Baroreceptor Sensitivity Predicts Functional Outcome and Complications after Acute Ischemic Stroke.

Autonomic dysfunctions including impaired baroreflex sensitivity (BRS) can develop after acute ischemic stroke (AIS) and may predispose patients to subsequent cardiovascular adverse events and serve as potential indicators of long-term mortality. This study aimed to determine the potential short-term prognostic significance of BRS after AIS. All patients admitted to Kaohsiung Veterans General Hospital within 72 h after onset of first-ever AIS between April 2008 and December 2012 were enrolled. Autonomic evaluation with continuous 10-minute monitoring of beat-to-beat hemodynamic and intracranial parameters was performed within 1 week after stroke by using the Task Force Monitor and transcranial Doppler. The 176 enrolled AIS patients were divided into high-BRS and low-BRS groups. All but two enrolled patients (who died within 3 months after stroke) attended scheduled follow-ups. The high-BRS group had significantly lower National Institutes of Health Stroke Scale (NIHSS) scores at 1 and 2 weeks after stroke and at discharge; lower modified Rankin scale (mRS) scores 1, 3, 6, and 12 months after stroke; and lower rates of complications and stroke recurrence compared to the low-BRS group. This study provides novel evidence of the utility of BRS to independently predict outcomes after AIS. Furthermore, modifying BRS may hold potential in future applications as a novel therapeutic strategy for acute stroke.

Association between heavy metal levels and acute ischemic stroke.

BACKGROUND: Few studies have examined the relationship between the amounts of heavy metal and stroke incidence. The aim of this study was to explore the relationship between levels of heavy metals, including Pb, Hg, As, and Cd, in patients with acute ischemic stroke (AIS). METHODS: We selected patients with first-ever AIS onset within 1 week as our study group. Healthy controls were participants without a history of stroke or chronic disease, except hypertension. The serum levels of Pb, Hg, As, and Cd in participants in the experimental and control groups were determined. All participants received a 1-g infusion of edetate calcium disodium (EDTA). Urine specimens were collected for 24 h after EDTA infusion and measured for heavy metal levels. RESULTS: In total, 33 patients with AIS and 39 healthy controls were enrolled in this study. The major findings were as follows: (1) The stroke group had a significantly lower level of serum Hg (6.4 ± 4.3 µg/L vs. 9.8 ± 7.0 µg/L, P = 0.032, OR = 0.90, 95% CI = 0.81-0.99) and a lower level of urine Hg (0.7 ± 0.7 µg/L vs. 1.2 ± 0.6 µg/L, P = 0.006, OR = 0.27, 95% CI = 0.11-0.68) than the control group. (2) No significant difference in serum Pb (S-Pb), As (S-As), and Cd (S-Cd) levels and urine Pb (U-Pb), As (U-As) and Cd (U-Cd) levels was observed in either group. CONCLUSIONS: Our study found low levels of serum and urine Hg in first-ever patients with AIS, providing new evidence of dysregulated heavy metals in patients with AIS.

Impact of MCA stenosis on the early outcome in acute ischemic stroke patients.

BACKGROUND: Asians have higher frequency of intracranial arterial stenosis. The present study aimed to compare the clinical features and outcomes of ischemic stroke patients with and without middle cerebral artery (MCA) stenosis, assessed by transcranial sonography (TCS), based on the Taiwan Stroke Registry (TSR). METHODS: Patients with acute ischemic stroke or transient ischemic attack registered in the TSR, and received both carotid duplex and TCS assessment were categorized into those with stenosis (≥50%) and without (<50%) in the extracranial internal carotid artery (ICA) and MCA, respectively. Logistic regression analysis, Kaplan-Meier method and Cox proportional hazard model were applied to assess relevant variables between groups. RESULTS: Of 6003 patients, 23.3% had MCA stenosis, 10.1% ICA stenosis, and 3.9% both MCA and ICA stenosis. Patients with MCA stenosis had greater initial NIHSS, higher likelihood of stroke-in-evolution, and more severe disability than those without (all p<0.001). Patients with MCA stenosis had higher prevalence of hypertension, diabetes and hypercholesterolemia. Patients with combined MCA and extracranial ICA stenosis had even higher NIHSS, worse functional outcome, higher risk of stroke recurrence or death (hazard ratio, 2.204; 95% confidence intervals, 1.440-3.374; p<0.001) at 3 months after stroke than those without MCA stenosis. CONCLUSIONS: In conclusion, MCA stenosis was more prevalent than extracranial ICA stenosis in ischemic stroke patients in Taiwan. Patients with MCA stenosis, especially combined extracranial ICA stenosis, had more severe neurological deficit and worse outcome.

