Steroid-responsive multifocal motor neuropathy with cranial manifestations - a case report

The typical presentation of multifocal motor neuropathy (MMN) is progressive asymmetric limb weakness. Cranial neuropathy is rare. We report a 28-year-old woman with cranial and bulbar palsies but with typical electrophysiological features of MMN by multifocal motor conduction blocks and serological markers of anti-ganglioside GM1 antibodies. The previous consensus on the treatment of MMN is intravenous immunoglobulins, but our patient responded to oral steroids and had clinical and electrophysiological improvement under continuous low-dose prednisolone treatment. In summary, MMN is a treatable chronic inflammatory disease of peripheral nerves. Cranial neuropathies can be its initial presentations. Electromyography studies are crucial for MMN diagnosis and helpful in monitoring disease activity and treatment responses. Although the previous guideline did not suggest using steroids for MMN, with careful patient selection, low-dose oral steroids can be an effective treatment in patients with relatively minor symptoms. Keywords: Multifocal motor neuropathy, conduction block, bulbar palsy, cranial nerve, cranial neuropathy.

Elevated plasma neurofilament light chain in immune-mediated neurological disorders (IMND) detected by immunomagnetic reduction (IMR)

BACKGROUND

In cases of immune-mediated neurological disorders (IMND), different syndromes are associated with antibodies against neuronal surface antigens, intra-neuronal antigens, astrocytic aquaporin, and gangliosides. These autoantibodies can be pathogenic or connected to neuroinflammation and resulting neuronal injuries. This study aims to identify a blood biomarker that can detect neuronal damage in individuals with IMND. To this end, we use immunomagnetic reduction (IMR) nanobead technology to measure plasma neurofilament light chain (NfL).

METHODS

The patients with IMND were enrolled in the Chang Gung Memorial Hospital at Keelung from 2018 to 2023. Seronegative patients were excluded based on the results of antibody tests. The healthy controls (HC) were community-dwelling adults from the Northeastern Taiwan Community Medicine Research Cohort (NTCMRC) conducted by the Community Medicine Research Center of the Keelung CGMH from 2020 to 2022. IMR technique detects magnetic susceptibility via measuring magnetic signal reduction caused by antigen-antibody immunocomplex formation on magnetic nanobeads. The plasma level of NfL was determined by the magnetic susceptibility changes in IMR.

RESULTS

The study enrolled 57 IMND patients from the hospital and 73 HC participants from the communities. The plasma NfL was significantly higher in the IMND than in the HC (11.022 ± 2.637 vs. 9.664 ± 2.610 pg/mL, p = 0.004), regardless of age effects on plasma NfL in an analysis of covariance (ANCOVA) (F = 0.720, p = 0.950). In the receiver of operation curve analysis, the area under curve for plasma NfL to discriminate IMND and HC was 0.664 (95% CI = 0.549 to 0.739, p = 0.005). The subgroup analysis of plasma NfL in the IMND patients showed no difference between peripheral immune-mediated neuropathy (IMN) and central immune-mediated encephalomyelitis (IMEM) (11.331 ± 2.895 vs. 10.627 ± 2.260 pg/mL, p = 0.322), nor between tumor and non-tumor IMND (10.784 ± 3.446 vs. 11.093 ± 2.391 pg/mL, p = 0.714). Additionally, the antibody class of ganglioside antibodies in IMN did not have an impact on plasma NfL level (p = 0.857).

CONCLUSION

Plasma NfL measurement is a reliable indicator of axonal injuries in patients with IMND. It is equally effective in detecting nerve injuries in inflammatory peripheral neuropathies and central neuroinflammation. The IMR nanobead technology offers a feasible method of detecting plasma NfL, which helps identify axonal injuries in IMND.

A Myotonic Dystrophy Type I patient with Predominant Proximal Muscle Weakness without Action Myotonia- A Case Report and Review of Pathology

PURPOSE

Early distal muscle weakness and myotonia are typical clinical presentations in type I myotonic dystrophy (DM1). We present a DM1 case with unusual predominant proximal weakness without action myotonia.

CASE REPORT

The chief complaint of this 48-year-old female was difficulty in raising her arms and frequent falling in recent years. On neurological examination, proximal muscle weakness was more pronounced than the distal muscle groups, in addition to facial involvement. Although she did not experience any action myotonia throughout her life, hand and tongue myotonia were readily inducible by percussion during neurological examination. The diagnosis of DM1 was later supported by electromyography and neuropathological studies, and confirmed by molecular testing. The pathological findings in this patient and the characteristic features in typical DM1 patients were briefly reviewed.

CONCLUSION

The unusual presentation of this DM1 patient suggests the importance of comprehensive neurological examination including percussion of thenar and tongue muscles, even in a patient with atypical distribution of muscle weakness and without a clear personal and family history of myotonia. In addition to molecular testing, muscle biopsy remains supportive in making the diagnosis.

