대한뇌졸중학회 역대 학술행사 초록검색

Inhibitory effect of platelet activating factor on the apoptosis of differentiated PC 12 cell

Kyeung Mo An

Platelet activating factor(PAF) has been suggested to play a critical role in the pathogenesis of neurological disorders. However, PAF or PAFR activation reveals a variable effect on cell death induced by various toxic insults. Moreover, the effect of PAF against the toxin-induced neuronal cell death has not been elucidated. We assessed the PAF effect on MPP+ toxicity in relation to apoptotic process. The effect of PAF on the MPP+ toxicity was assessed in PC12 cells differentiated by nerve growth factor. To assess the MPP+ treatment-induced apoptosis and clarify the inhibitory effect of PAF on MPP+ toxicity, we investigated the effect of PAF on the nuclear morphological changes observed in the MPP+-treated cells. The MPP+-induced apoptosis was assessed by measuring change in the apoptotic protein levels. We evaluated the effect of PAF on the MPP+-induced cytochrome c released and caspase-3 activation by performing the ELISA based quantitative analysis. The incidence of cell death after exposure to 500µM MPP+ for 24h was 47%. PAF exhibited differential effect against MPP-induced cell death depending on concentration(Fig. 1). Nuclear staining with Hoechst 33258 demonstrated that control PC12 cells had regular and round-shaped nuclei. In contrast, the fragmentation of nuclei were demonstrated in cells treated with 500µM MPP+. Treatment with 0.75µM PAF attenuated the MPP+-induced nuclear damage, while the nuclear morphology in cells treated with PAF alone was similar to that in control cells(Fig. 2). Treatment with caspase inhibitors prevented the MPP+- induced cell death(Fig 3.). The MPP+-induced apoptosis was assessed by measuring change in the apoptotic protein levels, which elicits cytochrome c release and caspase-3 activation. In western blot analysis, MPP+ decreased Bid and apoptotic Bcl-2 levels and increased pro-apoptotic Bax and cytochrome c levels in PC12 cells. Treatment with 0.75µM PAF prevented the MPP+-induced alteration of apoptotic protein levels (Fig. 4). Treatment with 0.75µM PAF or 0.5µM cyclosporin A significantly attenuated the MPP+-induced release of cytochrome c and caspase-3 activation. In contrast, 10µM PAF induced cytochrome c release and caspase-3 activation, and exhibited an addictive effect against the MPP+ toxicity(Fig. 5). The results show that PAF at low concentrations, which does not induce a significant toxicity, may prevent the MPP+ toxicity by suppressing the apoptotic protein activation and mitochondrial membrane permeability change that lead to the cytochrome c release and caspase-3 activation. In contrast, PAF at higher concentrations may exhibit an addictive toxic effect against the MPP+ toxicity by increasing apoptotic protein activation.

Isolated weakness of the index finger flexion in subcortical infarction

이승연

Background The efferent projections from the cortical area of the hand have not been fully defined. Moreover isolated finger weakness in association with cerebral infarction is rare. We describe a patient who showed isolated weakness of the left index finger flexion with a discrete cerebral infarction. Case A 60‐year‐old man suddenly developed weakness in his left index finger. He had essential hypertension and had been treated with a diuretics and a long‐acting calcium channel blocker during the last 1 year. His history included a right corona radiata lacune before 6 months without permanent sequelae. On admission, his physical examination showed no significant abnormalities. Other cranial nerves were within normal limits. Motor examination revealed mild weakness (V/IV) of his left index finger flexion. The strength of the index finger extension, other fingers, wrist, elbow, shoulder, and leg were normal. Sensations were normally perceived in all modalities in his left index finger as well as other body parts. No pain or paresthesia was felt in his fingers. Deep tendon reflexes were normoacitive and cerebellar function tests were performed normally. Brain MRI taken the admission day showed a small discrete infarction located in the subcortex of right frontal lobe(Figure1, 2). MR angiogram showed no evidence of steno‐occlusion and aneurysm in intracranial arteries. Holter monitoring and transthoracic echocardiogram did not find evidence of a cardiac embolic source. NCV showed no evidence of peripheral neuropathy. One week later, the index finger flexion weakness gradually improved (grade IV+). He takes an anti‐platelet agent for secondary prevention. Discussion MRI clearly demonstrated that a discrete infarction was the cause of weakness of isolated index finger flexion in our patient. The lesion was located in the medial margin of an inverted omega‐shaped precentral knob on axial MRI and in the subcortex of right frontal lobe on coronal MRI. The weakness of isolated index finger flexion in our patient may possibly be the cause of the motor dysfunction associated with damage to the corticospinal tract. Currently, there has been a controversial debate in the neuroscience community as to whether or not finger somatotopy in the primary motor cortex exists. Several studies on stroke patients supported the existence of alleged topography for fingers in the human motor cortex: ulnar fingers―medial and radial fingers―lateral. Other investigators demonstrated multiple representation or spatially overlapping patterns of the cortical motor hand area. Unexpectedly, the MRI lesion does not agree with a previous report that predominant weakness of radial‐ sided fingers is usually caused by laterally located infarcts whereas weakness of ulnar fingers is related to medial lesions in the precentral knob, topography, which also was observed in the previous report. Despite this, observations in our patient may be of value because this is the first report of isolated index finger flexion weakness caused by a small subcortical infarction. At the least, our findings strongly suggest that a discrete area for index finger flexion may exist.

A case of postcentral gyrus hemorrhage presenting sensory impairment limited to the left thumb ...

Jung Yun Hwang

Back ground Isolated hand weakness or sensory loss due to stroke is infrequently observed, and often misdiagnosed as peripheral lesions. Moreover isolated finger sensory deficits in association with cortical hemorrhage is rare. We describe here a case presenting with major sensory impairment of the thumb and index finger due to a cortical hemorrhage. Case An 82-year-old man presented to the out-patient department complaining of paresthesia in his left thumb and index finger. The symptom had begun suddenly in 4weeks ago. He received treatment at oriental medical clinic with ambiguous diagnosis. He had no hypertension, hyperlipidemia, diabetes mellitus or previous history of stroke. On admission, his physical examination showed no significant abnormalities. Other cranial nerves were within normal limits. The strength of the thumb, index finger including other fingers, wrist, elbow, shoulder, and leg were normal. Moderate hypesthesia for pin prick and light touch was noted in his left thumb and index finger. Impairment of two-point discrimination was also noted. Deep tendon reflexes were normoacitive and cerebellar function tests were performed normally. Brain MRI taken the admission day showed a small restricted diffusion lesion with reduced ADC map. The lesion was located at the superior portion of the postcentral gyrus with spared precentral gyrus. Both T1-weighted and T2-weighted MR images show high signal intensity suggestive of a late subacute hemorrhage. MR angiogram showed no evidence of steno‐occlusion and aneurysm in intracranial arteries. NCV showed no evidence of peripheral neuropathy. Discussion MRI clearly demonstrated that a discrete cortical hemorrhage was the cause of paresthesia of isolated thumb and index finger in our patient. Several studies on stroke patients supported the existence of alleged topography for fingers in the human motor and sensory cortex: ulnar fingers―medial and radial fingers―lateral. Expectedly, the MRI lesion agree with a previous report that predominant symptoms of radial‐ sided fingers is usually caused by lesions in the precentral knob, topography. At the same time. this case suggests that sensory disorders, localized in a single extremity with a distribution that suggests peripheral nerve lesions, can be caused by cerebral cortical lesions also.

rCBV ratio on perfusion MRI revealing the degree of collateral circulation predicts the ...

차재관

Backgrounds: Collateral circulation is one of the important factors to determine the tissue fate after acute ischemic stroke. However, until now, it is not easy to evaluate its degree in emergency setting. Recently, several reports demonstrated the usefulness of rCBV map on perfusion MRI to reveal the status of collateral circulation after AIS. Methods: We retrospectively recruited 111 consecutive patients with AIS involving anterior circulation. All patients were evaluated by MRI, including perfusion and diffusion images, and underwent digital subtraction angiography (DSA) for brain within 7 days. The collateral circulation was categorized into three groups, poor (0-1), intermediate (2-3), and good (4). We investigated whether rCBV ratio on perfusion MRI can reveal the status of collateral circulation and its ratio predict the early neurologic deterioration (END, within 7days) after AIS. Results: Of the one-hundred eleven subjected patients, 15 were subjected to poor, 59 intermediate, and 37 good collateral circulation. Diffusion size (p<0.001), neurologic severity (p<0.001), stroke type (p<0.001) and its pattern (p<0.001) was significantly different according to the three groups. Regarding to the rCBV ratio on perfusion MRI, its value on poor collateral group was significantly lower than intermediate and good collateral circulation group. Among 111 patients, 27 patients (24%) had early neurologic deterioration (END) within 7 days of ischemic events. Diffusion size on MRI (p<0.001), neurologic deficit at baseline (p<0.001), poor collateral circulation on DSA (p<0.001), presence of diffusion-perfusion mismatch (DPM, p=0.028), and rCBV ratio on perfusion images (p<0.001) were significantly related with the END after acute ischemic stroke. In multiple logistic regression analysis for predicting the neurologic deterioration after AIS, the poor collateral circulation on DSA (OR=6.92, 95% CI= 1.59 to 30.20; p=0.01), the presence of diffusion perfusion mismatch (OR=3.45, 95% CI= 1.02 to 11.70; p=0.047), and low rCBV ratio on perfusion MRI (OR=6.34, 95% CI= 1.62 to 25.11; p=0.008) had an independent significance for that. Conclusions: This study demonstrated that rCBV ratio on perfusion MRI correlated with the extent of angiographic collateral circulation and had a predictable value for the neurologic deterioration after AIS. Therefore, rCBV ratio on perfusion images might be an important tool to estimate the prognosis the fate in AIS. Further studies will be needed to verify this notion in the future.

Establishment of immortalized human brain microvessel endothelial cells and application for ...

Kim, Hyung-Seok

Background and aims: Several kinds of cell therapy models have been suggest treating for ischemic cerebral disease. However, there was no report that the effects of human brain microvessel endothelial cell (hBMEC) transplantation in focal cerebral ischemia. Materials and methods: Stable clonal lines of hBMEC have been generated from the human fetal telencephalon using a retroviral vector encoding human telomerase reverse transcriptase (hTERT) and beta-galactosidase (LacZ), named as HEN7. And HEN7 was also genetically engineered with a lentiviral vector carrying a rporter gene that firefly luciferase (fLuc). The cellular phenotypes of HEN7 were checked by FACS, matrigel assay, immunocytochemistry, and Western blot. And we intravenously transplanted HEN7 in photochemically induced focal cerebral ischemia model, and evaluate the clinical effects for clinical outcome. Results: In the FACS analysis, HEN7 showed CD31+/Flt-1+/CD44+/KDR+/CD34-/CD14-/CD45-. Matrigel assay showed good tube formation. In the immunocytochemistry and Western blot, HEN7 showed positive immunoreactivity for vascular (VEGF, CD31, laminin), stem cell (nestin, CD133), and tight junction protein (claudin-5, occluding). For X-gal staining, strong cytoplasmic staining was noted. Grafted HEN7 could be identified in the infracted area by bioluminescence and X-gal staining. To compare the PBS injection group, HEN7 transplanted group showed reduced infarct lesion volume and earlier recovery from the neurological deficit. Conclusions: Intravenously transplanted hBMEC is successfully targeted into cerebral ischemic area and could accelerate neurological functional recovery, which may be through the microenvironmental improvement.

Disability-Adjusted Life Year (DALY) Analysis for the Impact of Poststroke Complications

홍근식

Authors: Keun-Sik Hong, MD, PhD; Dong-Wha Kang, MD, PhD; Ja-Seong Koo, MD, PhD; Kyung-Ho Yu, MD, PhD; Moon-Ku Han, MD, PhD; Yong-Jin Cho, MD, PhD; Jong-Moo Park, MD, PhD; Hee-Joon Bae, MD, PhD; Byung-Chul Lee, MD, PhD Affiliations: Department of Neurology, Clinical Research Center, Ilsan Paik Hospital, Inje University, Goyang, Korea (K.-S.H., Y.-J.C); Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea (D.-W.K.) ; Department of Neurology, Seoul National University Bundang Hospital, Seongnam, Korea (M.-K.H., H.-J.B.); Department of Neurology, Hallym University Sacred Heart Hospital, Anyang, Korea (K.-H.Y., B.-C.L.); Department of Neurology, Eulji General Hospital, Eulji University School of Medicine, Seoul, Korea (J.K., J.-M.P.) Background: Complications after stroke increase disability or death. An organized stroke care reduces poststroke complications, but requires allocating human and structural resources. Therefore, stroke experts must delineate for public and health policy decision-makers the impact of poststroke complications and the benefits of organized stroke care with a more accessible, comparable, and validated measure. The disability-adjusted life year (DALY) analysis, developed by the WHO to measure the global burden of disease, is a promizing approach to measure the poststroke complication impact with a metric of life years lost that integrates both mortality and disability: one DALY lost is one year of healthy life lost due to either premature mortality and disability. Widely employed in population-level data analyses, it has not been applied to individual patient-level data captured in outcome registries. Objective: This study was to assess the DALY lost associated with poststroke complications. Methods: In prior studies, we derived, for each modified Rankin Scale (mRS) level, disability weights, disability-linked mortality hazard ratios, and age-specific life expectancies. In this study, we analyzed patient-level data from the outcome registry of 1254 consecutive acute ischemic stroke patients enrolled between September 1, 2004 and August 31, 2005 in South Korea. For each subject, we calculated DALY lost due to the qualifying stroke, and then analyzed additional DALY lost due to complications after stroke. Results: Among 1233 patients with available 3-month outcomes out of 1254 consecutive enrolled patients, mean age was 66.5, 43.9% were female, and median entry NIHSS was 4. The average DALY lost due to the index stroke was 3.82 (95% CI, 3.68 to 3.96). Any complications, neurological complications, and medical complications occurred in 34.0%, 20.8%, and 24.0%, respectively. The most common specific complications were ischemic stroke progression (16.9%) and pneumonia (11.7%). 230 (18.7%) and 200 (16.2%) patients experienced one complication and 2 or more complications, respectively. The additional DALYs lost associated with any, neurological, and medical complications were 2.11 (95% CI, 1.78 to 2.44), 2.15 (95% CI, 1.72 to 2.59), and 1.99 (95% CI, 1.59 to 2.40), respectively. For specific complications, ischemic stroke progression and pneumonia were associated with an additional DALY[3,1] lost of 2.18 (95% CI, 1.71 to 2.65) and 2.14 (95% CI, 1.54 to 2.73). As compared to patients without complications, those with one complication had 1.52 (95% CI, 1.15 to 1.89) additional DALY lost, and those with 2 or more complications had 2.69 (95% CI, 2.18 to 3.20) additional DALY lost. Conclusion: Early poststroke complications deprive patients of about 2 years of optimum health, free of disability. Greater numbers of complications is associated with greater loss of healthy life years. DALY analysis quantifies the burden of poststroke complications with an intuitively accessible, directly comparable, and widely employed metric potentially useful for health system planners.

Acute borderzone infarction in a Patient with Common Carotid Artery Occlusion

조광덕

Acute borderzone infarction in a Patient with Common Carotid Artery Occlusion Kwang Deog Jo, MD, PhD1, Seung Hoon You, MD2, Sun Hong Song, MD3 1Department of Neurology, 2Neurosurgery, 3Rehabilitation Medicine, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea Background: Symptomatic common carotid artery (CCA) occlusion is very rare type of cerebrovascular disease. Chronic CCA occlusion may be associated with recurrent transient ischemic attacks, stroke or chronic ischemia. Atherosclerosis is the main cause of CCA occlusion in most cases. We present a case of acute borderzone infarction secondary to occlusion of the unilateral CCA occlusion. Case: A 76-year-old man presented with dysarthria and abnormal behavior. He had a history of hypertension, diabetes mellitus, heavy smoking, and old cerebral infarction 15 years ago. Percutaneous transluminal coronary angioplasty was performed at the left anterior decending artery 12 years ago. He had not taken his prescribed medications in the past 7 years. Neurologic examination showed transcortical motor-sensory aphasia, right hemianopsia, dyscalcuria, left-right disorientation, and mild right hemiparesis. Diffusion weighted image showed a large posterior borderzone infarction in the left parieto-occipital cortex with multiple small subcortical borderzone infarctions between the left anterior and middle cerebral arteries (MCA). MR and diagnostic cerebral angiography showed total occlusion of the left distal CCA with collateral filling of the left external carotid artery through the thyrocervical trunk. Left subclavian angiogram showed occlusion of the left vertebral artery with delayed collateral filling of the cavernous internal carotid artery (ICA) through the maxillary artery. Right ICA angiogram showed mild irregular stenosis of the petrous portion of the ICA with good collateral circulation via the circle of willis to the left ICA territory. Brain CT perfusion showed severe decrease in regional cerebral blood flow (rCBF) and delay of mean transient time in the left ICA territory. After vasodilatory challange with acetazolamide, CT perfusion showed more decrease in mean rCBF and cerebral vascular reserve capacity [(acetazolamide rCBF - resting rCBF)/resting rCBF ￠®￠? 100] in the left MCA territory than other vascular territories. One month later after his admission, the patient was transferred to the rehabilitation department with residual right hemiparesis and aphasia. Conclusion: We report a rare case of unilateral CCA occlusion who later developed acute borderzone infarction in the territory of occluded CCA. We suggest that multiple risk factors of stroke may cause atherosclerotic occlusion of the CCA.

A Case of Temporal Lobe Epilepsy Mimicking Wernicke’s Aphasia

강경욱

A Case of Temporal Lobe Epilepsy Mimicking Wernicke’s Aphasia Kyung-Wook Kang Departments of Neurology Chonnam National University Medical School, Gwangju, Korea Wernicke’s aphasia is a language disorder that impacts the comprehension of written and spoken language. A 48-year-old woman had developed a transient sensory aphasia without focal neurological deficit. Brain MRI showed no structural lesion, but 18F-Fluorodeoxyglucose (FDG) positron emission tomography (PET) demonstrated hypermetabolic activity in the left medial and superior temporal gyri, and middle frontal gyrus. Electroencephalogram (EEG) revealed spike discharges from the same area. We report a case of Wernicke’s aphasia as an ictal phenomenon of temporal lobe epilepsy.

De Novo Silent Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and ...

권지현

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) is a hereditary small vessel disease that affects brain and leads to disability and dementia. It is due to mutations of the NOTCH3 gene on chromosome 9. Although clinical presentations of CADASIL vary between families, its initial manifestation is usually migraine with aura. White-matter (WM) abnormalities in T2-weighted image usually presents after migraine. We report a patient who was detected incidentally without clinical symptoms including migraine, ischemic stroke, mood disturbances and cognitive declines. A 46-year-old man visited outpatient clinic complaining of abnormalities in the brain MRI. He got a physical examination and checked brain MRI and MR angiography incidentally concerning for organic brain lesion. He was previously healthy and had no headache, history of stroke, depression or executive dysfunction. Family history revealed no certain abnormality. He had no risk factor of stroke. Fluid-attenuated inversion recovery (FLAIR) images showed diffuse and confluent WM hyperintensities involving anterior part of bilateral temporal lobes, subcortical areas and basal ganglia. Diffusion-weighted and gradient echo images and MR angiography revealed no abnormalities. Gene analysis showed pathologic point mutation in the NOTCH3 gene (c. 1010A>G, p. Tyr337Cys), and as far as we know, it was first case in Korea. Unfortunately, we could not check genetic analysis of his family due to refusal. In conclusion, clinician should be concerned the possibility of CADASIL if the brain MRI shows unexplainable WM lesions, even though the patient is clinically asymptomatic.

Cerebral Fat Embolism Detected in Delayed Gradient-Recalled Echo Sequence

권지현

Cerebral fat embolism is a relatively frequent and lethal complication after femur fracture or surgery. Neurological manifestations are diverse and clinical diagnosis is challenging. Gradient-recalled echo (GRE) sequence is well-known tool detecting fat embolism. We report a patient who showed definite fat embolism in delayed GRE sequence even though initial GRE sequence was negative. A-27-year-old man developed decreased consciousness 1 day after femur neck fracture due to traffic accident. Neurologic examination revealed stuporous mentality and quadriplegia, more severe in the lower extremities. Vital signs were within normal limits except mild hypoxia (SaO2 91%). Brain CT at that time showed no abnormality. Diffusion-weighted image revealed multiple dot-like embolic infarcts in bilateral subcortical watershed areas, occipital cortexes and thalami. GRE sequences showed no abnormally low signal intensities suggesting fat embolism. There was no stenosis in MR angiography. However, low signal intensity lesions corresponding to initially infarcted areas were detected in follow-up GRE sequences taken 17 days after symptom onset. Right to left shunt was present in the trans-esophageal echocardiography. His neurologic status improved gradually and he could walk without assistance although he complained of cognitive decline. In conclusion, a delayed GRE sequence may be useful in differentiating cerebral fat embolism from hypovolemic hemodynamic infarcts. Clinicians should be concerned the possibility of cerebral embolic infarct due to fat embolism in patients who are suddenly deteriorated after femur fracture.

Brainstem infarction secondary to persistent trigeminal artery occlusion : Successful treatment ...

권주영

Brainstem infarction secondary to persistent trigeminal artery occlusion: Successful treatment with t-PA Department of Neurology, University of Ulsan, Asan Medical Center, Seoul, Korea Joo Young Kwon, MD, Eun Jae Lee, MD, Jong Sung Kim, MD,PhD Background & significance Persistent trigeminal artery (PTA) is the most common embryonic carotid-basilar anastomosis that remains into adulthood. It is usually associated with hypoplasia or atresia of the vertebrobasilar artery. We describe a patient with brainstem infarction associated with PTA successfully treated with t-PA. Case A 70-year-old man with atrial fibrillation presented with right hemiparesis and dysarthria. Diffusion weighted magnetic resonance imaging (MRI) showed an acute ischemic lesion on the left side of the upper pons. MR angiography revealed non-filling of a left PTA with hypoplasia of the vertebrobasilar system. There were no atherosclerotic vascular lesions in both carotid and vertebrobasilar arteries. After intravenous thrombolysis therapy with tissue plasminogen activator (t-PA; 0.9mg/Kg), the distal basilar artery, superior cerebellar arteries (SCA) and the posterior cerebral arteries were well visualized through the left PTA on cerebral angiography. Follow up MRI demonstrated new high intensity area in the right side of the cerebellum within SCA territory. But the patient demonstrated good recovery. The presumed mechanism of infarction would be cardiac embolism occluding the PTA and the basilar artery. . Conclusion Here we present a unique case of brainstem infarction in the setting of the occluded PTA, which was re-canalized with intravenous thrombolysis. In this case, blood supply to the upper brainstem probably depended largely on the left PTA. Rapid recanalization of the occluded PTA may explain the favorable prognosis with mild residual neurologic deficits.

A Case of Cerebellar infarction presented as Thunderclap headache

조윤식

A Case of Cerebellar infarction presented as Thunderclap headache Yoon Sik Jo,M.D., Sang Don Han,M.D., Jin Young Choi,M.D. Department of Neurology, Chungju hospital, Konkuk University School of Medicine, Background & significance Thunderclap headache refers to a severe headache of sudden onset. It often heralds a serious intracranial vascular event such as subarachnoid hemorrhage, unruptured intracranial aneurysm, cerebral venous thrombosis, cervical artery dissection. We report a 60-year-old woman who developed thunderclap headache as an initial symptom, in the absense of focal or lateralizing neurological findings. Case A 60-year-old woman presented with sudden onset headache. The headache was maximal at onset and rapidly generalized from its origin in the right occipital region to entire head, rated as 10/10. Associated symptom included nausea without any phonophobia, photophobia. On initial neurological examination, there were no focal neurologic findings. At admission, initial brain CT revealed normal findings. There was no abnormality of electrocardiography and echocardiography Brain CT angiography performed at the 2nd day of admission showed mild stenosis of right vertebral artery without any vascular malformation. But, Brain MRI showed hyperintense lesions in the territory of right superior cerebellar artery. Discussion Clinicoradiologic studies have been demonstrated that cerebellar infarction presenting with thunderclap headache is a very rare condition. The mechanisms of headache in cerebral infarct are multifactorial. Headache is more common when stroke occurs in the area of the posterior circulation than in the anterior circulation. The posterior circulation is more densely innervated by the trigeminal system. We suggest that brain MRI should be performed in patients presented with thunderclap headache to rule out cerebellar infarction even if neurological examination, brain CT and CT angiography are normal as in our case.

A Case of Transient ischemic attack associated with Fahr’s disease

김영진

A Case of Transient ischemic attack associated with Fahr’s disease Young Jin Kim, Julie Jeong, Myoung Jea Yi, Ha Yeong Yoo, Sun Jung Han, Sung Ik Lee. Inam Neuroscience Research Center, Department of Neurology, Sanbon Medical Center, Wonkwang University School of Medicine Background & Significance : Extensive symmetric calcification of bilateral globus pallidus, putamen, dentate nuclei, and cerebral hemispheres is very rare in clinical practice, and is called bilateral striopallidodentate calcinosis or Fahr’s disease. The classical triads of bilateral striopallidodentate calcinosis (BPSDC), hypoparathyroidism, and neurological manifestations are called Fahr’s syndrome. We report a case of idiopathic basal ganglia calcification (Fahr’s disease) associated with an episode of transient ischemic attack. Case : The patient is a 81 year-old woman with hypertension and diabetes mellitus who presented with transient dysarthria and left hemiparesis. Initial blood pressure was 160/80mmHg. Laboratory findings showed iron deficiency anemia, increased parathyroidhormone level, and borderline low calcium level. Physical examination was unremarkable except for round face. No carotid bruit heard. Dysarthria and left hemiparesis improved during 3hours after the onset. Neuroimaging findings were compatible with those of Fahr’s disease. CT of the brain revealed increased density on bilateral cerebellar dentate nuclei, basal ganglia, and centrum ovales. MRI of the brain depicted no evidence of cerebral infarction, but multifocal calcification in the same areas as the brain CT. Conclusion : The patient had pseudo-hypoparathyrodism and transient neurologic deficit in addition to the neuroimaging findings compatible with Fahr’s disease. One hypothesized pathogenesis of Fahr’s disease is that precipitation of calcium and other minerals might have been triggered by local circulatory disturbances like regional ischemia. We report a case of idiopathic basal ganglia calcification (Fahr’s disease) presented with transient ischemic attack.

Multiple simultaneous intracerebral hemorrhages: two cases reports

KwangsubLee

Multiple simultaneous intracerebral hemorrhages: two cases reports Kwangsub Lee1, Nack-Cheon Choi1,2, Sukyeong Kim1,2, Heeyoung Kang1,2, Ki-Jong Park1,2, Oh-Young Kwon1,2, Byeong Hoon Lim1,2 Department of Neurology, Gyeongsang National University School of Medicine1 Gyeongsang Institute of Health Scienceb, Gyeongsang National University2 Background and Significance: Most common cause of ICH is hypertension. However, multiple simultaneous intracerebral hemorrhages (SIH) are rare and its predisposing factors and pathophysiology are still unclear. We experienced two patients with simultaneous infratentorial intracerebral hemorrhages extending thalamus. Case 1: A 42-year-old man was admitted with acute loss of consciousness on the street. Initial blood pressure was measured at 200/100 mmHg. We revealed that he took decerebrate posture to painful stimulus and made no response to doll’s eye and corneal reflex. Performed Brain CT scan was seen to us right cerebellar hemorrhage extending cerebellar peduncle, pontine hemorrhage, and bilateral midbrain hemorrhage extending into the left thalamus. He was not improved and died 6 days after the admission. Case 2: A 46-year-old man was cardiac arrest when he carried into the emergency room. After the admission he was performed CPR during 15 minutes. So vital signs were recovered except tachycardia, but he did not response to noxious pain, doll’s eye and corneal reflex. Brain CT scan showed a right cerebellar hemorrhage extending cerebellar peduncle, pontine hemorrhage, and bilateral midbrain hemorrhage extending into the left thalamus. We transferred to other hospital in hopeless. Conclusion or Comment: SIH accounts for approximately 0.7% to 3% of ICH. We rarely report two SIH cases that have different etiologies each other.

A Case of Acute Urinary Retention due to Lateral Medullary Infarction

김태형

A Case of Acute Urinary Retention due to Lateral Medullary Infarction Tae Hyoung Kim, Kwang Dong Choi, Sang Min Sung, Dae Soo Jung, Han Jin Cho Departments of Neurology, Pusan National University Hospital Background and Significance The occurrence of bladder dysfunction in brainstem stroke has been generally accepted to be associated with the pontine lesion in most cases. There have been few reports described of the causal relationship between urinary dysfunction and the medullary lesion, which has not been elucidated clearly. We report a case of acute urinary retention due to left lateral medullary infarction. Case A 75-year-old man presented with sudden onset of spontaneous vertigo and postural imbalance. Neurological examination revealed no remarkable findings except for axial lateropulsion to the left. Diffusion-weighted magnetic resonance imaging (DWI) of the brain showed no significant abnormal findings. On day 2 of his admission, he developed urinary retention abruptly despite his urgency. Follow-up DWI disclosed an acute infarction in the left lateral medulla. Urodynamic study revealed complete atonic bladder with the intact bladder sensation. The prostate was slightly enlarged on transrectal ultrasonography. After 4 weeks, most symptoms including urinary retention were nearly recovered. Conclusion and Comment Recent studies have investigated specific brain areas which are involved in the central control of the bladder. Based on previous researches with functional brain imaging, the dorsomedial pontine tegmentum is presumed to be the pontine micturition center to result in detrusor contraction and the relaxation of the urethral sphincter. Conversely, the ventrolateral pontine tegmentum has been proposed to maintain the contraction of the urethral sphincter. However, the anatomical location to participate in micturition control has not been well documented in the medulla. Our case showed acute urinary retention caused by lateral medullary infarction. We hypothesize that descending tracts from the pontine micturition center to the bladder motor neuron are interrupted, which may be laterally situated on the medulla. In addition, the importance of right side of the brain in bladder control has been implicated by the previous studies. However, as in our case, urinary retention could be resulted from the left-sided lesion of the brainstem. Further studies are necessary to clarify the function and the anatomical location for bladder control in the medulla.

Impact of Asymptomatic Hemorrhagic Transformation on 3-month Clinical Outcome after Acute ...