No adverse impact of depressive symptoms on the effectiveness of postacute care service: a multicenter male-predominant prospective cohort study.

BACKGROUND: Although the clinical effectiveness of community hospital-based postacute care (PAC) services has been shown, little was known regarding the impact of depression on the clinical outcomes of older patients receiving PAC services in Taiwan. METHODS: From January 2009 to August 2010, patients aged 65 years and older referred from tertiary medical centers or acute wards of community hospitals to PAC units were invited for study. All patients received the 4-week Comprehensive Geriatric Assessment-based intervention program in the PAC units. The functional assessment was composed of Geriatric Depression Scale-Short Form (GDS), Mini-Mental Status Examination, Barthel Index, Instrumental Activities of Daily Living, and Braden Score. RESULTS: Among the 401 participants (mean age, 82.0 years; 95.5% males), 66 (16.5%) patients were depressed at PAC unit admission. Depressed patients had significantly lower Barthel Index (38.1 ± 2.4 vs. 47.6 ± 1.2, p = 0.002) and Braden Score (17.7 ± 0.3 vs. 18.8 ± 0.2, p = 0.004) than nondepressed patients. Improvement was noted on all measures of functional outcome among patients receiving PAC services. Furthermore, GDS was significantly improved in depressed patients (from 6.4 ± 0.2 to 2.8 ± 0.2 in depressed patients vs. from 1.6 ± 0.1 to 0.9 ± 0.1 in nondepressed patients, p < 0.001). CONCLUSION: Depression was common when patients were newly admitted to PAC services, which was highly associated with poorer physical function. Improvement in physical function and depressive symptoms among all patients after PAC service was found, and the presence of depressive symptoms at PAC admission did not predict any adverse outcome of PAC services.

Association of cognitive impairment, depressive symptoms and sarcopenia among healthy older men in the veterans retirement community in southern Taiwan: a cross-sectional study.

AIM: To evaluate the association of cognitive impairment, depressive mood and sarcopenia among older men living in the veterans retirement community in southern Taiwan METHODS: This cross-sectional study recruited 353 men aged 65 years and older. In addition to demographic characteristics, all participants were measured for gait speed, handgrip strength and muscle mass by using bioelectrical impedance analysis (BIA). The diagnosis of sarcopenia was made according to the European Working Group on Sarcopenia in Older People criteria. Slow walking speed was defined as ≤ 0.8 meter/second. Low muscle strength was defined as the handgrip strength less than 22.5 kg which was adjusted according to Taiwanese norms. A height-adjusted muscle mass of 8.87 kg/m2 from a previous Taiwanese study was defined as low muscle mass. Cognitive function was evaluated by the Mini-Mental State Examination (MMSE), and the Geriatric Depression Scale-15 (GDS-15) was used for screening of depressive symptoms. RESULTS: Among the 353 participants (mean age 82.7 ± 5.3 years), 30.9% (109/353) were classified as sarcopenic. Multivariate logistic regression showed that sarcopenia was independently associated with cognitive impairment (adjusted OR 3.03, 95% CI 1.63-5.65, P < 0.001) and depressive symptoms (adjusted OR 2.25, 95% CI 1.03-4.89, P = 0.04). CONCLUSIONS: Sarcopenia was significantly associated with cognitive impairment and depressive symptoms among otherwise healthy older men living in the veterans retirement community. Further outcome study is required to explore the interrelationship of cognition, depressive symptoms and sarcopenia in older adults.

