Stroke in supplementary motor area mimicking functional disorder: a case report.

Supplementary motor area, the posterior third of the medial aspect of superior frontal gyrus, is known to be a heterogeneous area in function. It is involved in self-initiated motor movements, planning and sequencing the motor action, response inhibition, and bimanual movements. Blood supply for supplementary motor area is mostly by callosomarginal branch of anterior cerebral artery. Stroke in anterior cerebral artery territory is relatively uncommon, moreover, isolated supplementary motor area stroke is a rare entity. Supplementary motor area stroke, as a syndrome, has variable symptoms consisting of impairment of volitional movements, hemineglect, dyspraxia of contralateral limbs, impaired muscle tone, mutism and contralateral weakness. As symptoms are sometimes ambivalent, patients may be misdiagnosed as functional disorder and lose the chance for immediate adequate treatments such as thrombolysis. We report a 59-year-old man with previous history for myocardial infarction, referred to emergency room with an acute dense right-side hemiplegia, positive Hoover sign, asymmetrical Babinski responses and intermittent ability to move his arm in some specific reflex actions despite plegia. Since brain computed tomography scan was unremarkable we could not be sure whether his symptoms were organic or functional until a diffusion weighted imaging of magnetic resonance imaging elucidated the situation. To our knowledge, there is only one case report in the literature prior to ours, presenting a supplementary motor area stroke patient, mimicking functional disorder. Therefore, we may claim our report to be the second reported case.

Metabolic Syndrome and the Iodine-Dose/Creatinine Clearance Ratio as Determinants of Contrast-Induced Acute Kidney Injury.

BACKGROUND: Finding patients at risk of developing contrast-induced acute kidney injury (CI-AKI) is important because of its associated complications. In the present study, the contribution of different variables, such as the presence of metabolic syndrome (MetS), the volume creatinine clearance (V/CrCl) ratio, the iodine-dose (I-dose)/CrCl ratio, or hypertension, to CI-AKI was evaluated. METHODS: A total of 255 patients undergoing elective coronary angiography with or without intervention were enrolled and divided into a MetS and a control group. All patients were assessed for the development of CI-AKI after the procedures. RESULTS: CI-AKI occurred in 39.23% (51 of 130) of the MetS patients and 14.4% (18 of 125) of the control group (p < 0.001). The multivariable regression model showed that male sex and the use of statins decreased the risk of CI-AKI, and high triglyceride levels, I-dose/CrCl > 0.52, MetS, CrCl ≤60 mL/min, and age ≥70 years increased the risk of CI-AKI, independent of confounding factors. The difference in the mean V/CrCl ratio was statistically significant between patients who developed CI-AKI and those who did not show renal impairment (2.36 ± 1.35 vs. 1.43 ± 0.89, respectively; p < 0.001). The ROC curve analysis of I-dose/CrCl determined the best cutoff value for patients with and those without MetS as 0.51 and 0.63, with a sensitivity value of 68 and 72% and a specificity value of 73 and 74%, respectively. CONCLUSIONS: We showed that MetS is a strong risk factor for CI-AKI in nondiabetic patients undergoing elective coronary interventions; and the I-dose/CrCl ratio is a strong predictor of CI-AKI in these patients. We suggest that clinicians identify MetS patients and calculate their I-dose/CrCl ratio before coronary interventions.