박정현

Background and Purpose: The impact of asymptomatic hemorrhagic transformation (HT) on the clinical outcome in patients with acute ischemic stroke is not clear. We sought to elucidate it by ordinal analysis using the whole range of the mRS score as an outcome variable. Method: We identified prospectively and consecutively 1618 patients who were hospitalized due to ischemic stroke between January 2004 and August 2007. Among those 1618, patients with no relevant lesion on the MRI (N=12), with no T2-weighted gradient echo MRI within 14 days from symptom onset (N=83), with no available mRS at 3 months after stroke onset (N=94), or with symptomatic HT (N=17) were excluded. Finally, 1412 patients were included as the final subjects of this study. Symptomatic HT was defined as any neurological deterioration that accompanied HT and was considered to be caused by HT. Clinical outcome was categorized according to the full distribution of mRS score. The crude and adjusted odds ratios (ORs) of asymptomatic HT on outcome were calculated and adjusted for variables whose p-values were <0.25 with respect to both asymptomatic HT and clinical outcome. Results: Out of 1412 patients that were included in this study, 100 (7.1%) had asymptomatic HT. Patients who experienced asymptomatic HT were more likely to have cardioembolic stroke, to receive thrombolytic therapy, to receive anticoagulation with heparin and to have a higher initial NIHSS score. Compared with the mRS 0 group, the groups with a higher mRS score were more likely to have stroke by large artery atherosclerosis, to receive thrombolytic therapy and anticoagulation with heparin, as well as to have a higher NIHSS at baseline. Other contributing factors for a higher mRS score were old age, female sex, no current smoker, a history of stroke, and hypertension. Compared to no HT, the crude OR of asymptomatic HT were 2.9 (95% confidence interval, 2.0 to 4.2). After adjustment for age, stroke subtype, initial NIH stroke scale, thrombolysis, and use of heparin, the OR was 1.8 (1.2 to 2.7) for asymptomatic HT. Conclusions: Asymptomatic HT aggravates the functional outcome almost 2 times higher than that of no HT after acute ischemic stroke.

weakness of index and middle finger in cortical infarction

이재성

background: weakness involving only few fingers due to cerebral infarction has rarely been reported. Here we describe a case presenting with weakness of index and middle finger due to a cortical infarction confirmed by MRI. case: The patients was a 52 year old female taking hypertension and hyperlipidemia medication. Her occupation was a pharmacist and visited the neurology out patient department for the evaluation of weakness of her left 2nd and 3rd finger which developed while filling out prescriptions a day before. Neurologic examination showed index and middle finger motor MRC Gr 4 with no other abnormalities. Brain MRI results taken after admission was consistent with acute cerebral infarction of right precentral gyrus. conclusion: the presenting result suggests that there is a localized area predominantly responsible for the movement of finger

Posterior circulation infarction presenting as sudden blindness in acute aortic dissection patient

박은선

Background : Aortic dissection (AD) is uncommon, life-threatening. Its prompt diagnosis remains essential for successful management. AD typically presents with tearing chest and back pain. However, some patients (15%) with Aortic dissection do not present initially with typical pain. Infarcts of the vertebrobasilar territory in aortic dissection are very rare. We report a patient with posterior circulation infarction secondary to AD who first showed hemiparesis and blindness. Case : A 58-year-old man presented to our emergency room with dysarthria and right hemiparesis 78minutes after symptom detection. He was just under the observation of aortic aneurysm of valsalva sinus, moderate AR, and hypertension. Neurologic examination revealed dysarthria and right hemiparesis(III/III). The National Institues of Health Stroke Scale (NIHSS) score was 12 at that point. Recombinant tissue plasminogen activator (rTPA) was infused. Ten minutes after bolus injection, suddenly he complained bilateral blindness. Only light perception was available. Magnetic resonance (MR) imaging of the brain revealed bilateral cerebellar and occipital infarction. On MR angiography, both P2 and P3 of Posterior cerebral arteries were occluded. Sudden hypotension was detected. Chest and abdomen CT angiography revealed aortic dissection from ascending thoracic aorta into origin site of both renal arteries with hemopericardium. Conclusion : This case highlighted the rare posterior circulation stroke and the result of collateral circulation of basilar artery to anterior circulation occluded due to internal carotid occlusion. Painless aortic dissection could show many neurologic symptoms, thus requiring a high degree of clinical suspicion for an accurate diagnosis.

Cerebral sinus thrombosis in a Patient with Protein S Deficiency

조광덕

Cerebral sinus thrombosis in a Patient with Protein S Deficiency Kwang Deog Jo, MD, PhD1, Min Seok Oh, MD2, Jong Hyeog Lee, MD3 1Department of Neurology, 3Diagnostic Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea 2Department of Emergency Medicine, Seoul Asan Hospital, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Background: Protein S deficiency is a well-known cause of the hypercoagulable states and risk factor for venous thromboembolism. To our knowledge, cerebral venous thrombosis (CVT) associated with protein S deficiency has not been reported in Korea. We present a case of CVT associated with protein S deficiency. Case: A 32-year-old man presented with headaches for 2 months. The headaches are described as being moderately severe, last for most of the day, bilateral, dull or bursting, and often cause sleeping difficult. His past medical history was unremarkable except for 10 pack-years of smoking. Brain MRI showed thrombosis of the straight sinus. Diagnotic cerebral angiography showed obstruction of the right jugular bulb with adjacent venous collaterals and thrombosis of the right transverse, sigmoid, and confluens sinuses. Protein S antigen was 0.9 mg/dl (normal 1.35-2.41) and protein S activity was 43% (normal 65-140%). Other coagulation studies were within normal limits. He was treated with anticoagulant therapy and the headaches gradually improved. Two years later, he was readmitted to our hospital because of recurrent CVT. Follow-up cerebral angiography showed obstruction of the left sigmoid sinus and jugular bulb. Then he received anticoagulants therapy and aspirin after recurrence of CVT, however, his prothrombin time was maintained at a low level between international normalized ratio of 1.11 and 1.17. Four months after his second admission, he developed a deep vein thrombosis and treated by the insertion of an inferior vena cava filters. Two months after his third admission, the patient was transferred to other hospital for further therapy. Conclusion: We report a case of protein S deficiency with recurrent CVT and further developed deep vein thrombosis. We need further evaluation for protein S deficiency of his family.

Chronic subdural hematoma of right cerebral hemisphere with ipsilateral parkinsonism

이도경

Chronic subdural hematoma of right cerebral hemisphere with ipsilateral parkinsonism Do-Kyung, Lee, M.D., Sung Hyuk Heo, M.D.,Key Chung Park, M.D., Tae-Beom Ahn, M.D.,Sung Sang Yoon, M.D., Dae-il Chang, M.D., Kyung Cheon Chung, M.D. Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea Background The main role of structural imaging such as magnetic resonance imaging and computed tomography in the field of movement disorders was to exclude uncommon but potentially reversible structural abnormalities including tumors, chronic subdural hematoma, and communicating hydrocephalus presenting with parkinsonism. But in some situations, structural imaging would be confusing to the clinicians. Case 77 years old male admitted for memory loss and gait disturbance. His family members said that his right hand clumsiness and memory loss have been worsening since 7~8 years ago. Neurologic examination showed mild disorientation (he cannot answered the date) and moderate disturbance of memory recall. His language function was relatively intact. But, He failed interlocking pentagon. His total score of Korean mini-mental status examination was 17. His external ocular muscle examination was intact. Abnormal flexed posture and cogwheel rigidity of his right elbow was shown. He showed abnormal extensional posture of all right fingers and resting tremor of his right hand. Both arm swing was decreased and right leg was limped. Pull test was negative. Brain computed tomography revealed large chronic SDH with calcification on right cerebral hemisphere and severe hydrocephalus. Patient’s location of SDH and laterality of parkinsonism was not correlated. Therefore, we performed a dopamine transporter imaging with positron emission tomography to rule out the functional defects of left side dopamine pathway. It revealed asymmetric decreased uptake of isotope on the left putamen and globus pallidus. Parkinsonian symptom was improved after levodopa treatment. Conclusion In specific clinical situation with parkinsonism, when structural image findings and clinical symptom is not correlates, dopamine transporter imaging is useful tool for differential diagnosis.

A Case of Transcortical Mixed Aphasia and Clinical Correlation with SPECT

김준현

A Case of Transcortical Mixed Aphasia and Clinical Correlation with SPECT Jun Hyun Kim, P.D., Sung Hyuk Heo, M.D., Key Chung Park, M.D., Tae-Beom Ahn, M.D., Sung Sang Yoon, M.D., Dae-il Chang, M.D.Kyung Cheon Chung, M.D. Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea Background and significance Aphasia is one of the most disabling symptom in stroke patients and prediction of the site of the lesion after examination of an aphasic patient is important in neurologists. Transcortical mixed aphasia is rare and only a small number of studies are reported. It is known to be the result of lesion at fronto-temporal watershed area or large area of temporal lobe. We experienced a patient with sensory and motor aphasia but intact repetition ability. Case A 46 year-old man visited outpatient clinic for talking inappropriate word without making sense and talking less than usual. The talklessness had began suddenly from the day before the visit. The patient had walked independently that morning from his home. He had no medical history, but had 20 pack-years of smoking history. Neurologic exam revealed alert consciousness but he could neither speak spontaneously, nor obey examiner’s commands mostly except a few one-step commands. He could not name anything, but his repetition ability was relatively preserved. Cranial nerve, motor, sensory function was all normal. Brain MRI and MRA depicted cerebral infarction at left middle frontal gyrus and subcortical area around caudate nucleus and occlusion of left ACA and MCA. Transfemoral cerebral angiography was done and showed severe stenosis of left ACA and MCA. Decreased perfusion in left frontal and temporal cortex, basal ganglia and thalamus was observed at brain SPECT. Conclusion Transcortical mixed aphasia is rare and localization is not clearly understood. Large brain infarction involving temporal area or lesion at watershed area between MCA and PCA is reported. In this patient, Brain MRI lesion is confined to left frontal lobe but SPECT showed larger hemodynamic insufficiency. Hypoperfusion and hypometabolism can reflect patient’s clinicopathological correlation without structural lesion.

Retinal artery infarction during carotid angioplasty and carotid artery stenting

정유진

Retinal artery infarction during carotid angioplasty and carotid artery stenting Yu-Jin, Jung, M.D., Do-Kyung, Lee, M.D., Sung Hyuk Heo, M.D.,Key Chung Park, M.D., Tae-Beom Ahn, M.D.,Sung Sang Yoon, M.D., Dae-il Chang, M.D., Kyung Cheon Chung, M.D. Department of Neurology, Kyung Hee University College of Medicine, Seoul, Korea Background Carotid angioplasty and stenting is an alternative therapy to endarterectomy for the treatment of carotid artery stenosis. Various complications during intervention have been reported. But retinal artery complications during Carotid intervention were rarely reported. Case A 54-year-old man presented with transient dysarthria and left side weakness. Magnetic resonance imaging showed acute ischemic lesion on the water-shed zone of right hemisphere and magnetic resonance angiography showed left internal carotid artery occlusion and right internal carotid artery severe stenosis with ulceration. Right carotid angioplasty and carotid artery stenting were performed. Two hours after the stenting, patient complained blurred vision of right eye. Neurologic examination showed lower half visual field defect of right eye, which was diagnosed as retinal artery infarction. Low molecular weight heparin was administered for 3 days after stenting with continuation of aspirin and clopidogrel. He was discharged with no other neurologic deficit. Discussion Several possible explanations of retinal artery infarction after carotid artery stenting have been suggested. Retinal artery embolization from proximal vasculature is one possible mechanism. In patients with severe proximal internal carotid artery stenosis, the flow of the ophthalmic artery is often reversed, in which can be easily detected by transcranial doppler. The other possible mechanism of retinal artery ischemia is due to normalization of this reversed ophthalmic artery flow.

Intravenous Thrombolysis in an Adult Patient with Moyamoya Disease

서우근

Title: Intravenous Thrombolysis in an Adult Patient with Moyamoya Disease Woo-Keun Seo M.D., Ph.D., Yoohwan Kim M.D., Ji Hyun Kim M.D., PhD.D., Kyungmi Oh M.D., Ph.D., Seong-Beom Koh M.D., Ph.D. Moyamoya disease is a cerebrovascular condition characterized by progressive stenosis of the intracranial internal carotid arteries and their proximal branches. Although ischemic symptoms have been reported in about two thirds of patients suffering from Moyamoya disease, thrombolysis has rarely been reported. A 68-year-old man presented with left hemiplegia and severe dysarthria. He had been diagnosed as having Moyamoya disease. The patient was treated with intravenous thrombolysis. Fortunately, after infusion of t-PA, the patient’s neurological symptoms improved without hemorrhagic complication. Here, we report our experience with intravenous thrombolysis in a patient with Moyamoya disease. Although there can be limited generalization of our experience, intravenous thrombolysis should be considered as a therapeutic option for adult patients with Moyamoya disease who present with acute ischemic symptoms.

Evidence of Systemic and Peripheral Atherosclerosis in Stroke Patients: cIMT, ABI, and PWV ...

김일곤

Evidence of Systemic and Peripheral Atherosclerosis in Stroke Patients: cIMT, ABI, and PWV Studies Compared to Elderly Control Il-Gon Kim, Changseok Song, Yoonjae Choi, Chang-Gi Hong, Im-Tae Han, Joung-Ho Rha, So-Hyun Kim Inha University Hospital Neurology Background: Many studies have established that the cIMT is marker of generalized atherosclerosis, PWV correlates with arterial stiffness, and lower ABI indicates peripheral arterial stenosis, all reflecting systemic and peripheral atherosclerosis. Objective: Researches on cranial vessel status have been popular in stroke patients, but studies on other vascular beds are scanty. We tried to investigate the frequency of systematic atherosclerosis in stroke patients compared to that of elderly control. Carotid intima media thickness (cIMT), ankle-brachial index (ABI), pulse wave velocity (PWV) were performed for this purpose. Method: From January to June 2009, patients who admitted to Inha university hospital with acute ischemic stroke (<7 days) and elderly volunteer over 65 years-old were prospectively studied. cIMT, ABI, and PWV were investigated in both group. cIMT average (cIMT-aver) and maximum (cIMT-max) were measured by automated software (IntimaScopeR). Results were compared between the two groups. Results: Sixty stroke and 90 elderly control group were recruited. Stroke group were younger than control (61.3￠®¨u13.6 vs. 72.5￠®¨u5.6, P<0.001). There was no significant difference in the risk factor profiles such as hypertension, diabetes mellitus, and dyslipidemia, except more smoking history in stroke group than control (60.0 vs. 20.0%, P<0.001). By multivariate logistic regression analysis, cIMT-max and cIMT-aver were larger in stroke group than those of elderly control (0.86￠®¨u0.22 vs. 0.78￠®¨u0.12mm, p=0.001; 0.67￠®¨u0.15 vs. 0.64￠®¨u0.10mm, P=0.01 respectively). ABI of the stroke group were smaller than those of control (1.04￠®¨u0.12 vs. 1.16￠®¨u0.1, p=0.001). PWV of the stroke group were higher than those of control (1800.9￠®¨u435.4 vs. 1766.4￠®¨u333.1cm/sec, p=0.015). Conclusions: cIMT and PWV were higher and ABI was lower in stroke patients, suggesting more severe systemic and peripheral atherosclerosis than elderly control. These results demonstrate cranial atherosclerosis is often accompanied by changes in other vascular beds. Assessment of arterial status other than cranial vessels might have clinical implication for the evaluation of the stroke patients.

Is single small subcortical infarction homogeneous?: difference according to vascular ...

나현욱

Is single small subcortical infarction homogeneous?: difference according to vascular territory, lesion extension, and the presence of parent artery disease Hyun-Wook Nah, MD; Dong-Wha Kang, MD, PhD; Sun U. Kwon, MD, PhD; Jong S. Kim, MD, PhD Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea Background: Single small subcortical infarction (SSSI), so called lacune, is typically caused by small vessel disease (SVD). However, SSSI can be caused by underlying large parenteral arterial disease (PAD) and the pathology of perforator vessels may be heterogeneous (lipohyalinosis vs. microatheroma) according to the involved portion. We sought to investigate whether the markers for SVD and atherosclerosis are different according to the vascular territory, lesion extension, and the presence of PAD in SSSI patients. Methods: We included 449 patients who had a SSSI (lesion diameter ≤20mm) in the territory of middle cerebral artery (MCA, n=244), basilar artery (BA, n=141), and vertebral artery (VA, n=64) perforators on diffusion-weighted imaging performed within 48 hours of stroke onset. Patients were analyzed according to the vascular territory, lesion extension to the parent artery, and the presence of PAD. The prevalence of SVD markers (leukoaraiosis and microbleeds) and atherosclerosis markers (cerebral atherosclerosis and coronary heart disease) were compared between the groups. Results: Atherosclerosis markers significantly increased and SVD markers significantly decreased as the vascular territories got lower (MCA, BA to VA). SSSI with PAD had the highest prevalence of atherosclerosis markers and the lowest prevalence of SVD markers. Distal SSSI without PAD had the lowest prevalence of atherosclerosis markers and the highest prevalence of SVD markers. Proximal SSSI without PAD showed the intermediate feature. Conclusion: Differences in relation to SVD and atherosclerosis markers suggest that SSSI has a heterogeneous pathogenesis according to the vessel territory, lesion extension, and the presence of PAD.

A Case of Transient Amnesia and Cortical Blindness Associated with Moyamoya Disease

Lee Kee Ook

Background & significance : Acute onset of cortical blindness and anosognosia, amnesia are commonly encountered in patient with bilateral occipital and temporal lesions. Symptoms of moyamoya disease are typically associated with the regions of the brain supplied by the internal carotid arteries and middle cerebral arteries. We now describe a patient presenting transient cortical blindness and anosognosia, amnesia associated with moyamoya disease. Case : A 22-year-old right-handed woman presented with amnesia and visual impairment. She had no medical or family history. She completely denied her blindness and disturbances of recent memory with confabulation. Visual testing demonstrated normal direct and consensual light responses in both eyes. The next day, her blindness and amnesia were resolved. Diffusion and T2-weighted images of magnetic resonance imaging (MRI) showed high signal intensity on left basal ganglia, suggested acute ischemic stroke. In cerebral angiography, complete occlusion of distal ICA and posterior collateral flow were shown. This finding suggested moyamoya disease. Conclusions or comments : The neuropsychological or cognitive problems related with moyamoya disease were previously reported in some literature. However, these problems, like as Dide-Botcazo syndrome, may not be reported in previous literature. We believe that these symptoms reflect transient ischemia caused by disturbed hemodynamic status.

New biomarkers of asymptomatic carotid stenosis in patients with coronary artery disease : ...

김석재

Background and Purpose: Carotid artery stenosis is an important etiological factor of stroke related to coronary artery bypass surgery (CABG). To identify biomarkers for preexisting carotid artery stenosis in patients with coronary artery disease among candidates for CABG, clinical factors and various biomarkers were evaluated. Methods: Between June 2006 and September 2008, 811 patients underwent preoperative carotid artery duplex scanning as part of a preoperative assessment for nonemergency cardiac procedures. Of these patients, 54 patients with previous stroke or transient ischemic attack were excluded. The association between various biomarkers and carotid artery stenosis was analyzed by multiple logistic regression. Results: Prevalence of carotid stenosis of ≥50% and ≥70% was 26.4% (200 of 757) and 8.6% (65 of 757), respectively. In univariate analysis, age, hypertension and plasma levels of C-reactive protein (CRP), Homocysteine, lipoprotein (a) and apoB/apoA-I ratio were associated with carotid stenosis of ≥50%. In multivariate analysis, the plasma levels of homocysteine, lipoprotein (a) and apoB/apoA-I were independently associated with carotid stenosis of ≥50% (odds ratio (95% confidential interval) for homocysteine, lipoprotein (a) and apoB/apoA-I in the highest vs. lowest quartile, 2.13 (1.20-3.79), 2.19 (1.27-3.77) and 2.14 (1.21-3.79), respectively). Conclusion: Our findings indicated that the homocysteine, lipoprotein (a) and apoB/apoA-I can predict asymptomatic carotid stenosis in patients with coronary artery disease.

Intraopertive delayed blood filling of aneurysms after complete clipping detected with ...

장경술

Intraopertive delayed blood filling of aneurysms after complete clipping detected with Indocyanine green (ICG) angiography Kyung-Sool Jang M.D. Department of Neurosurgery, Neurosceince center, Incheon St. mary’s Hospital, The catholic university of Korea Objective We present some cases of the delayed blood filling of aneurysms after complete clip which were convinced by Indocyanine green (ICG) angiography Methods The total cases of clipping were 108 in 2009 at our hospital. After we convinced complete clipping of aneurysms, and then we performed intravenous ICG (indocyaningreen) injection in all of cases. The intravenous injected volume of ICG is 25mg/10cc of water per case. Injected ICG was detected by the Carl Zeiss Co. (Oberkochen, Germany) integrated the ICG videoangiography technology into its microscope. The system was designed to integrate near-infrared (NIR) imaging into the surgical miscroscope to assist in obtaining high-resolution and high-contrast NIR images. Results Among our 108 cases of cerebral aneurysms, we detect 7cases of delayed filling of injected ICG. In these cases, we performed re-position of clip, booster clipping or add of reinforced clip. These cases revealed the atherosclerosis of parent artery or wide neck, or large sized aneurysm. Conclusions Although, intraoperative cerebral angiography remains the methods of choice for cerebral vascular surgery, Indocyanine green (ICG) angiography is useful tool for the confirming of complete clipping of aneurismal surgery in this day.

Endoscopic viewing images of carotid artery dissection

장경술

Endoscopic viewing images of carotid artery dissection Kyung-Sool Jang M.D. Department of Neurosurgery, Neurosceince center, Incheon St. mary’s Hospital, The catholic university of Korea Objective We present for the endoscopic view of 3D rotational angiographic images in the patient who has internal carotid artery dissection. Case We performed carotid angiography with 3D rotational angiographic technique for detection of the patient who has internal carotid artery dissection. Our angiographic apparatus is Allura Xper FD20/20○R which made by Philips. The intima layer of internal carotid artery was dissected and intra luminal narrowing was detected by 3D rotational angiography. Also, we can easily measure the length and diameter of dissected internal carotid artery with this technique and 3D images. Conclusion Endoscopic view of 3D rotational angiographic images was very useful to detect for the dissection of internal carotid artery.

장기 침상 뇌병변 환자에서 침 조영술을 이용한 침 흡인의 확인

강인순

Detection of Saliva Aspiration Using Salivagram in Bedridden Patients with Brain Lesion In-Soon Kang, M.D., Jung-Gu Kwon, M.D., Sung-Uk Lee, M.D., Zee-Ihn Lee, M.D.1, Gi-Young Park, M.D., Hea-Woon Park, M.D. Department of Rehabilitation Medicine, School of Medicine, Catholic University of Daegu; 1Department of Rehabilitation Medicine, Daegu Fatima Hospital Background: Saliva aspiration can lead to substantial respiratory morbidity including unexplained lung disease or recurrent pneumonia in bedridden patients. Objective: The purpose of this study is to investigate the aspiration of saliva itself in bedridden patients with brain lesion using the response of radionuclide salivagram, and its association with patient characteristics and clinical factors. Method: Thirty two patients (21 men and 11 women) in bedridden state with brain lesion were performed the radionuclide salivagram. 99mTc sulfur colloid (1.0 mCi in a drop of saline) was instilled into patients’ tongue with supine position. The sequential images were obtained at first 5 minutes and 10 minutes interval for 1 hour, and evaluated the presence of saliva aspiration as the entrance of tracer into major airways or lung parenchyma. The characteristics of patients and the states of cooperation, drooling, tracheostomy, and method of feed were also assessed. Results: Seven out of 32 subjects exhibited positive response of saliva aspiration by radionuclide salivagram. Men, uncooperative, and anterior drooling was significantly associated with positive finding of salivagram (p<0.05). Conclusion: In bedridden patients with brain lesion, it seems that radionuclide salivagram may be one of methods for detection of the aspiration of saliva itself.

Cerebral Air Embolism after Removing Central Venous Catheter.

서소영

Cerebral air embolism is the most serious form of air embolism potentially caused by invasive procedures. An 81-year-old man abruptly developed left hemiplegia and conjugate eye deviation to the right after removing a central venous catheter in his left internal jugular vein. Brain CT demonstrated entrapped air bubbles in right frontal cortex and bilateral cavernous sinus. Brain MRI performed at the next day confirmed acute right frontal lesion relevant to clinical manifestations, which was thought to be attributed to arterial air embolism. However, serial DWIs and ADC maps showed atypical features which were not compatible with those of usual thromboembolic arterial ischemia. We discussed the pathophysiologic mechanism of neuronal injury in cerebral air embolism.

Changes in Cerebral Hemodynamics following Encephalo-duro-arterio-synangiosis (EDAS) in a ...

조광덕

Changes in Cerebral Hemodynamics following Encephalo-duro-arterio-synangiosis (EDAS) in a Unilateral Moyamoya Syndrome of the Middle Cerebral Artery with Hyperhomocystinemia and Protein C Deficiency Kwang Deog Jo, MD, PhD1, Jong Hyeog Lee, MD2, Seung Hoon You, MD3 1Department of Neurology, 3Diagnostic Radiology, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea Background: Moyamoya syndrome is the secondary intracranial arterial occlusive disease that produces basal collateral vessels. Homocystein is considered a risk factor for cardiovascular disease. Deficiencies of protein C are associated with thrombosis. We present a case of unilateral moyamoya syndrome of the middle cerebral artery (MCA) with controlateral occlusion of the proximal internal carotid artery (ICA) in a patient with hyperhomocystinemia and protein C deficiency. We obtained cerebral angiography and measured cerebral hemodynamics by acetazolamide challenged dynamic perfusion computed tomography (PCT) before and after encephalo-duro-arterio-synangiosis (EDAS). CASE: A 31-year-old man with a history of hypertension and smoking presented with transient right hemiparesis and dysarthria. Homocystein was 39.1 μmol/L (normal 5-15). Protein C antigen was 0.18 mg/dl (normal 0.18-0.29) and protein C activity was 35% (normal 70-130%). Brain MRI showed acute ischemic lesions in the borderzone between the left middle and anterior cerebral arteries. Cerebral angiography showed total occlusion of the M1 portion of the right MCA with fine basal collateral vessels, complete occlusion at the origin of the left ICA, and collateral filling of the left supraclinoid ICA from the vertebrobasilar system through the posterior communicating artery. The left anterior cerebral artery (ACA) and MCA branches were patent without stenosis. Brain PCT showed significant decrease in regional cerebral blood flow (rCBF) and delay of mean transient time (MTT) in the right MCA territory. The increase in rCBF and cerebral vascular reserve capacity were least significant in the right MCA territory after infusion of acetazolamide. The EDAS for the bilateral MCA territories was performed for revascularization. The patient was discharged 3 weeks after admission without residual weakness or other complications. Angiography one year after EDAS showed excellent collateral flow to the right MCA region and small collateral flow to the left MCA region of the parietal lobe. Brain PCT one year after EDAS showed significant increase of rCBF and improved delay of MTT in the bilateral MCA territories. However, rCBF was more decreased and MTT was more delayed in the bilateral ACA territories. The patient did not suffer further transient ischemic attacks at 12 month follow-up. Conclusion: We suggest that multiple risk factors of stroke with additional hyperhomocysteinemia and protein C deficiency may enhance intracranial and extracranial atherosclerosis. Regional cerebral blood flow was improved in the bilateral MCA territories after the operation, whereas the bilateral ACA territories were not adequately improved. Hemodynamic study using PCT can provide quantitative regional cerebral perfusion and may be used for the evaluation of outcome in patients with various cerebral artery steno-occlusive diseases.

Lipids, Apolipoproteins and Intracranial artery stenosis in acute ischemic stroke

조현지

Background and Object: The prevalence of stroke due to intracranial artery stenosis (ICAS) is common in Asian and its prognosis is poor with high recurrence rate. But the risk factors for ICAS are still unclear. So we investigated the relationship between major lipids, apolipoproteins (apo) and ICAS in acute ischemic stroke patients. Method: Clinical data were supplied on consecutive 2182 patients from stroke registry who admitted due to acute ischemic stroke between March 2005 and December 2008. Major lipid level [total cholesterol, triglyceride, low density lipoprotein cholesterol (LDL-C), high density lipoprotein cholesterol (HDL-C)] and the level of Apo B, Apo A-1 and lipoprotein A was measured. NonHDL, the ratio nonHDL-C/HDL-C, apoA1-/ApoB was calculated. ICAS and extracranial artery stenosis (ECAS) was defined as > 50% stenosis or occlusion of intracranial and extracranial cerebral arteries on MR angiography. Results: Significant factors for ICAS after χ2 test and t-test was hypertension, age, leukocyte count, Hb A1C, Apo A1, lipoprotein A and the ratio nonHDL-C/HDL-C. (P< 0.05) But after multiple logistic regression analysis, only age was the significant predictor for intracranial stenosis. (p=0.038) Comparing with patients of ICAS, Hb A1C was significantly higher in patients with ECAS. (p=0.004) Conclusions: The evidence of major lipids or apolipoproteins as risk factors for ICAS is not sufficient.

Cheiro-oral syndrome presented with bilateral perioral sensory symptoms in unilateral thalamic ...

서진영

죄송합니다. 사정상 참석이 힘들게 되어 초록 접수를 취소합니다.

Apolipoprotein B/AI Ratio is Associated with Multiple Ischemic Lesions in Patients with Large ...

Jong-Ho Park

Background and objective: History of a prior stroke significantly increases the risk for a subsequent stroke. Old asymptomatic infarction is also associated with risk factor for clinical stroke. Elevated level of apolipoprotein B (apoB)/apolipoprotein AI (apoAI) ratio is associated with the development of cardiovascular disease. Previous brain infarction (PBI) is not infrequently seen on brain MR imaging even in patients with clinically 1st ever ischemic stroke. It is not well known, however which factor is associated with the variability of extent of the PBI. We hypothesized that serum apoB/apoAI ratio could be associated with PBI. Therefore, we attempted to demonstrate the association of apoB/apoAI ratio with frequency of PBI in stroke patients. Methods: We investigated demographic features and risk factors in 331 patients with (sub)acute ischemic stroke (mean age 67.7 ± 12.6 years; 185 men) who underwent brain MRI and MRA between January 2008 and June 2009. The stroke subtypes were categorized as large artery atherosclerosis (LAA), small artery occlusion (SAO), cardioembolism (CE), and stroke of undetermined etiology (SUE). Lesions >=3 mm in diameter on T2-weighted and FLAIR images were considered to be PBI. We examined associations between PBI and apoB/apoAI quartiles by controlling traditional risk factors. Results: There were 232 (70.1%) patients with PBI. Male, hypertension, diabetes, antiplatelet therapy, and LAA subtype were higher in those with PBI (all P<0.05). Age, serum levels of HbA1c, apoB/apoAI ratio, and fibrinogen showed higher levels in patients with PBI, whilst apoAI and high density lipoprotein (HDL) levels were lower in those with PBI (all P<0.01). In LAA subtype, the quartiles of the apoB/apoAI ratio showed increased tendency as the number of PBI (i.e., ‘none’, ‘one’, ‘two’, and ‘>= three’) increased (P=0.026), while other subtypes not. After adjusting for age, male gender, hypertension, diabetes, coronary artery disease, body mass index (kg/m2), and smoking, patients with higher level of apoB/apoAI were more likely to be have multiple (³3) PBIs (P<0.05): as compared with patients with 1st quartile of apoB/apoAI, the adjusted ORs for PBI increased from 1.03 for 2nd quartile to 2.32 for 3rd quartile and as high as 3.34 for 3rd quartile. Conclusion: The apoB/apoAI ratio is independently associated with multiple PBI particularly in patients with LAA.