Spontaneous spinal epidural hematoma: a case report and review of the literatures.

PURPOSE: To emphasize the importance of early recognition and emergent surgery for spontaneous spinal epidural hematoma (SSEH). CASE REPORT: A 61-year-old female presented with sudden onset of severe neck and back pain after finishing worshiping Buddha followed by quadriparesis, sensory deficits below C4 level and sphincter dysfunction. MR imaging demonstrated acute extensive epidural hematoma of cervico-thoracic spinal segments (C2-T7). Idiopathic SSEH was diagnosed and emergent decompressive laminectomy with hematoma evacuation was performed within 12 hours of symptoms onset. Good functional and neurological outcomes were obtained. CONCLUSION: SSEH is a rare but disabling or even fatal entity. Early diagnosis and prompt surgery improve the neurological and functional outcome but still remain a clinical challenge. Relevant physicians should pay attention to the typical symptoms of the rare entity and SSEH should be one of differential diagnoses.

Urinary incontinence: an under-recognized risk factor for falls among elderly dementia patients.

AIMS: Elderly people with dementia are at increased risk of falls and intervention trials to prevent falls have failed to demonstrate clinical effectiveness in this population. This study evaluates the role of urinary incontinence as a fall risk factor in older patients with dementia, with the aim of developing relevant intervention strategies. METHODS: Elderly patients with dementia visiting our center were recruited. All subjects underwent a Comprehensive Geriatric Assessment (CGA), and patients were divided into two groups (fall and non-fall) according to their history of falls in the past year. Components of the CGA, including physical function, mental function, depressive symptoms, incontinence, and nutritional status, were evaluated according to fall history. RESULTS: Overall, 159 patients with dementia (mean age 77.3 ± 9.0 years, 59.1% male) participated. Fifty-four patients (34.0%) had experienced falls in the past year. Among all subjects, 50.3% were diagnosed with mild dementia, 37.7% with moderate dementia, and 12.0% with severe dementia according to an established Clinical Dementia Rating scale. Subjects in the fall group displayed poorer physical function, balance, depressive mood, nutritional status, urinary incontinence, and had an increased prevalence of polypharmacy. However, multivariate analysis revealed urinary incontinence as the only independent risk factor for falls (OR = 4.9 ± 2.2, 95% CI: 2.0-12.0, P < 0.001). CONCLUSIONS: Urinary incontinence is a previously unidentified risk factor for falls among elderly dementia patients. An interventional study with the focus of urinary incontinence could improve the effectiveness of fall prevention among these patients.

Impact of nutritional status on long-term functional outcomes of post-acute stroke patients in Taiwan.

Nutritional status is important in stroke care, but little is known regarding to the prognostic role of nutritional status on long-term functional outcomes among stroke survivors. The main purpose of this study was to evaluate to the prognostic role of nutritional status on long-term functional outcomes among stroke survivors. Data of acute stroke registry in Kaohsiung Veterans General Hospital were retrieved for analysis. Overall, 483 patients (mean age = 70.7 ± 10.3 years) with first-ever stroke were found. Among them, 95 patients (19.7%) were malnourished at admission, 310 (mean age = 70.4 ± 10.1 years, 63.5% males) survived for 6 months, and 244 (78.7%) had good functional outcomes. Subjects with poor functional outcomes were older (74.7 ± 8.9 vs. 69.0 ± 10.1 years, p < 0.001), more likely to be malnourished (56.2% vs. 26.6%, p < 0.001), to develop pneumonia upon admission (23.3% vs. 12.7%, p = 0.027), had a longer hospital stay (23.5 ± 13.9 vs. 12.5 ± 8.2 days, p < 0.001), had a higher National Institutes of Health Stroke Scale (NIHSS) score (12.9 ± 9.3 vs. 4.9 ± 4.3, p < 0.001), poorer stroke recovery (NIHSS improvement: 6.9% vs. 27.4%, p = 0.005), and poorer functional improvement (Barthel index = BI improvement in the first month: 31.4% vs. 138%, p < 0.001). Older age (odds ratio = OR) = 1.07, 95% confidence interval (CI = 1.03-1.11, p<0.001), baseline NIHSS score (OR = 1.23, 95%CI = 1.15-1.31, p < 0.001) and malnutrition at acute stroke (OR = 2.57, 95%CI: 1.29-5.13, p<0.001) were all independent risk factors for poorer functional outcomes. In conclusion, as a potentially modifiable factor, more attentions should be paid to malnutrition to promote quality of stroke care since the acute stage.

