A prospective reappraisal of motor outcome prediction in patients with acute stroke by using atlas-based diffusion tensor imaging biomarkers.

BACKGROUND: Diffusion tensor imaging (DTI) biomarkers can be used to quantify microstructural changes in the cerebral white matter (WM) following injury. OBJECTIVES: This prospective single-center study aimed to evaluate whether atlas-based DTI-derived metrics obtained within 1 week after stroke can predict the motor outcome at 3 months. METHODS: Forty patients with small acute stroke (2-7 days after onset) involving the corticospinal tract were included. Each patient underwent magnetic resonance imaging (MRI) within 1 week and at 3 months after stroke, and the changes based on DTI-derived metrics were compared by performing WM tract atlas-based quantitative analysis. RESULTS: A total of 40 patients were included, with median age 63.5 years and a majority of males (72.5%). Patients were classified into good-prognosis group (mRS 0-2, n = 27) and poor-prognosis group (mRS 3-5, n = 13) by outcome. The median (25th-75th percentile) of MD (0.7 (0.6-0.7) vs. 0.7 (0.7-0.8); p = 0.049) and AD (0.6 (0.5, 0.7) vs. 0.7 (0.6, 0.8); p = 0.023) ratios within 1 week were significantly lower in the poor-prognosis group compared to the good-prognosis group. The ROC curve of the combined DTI-derived metrics model showed comparable Youden index (65.5% vs. 58.4%-65.4%) and higher specificity (96.3% vs. 69.2%-88.5%) compared to clinical indexes. The area under the ROC curve of the combined DTI-derived metrics model is comparable to those of the clinical indexes (all p > 0.1) and higher than those of the individual DTI-derived metrics parameters. CONCLUSIONS: Atlas-based DTI-derived metrics at acute stage provide objective information for prognosis prediction of patients with ischemic or lacunar stroke.

Investigation of Neurological Complications after COVID-19 Vaccination: Report of the Clinical Scenarios and Review of the Literature.

Coronavirus disease 2019 (COVID-19), caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), broke out in 2019 and became a pandemic in 2020. Since then, vaccines have been approved to prevent severe illness. However, vaccines are associated with the risk of neurological complications ranging from mild to severe. Severe complications such as vaccine-induced immune thrombotic thrombocytopenia (VITT) associated with acute ischaemic stroke have been reported as rare complications post-COVID-19 vaccination. During the pandemic era, VITT evaluation is needed in cases with a history of vaccination within the last month prior to the event. Cerebral venous sinus thrombosis (CVST) should be suspected in patients following immunization with persistent headaches who are unresponsive to analgesics. In this article, we investigated neurological complications after COVID-19 vaccination and provided more subsequent related clinical studies of accurate diagnosis, pathophysiological mechanisms, incidence, outcome, and management.

A community-based computerised cognitive training program for older persons with mild dementia: A pilot study.

OBJECTIVES: Computerised cognitive training programs can improve cognitive function in patients with moderate-to-severe dementia or brain injuries and healthy older adults. However, most previous studies were not randomised controlled trials and did not examine older adults with mild dementia. The current study sought to analyse the effects of a computerised cognitive training program using a randomised controlled trial. METHODS: In a single-blinded randomised clinical trial, 30 older individuals with mild dementia were split into an experimental (n = 15) and a control (n = 15) group to analyse the effects of a computerised cognitive training program. Outcomes were assessed before and after each program session, and 1 and 3 months afterwards. RESULTS: Participants in the experimental group had better overall subjective memory, subjective retrospective memory and global quality of life, with fewer depressive symptoms than those in the control group 3 months following the program. CONCLUSIONS: Our computerised cognitive training program improved subjective memory and quality of life in patients with mild dementia and decreased their depressive symptoms. These results may be useful for health-care providers caring for people with mild dementia.

Association of eNOS and Cav-1 gene polymorphisms with susceptibility risk of large artery atherosclerotic stroke.