Does Blood Pressure Variability predict the Development of Hemorrhagic Transformation in Acute ...

고영채

Does Blood Pressure Variability predict the Development of Hemorrhagic Transformation in Acute Ischemic Stroke? Youngchai Ko, MD*; Jung Hyun Park, MD†; Mi Hwa Yang; Sang-Bae Ko, MD, PhD; Moon-Ku Han, MD, PhD; Chang Wan Oh, MD, PhD; JiSung Lee‡; Juneyoung Lee, PhD‡; Hee-Joon Bae, MD, PhD. Departments of Neurology, Neurosurgery, Stroke Center, Seoul National University Bundang Hospital *Department of Neurology, Chungbuk National University College of Medicine †Department of Neurology, Dongguk University Gyeongju Hospital ‡Department of Biostatistics, College of Medicine, Korea University Background and Purpose: High blood pressure (BP) is known to provoke hemorrhagic transformation (HT) after ischemic stroke but the effect of BP variability on HT is obscure. Methods: This study investigates patients with acute ischemic stroke hospitalized within 24 hours of onset and with no evidence of HT on initial gradient echo MRI. We analyzed systolic and diastolic BP (SBP and DBP) data obtained during the first 72 hours, using numerous BP variability measures: standard deviation (sd), maximum (max), minimum (min), difference between max and min (max-min), average squared difference between successive measurements (sv), and maximum sv (svmax). Results: Of 792 patients meeting the inclusion criteria, 70 (8.8%) developed HT. After categorizing BP variability parameters into quartiles, SBPmax, SBPmax-min, SBPsvmax, DBPsd, DBPmax, DBPmax-min, and DBPsvmax were all found to be significantly associated with HT when adjusting for clinical parameters and both initial and mean SBP. Analyses within each mean SBP quartile identified a number of parameters for which the risk of HT was higher in high variability group patients than in low variability group patients: SBPmax-min, SBPsvmax, DBPmax-min, DBPsv, and DBPsvmax. The common odds ratio (across all mean SBP quartiles) was the highest for DBPsvmax (8.48), followed by DBPmax-min (8.41), SBPmax-min (5.04), SBPsvmax (2.67), and then DBPsv (2.12). Conclusions: Our results reveal independent associations between many BP variability parameters and the development of HT during the acute stage of stroke. This suggests that the prevention of HT requires consideration of not only absolute BP levels but also of BP variability.

Effect of serum albumin on the occurence of symptomatic intracerebral hemorrhage after thrombolysis

김철호

Chulho Kim, MD, Seung-Hoon Lee, MD, PhD, Wi-Sun Ryu, MD, Beom Joon Kim, MD, Chung Jongwon, MD and Byung Woo Yoon MD, PhD Department of Neurology, Seoul National University Hospital, 28 Yongon-dong, Jongno-gu, Seoul, 110-744, Republic of Korea Backgrounds: It is reported in a experimental study using MCAO rat model that the occurence of thrombolysis-related symptomatic intracerebral hemorrhage(sICH) after reperfusion was related with synthesis of free radicals on the damaged vessels. Albumin has alledgely a protective effect on the disruption of blood brain barrier after repurfuion injury. Objective: Our aim is to identify whether albumin has a protective effect especially on the occurence of sICH after IV recombinant tissue-type plasminogen activator (rtPA) treatment Methods: A consecutive series of acute ischemic stroke patients who were treated with rtPA only within 3 hours of symptom onset in Seoul National University Hospital were included retrospectively for this analysis from November, 2002, to March, 2010. We defined sICH as any apparent hemorrhage on follow up brain CT or MRI in the brain with a clinical deterioration of 4 or more on NIHSS, or that led to death. Results: Serum albumin before rt-PA treatment showed a normal distribution. There was no statistical difference between two groups in demographic data & TOAST classification. NIHSS on admission was significantly associated with the occurence of sICH(p<0.001). There is no statistical significant between serum albumin level on admission and the occurence of sICH (p=0.071). On linear regreession analysis NIHSS on admission except serum albumin was strongly associated with the occurence of sICH after IV rtPA treatment(p=0.013). Conclusion: Albumin is not associated with the development of sICH after IV rtPA treatement. Further prospective studes are needed for the role of albumin in the occurence of sICH after thrombolysis.

Systemic Review: Predictors of symptomatic intracranial hemorrhage following acute ischemic stroke

Jihoon Kang

Background and objectives: Symptomatic intracranial hemorrhage (SICH) is occurred about 6% of patients with acute ischemic stroke (AIS) following thrombolysis. Previous evidence shows its association with high fatality and poor outcome, but with respect to what determines it, our knowledge is not enough. We have done a systemic review of all the available literatures about predictors of SICH after thrombolytic therapy. Methods: Relevant studies are gathered by electronic searches using PubMed. We selected the studies based on the following criteria: 1) The study should assess clinically important hemorrhagic transformation and cerebral hemorrhage; 2) the number of study subjects is more than 100 persons; 3) the time interval from first abnormal time to arrival in study subjects is less than 12 hours; 4) and the hemorrhagic lesion should be confirmed by the brain image. Randomized controlled studies (RCT) were excluded. Predictors of SICH were identified when they were statistically significant in multivariable analysis. Results: Nine studies met the eligibility criteria. Eight cohort studies and one observational study based on data from RCT were analyzed and total 3044 patients were enrolled. Independent risk factor of SICH were baseline stroke severity evaluated by National Institute of Health Stroke Scale (NIHSS) score, glucose level, diabetes history, lesion volume measured by Alberta Stroke Program Early Computed Tomography (ASPECT) score and one third rule of MCA territory, early ischemic Computed Tomography (CT) sign, time from onset to treatment (OTT), initial systolic blood pressure and antiplatelet medication before thrombolysis. In Intra-arterial thrombolysis, collateral flow and urokinase dose but not recanalization status was associated with SICH. They reported that age, gender, smoking history, early ischemic CT sign and OTT did not predict SICH with statistical significance in at least 2 studies. Discussion: This review shows some clinical and imaging factors may be helpful to predict SICH after thrombolysis. The necessity for the prospective study to confirm these lists is warranted.

Systemic Review: Predictors of symptomatic intracranial hemorrhage following acute ischemic stroke

Jihoon Kang

Systemic Review: Predictors of symptomatic intracranial hemorrhage following acute ischemic stroke

Jihoon Kang

Serial Duplex Findings of Proximal CCA stenosis

정주리

Serial Duplex Findings of Proximal CCA stenosis Julie Jeong, Young Jin Kim, Myoung Jea Yi, Ha Yeong Yoo, Sung Ik Lee. Inam Neuroscience Research Center, Department of Neurology, Sanbon Medical Center, Wonkwang University School of Medicine Background Magnetic resonance angiography is useful to evaluate intracranial and extracranial arteries. But there are artifacts adjacent to aortic arch and subclavian arteries including the proximal common carotid artery in MR imaging. So magnetic resonance angiography is not appropriate for proximal stenosis of carotid arteries. By comparison, carotid ultrasonography could be valuable for the proximal stenosis of carotid arteries. So CUS can show hemodynamic pattern, and complement to evaluate of arterial system with MR angiography. Method A 72-year-old man visited with a transient right arm weakness and dysarthria. Hemiparesis lasted for 3 hours with MRC motor grade IV+ and clumsy hand in the right side. The patient improved completely with no more neurologic deficit. He had a history of amaurosis fugax in the right eye 5 years ago, MRI/A and transthoracic echocardiography were normal findings at that time. On physical examination, the patient's blood pressure was 130/80mmHg, EKG was normal, blood sugar was 122mg/dl and he didn't have electolyte imbalance in laboratory work up. We perfomed the brain CT and EEG, and didn't detect abnormality. There was no abnormality in brain MRI and MRA correlated recurrent symptoms that patient complained. But CUS detected decreased flow velocity in the left CCA. We presumed stenosis lesion of the left proximal CCA, so perfomed CT angiography to evaluate aortic arch and proximal CCA that was not correctly showed in MRA by artifact. The proximal stenosis of carotid artery was confirmed with CT angiography. Conclusion CCA stenosis can cause of stroke but there are artifacts in proximal CCA part of aortic arch in MRA. CUS can be useful to evaluation atherosclerosis as well as proximal part of carotid artery by hemodynamic pattern.

An imaging-based stroke registry containing quantitative MRI data: DUIH_SRegI

김동억

Objective: Conventional stroke registries contain alphanumeric text-based information about the clinical status of stroke patients, but this format captures imaging data in very abbreviated form. There is a need for a new comprehensive stroke registry to capture both alphanumeric and image-based data. Methods: We designed a next-generation stroke registry containing quantitative MRI data, ‘DUIH_SRegI’, developed a supporting software-package, ‘Image_QNA’, and experiments to assess the feasibility and utility of the system. Results: Image_QNA enabled quantitative mapping of stroke-related MR lesions onto a standard brain template set, and storage of this extracted imaging data in a visual-database. Inter-/intra-user variability of the lesion mapping procedure was low. Clinical usefulness of an image-based registry was assessed by studying 47 consecutive patients with a first-ever lacunar infarction in the corona radiata. We showed that diffusion MR lesions overlapped in a more posterolateral brain location in the high NIH Stroke Scale (NIHSS≥4) group relative to lesions in the low NIHSS (≤3) group. We launched, in April 2009, the first prospective image-based stroke registry ‘DUIH_SRegI’ at our institution. Our first quantitative MR imaging analysis study was performed at 6 months (183 patients, 3226 MR slices with visible stroke-related lesions). Having seamless interlinkage between image-based and alphanumeric databases allowed us to show that first-ever lacunar stroke patients pre-treated with statin (n=24) had a lesser amount of leukoaraiosis on FLAIR MRI than non-treated patients (n=38). Interpretation: The addition of image based information is powerfully synergistic with existing alphanumeric stroke registries, and allows the formulation and testing of intuitive, image-based hypotheses in a manner not previously achievable.

Elevated free fatty acid concentration is associated with cardioembolic stroke subtype

서우근

Elevated free fatty acid concentration is associated with cardioembolic stroke subtype Woo-Keun Seo, Ji Hyun Kim, Kyungmi Oh, Sung-Beom Koh Department of Neurology, College of Medicine, Korea University Guro Hospital, Korea University Abstract Background and Objective Free fatty acids (FFAs), also known as non-esterified fatty acids (NEFAs) are important energy substrate. The association between FFA and cardiovascular diseases has been reported in terms of atherosclerosis, myocardial dysfunction and abnormal cardiac rhythm. Despite the theoretical association between FFA and ischemic stroke, limited reports are available for the issue. Therefore, we hypothesized that plasma FFA concentration could be associated with ischemic stroke subtype, especially cardioembolic stroke subtype. Methods The patients were recruited from hospital-based stroke registry (KUSR-G) between July 2007 and December 2009. Detailed demographic, laboratory and imaging data were collected including TOAST classification and presence of intracranial (ICAS) and extracranial atherosclerosis (ECAS). The patients were further classified into cardioembolic stroke group (CE) and non-cardioembolic stroke group (non-CE). Fasting FFA concentration was measured using colorimetric measurement methods. Results Finally 715 stroke patients were included in this study (male 62.9%, 65.83 ￠®¨u 12.65 years old). The concentration of FFA was the highest in CE group than other stroke subtypes. CE group showed significantly higher FFA concentration than non-CE groups (1194.68 ￠®¨u 806.45 for CE, 793.73 ￠®¨u 611.87 for non-CE, p < 0.001). According to the presence of atherosclerotic stenosis, the patients with ICAS showed significantly higher FFA (896.48 ￠®¨u 662.94) concentration than those without ICAS (830.18 ￠®¨u 657.58, p = 0.017). However, no significantly difference was found in terms of the presence or absence of ECAS (p = 0.139). Logistic regression analysis revealed increase in FFA concentration was significantly associated with CE subtype (OR 1.633, 95% CI 1.354 – 1.968, p <0.001) after adjustment of covariates. Decrease in TG and smoking habit was significantly associated with non-CE subtype. Among all stroke patients, 106 patients had atrial fibrillation (AF). The patient with AF showed significantly higher FFA concentration (1297.48 ￠®¨u 818.48) than those without AF (776.50 ￠®¨u 596.00, p < 0.001). The difference was also verified in subgroup with CE (1311.53 ￠®¨u 830.61 for AF positive, 894.77 ￠®¨u 663.20 for AF negative, p < 0.001). Conclusion Here, we report the significant association between fasting FFA concentration and cardioembolic stroke subtype. Atrial fibrillation is suggested as the mediating factor between FFA and cardioembolic stroke subtype.

Predictive factors of mannitol induced acute renal insufficiency

추인성

In Sung Choo, M.D., Dong Uk Kim, Hoo Won Kim, M.D., Jin Ho Kim, M.D. Seong Hwan Ahn, M.D. Department of neurology, Chosun university school of medicine , Gwang Ju, Republic of Korea Background & Objective : Mannitol is commonly used to reduce for cerebral edema. Acute renal insufficiency is one of its rare complications. The cause of mannitol induced acute renal insufficiency (ARI) is unknown, although renal function is rapidly normalized after stopping or hemodialysis. The goal of this study was to determine predicting factors of mannitol induced ARI. Methods: We retrospectively reviewed the medical records of 100 ischemic stroke patients treated with mannitol due to brain edema from January 2007 to December 2009 in Chosun university hospital. All patients received mannitol above 3 days. Maximum dose of mannitol was below 200g/day. ARI was defined as an increase in the creatinine level of > 0.5 mg/dl if the baseline value is < 2 mg/dl or an increase > 1 mg/dl if the baseline value is > 2 mg/dl. Serum osmolarity was calculated by sodium, glucose, and BUN. Results: The 14 patients in whom ARI was developed did not showed significant differences in demographics, NIHSS, past history related with stroke, and baseline renal function. Exposure to levofloxacine or furosemide, glucose level before use of mannitol, peak osmolarity during mannitol treatment were associated with ARI in univariate analysis. In logistic regression analysis, a predictive factor of mannitol induced ARI was a glucose level before use of mannitol (p=0.010). In the clinical course, patients with recovered renal function spontaneously returned to baseline after stopping mannitol were just 4 (28.6%). Conclusions: The glucose level before treatment and peak osmolarity during treatment were predicting factors for mannitol induced ARI. However, the prognosis of renal function may be not always benign.

A Case of Cerebellar Infarction with Pulmonary Arteriovenous Malformation

임정철

Background and significance: Pulmonary arteriovenous malformation(PAVM) is rare vascular anomaly, usually congenital and progressively enlarge with age. There are several case reports of ischemic stroke with PAVM. We report a case of cerebellar infarction secondary to an isolated PAVM. Case : A 31-year-old woman suddenly developed dizziness with nausea and vomiting. On the neurologic examination findings were not observed other than right side tilting. Brain magnetic resonance image(MRI) revealed multiple acute infarction of the right cerebellum and so anti-platelet medication was started. There was no stenosis or occlusion of the both vertebral arteries and basilar artery on the computed tomographic angiography(CTA). The laboratory test for evaluation of coagulopathy and autoimmune disease was all within normal range. For evaluation of cardiogenic source, transthoracic echocardiography(TTE) and transcranial Doppler(TCD) were done. TCD revealed a right to left shunt after agitated saline injection with and without valsalva maneuver. PAVM was suspected when transesophageal echocardiography(TEE) was done. So Pulmonary angiography was done and PAVM was confirmed. She underwent percutaneous catheterism with embolization of PAVM. After seven month, TCD was followed up and right to left shunt was not seen on the agitated saline injection. Conclusion : PAVM is a vascular anomaly characterized by communication between pulmonary arteries and pulmonary veins. Cerebrovascular event is known as a complication of PAVM. There are no vascular, hematologic risk factors, we should consider PAVM in all patients with cryptogenic stroke.

Safety & Effectiveness of Thrombolysis in Very Elderly Stroke Patients

김욱주

Wook-Joo Kim, Moon-Ku Hana, Myung Suk Janga, Mi Hwa Yanga, Jung Hyun Parkb, Youngchai Koc, Hee-Joon Baea Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicine Department of Neurology, Seoul National University Bundang Hospitala Department of Neurology, Dongguk University Gyeongju Hospitalb Department of Neurology, Chungbuk National University College of Medicinec Background and Purpose Thrombolysis becomes an important therapeutic option in patients with acute ischemic stroke. However, few information exist on its effectiveness in very elderly patients. So, we investigated whether there is a difference in the safety & effectiveness of thrombolysis between patients aged 80 years or old and those younger than 80 years. Methods A consecutive series of patients, who were hospitalized due to acute ischemic stroke within 12 hours from first abnormal time (FAT), were selected based on the prospective stroke registry between January 2004 and February 2009. We excluded patients who received thrombolysis before visiting our hospital. The symptomatic hemorrhagic transformation (sHT) was selected for safety outcome. With respect to effectiveness outcome, modified Rankin scale (mRS) at 3 months was chosen and dichotomized into 0 to 2 (favorable) and 3 to 6 (unfavorable). The adjusted odds ratios (ORs) of thromboysis were calculated in those ≥ 80 years and < 80 years and the heterogeneity of these ORs between two age groups were examined. Variables showing p<0.25 between patients with and without thrombolysis were selected for adjustments. Results In total, 1195 patients met our eligibility criteria. Among them, 271 patients (22.6%) were treated with thrombolysis (intravenous thrombolysis, 94; intra-arterial, 80; and combined, 97). Among 219 patients ≥80 years (18.3%), 46 received thrombolysis; and among 980 < 80 years (81.7%), 225 (23%) did. Thrombolysis modality did not differ by age group. With respect to sHT, the adjusted OR was 5.27 (95% confidence interval, 1.20 to 23.61) in those ≥80 years, and 4.52 (1.67 to 12.25) in those < 80 years. There was no heterogeneity of ORs between 2 age groups (P=0.86). Adjustments were done for initial NIH stroke scale, blood pressure, diabetes, prior antiplatelet use, prior anticoagulant use, FAT to arrival, and stroke subtype (TOAST classification). For assessing effectiveness, we further excluded 52 patients because mRS was not available. With respect to favorable mRS, the adjusted OR was 1.61 in those ≥80 years, and 1.71 in those < 80 years. There was also no heterogeneity of ORs (P=0.91). Adjustments were done for initial NIH stroke scale, prestroke mRS, blood pressure, fasting blood glucose, diabetes, atrial fibrillation, FAT to arrival, and stroke subtype. Conclusion: Thrombolysis may be safe and effective in ischemic stroke patients ≥80 years compared to those < 80 years. So we think that thrombolysis should be considered as a therapeutic option even in the very elderly stroke patients.

ASSOCIATION BETWEEN CEREBRAL ARTERY CALCIFICATION AND FUNCTIONAL OUTCOME IN PATIENTS WITH ACUTE ...

박광열

Background: Coronary artery calcification is known to be associated with subsequent cerebral and cardiovascular events. However, extra-coronary calcification has been less well studied. The aim of the present study was to investigate the association between cerebral artery calcification and short-term functional outcome in patients with acute ischemic stroke. Methods: We identified 126 consecutive patients with acute ischemic stroke who underwent CT angiography within seven days of symptom onset. Calcifications of the intracranial internal carotid artery on CT angiography were scored as follows: 0, no calcification; 1, minimal; 2, mild; 3, moderate; 4, severe. Functional outcomes were investigated at three months after admission using modified Rankin scale (<3 indicating good functional outcome). Results: The stroke patients ranged in age from 34 to 95 years (65￠®¨u12 years). The intracranial internal carotid artery (I-ICA) calcification was found in 172 arteries (68.3%). At three month, 98 patients (76%) had good functional outcome and five (4%) were dead. Multiple logistic regression analysis showed that I-ICA calcification was an independent prognosticator for survival at three months of acute ischemic stroke (odds ratio, 8.62; 95% confidence interval, 1.15 - 62.5; p < 0.05). But, independency was not significantly associated with I-ICA calcification (p = 0.82). Conclusions: I-ICA calcification is common in patients with acute ischemic stroke and is an independent predictor for short-term survival.

TCD spectral patterns observed during carotid stent interventions

김제

TCD spectral patterns observed during carotid stent interventions Jei Kim, Hee-Jung Song Department of Neurology, Chungnam National University Hospital and College of Medicine, Daejeon Background and objectives: The present study analyzed the relationship of TCD spectral patterns observed in carotid stent interventions. Methods: TCD monitoring data of 40 patients, who received successful monitoring during carotid stent intervention, was used. TCD spectral patterns of bilateral middle cerebral artery (MCA) were classified into four patterns; 1) right-left collateral flow on dye injection, 2) ballooning-related spectral change, 3) continuous spectral suppression after removal balloon, 4) microemboli signal. The relationships between spectral patterns and intervention-event, and/or diffusion weighted image (DWI) follow-up were analyzed. Results: Right-left collateral flow was observed in 49% of total patients. The presence of right-left collaterals was useful to expect ballooning-related spectral change on ipsilateral MCA (p<0.05). Most patients having right-left collaterals showed no (28%) or partial (58%) velocity changes during ballooning. However, no right-left collateral was significantly related with flattened spectra (45%) and partial velocity change (30%). In 2 patients, the spectral suppression continued after balloon removal due to filter occlusion by detached emboli. Microemboli signal was detected in 79% of included patients. Asymptomatic small high signal was detected on follow-up DWI in 12 patients (30%) of the patients. Only one patient showed symptomatic territorial infarction. Conclusion: The TCD spectral changes were useful to expect hemodynamic alterations changes during carotid interventions. The presence of right-left collateral was useful to expect balloon-related hemodynamic changes on distal circulation. Although microemboli signals frequently observed during TCD monitoring during carotid intervention, symptomatic infarction was not frequent.

Atypical presentation of stroke in patients with underlying dementic illness and severe white ...

권세윤

Background or Introduction With increasing proportion of the elderly population, the prevalence of dementia and severe white matter change also increases. Because the patients with dementia cannot notify their symptoms precisely, the recognition of stroke may be delayed and ignored. In addition, the clinical characteristics of stroke symptoms might be reported differently. We report four cases about atypical stroke presentation of the patients with underlying dementia and severe white matter change. Presentation of cases An 80-year-old patient and a 96-year-old patient both presented with a sudden onset of decreased consciousness, stuporous mentality and drowsiness. Both had been diagnosed with dementia before. None of them showed focal lateralizing neurological signs. Diffusion-weighted MRI showed multiple small acute ischemic infarctions on right corona radiata and left frontal cortex with severe white matter change, respectively in each patient. Their EEG showed no epileptiform discharge or slow activity. Their symptoms recovered over 1-2 days. A 62-year-old woman presented with a sudden onset of global aphasia. However, there was no acute ischemic lesion on diffusion-weighted MRI, but on CT perfusion, a definite decrease of perfusion (prolonged mean transit time) with MCA branch occlusion was observed. According to the history taken and the result of dementia screening questionnaire, she appeared to have unrecognized dementia before the onset of the stroke. On T2-weighted image, severe white matter change was observed. Her symptom (aphasia) recovered in 4 days. The follow-up diffusion-weighted MRI did not reveal any acute ischemic lesion and perfusion was improved on CT perfusion. A 79-year old woman with dementia presented with sudden onset of abnormal behavior and frequent fall. There was a focal ischemic lesion on the left anterior corona radiata on diffusion-weighted MRI and moderate white matter change on T2-weighted image. Her gait disturbance and abnormal behavior were slowly improved over the next month. All of the four patients had underlying dementia and showed severe white matter changes. Other causes for stroke symptoms such as metabolic illness or nonconvulsive seizure had been excluded. Conclusion In patients with white matter change and dementic illness, the clinical manifestation of stroke can be atypical. This clinico-radiological discrepancy may come from different susceptibility to ischemia in patients with underlying white matter change and dementia.

High thromboembolic risk on CHADS2 score stands for the risk of atherothrombotic stroke in ...

도영록

High thromboembolic risk on CHADS2 score stands for the risk of atherothrombotic stroke in patients with atrial fibrillation. Youngrok Do, MD1; Ju-Hun Lee, MD2; Kwang-Yeol Park, MD3; Hahn-Young Kim, MD4; Jee-Hyun Kwon, MD5; Hyung Geun Oh, MD6; Kyung Bok Lee, MD6; Kyung-Hee Cho, MD7; Sung-Il Sohn, MD7; Jong S Kim, MD, PhD1; Sun U. Kwon, MD, PhD1 Department of Neurology, Univ of Ulsan, Coll of Med, Asan Medical Ctr1, Hallym Univ, Coll of Med2, Chung-Ang Univ Medical Ctr, Chung-Ang Univ, Coll of Med3, Konkuk Univ, Sch of Med4, Univ of Ulsan, Coll of Med5, Soonchunhyang Univ, Coll of Med6, Keimyung Univ, Sch of Med, Dongsan Medical Ctr7, Republic of Korea Background The CHADS2 score has been widely applied for stratifying the risk of thromboembolism in the patients with nonvalvular atrial fibrillation (NVAF). Current guidelines recommend anticoagulant therapy in patients according to the risk. However, hypertension and diabetes in the CHADS2 score are crucial risk factors of atherosclerosis rather than cardiac embolism. Objective To elucidate the impact of atherosclerosis on the ischemic stroke patients with NVAF according to the CHADS2 score, which has never been evaluated. Method We retrospectively analyzed the clinical and radiological information of 374 patients with NVAF among who were registered in the acute cardioembolic stroke registry of 8 centers in Korea. Potential atherosclerotic stroke with NVAF (LAD stroke) was defined as cerebral infarction with definite atherosclerotic steno-occlusion of corresponding arteries of the index stroke. Stroke with isolated occlusion of the corresponding artery was not recognized as LAD. The thromboembolic risks were also categorized into low risk (score 0), moderate risk (1 or 2), and high risk (3 or more) by the CHADS2 score. Results LAD stroke was defined in 88 patients (23.5%), who were significantly older (73.1￠®¨u9.2 years old), had more hypertension (71.6%), had more history of stroke (34.1%) than non-LAD stroke (70.4￠®¨u10.0 years old, 60.8% and 25.9% respectively). However, heart failure was more common in non-LAD stroke (18.2%) than LAD (13.6%). The CHADS2 score was significantly higher in LAD stroke (2.22￠®¨u1.43) than non-LAD (1.86￠®¨u1.20, p=0.022). The high thromboembolic risk was more common (44.4%) in LAD than non-LAD (30.0%) (p=0.043) Conclusions Our study showed that high thromboembolic risk on CHADS2 score was associated more with atherothrombotic stroke than with cardiac embolism in patients with NVAF. Further studies should be performed to develop the management strategy in the high thromboembolic risk group.

Small deep subcortical infarction mimicking right MCA infarction in hyperglycemic hyperosmolar state

정산

Hyperglycemia can induce various neurologic manifestations. Mental changes from drowsy to coma are the most common, but focal or lateralizing signs such as hemiparesis, hemi-sensory change, homonymous hemianopia simulating stroke can be possible. A 72-year-old woman was admitted with her drowsiness and left hemiparesis. Neurological examination revealed left asomatognosia, left homonymous hemianopia, right sided gaze preference, sensory extinction sign, left sided hyperreflexia, and hemi hypoesthesia. Laboratory findings revealed hyperglycemia over 600mg/dl and high serum osmolarity without ketoacidosis. MRI showed only one small acute infarction on right corona radiata and no other lesions except old left PCA infarction. Her neurologic deficits were rapidly improved after correction of hyperglycemia and hyperosmolarity. We present a patient with very unusual focal cerebral infarct associated hyperosmolar hyperglycemic syndrome responding glucose control.

A Case of Carotid In-Stent Thrombosis with Fatal Outcome

이익성

A Case of Carotid In-Stent Thrombosis with Fatal Outcome Eek-sung Lee, Dong-woo Yoo, Yeong-in Kim, Jaseong Koo Department of Neurology, Seoul St. Mary Hospital, Catholic University of Korea. Background & Significance Carotid artery angioplasty and stenting (CAS) is an alternative to carotid endarterectomy in patients with extracranial internal carotid artery (ICA) stenosis. Among the acute complications of CAS, in-stent thrombosis is a rare, but potentially fatal complication. We present a case of in-stent thrombosis which resulted in fatal ischemic stroke 3 days after CAS. Case A 67-year-old male presented with right side weakness. He had a medical history of hypertension and diabetes for 10 years. He was a current smoker (100 pack years) and was taking aspirin (100 mg/day) for primary prevention of cardiovascular disease. Sudden weakness of right arm and leg developed 5 days ago. Brain MRI and MRA at a local hospital showed multiple acute ischemic lesions at border zone areas of left hemisphere and severe stenosis of left proximal ICA. Aspirin (100 mg/day) and clopidogrel (75 mg/day) were administrated and he was transferred for further management of carotid stenosis. A digital subtraction angiography at our hospital revealed more than 90% stenosis of left proximal ICA at 2 cm above the carotid bifurcation. We kept administrating aspirin and clopidogrel and performed CAS on the 19th day after the symptom onset. The stent was placed successfully without remarkable events and the left ICA was reconstructed with minimal residual stenosis. Though the patient complained mild left cervical discomfort after the procedure, there were no remarkable changes in neurological and medical status and he discharged with aspirin and clopidogrel on the 2nd day after the CAS. On the next day, he presented emergency department due to global aphasia and right side weakness which developed 3 and half hours ago. Initial NIHSS score was 18 and CT angiography showed occlusion of left proximal ICA. Emergency intra-arterial suction thrombectomy was done and the proximal ICA was recanalized successfully. After recanalization, tirofiban (total dose of 3.75 mg) was infused intra-arterially for 3 minutes. However, the patient did not recover and died from massive intracerebral hemorrhage. Comment The incidence of acute or subacute in-stent thrombosis is about 0.5~2.0%. Most of these incidents occurred due to an insufficient platelet treatment. Other possible causes are resistance to antiplatelet agents, dissection, and high degree residual stenosis. In our case, in-stent thrombosis occurred despite of successful CAS and sufficient peri-procedural dual antiplatelets therapy. We suggest that assessment for antiplatelets resistance and choice of proper antiplatelet regimen can be helpful in predicting and preventing fatal thrombotic event after CAS.