Screening depression among institutionalized older Chinese men by minimum data set: we need a new instrument.

OBJECTIVE: To compare the effectiveness of the Minimum Data Set-based Depression Rating Scale (MDS-DRS) and Geriatric Depression Scale (GDS) in screening depression among older institutionalized Chinese men living in Taiwan. METHOD: MDS Nursing Home 2.1 Chinese version, Mini-Mental State Examination (MMSE), and short form Geriatric Depression Scale (GDS-15) were used among elderly residents in Banciao Veterans Home. Screening results of MDS-DRS and GDS-15, and relationship between 16 MDS Mood and Anxiety symptoms and depression were evaluated. RESULTS: The prevalence of depression defined by MDS-DRS and GDS were 0.2% and 8.7%, respectively. Multiple logistic regression disclosed that E1a (OR: 12.9, 95% CI: 2.8-58.8, p = 0.001), E1k (OR: 15.6, 95% CI: 5.6-43.5, p < 0.001), and E1l (OR: 22.2, 95% CI: 6.1-83.3, p < 0.001) were all independent associative factors for GDS-defined depression but only explained 51.9% of all depressive subjects. CONCLUSIONS: The effectiveness of MDS-DRS is limited, and a new MDS-based depression screening instrument is needed.

Get With the Guidelines-Stroke performance indicators: surveillance of stroke care in the Taiwan Stroke Registry: Get With the Guidelines-Stroke in Taiwan.

BACKGROUND: Stroke is a leading cause of death around the world. Improving the quality of stroke care is a global priority, despite the diverse healthcare economies across nations. The American Heart Association/American Stroke Association Get With the Guidelines-Stroke program (GWTG-Stroke) has improved the quality of stroke care in 790 US academic and community hospitals, with broad implications for the rest of the country. The generalizability of GWTG-Stroke across national and economic boundaries remains to be tested. The Taiwan Stroke Registry, with 30 599 stroke admissions between 2006 and 2008, was used to assess the applicability of GWTG-Stroke in Taiwan, which spends ≈ 1/10 of what the United States does in medical costs per new or recurrent stroke. METHODS AND RESULTS: Taiwan Stroke Registry, sponsored by the Taiwan Department of Health, engages 39 academic and community hospitals and covers the entire country with 4 steps of quality control to ensure the reliability of entered data. Five GWTG-Stroke performance measures and 1 safety indicator are applicable to assess Taiwan Stroke Registry quality of stroke care. Demographic and outcome figures are comparable between GWTG-Stroke and Taiwan Stroke Registry. Two indicators (early and discharge antithrombotics) are close to GWTG-Stroke standards, while 3 other indicators (intravenous tissue plasminogen activator, anticoagulation for atrial fibrillation, lipid-lowering medication) and 1 safety indicator fall behind. Preliminary analysis shows that compliance with selected GWTG-Stroke guidelines is associated with better outcomes. CONCLUSIONS: Results suggest that GWTG-Stroke performance measures, with modification for ethnic factors, can become global standards across national and economic boundaries for assessing and improving quality of stroke care and outcomes. GWTG-Stroke can be incorporated into ongoing stroke registries across nations.

Efficacy and safety of levetiracetam as adjunctive therapy in adult patients with uncontrolled partial epilepsy: the Asia SKATE II Study.