Endothelial nitric oxide synthase (eNOS) is localized in caveole and has important effects on caveolar coordination through its interaction with caveolin-1 (Cav-1), which supports normal functioning of vascular endothelial cells. However, the relationship between genotypic polymorphisms of e-NOS and Cav-1 genes and ischemic stroke (IS) remains lesser reported. This hospital-based case-control study aimed to determine the genetic polymorphisms of the eNOS (Glu298Asp) and Cav-1 (G14713A and T29107A) genes in association with susceptibility risk in patients who had suffered from a large artery atherosclerotic (LAA) stroke. Genotyping determination for these variant alleles was performed using the TaqMan assay. The distributions of observed allelic and genotypic frequencies for the polymorphisms were in Hardy-Weinberg equilibrium in healthy controls. The risk for an LAA stroke in the Asp298 variant was 1.72 (95% CI = 1.09-2.75) versus Glu298 of the eNOS. In the GA/AA (rs3807987) variant, it was 1.79 (95% CI = 1.16-2.74) versus GG and in TA/AA (rs7804372) was 1.61 (95% CI = 1.06-2.43) versus TT of the Cav-1, respectively. A tendency toward an increased LAA stroke risk was significant in carriers with the eNOS Glu298Asp variant in conjunction with the G14713 A and T29107A polymorphisms of the Cav-1 (aOR = 2.03, P-trend = 0.002). A synergistic effect between eNOS and Cav-1 polymorphisms on IS risk elevation was significantly influenced by alcohol drinking, heavy cigarette smoking (P-trend<0.01), and hypercholesterolemia (P-trend < 0.001). In conclusion, genotypic polymorphisms of the eNOS Glu298Asp and Cav-1 14713A/29107A polymorphisms are associated with the elevated risk of LAA stroke among Han Chinese in Taiwan.

Polymorphisms of DNA repair pathway genes and cigarette smoking in relation to susceptibility to large artery atherosclerotic stroke among ethnic Chinese in Taiwan.

AIM: Cigarette-smoking induced oxidative DNA damage to endothelial cells has been reported to play an etiological role in atherosclerosis development. Individual vulnerability to oxidative stress through smoking exposure and the ability to repair DNA damage, which plays a critical role in modifying the risk susceptibility of large artery atherosclerotic (LAA) stroke, is hypothesized. Thus, we examined the effect of genetic polymorphisms of DNA repair pathway genes and cigarette smoking in relation to risk susceptibility of LAA stroke. METHODS: We enrolled 116 LAA stroke patients and 315 healthy controls from the Armed Forces Taoyuan General Hospital, Taoyuan, Taiwan. Genotyping of polymorphisms of the OGG1 (Ser326Cys), XRCC1 (Arg399Gln), ERCC2 (Lys751Gln), and ERCC5 (Asp1104His) genes was performed and used to evaluate LAA stroke susceptibility. RESULTS: Of those non-synonymous polymorphisms, the ERCC2 Lys751Gln variant was found to be associated with LAA stroke risk (OR: 1.69, 95%CI: 1.02-2.86), and this association was more pronounced in smokers, manifesting a 2.73-fold increased risk of LAA stroke (p=0.027). A joint effect on risk elevation of LAA stroke was seen in those patients with OGG1 and ERCC2 polymorphisms (OR: 2.75, 95%CI: 1.26-6.00). Moreover, among smokers carrying the OGG1 Ser326Cys polymorphism, there was a tendency toward an increased risk of LAA stroke in those patients who had a greater number of high-risk genotypes of XRCC1, ERCC2, and ERCC5 polymorphisms (p(trend)=0.010). CONCLUSION: The susceptible polymorphisms of DNA repair pathway genes may have a modifying effect on the elevated risk of LAA stroke in smokers among ethnic Chinese in Taiwan.

Myelopathy and polyneuropathy caused by nitrous oxide toxicity: a case report.

A 19-year-old man presented with a 1-month history of progressive 4-limb numbness and gait imbalance. Physical examination revealed mild general muscular weakness, areflexia, and wide-based, ataxic, steppage gait. Sensory tests showed diminished superficial sensation below the level of the cervical-thoracic junction and a glove-and-stocking pattern of sensory loss at the 4 extremities. An initial magnetic resonance imaging examination of the cervical spine revealed an increased bilateral signal from the posterior and anterior columns on T(2)-weighted images. Nerve conduction velocity and electromyographic tests revealed polyneuropathy. On further inquiry, the patient admitted to chronic recreational use of nitrous oxide. The final diagnosis was nitrous oxide-induced neurotoxicity. The patient was treated for 5 days with injections of 1000 µg/day vitamin B(12), followed by an additional 2-month treatment at a dose of 1000 µg/week. The numbness resolved after the first week, but there remained a mild sensory ataxic gait. The patient recovered fully after 2 months of treatment and nitrous oxide abstinence. We recommend an investigation of the patient's history of nitrous oxide exposure in cases where an individual presents to the emergency department or outpatient department with acute numbness characterized by megaloblastic red blood cells and symmetric neurologic deficits.