Distribution of the Stroke Warning Symptoms as Presenting Symptoms of Acute Stroke Patients in Korea

김욱주

Hee-Joon Bae, Youngchai Koa, Jung Hyun Parkb, Byeolnim Ban, Moon-Ku Han, Wook-Joo Kimc Department of Neurology, Stroke center, Seoul National University Bundang Hospital Department of Neurology, Chungbuk National University College of Medicinea Department of Neurology, Dongguk University Gyeongju Hospitalb Department of Neurology, Ulsan University Hospital, University of Ulsan College of Medicinec Background There have been many reports on the status of public knowledge about stroke symptoms in general population, but there is little information about the distribution of those symptoms in actual stroke patients in Korea. Methods Based on the prospective stroke registry, the consecutive series of patients, who were hospitalized to our stroke center due to stoke or transient ischemic attack (TIA) from 2004/01 to 2009/03 within 7 days from onset, were selected. Through reviewing the medical records by one investigator, we selected a most important presenting symptom of stroke and the presenting symptom of each patient was classified into the 5 stroke warning symptoms and the unclassified. The details of 5 symptom are as follows; 1) paralysis - sudden numbness or weakness of the face, arm, or leg, 2) speech – sudden confusion, trouble speaking or understanding speech, 3) vision – sudden trouble seeing in one or both eyes, 4) dizziness – sudden trouble walking, dizziness, loss of balance or coordination, 5) headache – sudden severe headache with no known cause. Results A total of 3027 patients were included. The mean age was 66.57±12.6 years. The median time interval form symptom onset to arrival time was 9.45 hours (interquartile range, 2.37-36.38). The frequency of each stroke symptom was as follows; 54.9% (paralysis), 27.5% (speech), 2.8% (vision), 10.5% (dizziness), 2.3% (headache) and 2.0% (unclassified). The 5 symptoms could represent the 98.0% of all the stroke or TIA patients. Speech symptom was associated with the shorter prehospital delay, whereas dizziness was related with the longer delay (p’s<0.01). TIA is the most frequent symptom in dizziness, and hemorrhagic stroke is in headache. Other symptoms were not different among stroke subtypes. Conclusion Our study shows that the 5 stroke warning symptoms represent the most of presenting symptoms of acute stroke or TIA patients in Korea.

Small Cerebral Infarction Volume Even Under Subtherapeutic Warfarin Level: Real-World Analysis ...

이진수

Small Cerebral Infarction Volume Even Under Subtherapeutic Warfarin Level: Real-World Analysis with Electronic Database of a Korean Tertiary Hospital Jin Soo Lee, MD, PhD1; Ji Man Hong, MD, PhD1; Rae Woong Park, MD, PhD2 Department of Neurology1 and Medical Informatics2, Ajou University School of Medicine, Suwon, South Korea Abstract Background: Warfarin therapy is necessary to prevent cerebral infarction (CI) if a patient has a potential source of thromboemolism. Nevertheless, CI often occurs in patients taking warfarin. An electronic database system, which includes estimated 1,000,000 patients has developed in a tertiary hospital. By using this database, risk factors of CI occurrence and characteristics of CI volume were evaluated in patients taking warfarin. Methods: The CI occurrence and responsible diseases for warfarin were determined by case ascertainment with database search and case confirmation with chart reviews (currently not completed). The duration of subtherapeutic range under INR 1.5 and the proportion of time spent within target ranges were calculated by Rosendaal’s linear interpolation method. DWI volumes were manually measured. Results: New CIs occurred in 167 of 2454 patients who had taken warfarin for at least 90 days. Patients with CI were older (60.28±11.72 vs 56.66±14.44, p<0.001) at the first warfarin prescription, had longer duration of total warfarin prescription (1350.27±1128.16 vs 1162.22±1062.95 days, p=0.035) and had longer subtherapeutic-range duration (349.13±431.40 vs 248.17±361.42 days, p=0.001) than control patients. The responsible diseases, male gender, concomitant antiplatelet prescription, and the proportion of time spent within target or subtherapeutic range were not different between groups. Age and subtherapeutic-range duration were independently associated with CI occurrence by logistic regression analysis. INR level was not correlated with CI volume (r=-0.094), which was under 10mL in 99 of 108 cases. Conclusion: Older age and longer duration of subtherapeutic INR level independently increased CI risk, and small CIs mostly occurred under warfarin prescription.

Effect of warfarin withdrawal on thrombolytic treatment in ischemic stroke patients

김영대

Effect of warfarin withdrawal on thrombolytic treatment in ischemic stroke patients Young Dae Kim, MD, Jung Hwan Lee, MD, Yo Han Jung, MD, Myoung Jin Cha, MD, Hye Yeon Choi, MD, Hyo Suk Nam, MD, Kyung-Yul Lee, MD, Ji Hoe Heo, MD, PhD Objectives: Abrupt discontinuation of warfarin may induce a rebound prothrombotic state. Thrombolytic agents may also paradoxically induce prothrombotic conditions, which involve platelet activation and thrombin generation. In this regard, a prothrombotic state may be enhanced when patients with warfarin withdrawal are subjected to thrombolytic treatment. The aim of this study was to determine whether patients with warfarin withdrawal have a different clinical outcome after thrombolytic treatment from those without warfarin use. Methods: A total of 148 consecutive patients with atrial fibrillation who were not on anticoagulation at admission and who received thrombolysis were included in this study. We compared outcomes between a warfarin withdrawal group and a no-warfarin use group. Results: Fourteen patients (9.5%) were included in the warfarin withdrawal group. Although baseline National Institute of Health Stroke Scale (NIHSS) scores, recanalization rates, and frequencies of hemorrhages were not different between the groups, the warfarin withdrawal group showed poor outcomes. Increases in the NIHSS score during the 7 days was more frequent in the warfarin withdrawal group (57.1% vs. 26.9%, p=0.029). Median percent improvement in the NIHSS score at 24 hours after thrombolysis was also lower in the warfarin withdrawal group. After adjusting for covariates, warfarin withdrawal was one of the strong predictors for poor functional outcome at 3 months (modified Rankin score ≥ 3) (odds ratio, 17.067, 95% CI 2.703-107.748). Conclusions: Discontinuation of warfarin was associated with early neurologic deterioration and poor long term outcomes after thrombolytic treatment.

Hypertensive Brainstem Encephalopathy with Acute Pontine Hemorrhage

김명국

Hypertensive Brainstem Encephalopathy with Acute Pontine Hemorrhage Meyung-Kug Kim, MD, Bong-Goo Yoo, MD, Department of Neurology, Kosin University College of Medicine Background and Significance: Hypertensive encephalopathy is defined as an acute organic brain syndrome that occurs as a result of failure of the cerebral vascular autoregulation. Hypertensive encephalopathy predominantly involves the posterior parieto-occipital lobes. Brainstem involvement without supratentorial lesions has been rarely reported. We present a case of hypertensive brainstem encephalopathy with acute pontine hemorrhage. Case: A 37-year-old man admitted due to dizziness and paresthesia on right hand and foot. His initial blood pressure was 230/140 mmHg. The neurologic examination showed bilateral gaze-evoked horizontal nystagmus. The fundoscopic examination revealed hypertensive retinopathy with multiple soft exudate and retinal hemorrhage. The serum creatine, urea nitrogen, renin and aldosterone were elevated. A brain CT showed high density in the left dorsal pons. The T2-weighted and fluid-attenuated inversion recovery images revealed diffuse hyperintense signals and swelling in the brainstem, with low signal intensity in the left dorsal pons. However, there was no signal change on diffusion-weighted images, except left dorsal pontine lesion. T2*-weighted gradient-echo image also demonstrated hypointense lesion in the left dorsal pons. Conclusion: Hypertensive brainstem encephalopathy can produce brainstem hemorrhage. Gradient-echo image may provide additional information in hypertensive brainstem encephalopathy.

Evaluation Delay of Patients with In-Hospital Ischemic Stroke

정유리

Evaluation Delay for Patients with In-Hospital Ischemic Stroke Yu-ri Jeong1, Jaseong Koo2, Jong-Moo Park1, Ohyun Kwon1, Jungju Lee1, Byung-Kun Kim1. Department of Neurology, Eulji General Hospital, Eulji University College of Medicine1 Department of Neurology, Seoul St. Mary Hospital, Catholic University of Korea2 Background: In-hospital stroke (IHS) represents 5–15% of all hospitalized acute stroke cases, and is associated with poor outcomes. Patients with IHS could potentially be assessed more rapidly and could be candidates for thrombolytic therapies. However, delays in recognition and assessment are common. Objective: We investigated the time delay from symptom recognition to neurological evaluation in patients with IHS and tried to identify the steps which related with delayed evaluation. Method:From 2005 to 2009, patients who referred to neurology department for acute treatment of ischemic stroke which occurred during admission at other departments were identified from admission registry. Times of symptom recognition, contact physician or nurse, neurologist, first brain imaging study were identified by review of medical record. Time intervals between symptom recognition and contact physician or nurse (Time Epoch 1, TE-1), between contact physician or nurse and consulting neurologist (Time Epoch 2, TE-2), between consulting neurologist and neurologic examination (Time Epoch 3, TE-3), and between symptom recognition and neurologic examination (total Time Epoch, TE-total) were calculated. To see the physician’s response to stroke symptom, the methods of consultation (direct vs. electronic consultation) were identified also. Other data abstracted from medical records were co-morbidities (heart disease, infection, renal failure, malignancy, trauma, and others) which were related with admission at other departments, invasive procedures or surgery, and type of stroke symptoms (change of consciousness, limb motor weakness, and others). Data on initial NIHSS score, risk factors for stroke, stroke subtype according to TOAST classification, use of thrombolytic treatment and modified Rankin Scale at discharge were obtained from stroke registries. Mann-Whitney U test and an analysis of variance were used for statistical analysis. Results: Among the 48 patients identified, 7 patients in whom onset time could not be identified and 2 patients in whom time of neurologic examination could not be identified were excluded. Finally 39 patients were included for analysis. Mean age was 70.2 (±11.2) years and 15 (39%) were male. Initial NIHSS score (media, IQR) was 8 (5-15) and 19 (74%) were dead or dependent at discharge. The most common stroke subtype was large artery atherosclerosis (n=16, 41%), followed by cardioembolism (n=14, 36%). Six patients (15%) received thrombolytic treatment. Fifteen patients (39%) received invasive procedure or surgery within 30 days before onset of stroke. The most common co-morbidity was infection (n=14, 36%) followed by heart disease (n=13, 33%). Symptom was recognized by a patient or care-giver in 19 (49%) patients and the mean TE-1 of them was 2.6 (±4.6) hours. The TE-2 was available in 33 patients and the mean was 16.1 (±36.0) hours. The TE-3 was available in 34 patients and the mean was 4.9 (±9.8) hours. The mean of TE-total was 23.8 (±39.2) hours. The TE-2 was significantly different according to the methods of consultation (direct vs. electronic consultation, 4.0±8.8 vs. 26.1±46.3 hours) and the person who first recognized symptom (patient or care-giver vs. physician or nurse, 2.9±5.2 vs. 27.0±46.2 hours) (p<0.05). The TE-3 and TE-total were significantly different according to the methods of consultation (TE-3, 0.2±0.2 vs. 9.1±12.1 hours; TE-total, 12.5±29.1 vs. 36.9 vs. 46.9 hours; p<0.01). Other factors investigated were not associated with difference in any Time Epochs. Conclusions In patients with IHS, the neurologic evaluation was quite delayed. The evaluation delay occurred in all steps from symptom recognition to neurologic examination. Among the steps, the most contributing step was delay between recognition of physician or nurse and neurologic consultation. Education for physicians and nurses as well as implantation of in-hospital stroke activation systems are needed to reduce the delay in evaluation.

Cerebral venous thrombosis related to the use of L-asparaginase in child with acute ...

빈창훈

Cerebral venous thrombosis related to the use of L-asparaginase in child with acute lymphoblastic leukemia Chang Hun Bin, Min Su Park, Se Jin Lee Department of Neurology, College of Medicine, Yeungnam University Background & Significance Cerebral sinovenous thrombosis in children is a rare disorder and there are numerous clinical conditions. Thromboembolic events are well-known complications of acute lymphoblastic leukemia (ALL) treatment, particularly L-asparaginase therapy. L-asparagine is non-essential amino acid on which many cells depend for normal metabolic processes. Because of interference with protein biosynthesis, asparaginase leads to acquired deficiencies of most coagulation proteins not only clotting factors but also inhibitors of the coagulation system. Despite a reduction of both pro- and anticoagulant activity, the hemostatic balance appears to be shifted towards the hypercoagulable state. Case A 10-year old boy presented with generalized tonic clonic seizure 2 times. He was diagnosed ALL 1 month ago and received induction chemotherapy with L-asparasinase for 8 days in pediatric department of our hospital. After seizure attack, his consciousness was recovered, but right side hemiplegia (MRC grade IV) was observed. Immediately brain image study was performed. MRI examination disclosed thrombosis of the superior sagittal sinus and cortical vein with secondary hemorrhagic infarction of the left frontal lobe. MR venography examination disclosed defection of superior sagittal sinus. He treated with low molecular weight heparin subcutaneously (1 mg/kg twice a day) and prophylactic oral anticonvulsant. After 1 week, his weakness was improved normally. Follow up MRI and MR venography on 14 days after onset showed partial recanalization of superior sagittal sinus and there was no additional cerebral infarction. Now, subcutaneous treatment with a low molecular weight heparin is applying since 1 month ago. Conclusion or Comment In cerebral venous thrombosis, seizures at presentation and the presence of hemorrhagic or non-hemorrhagic infarcts seemed to be predictors of poor neurological outcome. In our patient, rapid diagnosis and treatment of venous thrombosis may be lead to good prognosis. Therefore, patient who receiving L-asparaginase as part of their ALL induction therapy showed neurological deterioration, rapid brain imaging and appropriate treatment must be needed. Additionally, serial coagulation monitoring is considered because of L-asparaginase is high risk factor of hypercoagulation.

Neurological Deterioration after Emergency Carotid Angioplasty and Stenting in a Patient with ...

이세훈

Neurological Deterioration after Emergency Carotid Angioplasty and Stenting in a Patient with Acute Ischemic Stroke: Hyperperfusion or Hypoperfusion ? SeHoon Lee1, Jaseong Koo2, Jong-Moo Park1, Ohyun Kwon1, Jungju Lee1, Byung-Kun Kim1. Department of Neurology, Eulji General Hospital, Eulji University College of Medicine1 Department of Neurology, Seoul St. Mary Hospital, Catholic University of Korea2 Background & Significance: Carotid artery angioplasty and stenting (CAS) is a well established treatment for prevention of recurrent stroke in patients with extracranial internal carotid artery (ICA) stenosis. CAS can be a useful treatment option to improve cerebral perfusion in patients with fluctuating or progressive cerebral ischemia related to hemodynamic compromise with severe stenosis of ICA. However, the risk of periprocedural hemodynamic instability such as hyperperfusion or hypoperfusion can increase in acute period of cerebral ischemia. We present a patient who deteriorated after emergency CAS which was performed in 24 hours after onset of ischemic stroke. Case: A 69-year-old male visited emergency department with acutely progressive weakness of left arm and dysarthria which developed 12 hours ago. Neurological examination revealed mild gaze preference to right, left homonymous hemianopsia, mild left facial weakness with dysarthria, sensory extinction at left arm and leg, and moderate weakness of left arm (NIHSS score, 9). Diffusion MRI showed only a few small high signal intensities at right basal ganglia and periventricular white matters. MR angiography showed steno-occlusion at right proximal ICA with faint visualization of intracranial ICA and middle cerebral artery (MCA). Digital subtraction angiography revealed long segmental stenosis of more than 90% at right proximal ICA. We decided to perform emergency CAS to improve hemodynamic instability because the patient showed fluctuating neurologic deficit during evaluation. After administrating aspirin and clopidogrel, CAS was performed successfully at 20 hours after onset of symptom. Systolic BP was maintained between 170 and 200 mmHg during procedure and 150 and 160 immediately after stenting. Several minutes after stenting, the patient deteriorated rapidly to show deeply drowsy mentality with forced gaze preference to right and aggravated weakness of left arm and leg (NIHSS score, 18). Repeat angiogram showed normal arterial patency at right carotid circulation and diffusion MRI showed several new small high signal intensities at border zone areas of right hemisphere without evidence of hemorrhage. Brain MRI on the next day showed diffuse cortical swelling at right hemisphere and MR angiography showed only a little improvement in the visualization of right MCA. The results of transcranial doppler ultrasonography were not remarkable with flow velocities and pulsatility indices in normal ranges. With intensive antihypertensive treatment, the patient began to recover on the 4th day and MRI on the 15th day showed hemorrhagic infarction involving at right basal ganglia and corona radiata. Comment: Though hyperperfusion syndrome is the most likely cause of postprocedural neurologic deterioration in this patient, evaluations after CAS do not compatible with the classical findings of hyperperfusion syndrome. Hypoperfusion as well as hyperperfusion should be considered as a possible cause of neurologic deterioration after CAS.

LARGE TERRITORIAL INFARCTION ASSOCIATED WITH TUBERCULOUS MENINGITIS

신재원

Large territorial infarction associated with tuberculous meningitis. Jaewon Shin, Shin-Hye Baek, Hyung-Suk Lee, Dong-Ick Shin, Sung-Hyun Lee, Sang-Soo Lee Neurology, Chungbuk National University Hospital, Cheongju, Republic of Korea Background & Significance Tuberculous meningitis is caused by the spread of Mycobacterium tuberculosis from another site in the body. Tuberculous meningitis is associated with basal exudates, tuberculoma, hydrocephalus, and vasculitis, which determine the clinical picture and outcome. Small and medium vessels traversing the basal exudates may show vasculitis, which results in infarctions. However, only a few case reports of ischemic stroke with large-vessel occlusion have been published. This paper describes a patient with a large territorial cerebral infarction that occurred secondary to tuberculous meningitis. Case A 76-year-old man presented to our hospital with severe dysarthria and sudden right hemiparesis. The patient had no underlying disease and had been experiencing dysarthria with jaw pain and headache in the temporal area for about one month. Magnetic resonance imaging (MRI) showed an infarction in the left MCA territory, including the left temporal lobe, left periventricular white matter, and left internal capsule. Magnetic resonance angiography (MRA) revealed obstruction of the superior division of the left MCA. The day following admission, the patient demonstrated a high fever, semicomatose mental status, and a pinpoint pupil with no light reflex. The primary eye position was neutral but the oculocephalic and corneal reflexes were not elicited. The follow-up MRI revealed an increase in the extent of infarction in the left cerebral peduncle, lower portion of the basal ganglia, and internal capsule. Results of cerebrospinal fluid (CSF) analysis suggested tuberculous meningitis. After starting on anti-tuberculous medication and high doses of corticosteroids, the patient's neurological symptoms partially improved. Discussion Tuberculous meningitis creates inflammatory exudates that settle on the base of the brain as a result of gravity, and intense inflammation induces vasculitis in the adjacent vessels. Basal ganglionic infarcts are the most common, due to the involvement of perforating vessels. The internal capsule, thalamus, cerebral cortex, pons, and cerebellum are also susceptible. However, only a few reports about large-vessel occlusive stroke have been published. This case demonstrated that a large territorial stroke can also derive from tuberculous meningitis. It is difficult to determine whether a stroke is induced by tuberculous meningitis on the basis of history or neurologic examination. Because the outcome of a stroke in tuberculous meningitis can be poor, and depends on when treatment with steroid and anti-tuberculous medications is initiated, the possibility of tuberculous meningitis should be considered in situations similar to that obtaining in our case.

Posterior Reversible Encephalopathy Syndrome after Red Pack Cell Transfusion in a Patient with ...

허소영

Posterior Reversible Encephalopathy Syndrome after Red Pack Cell Transfusion in a Patient with Uterine Myoma So-Young Huh, MD, Meyung-Kuk Kim, MD, Bong-Goo Yoo, MD Departments of Neurology, Kosin University College of Medicine Background & Significance: Posterior reversible encephalopathy syndrome (PRES) is a clinical and radiological syndrome characterized by headache, potentially reversible neurological deficits and the presence of vasogenic edema in different areas of brain parenchyma. PRES has been described in various clinical settings, such as severe hypertension, eclampsia, and chemotherapy. Transfusion related PRES are rare. Among the 6 prior cases presented, 4 cases have uterine myoma. We report a patient with uterine myoma who manifested PRES after packed red blood cell transfusion confirmed by brain MRI and clinical features. Case: A 44-year-old woman was admitted for surgery of uterine myoma. She had been receiving ferrous sulfate for 5 months with anemia due to chronic bleeding from myoma. On admission, her hematocrit was at 27.5%, and her hemoglobin was at 8.9 g/dl. She received 2 packed red blood cell transfusion of 400 ml. After 5 hours of the transfusion, she had a generalized tonic-clonic seizure and prolonged confusion. Her hematocrit and hemoglobin increased 40.3 % and 13.6 g/dl, respectively. Her blood pressure was normal, and no other contributing factors for PRES were found. Right homonymous hemianopsia was observed. Brain MRI showed the bilateral occipital lobe hyperintensities on diffusion-weighted and T2-weighted images while apparent diffusion coefficient showed mild decreased values in these regions. Symptoms fully resolved within 14 days. On MRI performed 6 months later, all lesions had disappeared. Conclusion: In this case, some relation may have existed between uterine myoma and PRES, but the pathogenesis remains unclear. Although blood transfusion is a common procedure with rare neurological complications, great caution should be taken with chronic anemic patients because a rapid elevation in hemoglobin may precipitate PRES.

The Relation of Lifestyle Risk Factors and Ischemic Stroke: A Matched Case-Control Study based ...

박태환

The Relation of Lifestyle Risk Factors and Ischemic Stroke: A Matched Case-Control Study based on 2008 National Health and Nutrition Survey Tai Hwan Park, M.D.1, Jung Bin Lee, M.D.1, Sam Yeol Ha, M.D.2, Sang Won Ha, M.D.3, Hyung-Geun Oh, M.D.4, Keeho Park, M.D.5, Ph.D., Young Chul Youn, M.D.6, Min Ky Kim, M.D.1 Department of Neurology, Seoul Medical Center1; Department of Neurology, Chung-Ang University Yong-San Hospital2; Department of Neurology, Seoul Veterans Hospital3; Department of Neurology College of Medicine Soonchunhyang University, Cheonan, Korea4; Cancer Information and Education Branch, National Cancer Center5; Department of Neurology, College of Medicine, Chung-Ang University6 Background: Risk of stroke is associated with lifestyle such as alcohol consumption, exercise, smoking, and obesity, but this association has been rarely studied in stroke patients of Korea. Objective: To examine the associations of lifestyle risk factors with ischemic stroke. Methods: Multicenter-registered consecutive 545 patients aged 40-80 years with ischemic stroke who admitted between March 1, 2008 and December 31, 2008 were compared with frequency matched 1:1 controls according to age, sex, and residence (urban vs. rural) extracted from 2008 National Health and Nutrition Survey (NHNS). Age and sex-adjusted odds ratio (OR) and their 95% confidence intervals (CI) of alcohol consumption, exercise, smoking and obesity for ischemic stroke were examined. In multivariate analysis, monthly household income, education, and family arrangement were included as confounders. Results: Compared to the reference of BMI (23≤ <26), ORs (95% CI) of stroke were 1.55 (1.10-2.17), 1.36 (0.89-2.08), 1.26 (0.86-1.86), 1.29 (0.80-2.10), 1.14 (0.57-2.25), and 1.55 (0.97-2.48) for BMI <21, 21≤ <22, 22≤ <23, 26≤ <27, 27≤ <28, and 28≤, respectively. Light alcohol consumption is associated with a lower risk of stroke compared with those who drink heavily (OR 1.97, 95% CI 1.25-3.12) or do not drink at all (OR 1.65, 95% CI 1.21-2.26). Compared to current-smokers, the ORs of stroke (95% CI) were 0.57 (0.41-0.79) for those who quitted smoking and 1.10 (0.77-1.58) for never-smokers. However, exercise did not showed significant relation with stroke. In multivariate analysis, heavy or no alcohol consumption and current smoking showed consistent association with increased risk of stroke. Conclusion: Modifiable risk factors in life style such as smoking and alcohol consumption should be concerned to prevent ischemic stroke in Korean.

Infarction of the Splenium of the Corpus Callosum: Clinical implication of Magnetic Resonance ...

권석범

Infarction of the Splenium of the Corpus Callosum: Clinical implication of Magnetic Resonance Imaging Seok-Beom Kwon, Min-Keun Park, San Jung, Suk-Yun Kang, Sung-Hee Hwang Department of Neurology, Hallym University College of Medicine, Seoul, Korea Background and Objective: In many cases, brain MRI may display splenium of the corpus callosum (SCC) abnormalities unexpectedly. However, the clinical implications of this lesion are unclear and vascular lesions of the SCC are considered rare events. However, only few demonstrations of SCC infarction are available. Therefore we performed this study to describe clinical presentations, etiology classification, and clinical outcomes of patients with SCC infarction on MRI. Methods: Between 2006 and 2009, we retrospectively reviewed consecutive patients with MRI reported SCC infarction. We analyzed clinical and imaging findings, etiologic classification of stroke, and outcomes of patients with SCC infarction on MRI. Results: We found total 15 patients (Male=7; Female=8) who had SCC infarction on MRI. They were an average 60.6 years of age. Ataxia and hemiparesis were the most common clinical findings which account for 33% each other. Confusion (13%), dysarthria (20%), headache (26%), dizziness (20%), and mutism (13%) were other common clinical features. In 2 of 15 patients had nearly complete resolution, 12 improved partially, and 1 died. The most consistent SCC infarction evident from MRI were reduced T1 signal intensities, increased T2 and fluid-attenuated inversion recovery signals, and increased diffusion-weighted imaging (DWI). Infarctions of the SCC were divided to SCC in situ (n = 12) and multiple lesion (SCC infarction with other site involvement) (n = 3). Clinical findings were relatively more severe at SCC infarction with multiple involvement. The main stroke mechanism was cerebral embolism. Conclusions: Infarction of the CC may be more common than previously thought. The MRI-reported splenium infarction may have connection with altered mentality, ataxia, dizziness, hemispheric disconnection features, dysarthria and convulsive movements. Clinical courses and outcomes are comparatively good, especially in patients with isolated SCC infarctions.

Combined intravenous and intra-arterial thrombolysis based on MR angiography during intravenous ...

황양하

Combined intravenous and intra-arterial thrombolysis based on MR angiography during intravenous recombinant tissue plasminogen activator infusion – Single center experiences from acute ischemic stroke thrombolysis registry Yong-Won Kim, M.D.1, Dong-Hun Kang, M.D.2,3,Yang-Ha Hwang, M.D.1,3, Sung-Pa Park, M.D.1, Yong-Sun Kim, M.D.2,3, Chung-Kyu Suh, M.D.1,3 Department of Neurology1 and Neuroradiology2, Kyungpook National University Hospital, Daegu, Korea Daegu-Gyeongbuk Cardiocerebrovascular Center3, Daegu, Korea Background. Recanalization of target vessel with intravenous (IV) recombinant tissue plasminogen activator (rtPA) and/or intra-arterial thrombolysis (IAT) has been of prime importance on the outcome in acute ischemic stroke (AIS) patients with intracranial arterial occlusions. Objective. The aim of this study was to show the efficacy and safety of the combined IV and IA thrombolysis in AIS patients with intracranial arterial occlusions despite the use of IV rtPA and to find the effects of early recanalization before IAT in cases showing target vessel occlusion on MR angiography (MRA). Method. For more than 3 years, 86 consecutive AIS patients were enrolled for analysis. Inclusion criteria for enrollment was as follows: 1) AIS patients showing target vessel occlusion on MRA during IV rtPA infusion, and 2) patients who underwent transfemoral cerebral angiography (TFCA) for IAT. The factors affecting the good functional outcome (defined as modified Rankin scale score 0-2) were analyzed, and the characteristics between cases of early recanalization before IAT and of combined thrombolysis were also compared. Results. The mean age, male sex, and mean baseline NIHSS score were 67.7 years, 65%, and 13.7. The mean interval from the needle time of IV rtPA to the puncture time of TFCA was 102.2±56.5 minutes. The favorable functional outcome and symptomatic intracranial hemorrhage was 53.5% (46/86) and 11.6% (10/86). The persistent target vessel occlusion during TFCA was found 59 of 86 patients (68.6%). In cases of combined thrombolysis, target vessel recanalization (defined as thrombolysis in cerebral infarction (TICI) grade ≥ 2) was achieved 72.9% (43/59). The recanalization itself (spontaneous or by IAT) was the only predictive of the good outcome by multivariate analysis [odds ratio 4.64 (1.10-19.59)]. Patients with early recanalization before IAT had a more favorable outcome (74.1% vs. 44.1%) and lower baseline NIHSS score (11.4 vs. 14.7) than patients of combined thrombolysis (p=0.01 and 0.005). Conclusions. In this study, the good outcome and recanalization rate was comparable to the historical combined thrombolysis registries. In 31.4% of IV rtPA cases who had target vessel occlusion on MRA, the occluded vessels were spontaneously recanalized before IAT and the functional outcome was more favorable than the cases of persistent angiographic occlusions on TFCA. However, the recanalization itself was the most predictive of the favorable outcome irrespective of IAT.

A Case of CADASIL with Amyotrophic Lateral Sclerosis

박경필

A Case of CADASIL with Amyotrophic Lateral Sclerosis Min-Kyu Park, Jin-Won Bae, Se-Jin Oh, Jae-Wook Cho, Jae-Hyeok Lee, Dae-Seong Kim, Kyung-Pil Park Department of Neurology, Pusan National University Yangsan Hospital, Pusan National University School of Medicine, Yangsan, Korea Background & Significance: Cerebral autosomal dominant arteriopathy with subcortical infarcts and leucoencephalopathy (CADASIL) characterise a hereditary disease of small cerebral arteries in middle-aged adults. Although the clinical presentation of CADASIL varies from migraine with aura, subcortical ischaemic events, mood disturbances, apathy, and cognitive impairment, abnormalities of lower motor neuron has been rarely reported in literature. Case: A 49-year-old woman presented with acutely developed right side hand clumsiness and dysarthria. She had recently diagnosed hypertension. Her parents and two older sisters experienced stroke. She showed dysarthria, emotional liability, and mild weakness of right distal upper extremity. Neuropsychological testes revealed frontal lobe executive dysfunctions. Brain MRI showed periventricular white matter lesions and left subcortical lacunar infarcts. Genetic test revealed the presence of a heterozygous mutation in the Notch3 gene. Over several months, aggravated dysarthria, swallowing difficulty, limb muscle atrophy and fasciculation were noticed. The electromyography and nerve conduction study showed diffuse nerve degeneration and regeneration process, which is consistent with amyotrophic lateral sclerosis (ALS). Conclusion: Our case is compatible with CADASIL with Notch3 gene mutation and superimposed motor neuron disease. The possible pathogenic role for a mutation in the Notch3 gene in the pathophysiology of ALS can be suggested.