This study evaluated the safety and efficacy of levetiracetam as adjunctive therapy for partial seizures in everyday clinical practice in Asian populations. Patients aged > or =16 years (N=251) with inadequately controlled partial epilepsy were recruited from 29 centers across Asia. Levetiracetam was added to existing antiepileptic medication for 16 weeks at a starting dose of 500 or 1000 mg/day and titrated to a maximum of 3000 mg/day according to clinical response. The study completion rate was 86.9%. Adverse events were reported by 73.3% of patients and were generally mild, leading to treatment withdrawal in only 7.2%. The most common adverse events were somnolence (30.3%) and dizziness (14.7%). Compared with pretreatment baseline, 44.0% of patients had a > or =50% reduction in seizure frequency, with a median reduction of 46.4%, and 17.7% became seizure free during the treatment period. Levetiracetam was well tolerated and efficacious as adjunctive therapy for partial epilepsy in clinical practice among Asian populations.

Increased total TAU but not amyloid-beta(42) in cerebrospinal fluid correlates with short-term memory impairment in Alzheimer's disease.

Given the need for tools for early and accurate diagnosis, prediction of disease progression, and monitoring efficacy of therapeutic agents for AD, the study of cerebrospinal fluid (CSF) biomarkers has become a rapidly growing field of research. Several studies have reported conflicting data regarding the relationships between CSF biomarkers and dementia severity. In this study, we have focused on the identification of CSF biomarkers and their correlations with the impairment of different cognitive domains measured using the Cognitive Abilities Screening Instrument (CASI). Patients with AD (n=28), non-AD dementia (n=16), other neurological disorders (OND, n=14), and healthy controls (HC, n=21) were enrolled. Our results revealed significantly higher CSF total tau (t-tau) and lower amyloid-beta(42) levels in AD patients compared with those in HC and OND groups. Moreover, our data show that CSF t-tau levels, but not Abeta(42) levels, have an inverse correlation with the score of short-term memory in CASI for patients with AD (Spearman: r=-0.444; p=0.018). This data might indicate that the higher CSF t-tau level is associated with more NFT pathology and more severe impairment of short-term memory in AD patients.

Unusual subdural hematoma after SPA use.

We report a case of right tentorium subdural hematoma (SDH) in a 72-year-old man a few days after he visited a sanitas per aqua (SPA) facility. He had directed high-pressure water onto his head and neck. The patient was admitted to the emergency room during his 3rd day of severe throbbing and generalized headache. Cerebral computed tomography revealed a high-density SDH over the right tentorium. This is the first reported case of SPA-related SDH. Neurologists might consider the possibility that SPA use may be a factor in SDH or unexplained neurologic events in otherwise healthy persons.

Recurrent primary intracerebral hemorrhage: a hospital based study.

BACKGROUND: Primary intracerebral hemorrhage (ICH) occurs more commonly in Taiwan than in other western countries. Recurrence of primary ICH after a first episode is not rare. The purpose of this study is to investigate the incidence, risk factors, and prognosis of recurrent primary ICH. METHODS: From the stroke registration data of Kaohsiung Veterans General Hospital (KSVGH), all patients admitted between Jan. 1999 and Dec. 2003 with the discharge diagnosis of ICH were identified. The hospital records and images of each ICH patient were carefully reviewed and the diagnosis was confirmed by one of the investigators. For those patients admitted in this study period with the diagnosis of acute primary ICH who also had past medical history of ICH, the record and image of the past admission were also obtained for review, either from KSVGH or other hospitals. Patients with ICH due to secondary causes were excluded. RESULTS: 585 patients with primary ICH were reviewed. Among them, 34 (5.8%) patients were found to have recurrent primary ICH. The medical records of these 34 patients were obtained for further analysis. Cerebral amyloid angiopathy was diagnosed in 4 (11.7%) patients. Mean ages at the onset of the first and second hemorrhages were 64 +/- 13 and 66 +/- 13 years, respectively. The mean interval between first and second hemorrhages was 33 months (from 1 month to 10 years). The most common location of first-second bleeding was basal ganglion-basal ganglion. The mortality rate in this group was 23.5%. Fifteen (38.2%) patients became totally dependent or vegetative after the second ICH. CONCLUSIONS: Recurrent primary ICH is not uncommon. The main location of recurrent bleeding was basal ganglion. This may implicate hypertension as the main cause of ICH. Hypertension is an important risk factor of recurrent primary ICH. Amyloid angiopathy is another cause of recurrent primary ICH. The prognosis after the second hemorrhage is worse, while the mortality and morbidity after first ever primary ICH were 15.6% and 17.9%, respectively.