Expanding refractory rectus sheath hematoma: a therapeutic dilemma.

Rectus sheath hematoma is an uncommon but well-described complication of a tussive paroxysm. It is an accumulation of blood within the sheath of the rectus abdominis secondary to disruption of the epigastric vessels or the rectus muscle and is often misdiagnosed as acute abdomen. Increases in the number of elderly patients and the use of therapeutic anticoagulation may increase the prevalence and severity of rectus sheath hematomas encountered in clinical practice. Expanding rectus sheath hematomas are occasionally refractory to conservative treatment and may require hemostatic intervention. Here, we describe the case of an 87-year-old woman who presented with two separate rectus sheath hematomas that were precipitated by a paroxysm of coughing. Repeated computed tomography showed two separate expanding rectus sheath hematomas, which were not accompanied by obvious contrast extravasation on angiography. Empiric left inferior epigastric artery embolization resulted in rapid hemodynamic stabilization, and the hematomas shrank gradually. Early empiric transcatheter arterial embolization may be appropriate for patients who are poor surgical candidates and have enlarging hematomas that are refractory to conservative treatment.

An atypical case of Lennox-Gastaut syndrome not associated with mental retardation: a nosological issue.

The characteristic electroclinical features of Lennox-Gastaut syndrome (LGS) have been extensively reported, but the influence of the constellation of slow spike-and-wave (SSW) complexes with multiple seizure types (including atypical absence seizures [AAS] and tonic seizures [TS]) on patients with this syndrome is still unclear. We report the case of a 28-year-old woman who developed AAS and brief asymmetric TS at the age of 14 years. Her seizure disorder met diagnostic criteria for LGS (SSW on electroencephalogram and multiple seizure types), but there was no intellectual impairment and an interictal alpha EEG. Even 14 years after the onset of her epilepsy, she maintained fairly normal cognitive function, although she was bothered by frequent brief and subtle episodes of AAS and TS.

Reflex absence epilepsy induced by gait.

Reflex epilepsy is characterized by seizures that are precipitated by a specific identifiable factor. We describe here the case of a 21-year-old man with notable absence epilepsy since the age of 11 who experienced generalized convulsions 2 years after onset (in the absence of antiepileptic therapy) and reflex absence seizures triggered by walking 7-10 steps. To our knowledge, this case report is the first describing reflex absence epilepsy seizures induced by gait.

Association of MTHFR, MTR, and MTRR polymorphisms with Parkinson's disease among ethnic Chinese in Taiwan.

BACKGROUND: Influence of folate/homocysteine conversion is considered to be important in the pathogenesis of Parkinson's disease (PD). However, association of the folate metabolic pathway gene polymorphisms with PD susceptibility remains unclear. METHODS: To test this possibility in PD, we conducted a hospital-based case-control study constituting 211 patients and 218 age- and sex-matched controls of ethnic Chinese in Taiwan. Genotyping assay was performed to screen for polymorphisms of the methylenetetrahydrofolate reductase (MTHFR C677T), methyltetrahydrofolate-homocysteine methyltransferase (MTR A2756G), and 5-methyltetrahydrofolate-homocysteine methyltransferase reductase (MTRR A1049G and C1783T) genes and assess the association between these genotype polymorphisms and PD risk using logistic regression analysis. RESULTS: Of these four non-synonymous polymorphisms, the MTRR 1049GG variant was significantly associated with PD susceptibility (OR=3.17, 95%CI=1.08-9.35). Furthermore, we stratified our patients based on the MTHFR 677TT genotype in different strata, a significant association between the joint effect of polymorphisms and PD risk was observed in those patients whose genotypes were MTRR A1049G/MTR A2756G or MTRR C1783T/MTR A2756G (P<0.05). CONCLUSION: Our findings provide support for the synergistic effects of polymorphisms in the folate metabolic pathway genes in PD susceptibility; the increased PD risk would be more significant in carriers with the polymorphisms of MTHFR, MTR, and MTRR genes.

Association analysis of GRIN1 and GRIN2B polymorphisms and Parkinson's disease in a hospital-based case-control study.