Increased expression of NADPH oxidase 1 in ischemic penumbra after experimental stroke

최동희

Increased expression of NADPH oxidase 1 in ischemic penumbra after experimental stroke Dong-Hee Choi1, Hyun Jhung Jhun2, Moon Young Kim1, Kyoung-Hee Lee1, Hahn Young Kim1, Chan Young Shin1, Seol-Heui Han1, Jongmin Lee1,3 1Center for Geriatric Neuroscience Research, Institute of Biomedical Science & Technology, Konkuk University; 2Laboratory Animal Research Center, Konkuk University; 3Department of Rehabilitation Medicine, Konkuk University Medical Center, Seoul, Korea Background: Nicotinamide adenine dinucleotide phosphate (NADPH) oxidase (NOX) has been shown to play a significant role in ischemia–reperfusion (I/R) induced brain injury through superoxide production. Most of the NOX expression in I/R injured brain is known to be gp91phox (NOX2) in microglia. However, recent data have shown that NOX is also expressed in neurons and NOX1 is involved in neuronal cell death in Parkinson’s disease animal model. Expression of NOX1 after cerebral ischemia and its role in I/R injury remains unknown. Objective: To determine the expression of NOX1 in infarct core and penumbra after experimental stroke and its role in I/R brain injury. Method: Male SD rats (8 weeks, 280~320g, n = 5~6 each group) were subjected to 90 min middle cerebral artery occlusion (MCAo) followed by reperfusion. NOX1 immunoreactivity at ischemic core and penumbra, level of superoxide generation and neuronal cell death were serially determined from 1 hr reperfusion to 2 weeks. Primary rat cortical neuron cultures were exposed to oxygen-glucose deprivation (OGD) and reoxygenation. NOX1 expression, ROS generation and cell death were evaluated. NOX inhibitors such as diphenyleneiodonium (DPI) and apocynin were used to investigate the role of NOX1 in oxidative damage and neuronal death. Results: After MCAo and reperfusion, NOX1 expression was increased in penumbra at 1hr, 6hr, 24hr, 3day, 1week and 2weeks reperfusion. Superoxide generation was increased in infarct core at 1hr, 6hr and 24hr reperfusion and in penumbra at 1hr to 2weeks reperfusion. In primary cortical neurons treated with OGD and reoxygenation, NOX1 expression was increased. ROS generation and neuronal death were reduced by DPI or apocynin. Conclusion: Our data suggest that NOX1 may be involved in oxidative stress and neuronal death in ischemic penumbra from acute to recovery phase after stroke.

A case of toxocariasis with cerebral infarction

한우호

Background & Significance : Toxocariasis is a zoonotic, helminthic infection of humans caused by the dog, or cat roundworm. That has a broad clinical spectrum, from asymptomatic to systemic illness, but cerebral infarction associated with toxocariasis is rare. Case : A 60-year-old man developed speech and gait disturbance 10 days ago. He admitted and initial neurologic examination revealed mild left hemiparesis and dysarthria. He was diagnosed hypertension and take medication for 10 years. A diffusion-weighted brain MRI revealed multiple acute infarcts in bilateral border zones, as well as randomly distributed cortices. The blood work noted an elevated eosinophil count (7300/mm3, 52.6% of whole white blood cells) and IgE (>2000uIU/ml). And there were no evidence of cardioembolic source in cardiac evaluation. He had a history of ingestion of raw liver of cattle and blood of deer, so evaluation for parasite infection, and toxocariasis antibody serological test was positive. We treatment for embolic infarction and parasite infection. His clinical symptoms were almost recovered, he was discharged. Conclusions or Commentes : Cerebral infarction associated with toxocariasis is a rare case. So, we report it. Key Words: Toxocariasis, Cerebral infarction, Hypereosinophilia

Bilateral internal carotid artery dissection mimicking metabolic encephalopathy

임수환

Bilateral internal carotid artery dissection mimicking metabolic encephalopathy Soohwan Yim, MD, Myoung Jin Cha, MD, Hyo Suk Nam, MD, Ji Hoe Heo, MD, Young-Dae Kim, MD Background Bilateral basal ganglia lesions is usually associated with metabolic encephalopathy including uremia, carbon monoxide poisoning, hypoglycemia. Brain hypoxia secondary to hypotension or global anoxia has similar neuroimaging changes. Narrowing of a dissected internal carotid artery dissection can cause embolic infarction or cerebral hypoperfusion. We present a patient with an atypical clinical presentation of spontaneous bilateral ICA dissection. Case A 27 year-old man presented to our hospital with progressive apathy and cognitive decline for 3 days. He had no prior medical history including drug use or exposure to carbon monoxide. On neurologic examination, he was abulic although he had no definite motor weakness or sensory change. Standard blood tests and cerebrospinal fluid examination showed no abnormalities. Brain image showed bilateral basal ganglia hyperintensities with additional left frontal lobe lesion on DWI. Angiographic studies revealed right proximal internal carotid artery occlusion and string-like stenosis on left proximal internal carotid artery, which suggested carotid dissection. Anticoagulation was started and the patient improved slightly. After 6 months follow-up, his symptoms made a gradual recovery and his bilateral internal carotid artery was normalized. Conclusion. We report a case of spontaneous bilateral internal carotid artery dissection presenting atypical clinical presentation with bilateral basal ganglia lesion. This case illustrates the internal carotid artery dissection and its hemodynamic consequences.

Cardiac Parasymphathetic Function in Lateral Medullary Syndrome

홍지만

Cardiac Parasymphathetic Function in Lateral Medullary Syndrome Ji Man Hong, Jin Soo Lee, Dong Hoon Shin Dept. of Neurology, Ajou University School of Medicine, Korea Background: Few studies have investigated parasympathetic dysfunction in patients with lateral medullary syndrome (LMS). The aim of this study was to investigate cardiac parasympathetic function in patients with LMS. Methods: We included 12 patients with LMS who had ipsilateral Horner’s syndrome. Patients were excluded if they had diabetes, cardiac disease, or previous stroke. Patients took parasympathetic function tests including beat-to-beat heart rate variation during rest and deep breathing, 30:15 heart rate ratio with standing, and valsalva ratio. Sympathetic function tests were also performed including blood pressure during active standing, and blood pressure in response to sustained hand grip. We used the composite autonomic score (CAS) method with a total of 10 points. Parasympathic dysfunction was designated by ≥3 points in the parasympathetic subscores and sympatheric dysfunction by ≥2 points in the sympathetic subscores. Lesion locations were compared between patients with and without parasympathetic dysfunction. Results: Mean age was 48.7±7.8 years (range of 34-58 years). Seven patients had parasympathetic dysfunction, whereas as only 3 had cardiac autonomic dysfunction (≥4 points of CAS), and none had sympathetic dysfunction. Patients with parasympathetic dysfunction more frequently had lesion to the ventral part of the right medulla, whereas those without it more frequently had lesion on dorso-lateral part and of the left medulla. Conclusions: Parasympathetic dysfunction is common in patients with LMS, especially if lesion is located in ventral part of the right medulla. It may be caused by involvement of the nucleus ambiguous which is the efferent center of heart rate control.

Influence of Stroke Location on Galantamine Treatment in Chronic Poststroke Aphasia

홍지만

Influence of Stroke Location on Galantamine Treatment in Chronic Poststroke Aphasia Ji Man Hong, Dong Hoon Shin, and Jin Soo Lee Dept. of Neurology, Ajou University School of Medicine, Korea email: dacda@hanmail.net Background: We investigated whether the infarct location has influence on the effect of galantamine in chronic poststroke aphasia. Methods: We prospectively recruited 21 patients who were younger than 75 years with chronic aphasia (≥1 year since onset) due to left hemisphere stroke. Language testing was performed at week 0 and 16. Initial galantamine dose was 8mg/d for 4 weeks, and 16mg/d for the following 12 weeks. Efficacy was evaluated by the sum of 4 domains (spontaneous speech, comprehension, repetition, and naming) from baseline to endpoint on Aphasia quotient (AQ) of the Western Aphasia Battery. Patients were considered as ‘responding’ if AQ increase was ≥20 points. Results: Four out of the 21 patients were excluded due to intolerance to galantamine. Mean age was 57.7 years (33 to 72), and 7 patients were female. Two of the 17 patients were ambidextrous handed. Mean duration of aphasia was 2.4±1.4 years. A total of AQ score increased from 47.3 to 56.1%ile (p=0.036) after treatment. Spontaneous speech (50.9 to 65.4%ile, p=0.045) and naming (49.0 to 57.9%ile, p=0.034) domains were significantly improved, while comprehension (51.7 to 57.2%ile, p=0.103) and repetition (37.7 to 43.7%ile, p=0.156) domains were not. The responders more frequently had subcortical infarction rather than cortical one, although infarction volumes were not significantly different (61.2 vs. 104.1cc, p=0.244). Conclusions: Administration of galantamine had an effect on chronic poststroke aphasia, especially when the lesion was subcortical.

Prediction on Hemorrhagic Transformation of Immediate CT after Cerebral Angiography in Acute ...

홍지만

Prediction on Hemorrhagic Transformation of Immediate CT after Cerebral Angiography in Acute Ischemic Stroke Ji Man Hong, Skye Park, Dong Hoon Shin, Jin Soo Lee Dept. of Neurology, Ajou University School of Medicine, Korea email: dacda@hanmail.net Background: Hemorrhagic transformation (HT) is a devastating complication in the patients with acute ischemic stroke, especially in those after thrombolytic treatment. The aim of this study was to recognize the clinical relation of immediate non-contrast CT after 4-vessel angiography and HT in acute ischemic stroke. Methods: From March 2008 to Jun 2009, 58 patients who was undertaken immediate non-contrast CT after intra-arterial thrombolysis were prospectively investigated. Anatomical locations were evaluated as “within the ischemic area” and “outside the ischemic area”, and high density of the lesion was classified into 3 groups: faint (41-70 hounsfield units, HU), moderate 71-100 HU, and dense ≥101 HU in the setting of immediate non-contrast CT after angiography. Non-contrast CT scan was also undertaken after 3 days of symptom onset. According to European Cooperative American Stroke Study (ECASS) classification, hemorrhagic transformations were radiologically grouped: hemorrhagic infarction (HI)-1and -2, parenchymal hemorrhage (PH)-1, and PH-2 (symptomatic hemorrhage) on 3-day non-contrast CT. According to the thrombolysis in cerebral infarction (TICI) method, we evaluated angiographical recanalization status (≥ TICI grade 2). Results: Mean age and proportion of female in the patients was 65.2±12.6 years and 41.4%. Among enrolled 58 patients, fifty-four patients were the middle cerebral arterial (MCA) occlusive disease. Immediate non-contrast CT after 4-vessel angiography showed a high density lesion in 43 patients (74.1%), which was shown in 31 patients as “within the ischemic area” and in 12 patients as “outside the ischemic area”. There were 43 patients with high density: 19 faint, 10 moderate, and 14 dense densities. All types of Radiological hemorrhage were occurred in 38 patients, but 7 had symptomatic HT. Recanalization rate was 67.2%, but there was no significance difference in the proportion between PH-2 group and other HT groups (62.5 vs. 68.0%, p=0.454). High density was mainly located in within the ischemic area (72.1%). There was no symptomatic HT in patients with faint density, whereas 38.5% of symptomatic HT in those with dense density (p=0.022). Density on immediate non-contrast CT was a significant determinant to predict all types of radiological HT and symptomatic HT. Conclusions: Immediate non-contrast CT after angiography might show a significant predictive value for radiological HT, especially symptomatic HT as well. Dense extravasation within ischemic area has a tendency to symptomatic HT after IA-thrombolytic treatment.

Initial Focal Neurological Deficits and Vascular Cognitive Impairments at 3 Months after ...

조혜진

Initial Focal Neurological Deficits and Vascular Cognitive Impairments at 3 Months after Ischemic Stroke Hye-Jin, Cho1, Mi-Sun Oh1, Kyung-Ho Yu1, Byung-Chul Lee1, San Jung1, Ju-Hun Lee1, Soo-Jin Cho1, Hahn-young Kim2, Dong-Eog Kim3, Jae-Kwan Cha4, Seung-Hoon Lee5, Sun-Uck Kwon6, Jong-Moo Park7, Soo-Joo Lee8, Yong-Jae Kim9, Oeun-Kyu Kim10, Hee Jun Bae11, Ki-Hyun Cho12, Yeonwook Kang13, For Korean-Vascular Cognitive Impairment Harmonization Standards Study Group 1Department of Neurology, Hallym University College of Medicine 2Department of Neurology, Konkuk University Hospital 3Department of Neurology, Dongguk University international Hospital 4Department of Neurology, Dong-A University Hospital 5Department of Neurology, Seoul National University Hospital 6Department of Neurology, Ulsan University/Asan Medical Center 7Department of Neurology, Eulji University /Nowon Eulji Hospital 8Department of Neurology, Eulji University /Daejeon Eulji Hospital 9Department of Neurology, Ewha Woman University/Mokdong Hospital 10Department of Neurology, inJe University/Busan Paik Hospital 11Department of Neurology, Stroke Center, Seoul National University Bundang Hospital 12Department of Neurology, Chonnam University Hospital 13Department of Psychology, Hallym University Background Initial neurological severity has been well known clinical determinant of cognitive impairment in post-stroke survivals. However, debates about the role of focal neurological deficits on cognitive impairments, such as dysphasia, extremities motor weakness or facial palsy, are increasingly prominent in patients with post-stroke dementia. Objective We tried to examine the relations of initial neurological deficits evaluated with the subscale system of NIH Stroke Scales (NIHSS) and cognitive impairment in patients with ischemic stroke. Methods We enrolled prospectively 353 subjects who were randomly selected among the consecutive patients admitted to 13 hospitals with the ischemic stroke within 7 days after onset. The cognitive status was evaluated using Korean-Vascular Cognitive impairment Harmonization Standard (K-VCIHS) Protocol at 3 months after stroke onset and the initial focal neurological deficits were measured by NIHSS scores on admission. Results Of 353 patients, the prevalence of VCI at 3 months after stroke was 68.9% (N=226). Univariate analysis found that VCI was associated with increased age, low education, hypertension, diabetes, stroke subtypes, and total scores of NIHSS at admission. Among the NIHSS subscales, the correlates of VCI were only the visual field (CI 1.03-3.28, P= 0.038), facial palsy (CI 1.15-2.40, P=0.007), left arm weakness (CI 1.02-1.73, P=0.037), ataxia (CI 0.37-0.84, P=0.006), and dysarthria (CI 1.00-2.24, P=0.048) in multivariable logistic regression analyses adjusted by age, sex, education level, and risk factors. Conclusions Total scores of NIHSS on admission which represent the initial neurological severity was expectedly associated with cognitive impairments, but not all of the focal neurological deficits in NIHSS subscales such as sensory change, level of consciousness, best gaze, limb weakness (except left arm weakness), aphasia, and extinction.

Cross-sectional imaging with M-mode: A New Technique for Flow-mediated Vasodilation

신동훈

Cross-sectional imaging with M-mode: A New Technique for Flow-mediated Vasodilation Dong Hoon Shin, Ji Man Hong, Jin Soo Lee Dept. of Neurology, Ajou University School of Medicine, Korea email: dacda@hanmail.net Background: The temporal resolution of M-mode is superior to that of B-mode, especially in measuring the border with regular motion (eq. pulsating vessels or rhythmic heart). The changes in vasodilation are subtle and minimal in healthy status, and they are even smaller in disease status. Therefore, the aim of this study was to evaluate cross-sectional imaging with M-mode compared to longitudinal plane imaging for measurement of flow-mediated diltation (FMD). Methods: Thirty healthy volunteers without cardiovascular risk factors (18 men and 12 women; ranged ages of 23 and 71 years) underwent repeated brachial artery diameter measurements. Following baseline diameter recordings we assessed endothelium-dependent FMD by inflating a blood pressure cuff on the forearm. FMD measurements were performed by using both longitudinal and cross-sectional imaging with M-mode in the right brachial artery for 90 seconds. Results: Mean age was 48.3￠®¨u15.2 years (range of 23-71 years). As compared to longitudinal imaging, baseline vessel diameter (4.25￠®¨u0.67 vs. 4.03￠®¨u0.49 mm; p=0.016), maximum vessel diameter 4.65￠®¨u0.71 vs. 4.36￠®¨u0.54 mm; p=0.003), and FMD changes (9.43￠®¨u2.63 vs. 8.26￠®¨u1.85 %; p=0.012) were significant larger in cross-sectional imaging with M-mode. However, the achievement time for the maximum diameter was not significantly different in those methods (48.7￠®¨u9.0 vs. 49.3￠®¨u6.4 s, p=0.645) Conclusions: Cross-sectional imaging with M-mode showed bigger changes in diameter compared to longitudinal imaging. It can be caused by detecting small changes in the cross-sectional imaging as well as higher temporal resolution to discriminate pulsating cycle of the vessel.

Is Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) applicable for ...

이지현

Is Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) applicable for screening post-stroke dementia? Ji-Hyun Lee1, Mi-Sun Oh1, Kyung-Ho Yu1, Byung-Chul Lee1, San Jung1, Ju-Hun Lee1, Soo-Jin Cho1, Hahn-young Kim2, Dong-Eog Kim3, Jae-Kwan Cha4, Seung-Hoon Lee5, Sun-Uck Kwon6, Jong-Moo Park7, Soo-Joo Lee8, Yong-Jae Kim9, Oeun-Kyu Kim10, Hee Jun Bae11, Ki-Hyun Cho12, Yeonwook Kang13, For Korean-Vascular Cognitive Impairment Harmonization Standards Study Group 1Department of Neurology, Hallym University College of Medicine 2Department of Neurology, Konkuk University Hospital 3Department of Neurology, Dongguk University international Hospital 4Department of Neurology, Dong-A University Hospital 5Department of Neurology, Seoul National University Hospital 6Department of Neurology, Ulsan University/Asan Medical Center 7Department of Neurology, Eulji University /Nowon Eulji Hospital 8Department of Neurology, Eulji University /Daejeon Eulji Hospital 9Department of Neurology, Ewha Woman University/Mokdong Hospital 10Department of Neurology, inJe University/Busan Paik Hospital 11Department of Neurology, Stroke Center, Seoul National University Bundang Hospital 12Department of Neurology, Chonnam University Hospital 13Department of Psychology, Hallym University Background Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) has been widely used and approved as a reliable and validated screening tool for dementia, especially for degenerative type dementia, such as Alzheimer’s disease. However, considering it is sensitive, but not specific for Alzheimer’s disease, it might be inappropriate to predict post-stroke dementia (PSD). Objective Therefore, we aimed to investigate the usefulness and applicability of IQCODE as a screening tool to delineate PSD at 3 months after stroke onset. Methods We selected 127 subjects with normal cognitions and 55 with PSD from total 353 patients in multicenter, prospective stroke cohort who had acute ischemic stroke within 7 days after the onset from 13 hospitals. The cognitive status was evaluated with IQCODE as a screening tool and 60 minutes Korean-Vascular Cognitive Impairment Harmonization Standards (K-VCIHS) neuropsychological protocol as a diagnostic standard of PSD at 3 months after stroke onset. PSD was defined with the operational criteria based on the results of K-VCIHS and instrumental-Activity of Daily Living according to DSM-IV criteria. Results The PSD patients were older (61.26±14.09 vs. 68.7±9.7, p<0.0001), had lower education (35.4%vs. 56.4%, p<0.009), and more frequent prior stroke (13.4% vs. 30.9%, p<0.005) than the normal cognition group. The neurological deficit on admission, which was evaluated with NIHSS scores, was more severe in the PSD group (3.43 vs. 6.84, p<0.0001). Concordance between the results from K-VCIHS neuropsychological protocols and IQCODE at 3 months after stroke onset to define PSD was 45.3% (Kappa value=0.471, p<0.001), which proposed IQCODE might not be useful to predict PSD as a screening test. Moreover, when applying the cut-off point of IQCODE ≥3.6, which was designed for Alzheimer’s disease, receive operating curves of IQCODE showed sensitivity of 45%, specificity of 96%, and AUROC of 0.784. Conclusions We found IQCODE might not be appropriate as a screening tool and the different optimal cut-off point of IQCODE for PSD would be needed. Further prospective cohort study based on the stroke-clinic population should be performed to set the new cut-off point of IQCODE for clarifying PSD.

A case of infective endocarditis combined with moyamoya disease and hyperthyroidism

한임태

A case of infective endocarditis combined with moyamoya disease and hyperthyroidism Im-Tae Han, Chang-Gi Hong, Chang-Seok Song, Yoon-Jae Choi, Il-Gon Kim, So-Hyun Kim, Joung-Ho Rha Department of Neurology, Inha University hospital Background & Significance: Infective endocarditis is an uncommon source of cardioembolic stroke. Moyamoya disease is also another rare cause of stroke. Co-incidence of these two unusual conditions has not been reported yet. Case: A 45-year-old woman admitted for speech disturbance. One year prior to the admission, she experienced weight loss, palpitation, hand tremor and intolerance to heat. Hyperthyroidism was diagnosed and was well-controlled. Atrial fibrillation did not exist. On neurologic examinations, left facial palsy and dysarthria were observed. Brain MR images showed multi-focal acute infarctions in both frontal areas. Also, brain angiography revealed severe steno-occlusion of bilateral proximal anterior and middle cerebral arteries with abundant net-like collateral vessels, suggesting moyamoya disease. Two days after admission, fever and aphasia newly developed with aggravation of previous symptoms. The follow up MR was taken and the increased numbers of focal high signal intensity lesions were detected on the Diffusion weighted image. On trans-esophageal echocardiography, vegetations were detected and infective endocarditis was diagnosed. Splenic infarction was also found on abdomen-pelvis CT. Her thyroid function on admission was euthyroidic. Her symptoms were gradually improved after antibiotic treatment, and she discharged without major sequelae. Conclusion or Comment: The authors report a patient with moyamoya disease and controlled hyperthyroidism who developed infective endocarditis. This is a rare stroke event caused by co-morbidity of unusual stroke etiology.

Intracranial hemorrhage due to hyperperfusion syndrome after carotid artery stenting

노현두

Intracranial hemorrhage due to hyperperfusion syndrome after carotid artery stenting Hyun du Noh, Se Jin Lee Department of Neurology, Yeungnam University of College of Medicine Background & Significance Cerebral hyperperfusion syndrome (CHS), characterized clinically by ipsilateral headache, hypertension, seizures, and focal neurological deficits, is a rare complication of carotid revascularization. However, if not treated properly, CHS can result in severe brain edema, intracerebral or subarachnoid hemorrhage, and death. We experienced a case of intracranial hemorrhage after carotid artery stenting and suggest CHS may be the cause of intracranial hemorrhage. Case A 65 year-old man presented with left eye visual blurring which resolved within 10 seconds. 6 months ago, he developed dysarthria and right hand tingling sensation then brain MRI, MRA showed left cerebral multiple small infarction and left proximal ICA severe stenosis. He had a history of hypertension, hyperlipidemia, asthma and during 6 months, continuous treatment of antiplatelet and statin agent. Recent brain MRI, MRA showed no acute infarction and persistent left proximal ICA stenosis. Carotid artery stenting was carried out 1 month after presentation under local anaesthetic. Angiography showed a 50% stenosis of the left proximal ICA (NASCET method). Filter wire was deployed beyond the stenosis and then sudden onset aphasia was developed. Subsequent angiography showed left MCA (M2 segment) occlusion and mechanical, intra-arterial thrombolysis (urokinase, tPA) is done. Follow up angiography showed recanalization of M2 segment, but residual filling defect in M4 branches. Aphasia was immediately improvement, but developed left side headache. Follow up brain MRI showed multiple small cortical infarction and no intracerebral hemorrhage. We transfered to the stroke unit and used oral clopidogrel and maintenance IV heparin. His systolic blood pressure varied between 100 and 130 mmHg, but continuous complain of headache. On the third day, he was defecated and 2 minutes later, sudden onset right hemiparesis and dysarthria. We performed brain CT, intracerebral and subarachnoidal hemorrhage on the left hemisphere. Conclusions CHS is a rare but potentially dangerous complication post-carotid stenting and a major cause of death. It is thought to result from loss of autoregulation and loss of vasoconstriction of the chronically dilated distal vessels when the carotid stenosis is opened and can lead to cerebral edema or hemorrhage. In our case, we suggest that CHS may be the cause of intracranial hemorrhage and IV heparin triggered it. Therefore, patients with headache after angioplasty should be recognized early and they deserve intensive study for other features of cerebral hyperperfusion injury and prompt early management Key words Hyperperfusion syndrome, Carotid stenting

No adverse effect of Antithrombotic therapy on long term mortality in ischemic stroke with ...

오미선

No adverse effect of Antithrombotic therapy on long term mortality in ischemic stroke with incidental unruptured small intracranial aneurysm Mi Sun Oh; Sun-Hye Jung;Woo Joo Choi; Yeo Jin Kim;Kyung-Ho Yu;Byung-Chul Lee Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine Background; Incidental detection of unruptured intracranial aneurysms has increased in patients with acute ischemic stroke due to wide availability of noninvasive intracranial vascular imaging, such as CTA or MRA. However, there are few data about the safety of antithrombotic medication in the patients with both acute ischemic stroke and incidental unruptured small intracranial aneurysms. Objective; The aim of this study were to investigate the long term mortality in acute ischemic stroke patients with incidentally found unruptured small intracranial aneurysms and to examine whether antithrombotic medication use is associated with long term mortality of those. Method; A total of 965 patients with acute ischemic stroke admitted to Hallym stroke center from May 2003 to May 2005 were enrolled in the study. We reviewed demographics, risk factors, stroke subtypes, antithrombotic agent use, and death. Vital information was obtained on death data sources from Korean National Statics office. We included small aneurysms with diameters ranging from <2mm to 10 mm. The mean follow-up was 27.8 months (range 3 to 49 months). We determined a cumulative mortality rate by Kaplan-Meier analysis and compared the mortality between patients with incidental unruptured intracranial aneurysms and those without by Cox proportional hazard model. Results; Sixty-five unruptured intracranial aneurysms were identified for 56 (5.8 %) of 965 patients with acute ischemic stroke on MRA or CTA. The prevalence of unruptured intracranial aneurysms is higher in women than men (P=0.004). However, there was no significant difference in the age and stroke risk factors, such as current smoking and hypertension between patients with incidental unruptured intracranial aneurysms and those without. The most common location of unruptured intracranial aneurysms was the carvenous segment internal carotid artery (37%). The median diameter of 56 unruptured intracranial aneurysms was 3.5mm. Four patients had unruptured intracranial aneurysms larger than 7mm. Of 56 patients, 8 patients underwent surgical or interventional treatments. Twelve (21.4%) died during follow-up periods in patients with incidental unruptured small intracranial aneurysms. They were all taking antithrombotic agents until death, and there was no case with the aneurysmal rupture or subarachnoid hemorrhage as the cause of death. The cumulative death rate was 14%, 22%, and 23% at years 1, 3, 5 respectively in patients with incidental unruptured intracranial aneurysms, whereas 14.2 %, 23.1 %, 26.7 % at years 1, 3, 5 respectively in those without. Unruptured intracranial aneurysm was not the significant independent predictor of death in multivariate analysis of Cox proportional hazard model adjusted for plausible potential confounding factors, such as age, gender, current smoking, and hypertension. Conclusions; The long term mortality of incidental unruptured intracranial aneurysms in patients with acute ischemic stroke was not different from that in those without. Antithrombotic medication use did not increase long term mortality of patients with acute ischemic stroke and incidentally found unruptured intracranial aneurysms.

Acute gouty arthritis attack after tissue plasminogen activator Therapy

허소영

Acute Gouty arthritis Attack after Tissue Plasminogen Activator Therapy in Stroke So-Young Huh, Bong-goo Yoo, Meyung-kug Kim Department of Neurology, Kosin University College of Medicine, Busan Korea Background & Significance: Tissue plasminogen activator has been only approved for acute ischemic stroke. The side effect of tissue plasminogen activator (t-PA) has been reported intracranial hemorrhage, internal organ bleeding, allergic reactions, orolingual angioedema and cholesterol embolization. However, the relationship of arthritis and t-PA has not yet been well known. We report a case of a patient with acute gout arthritis attack after t-PA therapy in acute stroke. Case: A 78-year-old woman with hypertension, diabetes and hyperlipidemia, presented 1.5 hours after developing dysarthria and weakness in her right arm and leg. NIHSS was 5 and clinical diagnosis was left MCA infarction. The patient was subsequently treated with intravenous t-PA. Immediately, she improved neurologic symptoms (NIHSS 0). After 2days, she complained of the new onset feet pain that was the first time in her life. The physical examination showed redness, swelling and tenderness on the both 1st metatasophalageal(MTP) joint. Although the serum uric acid was normal level, x-rays shows multiple small tophi in right 1st MTP joint. Rheumatologist diagnosed of acute arthritis attack underlying hidden chronic tophaceous gout. After hydration and administration of oral colchicines, the patient’s feet pain subsided. Conclusions or comments: It is unknown the direct relationship between intravenous t-PA and acute gout arthritis attack. But plasmin is generated cleavage of plasminogen by the t-PA that has recently been reported to be able to induce expression of inflammatory cytokines and activation of certain enzyme cascades in joints. This is a case of acute gouty arthritis attack after administration of intravenous t-PA in a patient with underlying hidden tophaceous gout. We propose that the arthritis was activated a result of t-PA, but whether from direct effect of t-PA in joint or from acute stroke stress triggering arthritis is unclear.

Extracardiac features detected during cardiac evaluation with 64 row computed tomography in ...

유준상

Extracardiac features detected during cardiac evaluation with 64 row computed tomography in acute ischemic stroke patients Joon-Sang Yoo, MD, Jae Hoon Yang, MD, Myoung Jin Cha, MD, Young Dae Kim, MD, Hyo Suk Nam, MD, Ji Hoe Heo, MD, PhD Department of Neurology, Yonsei University College of Medicine, Seoul, Korea. Background Multidetector computed tomography (MDCT) of the heart is increasingly used to detect and evaluate coronary artery atherosclerosis. Most of the patients with ischemic stroke are aged person. They could have other diseases as well as ischemic stroke. The heart CT may be helpful for detecting diseases outside of the heart, occurring in the chest cavity and adjacent structures, because the entire chest can be visualized during heart CT evaluation. Methods Heart CT was considered in patients who had at least one of followings: 1) presence of atherosclerosis in the cerebral or peripheral artery, 2) old age (men>45 years, women>55 years), and 3) presence of two or more risk factors for coronary artery occlusive disease (CAOD). Patients with known CAOD were excluded. Between January 2006 and Jun 2009, 957 consecutive patients were undertaken heart CT. We investigated abnormal findings outside of the heart in them. Results Of 957 patients, 338 patients (35.3%) had one or more abnormal extracardiac findings. Pulmonary abnormalities were found in 314 patients, thyroid problems in 12 patients, diseases of the liver in 13, and mediastinal abnormalities in 6 patients. According to specific disease, 9 patients were highly suggestive of malignancy. Of them, 6 were newly detected and eventually 2 patients underwent operation. There were 11 patients with lesions suggesting pulmonary tuberculosis, pneumonia for 14 patients, other infections for 17 patients. Chronic obstructive pulmonary disease was detected in 57 patients. Pulmonary edema and pleural effusion were found in 14 and 19 patients, respectively. There were 2 patients with pulmonary thromboembolism. Conclusions Extracardiac abnormalities were frequently found during Heart CT evaluations. These findings suggest that heart CT can provide additional benefit for detecting extracardiac diseases, particularly involving the lung and mediastinum.