Familial hyperhomocysteinemia-related cerebral venous sinus thrombosis and pulmonary embolism: a case report.

Elevated plasma homocysteine levels are associated with an increased risk of deep vein thrombosis. Herein we report a case of familial hyperhomocysteinemia-related cerebral venous sinus thrombosis and pulmonary embolism in a 21-year-old man who presented with severe headache over bilateral frontal areas. Neurological examination revealed no evidence of focal neurological deficit. Chest CT showed pulmonary thromboembolism in bilateral basal lung fields and brain MRI disclosed right transverse and sigmoid venous sinus thrombosis. Routine immunological tests, coagulation factors and occult tumor screening were normal, as were vitamin B12 and folate levels. The DIC profile was negative, The only risk factor we were able to identify was an elevated serum homocysteine level, namely 46.23 microM/L. Hyperhomocysteinemia was also noted in the patient's asymptomatic elder brother (68.0 microM/L) and, to a lesser extent, in his parents (father 12.5 microM/L; mother 11.7 microM/L). In conclusion, the cause of cerebral venous thrombosis and pulmonary embolism in this young patient was most likely related to familial hyperhomocysteinemia, with the thromboembolic events precipitated by a preceding systemic infection. After anticoagulation therapy; the patient recovered completely without any residual neurological deficit.

The binding and phosphorylation of Thr231 is critical for Tau's hyperphosphorylation and functional regulation by glycogen synthase kinase 3beta.

Neuropathological hallmarks of Alzheimer's disease are extracellular senile plaques and intracellular neurofibrillary lesions. The neurofibrillary lesions mainly consist of the hyperphosphorylated microtubule-associated protein Tau predominantly expressed in the axon of CNS neurons. Hyperphosphorylation of Tau negatively affects its binding to tubulin and decreases the capacity to promote microtubule assembly. Among a number of proline-directed kinases capable of phosphorylating paired helical filament-Tau, glycogen synthase kinase 3beta (GSK3beta) was first identified as a Tau protein kinase I and has been demonstrated to phosphorylate Tau both in vivo and in vitro. However, the phosphorylation mechanism of Tau by GSK3beta remained unclear. In this study, we show that the T231 is the primary phosphorylation site for GSK3beta and the Tau227-237 (AVVRTPPKSPS) derived from Tau containing T231P232 motif is identified as the GSK3beta binding site with high affinity of a Kd value 0.82 +/- 0.16 mumol/L. Our results suggest that direct binding and phosphorylation of T231P232 motif by GSK3beta induces conformational change of Tau and consequentially alters the inhibitory activity of its N-terminus that allows the phosphorylation of C-terminus of Tau by GSK3beta. Furthermore, hyperphosphorylation reduces Tau's ability to promote tubulin assembly and to form bundles in N18 cells. T231A mutant completely abolishes Tau phosphorylation by GSK3beta and retains the ability to promote tubulin polymerization and bundle formation. Taken together, these results suggest that phosphorylation of T231 by GSK3beta may play an important role in Tau's hyperphosphorylation and functional regulation.

A follow-up study in a Taiwanese family with mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes syndrome.