Hyperactivation of N-methyl-d-aspartate receptors (NMDARs) leads to neuronal excitotoxicity and is suggested to play a role in many brain disorders, including Alzheimer's disease and schizophrenia. However, the association between polymorphisms in the genes that code for NMDAR subunits, N-methyl-d-aspartate 1 and 2B (GRIN1 and GRIN2B) and Parkinson's disease (PD) remains unclear. In a hospital-based case-control study of PD, DNA samples were collected from 101 PD patients and 205 healthy controls. Genotyping assays were used to screen for polymorphisms in the GRIN1 (rs2301364 T>C, rs28489906 T>C, and rs4880213 T>C) and GRIN2B (C366G, C2664T, and rs1805476 T>G) genes, and logistic regression analysis was then used to assess the association between these single nucleotide polymorphisms (SNPs) and PD susceptibility. None of the 6 SNPs were significantly associated with PD risk on their own. However, in conjunction with putative low-risk genotypes for the GRIN1 gene, the GRIN2BC366G variant was significantly associated with reduced PD risk compared with the homozygous genotype 366CC (OR=0.38, 95%CI=0.17-0.93, P=0.033). A synergistic effect on risk reduction was observed in subjects who carried multiple polymorphisms of GRIN1 and the GRIN2BC366G polymorphism (OR=0.78, 95%CI=0.59-1.02, P(trend)=0.073). Our results suggest that polymorphisms in the GRIN1 and GRIN2B genes may serve as potential biomarkers for a reduced risk of PD among the Chinese population in Taiwan.

Genotype polymorphisms of GGCX, NQO1, and VKORC1 genes associated with risk susceptibility in patients with large-artery atherosclerotic stroke.

BACKGROUND: Gamma-glutamyl carboxylation, a reaction essential for the biosynthesis of vitamin K-dependent coagulation factors, requires the participation of the gamma-glutamyl carboxylase (GGCX), vitamin K epoxide reductase (VKORC1), and NAD(P)H:quinone oxidoreductase (NQO1). We evaluated the role of these genotype polymorphisms in patients with large-artery atherosclerotic stroke. METHODS: In this hospital-based case-control study, 117 patients who were categorized as having large-artery atherosclerotic stroke and 115 age- and gender-matched controls were recruited. Genotyping determination for the GGCX1 (Gln325Arg), NQO1 (Pro187Ser), and VKORC1 (rs9923231) polymorphisms was performed. The associations of genotype with ischemic stroke (IS) risk were examined. RESULTS: A higher genotypic frequency of NQO1 C609T was found in the controls than in the patients, manifesting a 0.47-fold risk reduction in IS (95% CI=0.25-0.87). A tendency toward a reduced IS risk was statistically significant in those subjects who carried a greater number of the NQO1, GGCX, and VKORC1 polymorphisms (aOR=0.58, P(trend)=0.005). The synergistic effect of multiple genes on risk reduction was more significant in a subset of patients who were not alcoholics and who were non-smokers (P<0.05). CONCLUSIONS: Compartmentation of coagulation factor metabolism may account for the preferential role of NQO1, GGCX, and VKORC1 polymorphisms to lower the risk for large-artery atherosclerotic stroke.

Electrocorticogram changes during corpus callosotomy for uncontrolled symptomatic generalized epilepsy.

We report a 19-year-old man who presented to our facility with medically intractable, symptomatic generalized epilepsy manifesting as generalized tonic-clonic seizures (GTCs). Before he underwent an anterior callosotomy (6 cm), these seizures, which he had experienced for 11 years, seemed to have a left-sided focal origin. Intraoperatively, no epileptiform discharges were found on the electrocorticogram (ECoG) performed prior to sectioning, but more than 10 left-sided seizures were recorded after sectioning. In the 10 years since surgery, the patient's seizures have remained generalized; however, the frequency and severity of the seizures have decreased. These findings indicate that the presence of electrocorticographic seizures, as measured by ECoG immediately following callosotomy, may not predict a poor surgical outcome, even though such a finding might be indicative of epileptogenicity in general.

Corpus callosotomy in a patient of hemimegalencephaly and Lennox-Gastaut syndrome.

We report the case of a girl with hemimegalencephaly (HME) and Lennox-Gastaut syndrome (LGS) treated by callosotomy at 1 year of age. Over 10 years, her seizure frequency and severity decreased markedly. Hemispherectomy is the main surgical option for HME although HME appears to correlate with a less favorable seizure outcome. However, the clinical presentation of LGS and possible generalized cortical dysplasia, which is indicative of a secondarily generalized epilepsy, might predict a favorable surgical outcome of corpus callosotomy in patients of HME, as in our case.