Medial Longitudinal Fasciculus (MLF) Syndrome with Facial Palsy : 7 and 1/2 Syndrome ?

박상원

Medial Longitudinal Fasciculus (MLF) Syndrome with Facial Palsy : 7 and 1/2 Syndrome ? Sang-Won Park, M.D. Department of Neurology, Daegu Fatima Hospital Background & Significance : Vascular disorders of the brainstem manifest characteristic neurologic symptoms according to their localization. The medial longitudinal fasciculus (MLF) lies in the paramedian portion of the upper brainstem tegmentum, and the lesion in this fasciculus shows specific abnormality of the eye movement pattern which is known as the MLF syndrome. Although the MLF syndrome was reported frequently to be accompanied by varieties of other neurologic deficits according to the lesion extending into the adjacent structures in the brainstem, the combination of MLF syndrome and peripheral facial palsy has attracted less attention of neurologists. We experienced a case of MLF syndrome with facial palsy confirmed with diffusion-weighted MRI (DWI). Case : A 67-year-old man with hypertension was admitted for acute horizontal diplopia. Neurological examination was normal except for ocular and facial motor functions. Ocular examination revealed a left internuclear opthalmoplegia (INO) with incomplete adduction and normal vergence. Left peripheral-type VII cranial nerve palsy was also seen. DWI showed a small deep infarct on left dorsomedial portion of pontine tegmentum. Ocular symptoms resolved within 1 month but VII cranial nerve palsy still present after 2 months. Conclusions or Comments : We described a case with INO and facial nerve palsy as an acute manifestation of an isolated circumscribed pontine lesion demonstrated with DWI. The main interest of our report is to highlight the co-occurrence of both MLF syndrome and VII cranial nerve palsy without involvement of the abducens nucleus.

Facial myorhythmia after subdural hemorrhage

권용욱

Facial myorhythmia after subdural hemorrhage Department of Neurology, National Medical Center Yong-Uk Kwon, M.D., Hye-Young park, M.D., Kang-Sun Kim, M.D, Jong-Yun Lee, M.D., Im-Seok Koh, M.D., Phil-Za Cho, M.D. Myorhythmia is characterized by regular and rhythmic 2 to 3 Hz muscle contractions and usually involves isolated limbs or appears in combination with other body regions. Hodgkin's lymphoma, Whipple’s disease, Hashimoto’s encephalopathy, brainstem and cerebellar diseases are conditions associated with this movement disorder. We report a case of facial myorhythmia after traumatic subdural hemorrhage(SDH). A 58-year-old man was referred to our department as involuntary facial movement. He was hospitalized with traumatic SDH. From 5days after burr-hole trephination, he had the gradual onset of involuntary facial movement. This movement was involuntary, rhythmic and repetitive. The brain CT and MRI showed subdural hematomas in the right fronto-temporo-parietal lesions. Thyroid function test, renal function and electrolytes were normal. His facial myorhythmia completely improved with carbamazepin and clonazepam. Two months later after stopping medications involuntary movements in the left arm and face were recurred. After the medication was restarted, symptoms were improved. Clinico-pathologic studies demonstrate frequent cerebellum and substantia nigra involvement and thus the dopaminergic dysfunction is considered as the cause in myorhythmia. But it is unknown what the exact cause is. SDH may be one of the causes in myorhythmia.

Association between vertical extension of the lesion and progressive motor deficits in patients ...

정필욱

Association between vertical extension of the lesion and progressive motor deficits in patients with acute lacunar infarction PW Chung, DK Jin, YB Kim, HS Moon, BC Suh Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan university school of medicine Background: Patients with acute lacunar infarction in the lenticulostriate artery (LSA) territory often show neurologic progression and have a poor functional outcome. Objective: The purpose of this study is to investigate the lesion patterns associated with neurologic progression. Methods: Patients with acute lacunar infarction within 24 hours of stroke onset in the LSA territory were enrolled. Progressive motor deficits (PMD) was defined as the increase of NIHSS motor score by ≥ 1 within 7 days after onset. Topographic patterns on DWI, demographic features, and risk factors were compared between patients with PMD and those without PMD. Results: Of the 95 patients in the study group, 15(15.8%) showed PMD. Demographic factors, vascular risk factors, and severity of initial neurologic deficits were not associated with PMD. Axial diameter of lesion was not significantly different between the two groups (PMD group, 15.9±4.5 mm vs. no PMD group, 13.5±4.4 mm; p=0.058). Vertical lesion length was significantly longer in the PMD group than in the no PMD group (21.5±8.7 mm vs. 16.4±8.1 mm; p=0.03). Isolated corona radiata infarction did not show PMD (0/16 vs. 15/79; p=0.067). Multivariate logistic analyses revealed that vertical extension of the lesion ( ≥24mm) was only independent predictor of PMD (odds ratio, 5.3; 95% CI, 1.5-18.3, p=0.008). Conclusions: Vertical extension of infarct was associated with PMD in patients with lacunar infarction in the LSA territory. We postulate that stepwise occlusion of the penetrating artery from the proximal portions clinically manifest as PMD and radiologically manifest as vertical extension of the lesion.

Recurrent ischemic events in a patient with essential thrombocythemia

김근태

Recurrent ischemic events in a patient with essential thrombocythemia Keun-Tae Kim, Byung-Chan Lee, Ji-Hoon Kim, Suh-Yun Hong, Kyung-Hee Cho Department of Neurology, Keimyung University School of Medicine, Dongsan Medical Center, Daegu, Korea Background: Hematological disorders are relatively rare causes of stroke. Essential thrombocythemia (ET) is a clonal myeloproliferative disorder of unknown etiology, characterized by an increased number of apparently normal platelets. ET may have a high incidence of thrombotic complications. We report a patient with ET who developed recurrent ischemic events involving both arterial and venous systems. Case: A 46-year-old man suddenly developed tingling sensation in his left face, arm, and leg. The patient had first been seen at our hospital eight years earlier because of abdominal pain. Abdominal CT showed multiple splenic infarctions and thrombosis in superior mesenteric vein, splenic vein and portal vein with splenomegaly. Laparoscopic splenectomy was performed. His platelet count was 729,000/uL. Bone marrow biopsy revealed ET. Six years ago, the patient visited our hospital because of severe chest pain. EKG showed ST elevation and coronary angiography found 2 vessel diseases. A diagnosis of ST elevation myocardial infarction was made and stent placement was done. His platelet count was 821,000/uL. Hydroxyurea was prescribed since ET was diagnosed, and he also has been on medication of aspirin, cilostazol, and dilatrend since myocardial infarction. He had no history of hypertension and diabetes. He had never smoked and did not drink alcohol. On examination, cardiac murmur and cervical bruit were not heard. EKG revealed abnormal Q waves in leads V1. On neurologic examination, he was alert and presented mild left pronator drift, decreased pinprick, temperature, light touch, and vibration sense on the left face and half of the body. He had no visual field defect on confrontation testing. Diffusion-weighted MRI 8 hours after last normal time showed a high signal lesion in the right lateral thalamus. In addition, there was the increased T2 signal in the left parietal cortex consistent with subacute cerebral infarct. MR angiography showed isolated, focal stenotic lesion of right posterior cerebral artery (P2 portion) without other large vessel lesion. A cardiologic evaluation excluded possible sources of cardioembolism. However, repeated tests showed high platelet counts (624,000-720,000/uL). ET was identified as the cause of the acute cerebral infarct and arterial thrombosis. We changed the medication of cilostazol to clopidogrel, and increased the dosage of hydroxyurea from 1000mg to 1500mg per day in order to control elevated platelet counts. On discharge from the hospital, he did not have any neurological deficits. Conclusion: Prior thrombosis is a well-established risk factor for re-thrombosis in ET. The cause of recurrent ischemic events involving both arterial and venous systems can be explained by sustained elevation of the platelet counts over 400,000/uL. Aggressive cytoreduction therapy should be considered for protecting against recurrent thrombosis.

A Case of Right Aortic Arch With Isolated Left Subclavian Artery And Common Carotid Artery ; Is ...

박혜영

background & Significance Right aortic arch with isolated left subclavian artery and common carotid artery is extremely rare. Here we report a case of congenital vessel anomaly presenting with a subclavian steal syndrome. Case A 22-year-old female patient with 3-month history of dizziness visited the hosptal. The results of physical and neurological examinations were unremarkable. She has felt non-whirling type of dizziness since she was twelve, but the symptom was aggravated about 3 months ago. Computed tomography angiography of neck and head was performed and it showed relatively smaller size of vertebral artery and common carotid artery of left side. Right side had a normal configuration. Color-coded duplex ultrasonography revealed complete flow reversal of left vertebral artery. A side-to-side difference in systolic brachial arterial blood pressure was 20 mmHg. There was no claudication in left arm and the symptom was not aggravated by left arm movement or lifting. Percutaneous catheter aortogram showed right aortic arch with normal brachiocephalic trunk and no connection with great vessels of left side. Left transradial subclavian angiogram showed isolation of left subclavian artery and left common carotid artery with competition flow of left vertebral artery. Conclusioss or Comments This case demonstrated a right aortic arch with only on functional branch arising from the aorta. This patient’s symptoms might be secondary to inadequate blood flow which is same mechanism of subclavian artery steal phenomenon.

Progression of symptomatic intracranial large artery atherosclerosis:

정상욱

Background and Purpose: Studies on the molecular pathways involved in the progression of intracranial large artery atherosclerosis are rare. We aimed to study the relationship between biomarkers and the risk of progression of symptomatic intracranial large artery atherosclerosis. Methods: Of 409 patients in Trial of cilostazol in symptomatic intracranial stenosis-2 (TOSS-2) study, 52 patients showed progression of symptomatic intracranial large artery atherosclerosis on MRA after 7 months. We selected 20 patients with progression and 20 age- and sex- matched control patients. We collected blood sample initially, one month and 7 month after infarction, and multiplex analysis of biomarkers including interleukin-1,2,6,8,10, soluble CD40ligand, TNF alpha, PDGF, soluble ICAM, E-selectin and VCAM , MMP-2,3,9, SOD1,2,3 and adipokines, were performed. Results: Demographic features such as age, sex, hypertension, diabetes and smoking history were not different between both groups. On univariate analysis, soluble CD40ligand (18298.9￠®¨u28597.9 pg/ml vs 3925.0￠®¨u5543.5 pg/ml) and PDGF-AB/BB (16487.0￠®¨u20328.8 pg/ml vs 5664.4￠®¨u6692.7 pg/ml) level were higher in progression group. On multivariate analysis using mixed model, soluble CD40ligand (p=0.034) and PDGF-BB (p=0.013) were independent prognostic factor for progression of intracranial large artery atherosclerosis. Conclusion: Both soluble CD40ligand and PDGF-AB/BB are associated with progression of symptomatic intracranial large artery atherosclerosis.

Two cases of cervical epidural hematoma mimicking transient ischemic attack.

이형석

Hyungsuk Lee, MDa, Shin-Hye Baek, MDa, Mi-young Ahn, MDa, Ho-Seong Han, MDb, Dong-Ick Shin, MD, PhDa Department of Neurology, Chungbuk National University, College of Medicinea Department of Neurology, Sun General Hospitalb Background A spontaneous cervical epidural hematoma is a rare cause of cord compression that usually requires surgical evacuation for relieve symptoms. Spontaneous resolutions are seldom reported. In those cases, transient neurological abnormalities resolved over at least several hours to days, usually. We present two cases of cervical epidural hematoma mimicking transient ischemic attack(TIA) because those neurological abnormalities lasted for only short times. Case I A 78 year-old man who had hypertension and took antihypertensive medication and aspirin had sudden onset of posterior neck pain and weakness in his left limbs. The symptoms relieved as times go by and the weakness recovered at the arrival for our hospital which last for 30 minutes. On the neurological examinations, there was no obvious abnormalities. Brain magnetic resonance image(MRI) and angiography(MRA) showed no relevant abnormalities. Under the diagnosis of TIA, antiplatelet agent and hydration were given. On the second day, he complained severe neck pain again without weakness. The cervical MRI performed that day revealed a posterior epidural hematoma at left side of C2-C6 level and severe spinal canal narrowing. Because he never had neurological abnormalities, a conservative management only for the pain was done and pain was relieved. Case II A 67 years old woman who took cilostazole, because she had right pontine infarction one years ago and hypertension for 2 years, came to our hospital due to sudden severe posterior neck pain and right side weakness 3 hours ago, before the visit. The weakness was improving. Neurological examinations reveals no obvious abnormalities. Brain MRI and MRA showed no relevant abnormalities. Considering as a TIA, antiplatelet and hydration was given. The cervical MRI performed because she complained severe posterior neck and shoulder pain continuously after admission, which showed epidural hematoma at C3-4 level. Discontinuation of antiplatelet drugs and conservative care was done. Six days later cervical MRI repeated showed no residual hematoma. Discussion A spontaneous cervical epidural hematoma is an infrequent condition. The commonest clinical presentations are with paraparesis and tetraparesis. Transient hemiparesis is very rare. The mechanism of spontaneous recovery from para- and tetra-paresis is assumed that the spreading of hematoma in epidural space up- and downwards to the rostro-caudal direction results in decompression. In that cases, the improvement required usually several days. We experienced two case of spontaneous epidural hematoma which improved during shorter times than those of previously reported cases so we were confused with the diagnosis, regarding TIA. The different nature in our case from usual TIAs is severe posterior neck pain. Conclusively, a severe posterior neck pain would be red flags of cervical epidural hematoma, although TIA is suggested.

Added Information of FIESTA Sequence in Stenoocclusive Vertebrobasilar Dissection

장혁원

Background Time-of-flight (TOF) magnetic resonance angiography (MRA) provides useful information about pathologies of intracranial vessels. But, TOF MRA gives limited information in occlusion type vertebrobasilar artery (VBA) dissection. So we evaluate Fast Imaging Employing Steady-state Acquisition (FIESTA) sequence for detection of VBA dissection. Methods We performed additional FIESTA sequence in 44 of patients diagnosed as VBA discontinuity or focal luminal irregularity by means of TOF MRA and compare TOF MRA and FIESTA for detection of VBA dissection. Results Among them, 36 cases show hypoplastic or atherosclerotic VA. In 3 aneurysmal type VBA dissections, both TOF MRA and FIESTA sequence can detect the lesion. In 5 occlusion type VBA dissections, TOF MRA cannot detect the lesion. But, FIESTA sequence can depict the lesion in all 5 occlusion type VBA dissection. Conclusions FIESTA sequence may give additional information in stenoocclusive VBA dissection. FIESTA sequence is more valuable than TOF MRA especially in occlusion type VBA dissection.

Neutrophil to Lymphocyte Ratio at Admission : Prognostic Factor in Patients with Acute Ischemic ...

오형근

Neutrophil to Lymphocyte Ratio at Admission : Prognostic Factor in Patients with Acute Ischemic Stroke Hyung-Geun Oh , Yun-Im Choi, Il-Kyo Seo, Jong-Kyu Park Department of Neurology, College of Medicine, Soonchunhyang University, Cheonan, Korea Background: Inflammatory mechanisms play an important role in the risk of stroke and during the acute phase of brain ischemia, which contribute to functional outcome of patients. The neutrophil to lymphocyte ratio (NLR) has recently been described as a predictor of outcomes in patients with acute coronary syndrome. Objective: The purpose of this study is to assess the clinical significance of NLR as a new predictor of outcomes in patients with acute ischemic stroke. Method: The study included 371 patients diagnosed as acute ischemic stroke on admission. All subjects were divided into 3 groups according the tertiles of the NLR. Functional outcomes were divided into two groups, favorable (mRS 0-2) or unfavorable (mRS 3-6), and they were followed-up at 3-month and 1-year. Results: The proportion of patients with mRS 0-2 was reduced as the tertiles of NRL increased from 1st to 3rd at discharge (74, 62.9 and 49.2%, p<0.001), 3-month (74, 66.9 and 42.7%, p<0.001), and 1-year (67.5, 64.5, 41.1%, p<0.001). Patients with unfavorable outcome had higher 3-month (3.88 vs. 2.27) and 1-year (3.67 vs. 2.31) NLR compared with those with favorable outcome (p <0.001). High NRL at admission (OR 2.23, 95% CI 1.11-4.48) was the significant predictor for unfavorable outcome at 3-month along with age (OR 1.05, 95% CI 1.02-1.07) and NIHSS at admission (OR 1.29, 95% CI 1.21-1.38). Conclusions: NLR at admission can be used in the prediction of functional outcome in patients diagnosed with acute ischemic stroke.

A case of recurrent spontaneous internal carotid artery dissection

성민재

Ischemic stroke Caused by Recurrent Spontaneous Internal Carotid Artery Dissection Min Jae Seong, Tai Hwan Park, Soo Ji Lee, Jae-Hyeok Heo, Jin Young Ahn, Min Ky Kim Department of Neurology, Seoul Medical Center Background & Significance: Spontaneous dissection of internal carotid artery (ICA) is very rare cause of stroke among elderly. We describe a case of recurrent ischemic stroke due to remotely occurred spontaneous dissection of bilateral petrous ICAs. Case: A 65-year-old right-handed man had sudden onset of left hemiparesis and hemineglect while painting home. MRI on admission disclosed multiple scattered cortical and subcortical acute ischemic lesions in right MCA territory. MRA showed moderate stenosis of the ipsilesional ICA at proximal petrous portion. He had a well-controlled hypertension and diabetes. Pathognomonic double lumen of arterial dissection was observed on oblique plane perpendicular to the stenotic arterial segment from CT angiography source images. He nearly completely recovered from motor weakness within 7 days of admission and followed up out-patients clinic (OPD) regularly with prescription of oral clofidogrel. After 19 months of first stroke, he visited hospital due to sudden right sided weakness which had occurred during gait 2days ago. Diffusion weighted MRI showed small scattered cortical and subcortical ischemic lesions in left MCA territory. Relevant stenotic lesion was found in the proximal petrous segement of left ICA. Contralateral stenotic lesion of ICA observed in previous MRA was disappeared. He did not have any clinical, laboratory, or radiological evidence of other well-known causes of arterial dissection. Comments: The recurrence of stroke in dissection of ICA is very rare except for familial cases. Petrous ICA has been known to be unusual site of dissection, but proximal portion of which might be susceptible to vessel wall trauma from bony margin of carotid canal.

Simultaneous multiple lacunar infarction: different disease entity from single lacunar infarction

이준화

Simultaneous multiple lacunar infarction: different disease entity from single lacunar infarction Joon Hwa Lee, Department of Neurology, Konkuk university medical center Backgrounds Stroke mechanism other than small artery disease has been reported in patients with lacunar infarction. We hypothesized that acute simultaneous multiple lacunar infarction (SMLI) may have different clinical characteristics from acute single lacunar infarction (SLI). Methods We retrospectively reviewed stroke patients with acute simultaneous multiple lacunar infarction or acute single lacunar infarction in the prospectively collected stroke registry from March 2008 to February 2010. A lacune was defined as a hyperintense signal shown in the diffusion weighted magnetic resonance imaging, <2.5cm in diameter, located in the subcortex and perforating artery territories. Clinical characteristics such as conventional risk factors, premorbid cognitive and functional state, and clinical outcome were studied. Imaging characteristics such as white matter ischemic changes, previous lacunes, micro or macrohemorrhage, and concomitant intra or extracranial stenosis were studied. Results Of 548 acute ischemic stroke patients, SMLI was 23 (4.1%) and SLI was 148 (27%). Conventional vascular risk factors including and D-dimer, fibrinogen, hs CRP showed no difference between two groups. Previous history of stoke was more prevalent in SMLI group. In SMLI group, age was older and premorbid functional state was poorer. SMLI group showed higher white matter ischemic scores (PVWM, p<0.05; DWM, p<0.01), number of microbleeds (p<0.05), number of previous lacunes (p<0.01). Cardioembolic mechanism was rare in both groups. Generalized atherosclerosis such as peripheral artery occlusive disease (p<0.01), symptomatic carotid disease (p<0.05) was more prevalent in patients with SMLI than SLI. Conclusions Mechanism of SLMI might be a small vessel disease rather than cardioembolism. However, clinical and imaging characteristics suggest that SLMI might be a more severe disease entity of the small vessel disease accompanied by generalized atherosclerosis

Long-term outcome of acute ischemic stroke patients with symptomatic or asymptomatic stenosis ...

김영진

Long-term outcome of acute ischemic stroke patients with symptomatic or asymptomatic stenosis of vertebral artery origin Young Jin Kim, Department of Neurology, Konkuk university medical center Backgrounds Symptomatic atherosclerosis of vertebrobasilar artery is a major cause of the ischemic stroke in the posterior circulation. Asymptomatic vertebral artery origin stenosis (VAOS) is also common in patients with acute ischemic stroke. This study was performed to determine long-term clinical significance of the symptomatic or asymptomatic VAOS in acute stroke patients. Methods We retrospectively reviewed acute ischemic stroke patients with symptomatic (Sx-VAOS) or asymptomatic (Asx-VAOS) vertebral artery origin stenosis in the prospectively collected stroke registry from December 2007 to December 2008. VAOS was defined more than 30% stenosis of either vertebral artery origin on a contrast-enhanced MRA focused on vertebral artery origin. Long-term outcome including recurrent stroke, cardiovascular event, vascular death and non-vascular death were investigated. Results Of 317 acute ischemic stroke patients, Sx-VAOS or Asx-VAOS were observed in 138 patients (43.5%). Sx-VAOS was 91 (65.9%) and Asx-VAOS was 47 (34.1%). All patients had intensive medical treatment and 8 patients with Sx-VAOS underwent angioplasty and stenting. During 399 patient-years of follow up (338 in Sx-VAOS and 61 Asx-VAOS), there were three recurrent ischemic stroke in Sx-VAOS (2 in posterior and 1 in anterior circulation) and one in Asx-VAOS (posterior circulation). Vascular death was 1 in Sx-VAOS and 1 in Asx-VAOS. Non-vascular death was 1 in Sx-VAOS and 2 in Asx-VAOS. Conclusions Long-term outcome of acute ischemic stroke patients with more than 30% symptomatic or asymptomatic VAOS was favorable on intensive medical treatment and selective angioplasty and stenting.

Can silent ischemic cerebral lesions clinically affect cognitive impairment of Parkinson’s ...

정성우

Can silent ischemic cerebral lesions clinically affect cognitive impairment of Parkinson’s disease patients with mild dementia? In-Uk Song, Young-Do Kim, Sung-Woo Chung Department of Neurology, The Catholic University of Korea Background: Several studies have shown that the presence of cerebrovascular lesions may play an important role for determining the severity of the clinical symptoms of dementia. But no study to date has explored the clinical effect of cerebrovascular disease in Parkinson’s disease with dementia(PDD), although cerebrovascular disease is common causes of dementia in elderly population. Therefore we conducted this study to evaluate the relationship between silent cerebrovascular lesions and cognitive decline in PDD. METHODS: Only 27 patients with PDD were chosen; 17 patients had PDD with silent cerebral ischemic lesions (PDDI) and 10 patients had PDD without silent cerebral ischemic lesions (pure PDD). These subjects received the global cognitive function testing and were all evaluated with detailed neuropsychological tests including attention, memory, language, and also the visuospatial and frontal function. Results: There were no significant differences between pure PDD and PDDI group on general cognitive functions tests. Regard to mean time duration of suffering from Parkinson motor symptoms and motor function scale, pure PDD group showed more long duration than PDDI group but there was no significant difference between two groups. Furthermore, there were not any significant differences between the two groups on detailed neuropsychological tests. Conclusion: we concluded that silent cerebrovascular lesions do not contribute to neuropsychological severity of PDD, although vascular disease is a common cause of cognitive impairment in the elderly. Thus the results of the present study suggest that factors other than cerebrovascular disease contribute to severity of PDD.

Is cardioembolism the most common cause of MCA inferior division infarction?

노상미

Sang-Mi Noh, Sang-Wuk Jeong, Myung-Goo Ji, Dong-Eog Kim Department of Neurology,Dongguk University International Hospital,Goyang,Korea Backgrounds and objective It is known that the inferior division of the middle cerebral artery (MCA) is occluded less often than the superior one, and nearly always due to cardiogenic embolism. We tested these hypotheses. Methods We prospectively collected cases of MCA infarction according to TOAST classification. A total 253 cases were included, who were admitted to our hospital from december 2007 to january 2010. To study the topographical characteristics of the presenting stroke, we analyzed diffusion weighted image. After excluding MCA total infacrt, borderzone infarct and striatocapsular infarct ,we studied 94 cases with either MCA infarct of superior division or inferior division. Stroke mechanism categorized as large artery, cardioembolic, undetermined (negative, two or more). Pearson's Chi-square test was used. Results In large artery disease group, proportion of MCA superior division infarct (29 cases) was higher than that inferior division (16 cases, p=0.06). Undetermined group revealed inferior division (18 cases) more predominantly than superior division (12 cases, p=0.09). In cardioembolic group, there are little difference between superior division (10 cases) and inferior division (9cases). Proportion of cardioembolic infarct was not significantly different between superior division and inferior division of MCA (p=1.0). Conclusion The frequency of inferior division MCA infarct was similar to that of superior one. Proportion of cardioembolic infarct was not different between superior division and inferior division of MCA.

Risk of early recurrent ischemic events in Korean patients with TIA: What is the most reliable ...

이용석

Risk of early recurrent ischemic events in Korean patients with TIA: What is the most reliable predictor ? Yong-Seok Lee, Chae Won Shin, Hyung-Min Kwon Department of Neurology & Stroke Center, Boramae Medical Center, Seoul National University College of Medicine Early recurrence of stroke is common after TIA in Western series. Clinical scores like ABCD2, presence of DWI lesion, or vascular stenosis/occlusion has been suggested for the prediction of the risk. However, the risk of early recurrent ischemic events or the accuracy of such predictors has not been defined and validated in Korean patients. We retrospectively investigated the clinical parameters, neuroimaging findings, and the risk of early recurrent ischemic events. Consecutive patients with TIA admitted within 48 hours from symptom onset were included. Symptoms, duration, risk factors, blood pressure, laboratory findings, ABCD2 scores, and recurrent ischemic events of stroke or TIA within 7 days were reviewed from medical records. Baseline DWI lesions and presence of vascular stenosis or occlusion of symptomatic vessel were also evaluated. A total of 74 patients (mean age 65 years, 51% men) were included. Focal weakness (54%), speech disturbance (39%), and vertigo (14%) were frequent symptoms. Distribution of symptom duration was 46% (≥ 60 min), 32% (11-59 min), and 22% (10 min). Distribution of ABCD2 score was 28% (0-3), 54% (4-5), and 18% (6-7). DWI lesion was present in 10% and symptomatic stenosis in 35%. Three events of stroke and 9 TIAs occurred within 7 days, of which 9 events occurred within 48 hours. Recurrent events were more common in patients with symptomatic stenosis (19% vs. 9%, P>0.05), while not more common in patients with higher ABCD2 score (6-7) or positive DWI lesion. In conclusion, early recurrent TIA or stroke is common (>10%) in patients with TIA, especially within 48 hours. Presence of symptomatic stenosis may be an important predictor for early recurrence. With limitations, these results suggest strong needs for further large, multi-center, prospective study in Korean patients.

Three Cases of Cerebral Deep Venous Thrombosis; Variable Outcome From Mild Headache to Death

최 낙천

Three Cases of Cerebral Deep Venous Thrombosis; Variable Outcome From Mild Headache to Death Nack-Cheon Choi, M.D., Sookyung Kim, M.D., Heeyoung Kang, M.D., Ki-Jong Park, M.D., Oh-Young Kwon, M.D., Byeong Hoon Lim, M.D. Department of Neurology, Gyeongsang National University School of Medicine Gyeongsang Institute of Health Science, Gyeongsang National University Background: Cerebral deep venous thrombosis of internal cerebral veins, vein of Galen and straight sinus without associated sagittal sinus thrombosis is a very rare disorder and can be associated with poor outcome. Case: Case 1) A 76 years old female presented with complaints of headache for 3 weeks. Neurological examination was normal. MRI showed normal and MR venography demonstrated non visualization of cerebral deep vein. Case 2) A 43 years old female presented with complaints of left hemiparesis, vertigo, and headache for 2 days. MRI showed high signal intensity in both BG and thalami. MR venography demonstrated non visualization of cerebral deep vein. Case 3) A 49 years old female presented with complaints of headache, nausea, and vomiting for 3 days and decreased mentality for 1 day. MRI showed high signal intensity in both cerebellum and thalami. MR venography demonstrated non visualization of cerebral deep vein. She was died 3 days later. Comment: The diagnosis of cerebral deep venous thrombosis based on clinical symptoms is difficult but modern technology of MRI is very useful for its diagnosis. Clinical findings of deep cerebral venous thrombosis can be non-specific and include headache, alteration of consciousness and coma. Venous infarction of thalami, basal ganglia and rarely cerebellar infarcts occur. Multiple infarcts of posterior circulation are usually attributed to thromboembolism of the top of the basilar artery. Apart from the top of the basilar artery syndrome, deep cerebral venous thrombosis should also be considered as a cause of multiple infarcts of posterior circulation.

Low Non-High Density Lipoprotein Cholesterol Level In Cardioembolic Stroke

오미영

Backgrounds and Purpose : Recently, various non-traditional lipid indices were reported to associate with various cardiovascular and atherosclerotic stroke events. Apart from each lipoprotein level, ratio or combination of lipoproteins may give more detailed insights into pathophysiology and development of atherosclerotic diseases. In this context, we investigated non-traditional lipid indices among acute ischemic stroke patients. Methods : Among a total of 929 acute stroke patients who admitted to Seoul National University Hospital between January 2008 and December 2009, 574 cases due to large artery atherosclerosis (n=250), small vessel occlusion (n=162) or cardioembolism (CE; n=162) were included in this study. Demographic, clinical, laboratory data were collected, and the levels of each lipoprotein were measured at the subsequent morning of admission with overnight fasting. Results : Comparing CE to non-CE subgroup, the level of total cholesterol (TC; 167.3￠®¨u41.8 mg/dL vs. 178.5￠®¨u37.2 mg/dL; P<0.01) and low density lipoprotein (LDL; 98.0￠®¨u39.0 mg/dL vs. 107.7￠®¨u34.0 mg/dL; P<0.01) and triglyceride (TG) level were lower (132.2￠®¨u76.7 mg/dL vs. 113.9￠®¨u85.2 mg/dL; P=0.01). However, high density lipoprotein (HDL) level was similar (P=0.11). Non-HDL cholesterol level was significantly elevated in non-CE patients (120.7￠®¨u42.0 mg/dL vs. 134.4￠®¨u35.5 mg/dL; P<0.01). The association between non-HDL cholesterol and non-CE remained significant after adjusting for age, gender, hypertension, diabetes, smoking, body mass index (OR, 1.01 per 10-mg increase; 95% CI, 1.004-1.016). Conclusions : Non-HDL cholesterol may be helpful in clarifying stroke mechanisms.