BACKGROUND/PURPOSE: MELAS (mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes) syndrome is often associated with A3243G point mutation of mitochondrial DNA (mtDNA). We previously described a MELAS family characterized by harboring an additional approximately 260 bp tandem duplication in the D-loop and a novel C3093G point mutation in the 16S rRNA gene of mtDNA in the proband. We studied the clinical progression and fluctuation of mtDNA mutations in this Taiwanese MELAS family. METHODS: We followed up the clinical course in all members of this family (1 proband, her mother and 3 sons) for 12 years. Mutations of mtDNA in serial muscle biopsies of the proband and blood samples and hair follicles taken at different time points from the members of this family were analyzed. RESULTS: The proband developed repeated stroke-like episodes, chronic intestinal pseudo-obstruction, polyneuropathy, progressive renal failure and dilated cardiomyopathy with heart failure. During the follow-up period, the mother and one of the siblings of the proband developed stroke-like episodes at age 62 and 12, respectively. There was no significant difference in the proportions of mtDNA with A3243G mutation among five serial muscle biopsies of the proband. In one carrier (I-2), the proportion of A3243G mutated mtDNA in blood cells was slightly increased with disease progression. CONCLUSION: This study underlines the importance of early detection of extraneuromuscular symptoms in the members of a family with MELAS syndrome by adequate follow-up. The age of onset of stroke-like episode in MELAS syndrome may be as late as 62 years. We suggest that the manifestations of MELAS syndrome in this family might be associated with the additional approximately 260 bp tandem duplication in the D-loop region and the coexistence of C3093G mutation in the 16S rRNA gene with the A3243G mutation of mtDNA.

Lithium intoxication-induced acute parkinsonism complicated with hyperparathyroidism and nephrogenic diabetes insipidus: report of a case.

OBJECTIVE: To describe a patient with lithium intoxication presenting as acute parkinsonism, adverse metabolic effects and nephrogenic diabetes insipidus (DI). CASE REPORT: We report a case of a 67-year-old woman with a bipolar affective disorder who was treated with lithium for 10 years. Under concomitant renal insufficiency and urinary tract infarction, she experienced progressive hand tremor, bradykinesia, and unsteady gait. Laboratory results revealed hypercalcemia and hypermagnesiemia. A high serum lithium level (3.6 mEq/L) was found; thus lithium was discontinued. She was found to have a high serum level of intact parathyroid hormone: 135.0 pg/ml and a suspicious parathyroid adenoma. Polyuria with hypernatremia was also noted. A water deprivation test confirmed nephrogenic diabetes insipitces. After correction of electrolyte imbalance and reduction of lithium level, her consciousness recovered. Her parkinsonian features were responsive to levodopa 400 mg/day in 2 divided doses. One month later, apart from the residual extrapyramidal symptoms and mania, her condition was otherwise stationary. CONCLUSIONS: Tremor is the most frequent movement disorder associated with lithium therapy, while severe parkinsonism has been rarely reported. It should be kept in mind in differential diagnosis of acute parkinsonism especially in elder patients who receive a chronic lithium carbonate therapy.

Central vasomotor failure in a patient with medulla arteriovenous fistula.

We report on the case of a 60-year-old man who suffered from hiccup, dysphagia and unsteady gait for three months. He was diagnosed with intracranial dural arteriovenous fistula in medulla with retrograde perimedullary vein drainage. He developed quadriplegia, persistent shock status and symptomatic bradycardia immediately after a conventional cerebral angiography study. After excluding cardiogenic, hypovolemic, anaphylactic and septic shock, central vasomotor failure caused by venous thrombosis of the lesion was considered. The patient's central vasomotor failure recovered after continuous dopamine infusion treatment for 42 days. We concluded that venous hypertension with venous thrombosis in rostral ventrolateral medulla (RVLM), a major vasomotor center in the brainstem, was the lesion site. In our case, vasomotor dysfunction caused by an RVLM lesion related to venous thrombosis is considered as causative.

Computed tomographic angiography for determination of brain death.

A 69-year-old woman developed deep coma and brain stem areflexia after subarachnoid hemorrhage. Due to unstable vital signs, she was not a candidate for an apnea test. Computed tomographic angiography revealed absence of intracranial circulation, and brain death was diagnosed.