knowledge, this is the first formal case report of pure menstrual migraine with aura.

A case report of intracranial vertebral-basilar artery hypoplasia presenting with episodic dizziness.

Basilar artery hypoplasia (BAH) is usually accompanied with unilateral vertebral artery hypoplasia (VAH); however, BAH with bilateral VAHs composing vertebral-basilar artery hypoplasia (VBAH) is indeed a rare curiosity. A 61-year-old woman presented with episodic dizziness for ten years. It accompanied with headache, bilateral tinnitus and blurred vision. Time-of-flight magnetic resonance angiogram with T2 true fast imaging in steady state precession confirmed the VBAH, rather than a stenosis. Symptoms subsided after daily oral aspirin and life-style change has been recommended for three months. The following one year was uneventful, and hearing improved. Finally, we conclude that the episodic dizziness with sensori-neural hearing impairment might attribute to the VBAH. It appears that life-style change was the main therapy and the antiplatelet was simply a supplementary one.

Chronic daily headache in a patient with nasopharyngeal carcinoma.

Chronic daily headache (CDH) among nasopharyngeal carcinoma (NPC) patients is a multidisciplinary challenge. Although imaging studies are recommended to identify skull-base invasion, intracranial metastasis or skull-base osteoradionecrosis, a headache diary is also a practical approach. A 42-year-old woman had been bothered with CDH since she was diagnosed with T3N1M0 stage III NPC 2 years earlier. Although the imaging studies did not show any abnormality, the attending doctor informed her that there remained the possibility of an intracranial or skull-base lesion. She was regularly taking painkillers. Eventually, when her headache diary was examined, the diagnosis of chronic migraine superimposed on medication overuse headache was made according to the ICHD-IIR. The CDH abated after 1 week of outpatient detoxification. The following half year was uneventful. In reporting this case, we suggest that it would be of interest to a number of disciplines including otorhinolaryngologists, oncologists and radio-oncologists. By avoiding medication overuse in similar patients, we hope to improve the quality of life of these individuals.