A Case of Reversible Malignant Cerebral Edema with Infarction of Left MCA and Both ACA Territories

노진홍

A Case of Reversible Malignant Cerebral Edema with Infarction of Left MCA and Both ACA Territories Jinhong Roh*,M.D., Nack-Cheon Choi*†,M.D., Oh-Young Kwon*†,M.D., Sookyung Kim *,M.D .,Heeyoung Kang*,M.D., Ki-Jong Park*†,M.D., Byeong Hoon Lim*†,M.D. Department of Neurology, Gyeongsang National University School of Medicine* Gyeongsang Institute of Health Science, Gyeongsang National University† Background: Massive hemisphere infarction may lead malignant cerebral edema and high motality rate, as well as poor functional outcome. We reported a case malignant cerebral edema with infarction of MCA and both ACA territories associated with azygotic ACA. Case: A 55-years-old man was admitted to the hospital because of decreased mentality. Neurological examination on admission revealed stupor consciousness, left deviated eyeballs and right side hemiparesis to painful stimulus. The brain MRI showed acute hemorrhagic infarction in the right ACA territory and acute infarction in the left MCA and ACA territories. MR angiography reveals left ICA stenosis with occlusion of right ACA A2 and left MCA M1 and azygotic ACA. After 3 days later, follow-up CT showed malignant cerebral edema with midline shifting. Mental status was stupor and he did not response with corneal reflex on left side. Twenty days later, his mental status had improved to alert, although global aphasia and right hemiparesis were persistent. Conclusion: Motality rates of malignant MCA infarction are reported up to 80%. CT findings, extent of tissular hypodensity and attenuated corticomedullary contrast are predictor of fatal brain swelling. Deterioration of neurological and consciousness status are clinical sign of uncal herniation and mass effect so that are important to determined prognosis of patients. In our case, malignant cerebral edema was accompanied massive cerebral infarction due to associated right A1 segment hypoplasia, but Lt. ACA territory stunned brain that case the prognosis is not poor.

A case of Cerebral infarction complicating Evans’ syndrome

신종욱

A case of Cerebral infarction complicating Evans’ syndrome Department of Neurology, Internal Medicine*, Chungnam National University Hospital Jong wook Shin, Ji eun Oh, Jei Kim, Deog-Yeon Jo*, Hee-Jung Song Background and significance Evans’ syndrome (ES) is a rare autoimmune disorder characterized by the simultaneous or sequential development of autoimmune hemolytic anemia and immune thrombocytopenia in the absence of any underlying cause. Reportedly, ischemic stroke in Evans’ syndrome is known to occur infrequently. We report a case of territorial cerebral infarction accompanied with Evans’ syndrome that was diagnosed at a same time for the first in the elderly. Case A 72 year old woman was presented with left hemiparesis. On examination, motor weakness was predominant in left proximal upper extremity. She was hypertensive and had been treated with right femoral vein thrombosis three years before. At the time of diagnosis of deep vein thrombosis, her blood profiles were within normal limit. On admission, bicytopenia was noted, and both direct/indirect Coomb’s tests were positive, but lupus studies were negative. She was diagnosed as idiopathic Evans’ syndrome. Diffusion weighted image depicted multiple high signal intensities in right middle cerebral artery territory. Magnetic resonance angiography showed no stenosis or occlusion. Electrocardiography and echocardiography were normal. Conclusion The concurrence of ES and ischemic stroke is very rare and the pathomechanisms are pooly understood. Because an immune thrombocytopenia is a characteristic in ES, it is thought to be that the risk of bleeding is more significant than that of thrombotic event. Although the pathogenesis of cerebral infarction remains unknown, hypercoagulable state considered to be responsible especially in this case.

Paroxysmal kinesigenic dyskinesia caused by isolated internal capsular infarction.

정종원

Paroxysmal kinesigenic dyskinesia caused by isolated internal capsular infarction. Jong-Won Chung, Sang-Soon Park, Kyeong-Joon Kim, Byung-Woo Yoon. Department of Neurology, College of Medicine and Neuroscience Research Institute, Medical Research Center, Seoul National University. *Backgrounds Paroxysmal kinesigenic dyskinesia (PKD) is a neurological condition which results in dystonia, chorea, athetosis, or ballism that is precipitated by sudden movement affecting as a rule the musculature of one or more limbs and often the head and trunk. We report a case of PKD after a focal internal capsule posterior limb infarction. Previously PKD associated with isolated internal capsule infarction has not been reported. *Case A 69 year old man presented to the emergency room with a 1 week history of dystonic episodes involving his lt. arm, precipitated by sudden movement, lasting 1 minute. Episodes initially involved only his left hand, but progressed to involve his left leg. The frequency of episodes increased to a maximum of 12 attacks daily. All episodes were preceded by a tingling sensation in the left shoulder radiating to the wrist. Involuntary movement was aggravated by suddenly bending her back forward or lifting up his left arm. His left thumb adducted and fingers contracted at proximal interphalangeal joints. Then there was flexion of his left wrist and elbow and internal rotation of her left arm. Sometimes his left hip and knee joint was also contracted. A diffusion weighted magnetic resonance imaging with 5-mm slices revealed a focal area of high signal intensity involving the right internal capsule posterior limb. T-2 fluid attenuated reverse image revealed same focal high signal intensity lesion in right internal capsular posterior limb. Treatment with clonazepam and carbamazepine resulted in complete resolution of attacks. *Conclusion In previous reports PKD was thought to be caused by lesions in basal ganglia resulting in imbalance in the cortico-striato-pallidothalamic loop acting as a center for movement initiation. In our patient PKD was caused by contralateral focal lesion in posterior limb of internal capsule, which can account for the face, arm, and leg motor and sensory involvement.

Two Cases of Simultaneously Occured Intracranial Hemorrhage and Cerebral Infarction

주은정

Two Cases of Simultaneously Occured Intracranial Hemorrhage and Cerebral Infarction Eunjeong Joo*,M.D., Nack-Cheon Choi*†,M.D., Oh-Young Kwon*†,M.D., Sookyung Kim *,M.D .,Heeyoung Kang*,M.D., Ki-Jong Park*†,M.D., Byeong Hoon Lim*†,M.D. Department of Neurology, Gyeongsang National University School of Medicine* Gyeongsang Institute of Health Science, Gyeongsang National University† Background: The simultaneously happening of intracranial hemorrhage and acute infarction is not common. This can be observed in specific abnormal conditions like, Cerebral amyloid angiopathy, smll vessel disease, moyamoya disease, primary angitis , sickle cell anemia and cardiogenic brain embolism. We experienced two patients with intracranial hemorrhage and acute cerebral infarction at the same time. Case: Case 1) A 44-years-old man with a history of hypertension was visited to the hospital because of abrupt occured right side hemiparesis and memory change. Neurological examination revealed right side hemiparesis, paresthesia and dysarthria. The brain MRI showed acute hemorrhage in the left basal ganglia and acute infarction in the right corona radiata. There were absent cerebral microbleeds but multiple old lacunar infarcts. Case 2) A 51-years-old woman who had diagnosed with hypertension was admitted to the hospital with headache and isolated left side homonymous hemianopsia. The brain MRI revealed intracranial hemorrhage in right temporoparietal lobe, two small recent infarctions in left frontal lobe and multiple microbleeds. Comment: The small cerebral arteries that supply the territory of the lacunar infarcts undergo segmental arterial disorganization, fibrinoid degeneration and lipohyalinosis in small vessel disease. These pathophysiologies are related with vascular risk factor such as hypertension. Also these changes can result in intracanial hemorrhage, lacunar infarcts and microbleeds. Considering previous two cases, both of them was diagnosed with hypertension and one had a few lacular infarcts and the other had multiple microbleeds. In conclusion chronic hypertension can be induced small vessel disease. The small vessel disease could be causative of hemorrhage or infarction or both of them. When the evidence of small vessel disease like microbleeds and silent lacunar infarcts are observed, we must pay attention to the development of additional cerebrovascular events.

The CBV-ASPECT score as a predictor of fatal stroke in a hyperacute state

김준태

Backgrounds: Many parameters of multimodal CT have been assessed to predict clinical outcome and recanalization after thrombolysis. However, early predictor of the fatal stroke has not been clearly identified. Therefore, this study was conducted to identify early predictors related to the fatal stroke. Methods: We retrospectively analyzed subjects with acute ischemic stroke within 6 hours of onset between March 2007 and January 2009. Early fatal stroke was defined as death or coma in 1 week from the initial ischemic stroke. Multimodal CT images were scored according to previous studies, such as ASPECT score, collateral score, and clot burden score. Results: A total of 68 patients were finally analyzed in this study. Twenty-two patients (32.4%) became coma or died within 1 week from the initial stroke. Patients with fatal stroke had lower CS, CBS and ASPECTS score in the cerebral blood volume (CBV) and time to peak maps than those with non-fatal stroke. The initial NIHSS score, CBV-ASPECTS, age and diabetes mellitus were associated with fatal infarct in multivariate logistic regression analysis. Conclusions: Our study demonstrated that initially low CBV-ASPECT scores on perfusion CT could predict early fatal stroke and that a CBV-ASPECTS threshold of < 4 with a modest sensitivity and specificity could be considered as an early predictor of fatal stroke.

The CBV-ASPECT score as a predictor of fatal stroke in a hyperacute state

김준태

Clinical and biochemical markers as a predictor of early neurological deterioration in acute ...

권형민

Clinical and biochemical markers as a predictor of early neurological deterioration in acute lacunar infarction Hyung-Min Kwon, MD, PhD, Hong-Kyun Park, MD, Yong-Seok Lee, MD, PhD Department of Neurology, Seoul National University Boramae Hospital Background: Early neurological deterioration (END) is common problem in patients with acute ischemic stroke ranging 12~42%. Previous studies revealed several factors associated with END through retrospective design or heterogeneous patient group. Objective: In this study, we investigated the clinical characteristics, biochemical markers to identify the predictors of END in acute lacunar infarction. Methods: We prospectively enrolled 131 consecutive patients with acute lacunar infarction within 48 hours. END was defined when there was a decrease of ≥1 point in motor power or a decrease of ≥2 points in any scores in the National Institute of Health Stroke Scale during the first week of symptom onset. We assessed the patients with clinical findings such as vascular risk factors, blood pressure (BP) on admission and laboratory variables. Results: The mean age of the included patients was 64.2±11.3 years, and male was 80 (61.1%). Seventeen (13.0%) of the 131 patients revealed END after admission. About half (52.9%) of the END patients occurred within the first 48 hours after admission. By univariate analysis, diabetes, systolic BP, triglyceride, total cholesterol, low density lipoprotein-cholesterol, and homocysteine level were higher in patients with END than in those without. After multiple logistic regression model, independent predictor of END was higher triglyceride level (> 145mg/dL, 4th quartile OR 17.67, 95% CI 1.73-180.57, P=0.015). Conclusions: Our study suggests that higher triglyceride level can be used to identify patients at high risk for END in acute lacunar infarction. Pathophysiological mechanism remains to be determined and further studies in various subtypes of stroke are also needed.

A case of the hemimedullary syndrome halted after progression for two days

Mi-young Ahn

Background: Hemimedullary infarction in which medial and lateral medullary lesions occur simultaneously is a rare cerebrovascular disease. The combination of lesions may result from obstruction of the vertebral artery. Nevertheless, few reports exist of hemimedullary syndrome caused by consecutive infarctions confirmed with follow-up magnetic resonance imaging (MRI). We present a case of hemimedullary infarction that was terminated after progression for 2 consecutive days. Case: A 75-year-old man presented with vertigo and right beating nystagmus. Brain MRI revealed a left lateral medullary lesion. Antiplatelet management and proper hydration was given, but the patient developed severe hemiparesis of the right extremities 1 day later. Follow-up brain MRI revealed ipsilateral medial and lateral medullary infarctions, primarily left lateral medullary infarction. Anticoagulation was started and the symptom progression ceased. Discussion: Hemimedullary syndrome is a rare cerebrovascular disease that usually occurs simultaneously as a result of vertebral artery occlusion. Only one report has described hemimedullary syndrome that was stopped after progression of vertebral artery dissection for several days. In our case, however, no evidence of vertebral artery dissection was observed. We believe that the cause was propagation of a thrombus.

Characteristics of small vessel occlusive stroke with irrelevant intracranial arterial stenosis

김지연

Characteristics of small vessel occlusive stroke with irrelevant intracranial arterial stenosis Jiyeon Kim, Byung-Kun Kim, Ohyun Kwon, JungJu Lee, Kyusik Kang, Jong-Moo Park Department of Neurology, Eulji Hospital, Eulji University Background & Objectives Recent studies suggest that lacunar strokes with parent arterial pathology tend to suffer more severe disability and poorer outcome than pure small vessel occlusive strokes (SVO). However, the characteristics of pure SVO with irrelevant intracranial atherosclerosis (ICAS) have not been well investigated. We compared the risk factor profiles, stroke severity and outcome between SVO patients with and without irrelevant ICAS. Methods We retrospectively analyzed data of pure SVO patients admitted to Eulji hospital from October 2007 through December 2009. Pure SVO was defined as less than 2cm DWI lesion in perforator territory without parent arterial stenosis on MRA. We determined the accompanying irrelevant ICAS when any steno-occlusion was observed in any other intracranial arteries on MRA. Risk factors, initial NIHSS, 3 months modified Rankin score (mRS) were compared between SVO patients with and without irrelevant ICAS. Results Among consecutive 753 acute ischemic stroke patients during study period, 130 patients were pure SVO patients. We analyzed 101 pure SVO patients with full data set, of whom 26 patients (25.7%) showed irrelevant ICAS. DM was more prevalent in SVO patients with ICAS (15, 57.7% vs. 26, 34.7%, p<0.04). Age (73.5￠®¨u10.4 vs. 67.3￠®¨u13.9, p<0.05) and LDL level (129.5￠®¨u36.8 vs. 111.6￠®¨u34.6, p<0.03) were also higher in ICAS group. SVO patients with ICAS showed higher initial NIHSS (4.8￠®¨u4.1 vs. 2.9￠®¨u2.0, p=0.04) and poor outcome (3 months mRS >2, 44.0% vs. 21.3%, p=0.03) than those without ICAS. The differences in initial NIHSS between SVO patients with and without irrelevant ICAS remained significant after adjustment for age, DM and LDL level. Conclusions Our data suggest that SVO patients with irrelevant ICAS may suffer more severe stroke and worse clinical outcome than those without ICAS.

Cerebral infarction in a young female with renovascular hypertension suggesting fibromuscular ...

허성혁

Background & Significance: Takayasu arteritis, Moyamoya disease, and fibromuscular dysplasia are the major causes of childhood renovascular hypertension in Korea. We present a patient who had suffered from renovascular hypertension caused by fibromuscular dysplasia developed acute ischemic stroke with intracranial artery involvement. Case: A 28-year-old woman was referred to the emergency department with recurrent clumsiness of right hand and dysarthria. She had been admitted for hypertensive encephalopathy when she was 7 and 10 years old. She had been diagnosed as right renal artery stenosis due to fibromuscular dysplasia, so percutaneous transluminal ballon angioplasty was done twice. After then, she has been healthy, and she did not receive antihypertensive drugs. Only hypertension among atherosclerotic risk factors was found, and various inflammatory markers and coagulation profile were normal. Brain MRI and MR angiography showed an acute ischemic stroke on the left frontal cortex. Cerebral angiography revealed multifocal tubular vascular lesions on the orifice and middle M1 portion of left MCA. Whole aorta 3-dimentional computed tomography showed a tubular, concentric irregular narrowing of proximal right renal artery. Stenotic lesion of the right renal artery was much improved after balloon angioplasty. Conclusion: Fibromuscular dysplasia may be involved by multiple systemic vascular lesions. Therefore, childhood renovascular hypertension should be mfanaged and follow-up regularly.

Bilateral medullar infarction

Mi-young Ahn

background Bilateral medial medullary infarction (bilateral MMI) is an extremely rare cerebrovascular accident presenting with quadriplegia. We present a case of bilateral medial medullary infarction observed on horizontal MRI sections the characteristic “heart appearance” sign. Case presentation A 64-year-old man was admitted to our hospital with suddenly developed dysarthria and right hemparesis. MRI done on the first day of admission revealed anterior medullary infarction and mild stenosis of left vertebral artery. The symptoms gradually progressed to hemiplegia and newly developed left hemiparesis and tachypnea after 7 days. Follow-up MRI showed showed heart-shaped hyperintensity areas in bilateral ventral medulla. Conclusion For an early diagnosis of bilateral medial medullary infarction, it is essential to bear in mind that characteristic findings may be obtained by diffusion-weighted MRI.

Evaluations of Cerebral Hemodynamics in Patients with Moyamoya Syndrome Associated with ...

조광덕

Evaluations of Cerebral Hemodynamics in Patients with Moyamoya Syndrome Associated with Atherosclerotic Steno-occlusion of the Bilateral Middle Cerebral Arteries Kwang Deog Jo, MD, PhD1, Jong Hyeog Lee, MD2, Seung Hoon You, MD3 1Department of Neurology, 2Diagnostic Radiology, 3Neurosurgery, Gangneung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea Objectives: Moyamoya syndrome is the secondary intracranial arterial steno-occlusive disease that produces basal moyamoya-like vessels. The underlying pathology may be variable and includes atherosclerotic disease. Ischemic symptoms in patients with moyamoya syndrome are most closely related to disturbed cerebral hemodynamics, and evaluation of abnormal cerebral perfusion in these patients is therefore clinically important. We evaluated cerebral hemodynamics measured by acetazolamide challenged CT perfusion (CTP) imaging in patients with moyamoya syndrome associated with atherosclerotic steno-occlusion of the bilateral middle cerebral arteries (MCA). Methods: Three patients with moyamoya syndrome associated with atherosclerotic steno-occlusion of the bilateral proximal MCA (mean age, 81 years) underwent cranial MRI, cerebral angiography, and CTP imaging. CT examination was performed using a multidetector helical CT scanner (Light Speed 16, GE Healthcare, USA). Quantitative values of regional cerebral blood flow (rCBF), cerebral blood volume (rCBV), and mean transit time (rMTT) were measured in the bilateral anterior cerebral artery (ACA), MCA, and posterior cerebral artery (PCA) territories in the patients and in normal control (n = 3). The Cerebral vascular reserve (CVR) capacity was measured using acetazolamide. Results: The all rCBF, rCBV, and rMTT parameters were not significant different between the moyamoya syndrome group and normal controls before and after acetazolamide challenge. The CVR capacity was not significantly changed among the affected MCA, ACA, and PCA territories. Conclusions: These findings suggest that the hemodynamics in moyamoya syndrome associated with atherosclerotic steno-occlusion of the bilateral MCA was relatively preserved by abundant collateral circulation through the basal moyamoya vessels.

CADASIL presenting right leg paralysis combined with ipsilateral herniated lumbosacral disc

양충용

CADASIL presenting right leg paralysis combined with ipsilateral herniated lumbosacral disc Chung-Yong Yang, Hyo-In Park, Jae-Eun Song, Jong-Tae Park* Department of Physical Medicine and Rehabilitation, *Neurosurgery, Institute of Wonkwang Medical Science, Wonkwang University College of Medicine, Iksan, Republic of Korea Background and Significance: Cerebral Autosomal Dominant Arteriopathy with Subcortical Infarcts and Leukoencephalopathy (CADASIL) is an inherited arteriopathy with missense point mutations clustered in exon 2~11, 14, 18~20, 22~23 of the NOTCH 3 gene. There is great variability in the clinical expression of CADASIL between and within families. Clinical features include recurrent strokes, migrain, psychiatic symptom, epileptic seizure, acute reversible encephalopathy, intracranial hemorrhage and cognitive impairment. Case: Forty five year-old female had aggravated symptoms 2 months ago of low back pain with right sciatica for 8 years. She had paresthesia on right S1 sensory dermatome. The lumbar MRI revealed mild focal protruding disc herniation with mild inferior migration at the right L5/S1 causing S1 nerve root compression, and mild posterior disc bulging on L4/5. She had taken the right partial hemilaminectomy, diskectomy, foraminotomy on L5/S1 and L4/5 level. After the surgery, she improved symptoms of right anterior thigh numbness, weakness and hypesthesia. However, the symptoms of antalgic limping gait with drag, pulling sensation, hypesthesia, numbness on the right lateral thigh growed up slowly for postoperation 1 year. Persistent gait difficulty and thigh pain bring her to further neurologic evaluations. She had paralysis of grade 4/5, hypesthesia, hypertonus on right lower extremity, increased deep tendon reflex on bilateral knee and ankle, positive right Barbinski's reflex. Electrodiagnosis revealed lower lumbar radiculopathy, and the brain MRI showed cystic lesions on left anterior temporal lobe, subcortical area and posterior internal capsule with hyperintensity lesions on deep white matter, corpus callosum, central gray matter and brain stem. The Brain SPECT indicated diffuse and moderate hypoperfusion in whole brain including bilateral temporal, frontal, parietal lobes, thalami and right association cortex of occipital lobe with bilateral corticopontocerebellar diaschisis, and preserved vascular reserve. The gene study showed the mutation of c.1819C>T (p.Arg607Cys) at exon 11 on NOTCH3 gene. Younger brother 44 year-old out of 5 brothers and died her mother had stroke history. Conclusion: Authors report a new case of CADASIL combined with monoparetic lumbar disc herniation and spinal stenosis. Clinician should pay attention to make the diagnosis of lumbar radiculopathy patient with non-specific upper motor neuron sign on only one leg.

Longevity in obese hemorrhagic stroke survivors: obesity paradox in intracerebral hemorrhage

김범준

Longevity in obese hemorrhagic stroke survivors: obesity paradox in intracerebral hemorrhage Beom Joon Kim, MD,1 Seung-Hoon Lee, MD.PhD,1 Wi-Sun Ryu, MD,1 Chi Kyung Kim, MD,1 Byung-Joo Park, MD.PhD,2 Byung-Woo Yoon, MD.PhD1 1 Department of Neurology, Seoul National University Hospital 2 Department of Preventive Medicine, Seoul National University College of Medicine BACKGROUND: Obesity is widely recognized risk factors for various atherosclerotic diseases. However, recent evidence suggested an abstruse phenomenon, the obesity paradox, that obese patients tend to survive much longer than normal or underweight individuals after heart failure, coronary artery disease, acute kidney injury, or percutaneous coronary intervention. We sought to investigate whether obesity paradox also holds true in intracerebral hemorrhage (ICH) survivors. METHODS: Among a total of 1,604 ICH patients screened for eligibility of Acute Brain Bleeding Analysis (ABBA) study, which recruited participants from 33 hospitals with nationwide coverage between October 2002 and March 2004, 1,275 subjects were included in the final analysis after excluding 329 patients without clinical or imaging variables. Demographic, clinical and laboratory information was collected, and mortality status was ascertained from Korean National Death Certificates on December 31, 2006. Obesity was classified according to the WHO Western Pacific Regional Office proposition. Multivariable analyses were performed using binary logistic regression models taking 30-day mortality as a dependent variable, and Cox proportional hazard models to document independent predictors for long-term mortality. RESULTS: In the 1,275 included ICH survivors, the mean±SD of body-mass index (BMI) was 23.30±3.21 Kg/m2, and obesity classification was as following; 77 (6.0%) underweight (<18.5 Kg/m2), 528 (41.4%) normal range (18.5 – 22.9 Kg/m2), 325 (25.5%) overweight (23.0 – 24.9 Kg/m2), and 345 (27.1%) obese patients (≥25.0 Kg/m2). Mortality within 30-day after ICH occurred in 96 (7.5%) subjects, and 351 (27.5%) survivors were deceased at the end of 2006. In multivariable logistic regression analysis, BMI (OR 0.99, 95% CI 0.91 – 1.08; continuous variable) as well as underweight (OR 0.71, 95% CI 0.25 – 2.01) or obesity (OR 0.91, 95% CI 0.48 – 1.71; compared to normal weight) failed to show independent associations with 30-day mortality. However, the effect of BMI on long-term mortality remained significant (HR 0.91, 95% CI 0.87 – 0.95; continuous variable) after adjusting for confounders. Compared to ICH survivors in normal weight range, underweighted patients had a 72% more chance of dying (HR 1.72, 95% CI 1.17 – 2.52), and overweight (HR 0.70, 95% CI 0.50 – 0.98) and obese patients (HR 0.62, 95% CI 0.44 – 0.89) were identified to have a lower risk of long-term mortality. CONCLUSIONS: From our study, it was documented that obesity showed inverse relationship with long-term risk of mortality in ICH survivors.

Social Risk Factors for Hemorrhagic Stroke: post hoc analysis of Acute Brain Bleeding Analysis ...

김범준

Social Risk Factors for Hemorrhagic Stroke: post hoc analysis of Acute Brain Bleeding Analysis (ABBA) study Beom Joon Kim, MD,1 Seung-Hoon Lee, MD.PhD,1 Wi-Sun Ryu, MD,1 Chi Kyung Kim, MD,1 Byung-Joo Park, MD.PhD,2 Hee-Joon Bae, MD.PhD,3 Byung-Woo Yoon, MD.PhD1 1 Department of Neurology, Seoul National University Hospital 2 Department of Preventive Medicine, Seoul National University College of Medicine 3 Department of Neurology, Seoul National University Bundang Hospital BACKGROUND and PURPOSE: Stressful working conditions and unhealthy life styles have been speculated to increase risk of stroke. However, the influence of social risk factors on the risk of hemorrhagic stroke (HS) has not been documented. We sought to investigate the association between hemorrhagic stroke and social risk factors, such as working condition, occupation, and dietary habits, in the Acute Brain Bleeding Analysis (ABBA) cohort, a nationwide prospective hemorrhagic stroke cohort. METHODS: The ABBA study was a multicenter matched case–control study in which the cases were recruited from 33 hospitals in Korea with nationwide coverage between October 2002 and March 2004. From a total of 2,710 HS patients initially screened for eligibility, 940 subjects were finally included as HS cases, and two age- and sex- matched non-HS subjects were recruited as hospital and community controls. Highly structured questionnaires were used to collect information on year of education, family history of stroke, recent infection, working hour, working condition, type of occupation, and dietary habits. Demographic, clinical and laboratory information was also gathered. Conditional logistic regression analyses were performed to establish independent associations between HS and social risk factors with adjusting for relevant covariates. RESULTS: Multivariable conditional logistic regression analyses showed significant inverse association between HS risk and year of education (P<0.001). It was documented that subjects with 12 year of education (completed high school) had 45% lower risk (OR 0.55, 95% CI 0.38 – 0.81), subjects with 12-14 year of education (completed community college) had 33% lower risk (OR 0.67, 95% CI 0.46 – 0.98), and subjects who completed university education had 56% lower risk (OR 0.44, 95% CI 0.29 – 0.66) of HS, compared to those with less than 6 year of education. Stressful working condition was also documented to increase risk of HS, such as working hour ≥ 12 hours a day (OR 1.85; 95% CI 1.26 – 2.69; compared to < 4 hours a day), strenuous working duration ≥ 7 hours a week (OR 1.84, 95% CI 1.47 – 2.31; compared to no strenuous duration) and blue-collar occupation (OR 1.49, 95% CI 1.10 – 2.02; compared to housewives or no occupation). High salty diet (OR 1.33, 95% CI 1.10 – 1.59; compared to low salty diet) and frequent spicy food eater (OR 1.21, 95% CI 1.003 – 1.45) were also identified to increase risk of HS. CONCLUSIONS: From our study, low educated subjects who exposed to heavy work duties and unhealthy dietary habits showed higher risk of developing HS. Therefore, HS prevention strategy in the perspective of society and population should focus on incorporating safer working condition and healthier life style.

Isolated ptosis associated with thalamic hemorrhage

강진휘

Isolated ptosis associated with thalamic hemorrhage Jin-hwi Kang Chugnbuk National Hosipital University Hosipital, Jaewon Sin Chugnbuk National Hosipital University Hosipital' Mi-young Ahn Chugnbuk National Hosipital University Hosipital, Dong-ick Shin Chugnbuk National Hosipital University Hosipital, Sung-hyun Lee Chugnbuk National Hosipital University Hosipital, Sang-soo Lee Chugnbuk National Hosipital University Hosipital Background: Ptosis can result from damage to the motor system at any level that causes elevation of the levator palpebrae superioris. Supranuclear ptosis is due to cortical lesions and is called ‘cortical ptosis’. Ptosis is reported mostly after right-sided hemispheric lesion or bilateral frontal infarctions. Some authors have presented cases of ipsilateral isolated ptosis due to thalamic infarction. However, isolated ptosis without miosis and anhidrosis in thalamic hemorrhage has not been reported. We describe a patient with ipsilateral isolated ptosis with thalamic hemorrhage. Case: A 41-year-old woman was admitted to our hospital with right-sided ptosis. The neurological examination revealed right ptosis without a pupillary defect or anhidrosis and no other neurologic deficit. Brain magnetic resonance imaging revealed an intracerebral hemorrhage in the right anterolateral thalamus. Discussion: The pathophysiology of ipsilateral ptosis associated with a thalamic or cerebral hemispheric lesion is not fully understood. Based on this case and a literature review, we propose that a thalamic lesion may induce ipsilateral isolated ptosis by disrupting the thalamocortical connections.

Pure Dysarthria in acute ischemic stroke

김수경

Pure Dysarthria in acute ischemic stroke Soo-Kyoung Kim, M.D., Kwangsub Lee, M.D., Roh-Jin Hong, M.D., Heeyoung Kang, M.D., Ki-Jong Park, M.D., Oh-Young Kwon, M.D., Nack-Cheon Choi, M.D., Byeong Hoon Lim, M.D. Department of Neurology, Gyeongsang National University College of Medicin, Jinju, Korea Background and Purpose: Isolated or pure dysarthria (PD) without other neurologic signs in acute ischemic stroke is hardly detectable by CT or conventional MRI. There is little information on its anatomic specificity, spectrum of associated clinical characteristics, and etiologic mechanisms. Subjects and methods. An investigation of 6 consecutive patients with sudden onset of PD without or with only minimal other neurologic symptoms or signs among 784 patients due to a single infarction confirmed by Diffusion-weighted MRI (DWI) was conducted. Results: There were six patients (four women and two men), ranging in age from 57 to 85 years. Risk factors included hypertension in three and current cigarette smoking in one. One had patent foramen ovale with right to left shunt. Supratentorial lesions on DWI were found in 5 (83%) patients. The lesions were due to small-artery disease in 2 (33%), cardioembolism in 1 (17%) and a cryptogenic embolism etiology in 3 (50%). Lesions on DWI were found in the motor cortex, insular cortex and/or occipital cortex (n = 3), the corona radiate or centrum semi ovale (n = 2), and cerebellum (n = 1). Conclusion: Cortical involvement with/without the corticobular tract was more frequent in acute ischemic stroke patients with pure dysarthria. We suggest that the pure dysarthria syndrome has a different stroke pathogenesis including embolism in some cases, rather than a typical lacunar syndrome.

