Acute Spinal Subdural Hematoma Presenting with Spontaneously Resolving Hemiplegia

Although prompt diagnosis and emergent surgical intervention are important in acute spinal subdural hematoma (SSDH), some cases with spontaneous remission of symptom and hematoma without surgery have been reported. We present a case of acute nontraumatic SSDH presenting with transient left hemiplegia for 4 hours. A magnetic resonance imaging study of cervical spine confirmed SSDH with C3-6 cervical cord compression at the left side. The patient had conservative management without recurrence. Although hemiplegia is an unusual clinical manifestation of SSDH, it should be differentiated from that of cerebrovascular origin promptly. Conservative management may be an alternative therapeutic option for selective cases with transient neurological deficits.

Multiple Fusiform Cerebral Aneurysms and Highly Elevated Serum Interleukin-6 in Cardiac Myxoma

Cerebral embolic infarction is the most common neurologic complication of cardiac myxoma (CM). Development of cerebral aneurysms in CM is very rare. We present a 64-year-old woman with acute cerebral infarction and multiple cerebral aneurysms complicated by CM. The aneurysms were multiple, fusiform-shaped, and located in distal branch of major cerebral arteries. The serum interleukin (IL)-6 was highly elevated, which was normalized after surgical resection of CM. There was no regression of aneurysms on follow-up neuroimaging. Multiple cerebral aneurysms in CM are rare condition. Highly elevated serum IL-6 may be associated with increased risk of cerebral aneurysmal formation.

A Case of Dementia with Transient Splenial lesion on MRI after Hypoglycemia

We report a rare case having dementia with transient splenial lesion on MRI after hypoglycemia. A 75-year-old woman with type 2 diabetes was admitted with mental change after medication of a hypoglycemic agent. Initial serum glucose was 22 mg/dL. High signal intensity in the splenium on diffusion-weighted MRI was shown. After conservative management, she was gradually improved and splenial lesion was disappeared, but her cognitive impairment remained.

The Effect of Folic Acid to the Level of Homocysteine and Analysis of the Factors in Epilepsy Patients / 대한간질학회지

BACKGROUND: Folic acid has been frequently used for hyperhomocyesteinemia in various diseases and decreases the level of homocysteine. OBJECTIVES: To assess the effect of folic acid in the level of homocysteine in epilepsy patients, and to analyze factors affecting its responsiveness and the difference of its efficacy according to methylenetetrahydrofolate reductase (MTHFR) C677T polymorphism. METHODS: Total 75 epilepsy patients with antiepileptic drugs (AEDs) therapy were included. 41 patients had normal level of homocysteine and 34 patients with hyperhomocysteinemia (> or =12 micro mol/ ) were supplemented with folic acid for 1 year. Thirty-four patients with hyperhomocyteinemia were divided into two groups according to the responsiveness of homocysteine to folic acid; decrease group (DG) and non-decrease group (NDG). RESULTS: The level of homocysteine in patients with hyperhomocysteinemia was significantly decreased after administration of folic acid, comparing with patients with normal level. DG was younger and had more male gender, shorter duration of seizure, and initial higher homocysteine level, compared to NDG (p<0.05). Patients with mutant type of MTHFR (CT+TT) had more decreased homocysteine level after supplement of folic acid, but had more increased homocysteine level without supplement of folic acid. Comparing between MTHFR genotypes, TT type had the most decreased homocysteine level than others, but there was no significance. CONCLUSION: Folic acid is useful treatment of hyperhomocysteinemia in epilepsy patients and the supplement of folic acid might be considered in patients with mutant type of MTHFR regardless of homocysteine level. The effect of folic acid supplement is greater in younger age, male sex, shorter duration of seizure, and initial higher homocysteine level.

Genetic Polymorphism of Thymidylate Synthase Enhancer Region (TSER) in Patients with Silent Brain Infarction

BACKGROUND: Hyperhomocysteinemia is an independent risk factor for silent brain infarction (SBI). The plasma homocysteine (pHcy) level is influenced by the activities of enzymes such as 5,10-methylenetetrahydrofolate reductase (MTHFR). Thymidylate synthase (TS) also competes with MTHFR for their common cofactor, 5,10-methylenetetrahydrofolate (5,10-meTHF). The polymorphism of thymidylate synthase enhancer region (TSER) might affect homocystein metabolism by modulating the activity of TS, and may be a determinant of SBI by elevating pHcy concentrations. Therefore, we studied the polymorphism of TSER in patients with SBI. METHODS: 98 patients with SBI and 92 healthy controls were included in the study. The genotypes of TSER and MTHFR were identified with the PCR-RFLP methods. RESULTS: The mean pHcy level was significantly higher in SBI patients (13.5+/-8.5 micro mol/L) than in controls (10.3+/-4.1 micro mol/L)(p<0.01). The frequencies of MTHFR C677T genotype and TSER 28 bp tandem repeat genotype were not different between the patients and the controls. The pHcy concentrations were not considerably different between the 3R3R and 2R3R genotypes in the population as a whole (p=0.712), nor in subsets of patients with SBI (p=0.484). However, in cases with the TSER 3R3R genotype, the pHcy level was significantly higher in patients (14.0+/-10.26 micro mol/L) than in controls (9.9+/-3.1 micro mol/L)(p=0.006). Folate and pHcy was inversely correlated in the SBI patients with the TSER 3R3R genotype (r=-0.424, p=0.039). CONCLUSIONS: Our findings suggest that the TSER genotype is not a major determinant of pHcy concentrations and is neither a risk factor for SBI in the Korean population. However, further study will be needed to confirm this findings.

A Case of Valproate-Induced Hyperammonemic Encephalopathy with Triphasic Waves / 대한간질학회지

Valproate is a widely used antiepileptic drug with rarely occurring serious side effects. However, valproate may induce hyperammonemic encephalopathy. A 85-year-old woman was admitted with stuporous mental status. Brain MRI showed old cerebral infarction and EEG showed sharp waves in the right frontal region. Under the impression of postictal confusion, we used phenytoin and then she was improved. However, the intermittent vacant staring was seen, and valproate was administered additionally. On the 5th day after adding valproate, her mentality was deteriorated and intermittent triphasic waves appeared on EEG. Due to confused mentality and hyperactivities, we injected lorazepam and then semicomatous mentality was developed. Follow-up EEG showed nearly continuous triphasic waves and slightly elevated ammonia with normal liver function was shown. After stopping antiepileptic drugs, we used lactulose and flumazenil, and then she was fully recovered with normalized EEG. This is a rare case of valproate-induced hyperammonemic encephalopathy with triphasic waves.