A case of Cerebral Infarction with Sildenafil Citrate Use

임정철

Background and significance : Sildenafil citrate (Viagra￠c) is widely used prescription medication for men with erection dysfunction. The relationship between use of sildenafil citrate and stroke is uncertain. Several hypotheses have been suggested that temporal hypotension, cardioembolism, and hypercoagulation are related. We report a case of cerebral infarction after sildenafil citrate use in korea. Case : A 50-year-old man presented with visual disturbance for 2 weeks. He took 25mg of sildenafil citrate and participated in sexual intercourse. The next morning, he knew left side visual disturbance when he woke up. On the neurologic examination findings were not observed other than left hemianopsia. Brain magnetic resonance image(MRI) revealed subacute infarction of the right occipital lobe and so anti-platelet medication was started. There was no stenosis or occlusion of the posterior cerebral artery in the computed tomographic angiography. The laboratory test for evaluation of coagulopathy and autoimmune disease was all within normal range. The electrocardiogram and transthoracic echocardiogram resulted in normal findings. All other evaluation for cerebral infarction was normal and left hemianopsia was not improved. Discussion : The Common side effects of sildenafil include headache, dyspepsia, flushing, rhinitis, visual disturbance, nasal congestion. And also hypotension, myocardial infarction are known as cardiovascular adverse effects. However, there are some reports of cerebrovascular event that the mechanism is still unknown. Further studies are needed to reveal the mechanism between cerebral infarction and sildenafil citrate.

Risk of micro- and macroangiopathy in type 2 diabetes mellitus: endothelial microparticle ...

정근화

While the adverse impact of diabetes on microvessels is well-known, the risks and mechanisms of macroangiopathy are less well recognized. Here, we determine the differential risk and potential biomarkers of diabetic vascular complications, i.e., micro- and macro-angiopathy. We prospectively enrolled type 2 diabetic patients, and evaluated the status of microangiopathy (retinopathy, nephropathy, and neuropathy) and macroangiopathy (cerebrovascular disease, coronary artery disease, and peripheral artery disease). Clinical, laboratory, and radiologic factors were compared among patients with no vascular complications, microangiopathic complications, and macroangiopathic complications. Various types of endothelial microparticles (EMPs) were also examined by flow cytometry using CD31, CD42b, Annexin-V (AV), and CD62E antibodies in the peripheral blood of patients. We studied 149 patients (no vascular complications [n=60], microangiopathy [n=36], macroangiopathy [n=27], and both micro- and macro-angiopathy [n=25]). Diabetes of long duration, an elevated HbA1c, and concomitant hypertension were significantly associated with the occurrence of vascular complications. The dyslipidemia and high body mass index was significantly associated with macroangiopathy, while a long duration of diabetes and a high value of HbA1c were associated with microangiopathy. The EMP (CD31+/CD42b-, CD31+/AV+) levels were greater in patients with macroangiopathy than in patients with microangiopathy and no complications. The EMP level was also a significant independent predictor of macroangiopathy in diabetic patients. The susceptibility of the diabetic patients to micro- and macro-angiopathy depends on glycemic status and associated risk factors, respectively. The measurement of EMP may be a potentially valuable tool to assess macrovascular risk in diabetic patients.

Premorbid warfarin use is related to spontaneous early improvement in patients with acute ...

윤혜원

Background & Objectives: The factors determining spontaneous early improvement in cardioembolic strokes are not well known. We investigated the incidence and determining factors of spontaneous early improvement in cardioembolic strokes. Methods: Data from 67 consecutive patients with acute cardioembolic stroke were analyzed. Inclusion criteria was a) patients admitted within the first 6 hours after symptom onset; b) evident cardioembolic stroke by SSS-TOAST classification; c) acute ischemic lesions on diffusion-weighted MRI. We defined early spontaneous improvement as a ≥4 point NIHSS score improvement from time of initial evaluation to time of thrombolysis decision. Results: Of these, 15 patients (22.4%) showed early spontaneous improvement. Premorbid warfarin use (P=0.010), D-dimer (p=0.007) and C-reactive protein (p=0.012) were significantly associated with early improvement. In a logistic regression model, premorbid warfarin use (OR: 15.21, 95% CI: 1.88-122.76) remained as an independent predictor of early improvement in cardioembolic stroke. In a subset of patients with premorbid warfarin use, there was no difference in initial international normalized ratio (INR) between early and no improvement groups. Conclusion: Premorbid warfarin use regardless of INR is independent predictor of early improvement in cardioembolic stroke.

Association of concomitant cardiac sources of embolism with a CHADS2 score in stroke patients ...

차명진

Association of concomitant cardiac sources of embolism with a CHADS2 score in stroke patients with atrial fibrillation Myoung-Jin Cha, MD, Young Dae Kim, MD, Hyo Suk Nam, MD, PhD, Ji Hoe Heo, MD, PhD Department of Neurology, Yonsei University College of Medicine, Seoul, South Korea Background Atrial fibrillation (AF) is a significant risk factor for stroke. A CHADS2 is known to predict risk of thromboembolism, and higher scores are associated with an increased risk of stroke. Patients with AF frequently accompany by other potential cardiac sources of embolism (PCSE). Risks of thromboembolism increase when concomitant PCSE presents in patients with AF. We investigated the association of concomitant PCSE with a CHADS2 score. Methods Patients who were registered to the Yonsei Stroke Registry from March 1999 to February 2010, were considered for this study. Among them, 992 consecutive patients with AF were included for the analysis. We calculated the CHADS2 score and investigated association between the CHADS2 score and the presence of PCSE in them. PCSE was based on those in Trial of Org 10172 in Acute Stroke Treatment classification. Results Of 992 stroke patients with AF, concomitant PCSE was found in 481 (48%) patients. Congestive heart failure was most common and detected in 183 (18.4%) patients, followed by spontaneous echo contrast (n=177, 17.8%), left atrium thrombus (n=59, 5.9%), mechanical prosthetic valve (n=59, 5.9%) and patent foramen ovale (n=36, 3.6%). As the CHADS2 score increased, the frequencies of akinetic left ventricular segment (p<0.05), hypokinetic left ventricular segment (p=0.003), and myocardiac infarction <4 weeks (p=0.002) increased in linear by linear association. When we dichotomized patients with high and low CHADS2 scores, those PCSE were also more common in patient with high CHADS2 scores (4,5,6) than those with low CHADS2 scores (0,1,2.3), Conclusions Concomitant PCSE that were more common in patients with higher CHADS2 scores were myocardial infarction and those that are usually associated with myocardial infarction. Considering components of the CHADS2 scores are those of risk factors for atherosclerosis, higher CHADS2 scores in patients with AF may be associated with coronary artery disease.

Effect of Antiplatelet Agent on the Progression of White Matter Change – Preliminary Study

So-Hyun Kim, Yoonjae

Background: Asymptomatic elderly commonly show the incidental white matter ischemic change on MRI. However, there is no consensus on the treatment of these patients, including the usage of antiplatelet. We performed this study to assess the effects of antiplatelet treatment on the progression of white matter change. Methods: From 2003 to 2005, subjects with white matter change only and no significant lesion on brain MRI were recruited. Patients either received antiplatelet or not according to the attending physician’s preference. Follow up brain MRI were performed in 2010. White matter change in FLAIR was blindly assessed by one investigator using Rotterdam study grading system. Result: Among 192 screened patients, 93 patients were followed and analyzed. Male was 33(35.5%) and mean age at the time of initial MR was 60.6 (47-88) years old. The interval between initial and second MR was about 5.2 years. Fifty-four(58.1%) subjects were taking antiplatelet during follow up period. Prevalence of hypertension, diabetes, hypercholesterolemia, and smoking were 29.0, 12.9, 8.6, and 4.3%, respectively. There is no differences in age, sex, MR interval, and risk factors except hypertension, which is more prevalent in those taking antiplatelets (38.9 vs. 15.4%, P=0.002). This group also showed severer baseline grade (4.6±2.2 vs. 3.2±1.9, P=0.002) and more progression of white matter change (1.1±1.4 vs. 0.7±1.1, P=0.001) compared to those without antiplatelet therapy. Conclusion: Subjects with higher white matter grade on MRI were more likely to take antiplatelet, but there was no effect on the progression of white matter change.

Further development and validation of predictive algorism for steady-state warfarin dose in ...

김응규

OBJECTIVES: The objective of this study was to validate the previous reported algorism of steady-state warfarin dose in Korean patients from the larger data set and further develop the predictive model for the randomized clinical trial of genotype-guided personalized warfarin pharmacotherapy. METHODS: Genotyping for CYP2C9*3, *13, *14 and VKORC1 -1639G>A were performed in Korean 560 patients receiving warfarin maintenance therapy for mechanical heart valve replacement(MHVR), atrial fibrillation, stroke, valvular heat disease or pulmonary embolism Multivariate linear regression was performed to model the relationships of warfarin dose with other variables and to develop a warfarin dosing algorithm. RESULTS: Previous developed model of steady state warfarin dose estimation in Korean patients with MHVR was over-predicted in other indications due to co-administration of more frequent warfarin-interacting drug. The model for steady-state warfarin dose was newly developed including the variables of CYP2C9 and VKORC1 genotype, age, body surface area, gender, co-administration of warfarin-interacting drug, concurrent congestive heart failure or cardiomyopathy and dietary supplements produced the best model for estimating steady-state warfarin dose (R2=0.64). CONCLUSIONS: This predictive model seems to be the best model for the prediction of optimum warfarin dose in Korean patients and will be evaluated in the randomized clinical trial for genotype guided warfarin therapy.

Frequency and Hemodynamic Status of Diffusion Negative Stroke

송창석

Frequency and Hemodynamic Status of Diffusion Negative Stroke Chang-Seok Song, Yoonjae Choi, Il-Gon Kim, Im-Tae Han, Chang-Gi Hong, So-Hyun Kim, Joung-Ho Rha Department of Neurology, Inha University Medical College, Incheon, Korea E-mail: salala1977@naver.com Objectives – Definite diffusion weighted image (DWI) lesion is not always identified despite the clinical setting of acute ischemic stroke. We tried to estimate the frequency and the hemodynamic status of the diffusion negative stroke. Methods – Since January 2007, we prospectively registered acute ischemic stroke within 1 week from the onset. All the patients were evaluated by neurologist and diagnosed as acute ischemic stroke or transient ischemic attack (TIA) until proven otherwise. Brain MRI and including DWI, perfusion weighted image (PWI), and MR angiography (MRA) were performed in all the patients. Patients who received thrombolytic therapy, of hemorrhagic stroke or other stoke-mimicking conditions were excluded from this study. Results – Until October 2009, 1135 acute ischemic stroke have been registered, with eighty five patients (7.5%) of initially negative DWI finding. Among them, significant stenosis/occlusion of corresponding artery on MRA were found in 21 (24%), including 12 patients (57%) with evidence of perfusion defect on PWI. Among those perfusion defect patients, in 9 patients (75%) neurologic deficit subsided within 24 hours and met the WHO criteria of TIA whereas the neurologic deficit persisted over 24 hours in 3 patients. Among the 9 patients with arterial stenosis/occlusion but no perfusion defect, 1 patient showed neurologic deficit over 24 hours, and in the remaining 8 patients (89%) the neurologic deficits subsided within 24 hours(p<0.05). Sixty four patients without significant stenosis on MRA did not show evidence of perfusion defect, and in most 61 patients (95%) neurologic deficits subsided within 24 hours, but in 3 patients the neurologic deficits persisted over 24 hours (p<0.05). Follow up MRI was taken in cases of aggravated or newly developed neurologic deficits, which were all in the perfusion defect group, and 3 patients showed newly appeared DWI lesion in the territory of perfusion defect. Conclusion – Our data provide the frequency of diffusion negative stroke, and suggests that hemodynamic status is important determinant of the clinical symptom in the DWI negative case. Patients with significant stenosis and perfusion defect are more likely to have symptom longer than 24 hours and subsequently develop acute infarction.

PENTRAXIN 3: A NOVEL, INDEPENDENT PROGNOSTIC MARKER IN PATIENTS WITH ISCHEMIC STROKE

류위선

Background Recent studies have revealed that pentraxin3 (PTX3) is one of the pattern-recognition receptor related with the initial step of immune response. In addition, clinical studies have shown that higher levels of PTX3 are associated with an increased mortality in patients with myocardial infarction and heart failure. This study aimed to elucidate the relationship between PTX3 and ischemic stroke in terms of mortality. Method This study was based on the prospective cohort of patients with ischemic stroke. From October 2002 to September 2008, we enrolled 376 eligible patients. The patients were divided into tertile according to levels of PTX3. We used Cox-regression analysis to examine hazard ratios (HR) and 95% confidence interval (CI) of tertiles of PTX3 for all-cause mortality with adjusting for age, sex, previous stroke, hypertension, diabetes mellitus, hypercholesterolemia, smoking, heart disease, admission NIHSS, and serum glucose. Results In Cox-regression analysis, compared with the first tertile of PTX3, adjusted HR of the second and third tertile for all-cause mortality were 1.65 (0.84-3.26), and 1.96 (1.02-3.78). When log transformed of PTX3 were incorporated as continuous variable, higher levels of PTX3 were also associated with an increased mortality after ischemic stroke (increase per log unit; HR, 1.32; 95% CI, 1.03-1.69). Additionally, when we excluded the patients with admission NIHSS > 4, these associations still remained significant. Conclusion In the present study, we found that the higher levels of PTX3 are associated with an increased mortality after ischemic stroke.

A Case of Joubert Syndrome Presenting with Ischemic Stroke

은미연

A Case of Joubert Syndrome Presenting with Ischemic Stroke Mi-Yeon Eun, MD, Do-Young Kwon, MD, PhD Department of Neurology, Korea University Medical Center Korea University College of Medicine Background and Significance Joubert syndrome is a rare autosomal recessive disorder characterized by hypotonia, developmental delay, ataxia, respiratory abnormality, and abnormal eye movement with typical neuroradiological findings, “molar tooth sign”. There is no report of Joubert syndrome presenting with ischemic stroke. Here, we describe a 21-year-old female patient with clinical diagnosis of Joubert syndrome showing the molar tooth sign and ischemic stroke on magnetic resonance imaging. Case A 21-year-old female patient was referred by confused mentality, general weakness, nausea, vomiting, and oliguria. She had a history of hypotonia after birth, episodic tachypnea and developmental delay. Her older brother also was reported with severe hypotonia and developmental delay. On admission, physical examination showed dysmorphic features of prominent forehead, bilateral ptosis, broad nasal bridge, mild epicanthus, and trapezoid shaped open mouth. Neurologic examination revealed confused mentality and no focal motor and sensory signs existed, however there was general weakness. On fifth hospital day, alert mentality, cognitive impairment, strabismus, oculomotor apraxia, truncal and limb ataxia were observed. Laboratory studies revealed renal dysfunction with blood urea nitrogen 38mg/dL, creatinine 6.3 mg/dL, creatine clearance 16.7 ml/min. Brain magnetic resonance imaging(MRI) demonstrated deep interpeduncular fossa, thick superior cerebellar peduncles, vermian hypoplasia compatible with “molar tooth sign” and “bat- wing” shaped enlarged fourth ventricle in the T1 weighted magnetic resonance imaging. Acute diffusion restriction lesion the right frontal subcortical area was also observed on diffusion weighted. Magnetic resonance angiography showed no stenosis or aneurysm. A clinical diagnosis of Joubert syndrome accompanied by acute ischemic stroke and acute exacerbation of chronic kidney disease was made. She was treated with antiplatelet agent, folic acid and hemodialysis. Conclusion or Comment This case is unique because this is the first report of acute ischemic stroke in Joubert syndrome patient. Our patient was relatively young age, 21-year-old, and has no conventional stroke risk factor such as hypertension, diabetes mellitus, hyperlipidemia, and potential cardiac source of embolism. This case suggests that ischemic stroke could be the manifestation of Joubert syndrome. Further studies are needed to elucidate the prevalence, subtype, and pathomechanism of stroke in Joubert syndrome.

A Case of cerebral cortical infarction associated with cortical venous thrombosis in acute ...

김주연

A Case of cerebral cortical infarction associated with cortical venous thrombosis in acute carbon monoxide poisoning Juyeon Kima, Jisun Kima, Jaekook Yooa, Kunwoo Parka, Sungwook Yua* aDepartment of Neurology, Korea University Medical Center, Korea University College of Medicine, Seoul, Republic of Korea Background & significance Carbon monoxide (CO) intoxication usually affects basal ganglia, cortical gray matter, white matter, hippocampi. However, cortical ischemia associated with cortical venous thrombosis has been rarely reported in acute CO intoxication. Here, we present a case of acute CO poisoning with cerebral cortical venous thrombosis. Case A 66 year-old man arrived at emergency room due to stuporous mentality. He slept in the room next to kitchen while brewing herbs, and was discovered collapsed in his room full of smoke about 11 hours later. His past medical history was unremarkable except hypertension. Neurologic examination revealed mild right hemiparesis with ipsilateral Babinski sign. A carboxyhemoglobin level was 14.4%. The diffusion weighted image showed cortical ischemic lesion in anterior and posterior borderzone area in left hemisphere. Interestingly, abnormal low signal intensity in cortical cerebral vein on T2*-gradient echo image was found in left parieto-occipital cortex. Bilateral globus pallidi revealed lesion in T2 weighted image. The MRA showed left distal ICA stenosis. He regained consciousness two days later but developed akinetic mutism. Conclusion This case suggests that focal cortical venous thrombosis could be a pathophysiologic mechanism of focal cortical cytotoxic edema in acute CO poisoning.

A case of lateral medullary infarction presenting as cluster-like headache

석흥열

A case of lateral medullary infarction presenting as cluster-like headache Hung Youl Seok, MD, Sung-Wook Yu, MD, PhD. Department of Neurology, Korea University College of Medicine Background & Significance; Headache is a common, although underemphasized, complaint of lateral medullary infarction (LMI). Recent studies reported headache in 54% to 76% of patients with LMI. Although sympathetic dysfunction in the form of Horner’s syndrome is a well known manifestation of LMI, signs of parasympathetic overactivity, such as eye injection, have only rarely been described in LMI. Here, we describe a unique case of LMI presenting with cluster-like headache. Case; A 46-year-old man was admitted to our hospital for evaluation of the sudden development of headache. The next day, he developed vertigo and dysphagia. The headache was throbbing in nature with moderate intensity and was localized to the left temporal area. Interestingly, the headache was constantly accompanied by ipsilateral conjunctival injection. Neurological examination showed left-sided ptosis and miosis, suggestive of left Horner’s syndrome. He also had mild truncal ataxia and left-sided incoordination. Magnetic resonance imaging revealed a wedge-shaped infarct in the left medullary region. Conclusion; We suggest that LMI should be suspected in patients with cluster-like headache, especially when the headache is accompanied by other symptoms commonly associated with LMI including Horner’s syndrome, as in our case. Moreover, performance of appropriate imaging studies to establish an accurate diagnosis should be considered in these situations.

Moyamoya Syndrome With Hyperthyroidism Presented As Seizure

김정빈

Moyamoya Syndrome With Hyperthyroidism Presented As Seizure Jung Bin Kim, Sung-Wook Yu, Ki-Young Jung, Kun-Woo Park Department of Neurology, Korea University College of Medicine Background & Significance There are reported links between Moyamoya and a wide variety of other disorders. Hyperthyroidism is one of the rare associated disorders. We report a patient of Moyamoya syndrome associated with hyperthyroidism presented as seizure. Case A forty nine-year-old woman admitted to our hospital for the first-ever generalized seizure for 1 minute. She has a history of hyperthyroidism and hypertension which have been well controlled under medication. Electroencephalography (EEG) showed no abnormal finding. Brain CT showed no definite structural lesion, however perfusion CT revealed perfusion defect in the right hemisphere. To evaluate this asymmetric finding, brain MRI and MR angiography were taken. Brain MRI showed multiple white matter ischemic changes. Brain MR angiography showed diminished bilateral distal internal carotid artery and proximal middle cerebral artery flow, more dominantly in the right hemisphere that were compatible to Moyamoya vasculopathy. Thyroid function test revealed hyperthyroidism state and anti-thyroglobulin antibody and anti-microsomal antibody were positive which findings were compatible to Grave’s disease. She is diagnosed Moyamoya syndrome associated with Grave’s disease. Also she is diagnosed breast cancer on admission. She is seizure-free under the antithyroid medication control since the first seizure attack. Conclusion There has been a few report of Moyamoya syndrome associated with Grave’s disease. In this case, the first presenting manifestation was seizure which is less common in Moyamoya syndrome. The diagnosis of Moyamoya syndrome without any definite structural lesion in the brain parenchymal image could be delayed. In our case, brain perfusion CT image which revealed asymmetric perfusion defect was helpful to perform the evaluation of vasculopathy. We report the Moyamoya syndrome patient who had presented less common manifestation with rare associated condition. Also we suggest that malignancy such as breast cancer could be an associated condition of Moyamoya syndrome whether it is an epiphenomenon or not.

Rescue intra-arterial thrombolysis for fluctuating vertebrobasilar insufficiency

김은혜

Rescue intra-arterial thrombolysis for fluctuating vertebrobasilar insufficiency Eun Hye Kim, MD, Myoung-Jin Cha, MD, Young Dae Kim, MD, Ji Hoe Heo, MD, PhD, and Hyo Suk Nam, MD, PhD Department of Neurology, Yonsei University College of Medicine Background Acute basilar artery occlusion (BAO) is associated with poor prognosis. With rare exceptions, patients usually are not treated with thrombolysis beyond 12 hours windows in cases of BAO. Case A 63-year-old man was admitted with sudden mental change. He had no past medical illness except chronic alcohol consumption. Fourteen hours before admission, his wife witnessed he could not speak any word, and showed irritability. At the emergency room of local hospital, he regained consciousness after CT scanning, and he was discharged. Next day morning, his wife found that he cannot be awakened, again. He was transferred to our hospital. On admission, neurological examination demonstrated stuporous mental state and minimal response to painful stimuli. Oculocephalic maneuver showed a medial gaze palsy on his right eye. Diffusion-weighted MR images revealed acute ischemic lesions on bilateral thalamus, which was correspond with posterior thalamoperforator and right posterior choroidal artery territory. CT angiography showed left proximal posterior cerebral artery (PCA) occlusion. After CT angiography, he regained his consciousness, again. After stroke unit admission, his mentality was decreased and became uncommunicable. Decision was made to resolve thrombus. During intra-arterial thrombolysis, thrombus form basilar top to left PCA was found. Total 600,000 unit of urokinase was infused and recanalization was achieved, after 22 hours symptom onset. On the table, he regained consciousness and resolved eye movement abnormalities. Next day examination showed alert mental state and partial right upper quadrant visual field defect. Conclusion In this case, a life-threatening thromboembolism by thalamoperporator obstruction at the basilar top, showed fluctuating mental changes without weakness. Rescue thrombolysis beyond 12 hours against basilar artery occlusion was feasible and life-saving.

Population-based Case-Control Study on Major Risk Factors for Stroke in Korea

박종무

Population-based Case-Control Study on Major Risk Factors for Stroke in Korea Jong-Moo Park1, Yong-Jin Cho2, Kyung Bok Lee3, Tai Hwan Park4, Soo Joo Lee5, Moon-Ku Han6, Youngchai Ko7, Jun Lee8, Jae-Kwan Cha9, Byung-Chul Lee10, Kyung-Ho Yu10, Mi-Sun Oh10, Ji Sung Lee11, Juneyoung Lee11, Hee-Joon Bae6 1Department of Neurology, Eulji General Hospital, Eulji University 2Department of Neurology, Ilsan Paik Hospital, Inje University College of Medicine 3Department of Neurology, Soonchunhyang University College of Medicine 4Department of Neurology, Seoul Medical Center 5Department of Neurology, Eulji University Hospital, Eulji University 6Department of Neurology, Seoul National University Bundang Hospital 7Department of Neurology, Chungbuk National University Hospital 8Department of Neurology, Yeungnam University College of Medicine 9Department of Neurology, College of Medicine, Dong-A Unversity 10Department of Neurology, Hallym University College of Medicine 11Department of Biostatistics, Korea University College of Medicine Background Relative risk (RR) and population attributable risk (PAR) of the major risk factors for stroke in Korean population has not been investigated comprehensively. Objective We examined the prevalence, RR and PAR of several risk factors for ischemic stroke through population-based case-control study. Methods The control subjects were recruited by a web-based questionnaire from April 2008 to September 2009. The cases were the consecutive acute ischemic stroke patients admitted to 10 hospitals during the same period, covering considerable areas of South Korea. Each control was matched with 2 cases for age and sex. The prevalence of hypertension, diabetes, hypercholesterolemia, smoking, atrial fibrillation, obesity, ischemic heart disease, history of stroke, and family history of stroke was investigated in both group. From adjusted odds ratio (OR) of each risk factors, RR and PAR were calculated by conditional logistic regression analysis. Results During study period 1,041 control subjects were matched with 2,082 cases. Adjusted OR of hypertension for ischemic stroke was 1.56 (95%CI, 1.38-1.76), diabetes 1.48 (1.31-1.68), smoking 1.65 (1.47-1.93), and history of stroke 1.47 (1.28-1.70). Hypercholesterolemia, atrial fibrillation, obesity, ischemic heart disease, and family history of stroke were not more prevalent in cases. The PARs were 9.83% for hypertension, 4.30% for diabetes, 9.05% for smoking, and 2.56% for stroke history. Conclusions We are reporting the prevalence and PARs of major risk factors in Korea, which can be used to set up the strategies for the prevention of the ischemic strokes effectively in Korea.

Influencing factors on drug adherence after ischemic stroke with atrial fibrillation

이경복

Influencing factors on drug adherence after ischemic stroke with atrial fibrillation Deok-Hyun Heo, M.D; Doh-Eui Kim, M.D; Ji-Sun Kim, MD; Kyung-Bok Lee, MD; Hakjae Roh, MD; Moo-Young Ahn, MD Department of Neurology, SOONCHUNHYANG University Hospital Background and objectives: Oral anticoagulation with warfarin has proved to be effective in the prevention of cerebral embolism in patients who have increased risk of cardioembolism. Although there are many factors that affect patient’s compliance and rate of follow up after discharge, these factors have rarely been systematically studied in Korea. The objective of study is to analysis of clinical factor to influence on drug compliance in acute ischemic stroke with atrial fibrillation (AF). Methods: The medical records of 82 consecutive patients admitted to SOONCHUNHYANG University Hospital between January 2005 and January 2010 for acute ischemic stroke with AF were reviewed to determine factors influencing medical adherence after discharge. The patients were categorized into two groups. Good adherence was defined as the patients who had taken anticoagulant or antiplatelet and were regularly followed up in the out-patients clinic at 3 months and 1 year after discharge, whereas poor adherence as those who stopped follow-up without transfer to other medical center. Results: Among the total 82 patients with AF, 29 patients were expired in hospitalization or during follow up period. Thirty four patients (41.5%) were visited out-patient clinic and 19 patients (23.2%) were lost. The discharge mRS (P=0.016) and region of address (P=0.063) were significant influencing factors for adherence of medication. However, other factors including age, gender and initial NIHSS were not significant. Conclusion: This study suggests that the functional status at discharge and regional accessibility to hospital may be important factor to medical adherence in the acute stroke with atrial fibrillation.

Cigarette smoking as a risk factor for atherosclerosis of intracranial arteries in acute ...

이경복

Cigarette smoking as a risk factor for atherosclerosis of intracranial arteries in acute ischemic stroke Doh-Eui Kim, M.D; Ji-Sun Kim, MD; Kyung-Bok Lee, MD; Hakjae Roh, MD; Moo-Young Ahn, MD Department of Neurology, SOONCHUNHYANG University Hospital Background and aims: Cigarette smoking has established as an important risk factor for stroke. However, this effect which was based on observational studies was controversial. We were to compare profiles of the risk factors between smokers and non-smokers, and investigate the association between smoking and cerebral atherosclerosis. Methods: From June 2004 to February 2010, we analyzed risk factors of stroke and brain MR angiography of consecutive patients with acute ischemic stroke (n=905). Smoking was classified into two categories: (1) non-smokers (never smoked regularly or stopped regular smoking ≥5 years ago) and (2) smokers (regular smoking within the last 5 years). To evaluate the influence of only smoking on intracranial stenosis, we randomly matched the patients by age, hypertension, diabetes, and hyperlipidemia. The χ2-test was used to compare the frequencies among the categories. Results: We observed a large difference in the distribution of risk factors between 670 (74%) nonsmokers and 235 (26%) smokers. Smokers (mean age: 62.83±12.03) were younger than nonsmokers (mean age: 69.91±12.24). The frequencies of hypertension and diabetes were higher in nonsmokers than in smokers: hypertension (71.0% vs 65.15%), diabetes (38.1% vs 36.2%). But frequency of hyperlipidemia was lower in nonsmokers than in smokers (18.1% vs 27.2%). After matching the patients by age, hypertension, diabetes, hyperlipidemia, smoking influence on the incidence of stenoses of intracranial vessels (nonsmokers 43.9%, smokers 52.2%, p=0.08) than those of extracranial vessels (nonsmokers 22.8%, smokers 23.3%, p=1.0). Conclusion: The frequencies of major risk factors are different between smokers and nonsmokers. Smoking might be more influence on atherosclerosis of intracranial cerebral arteries than extracranial cerebral arteries.

Hyperlipidemia may have protective effect on progression of white matter lesions

박상순

Hyperlipidemia may have protective effect on progression of white matter lesions Sang-Soon Park,1 Young Seo Kim,2 Su-Ho Lee,3 Kyusik Kang,4 Jong-Won Chung,1 Seung-Hoon Lee,1 Byung-Woo Yoon1 1Department of Neurology and clinical Research Center for Stroke, Seoul National University Hospital, Seoul, Republic of Korea 2Department of Neurology, Han Yang University Hospital, Seoul, Republic of Korea. 3Department of Neurology, Seoul Daehyo Hospital, Seoul, Republic of Korea. 4Department of Neurology, Eulji University Hospital, Seoul, Repulbic of Korea. Background and Objective We conducted a prospective study to known the natural history of wihte matter lesions(WML) in Korean and to determine which factors are associated with the progression of WML. Methods We reviewed records to identify subjectis with WML on baseline brain magnetic resonance imaging(MRI) underwent in Seoul National University between January, 2001 and December, 2003. Serial brain MRI were performed during the period of August, 2007 to July, 2009. WML were measured using semiautomated volumetric image analysis, Medical Image Processing Analysis and Visualization(MIPAV). Associations between progression of WML and study variables were analyzed. Results We identified 80 subjects (mean age 75 years, 46% male) with WML who underwent repeat MRI at an average interval of 5.7 years. In univariate and multivariable analyses, hyperlipidemia was assoicated with less progression of WML (p=0.014 and p=0.016, respectively) Conclusions In this prospective study, subjects with a history of hyperlipidemia have less progression of WML. These data support the hypothesis that hyperlipidemia may have protective effect on progression of WML. We are continuously enrolling new patients in this study.