Case Report: Plasma Biomarkers Reflect Immune Mechanisms of Guillain-Barré Syndrome

This case series reported a group of patients with Guillain–Barré syndrome (GBS) and their plasma cytokine changes before and after immunotherapy. We aimed to understand GBS's pathogenesis and pathophysiology through observing the interval differences of the representative cytokines, which were the thymus and activation regulated chemokine (TARC) for T-cell chemotaxis, CD40 ligand (CD40L) for cosimulation of B and T cells, activated complement component C5/C5a, and brain-derived neurotrophic factor (BDNF) for survival and regenerative responses to nerve injuries. The fluorescence magnetic bead-based multiplexing immunoassay simultaneously quantified the five cytokines in a single sample. From June 2018 to December 2019, we enrolled five GBS patients who had completed before–after blood cytokine measurements. One patient was diagnosed with paraneoplastic GBS and excluded from the following cytokine analysis. The BDNF level decreased consistently in all the patients and made it a potential biomarker for the acute stage of GBS. Interval changes of the other four cytokines were relatively inconsistent and possibly related to interindividual differences in the immune response to GBS triggers, types of GBS variants, and classes of antiganglioside antibodies. In summary, utilizing the multiplexing immunoassay helps in understanding the complex immune mechanisms of GBS and the variation of immune responses in GBS subtypes; this method is feasible for identifying potential biomarkers of GBS.

Detecting Glaucoma With a Portable Brain-Computer Interface for Objective Assessment of Visual Function Loss

Importance

The current assessment of visual field loss in diseases such as glaucoma is affected by the subjectivity of patient responses and the lack of portability of standard perimeters.

Objective

To describe the development and initial validation of a portable brain-computer interface (BCI) for objectively assessing visual function loss.

Design, Setting, and Participants

This case-control study involved 62 eyes of 33 patients with glaucoma and 30 eyes of 17 healthy participants. Glaucoma was diagnosed based on a masked grading of optic disc stereophotographs. All participants underwent testing with a BCI device and standard automated perimetry (SAP) within 3 months. The BCI device integrates wearable, wireless, dry electroencephalogram and electrooculogram systems and a cellphone-based head-mounted display to enable the detection of multifocal steady state visual-evoked potentials associated with visual field stimulation. The performances of global and sectoral multifocal steady state visual-evoked potentials metrics to discriminate glaucomatous from healthy eyes were compared with global and sectoral SAP parameters. The repeatability of the BCI device measurements was assessed by collecting results of repeated testing in 20 eyes of 10 participants with glaucoma for 3 sessions of measurements separated by weekly intervals.

Main Outcomes and Measures

Receiver operating characteristic curves summarizing diagnostic accuracy. Intraclass correlation coefficients and coefficients of variation for assessing repeatability.

Results

Among the 33 participants with glaucoma, 19 (58%) were white, 12 (36%) were black, and 2 (6%) were Asian, while among the 17 participants with healthy eyes, 9 (53%) were white, 8 (47%) were black, and none were Asian. The receiver operating characteristic curve area for the global BCI multifocal steady state visual-evoked potentials parameter was 0.92 (95% CI, 0.86-0.96), which was larger than for SAP mean deviation (area under the curve, 0.81; 95% CI, 0.72-0.90), SAP mean sensitivity (area under the curve, 0.80; 95% CI, 0.69-0.88; P = .03), and SAP pattern standard deviation (area under the curve, 0.77; 95% CI, 0.66-0.87; P = .01). No statistically significant differences were seen for the sectoral measurements between the BCI and SAP. Intraclass coefficients for global and sectoral parameters ranged from 0.74 to 0.92, and mean coefficients of variation ranged from 3.03% to 7.45%.

Conclusions and Relevance

The BCI device may be useful for assessing the electrical brain responses associated with visual field stimulation. The device discriminated eyes with glaucomatous neuropathy from healthy eyes in a clinically based setting. Further studies should investigate the feasibility of the BCI device for home-based testing as well as for detecting visual function loss over time.

Polychromatic SSVEP stimuli with subtle flickering adapted to brain-display interactions

OBJECTIVE

Interactive displays armed with natural user interfaces (NUIs) will likely lead the next breakthrough in consumer electronics, and brain-computer interfaces (BCIs) are often regarded as the ultimate NUI-enabling machines to respond to human emotions and mental states. Steady-state visual evoked potentials (SSVEPs) are a commonly used BCI modality due to the ease of detection and high information transfer rates. However, the presence of flickering stimuli may cause user discomfort and can even induce migraines and seizures. With the aim of designing visual stimuli that can be embedded into video images, this study developed a novel approach to induce detectable SSVEPs using a composition of red/green/blue flickering lights.

APPROACH

Based on the opponent theory of colour vision, this study used 32 Hz/40 Hz rectangular red-green or red-blue LED light pulses with a 50% duty cycle, balanced/equal luminance and 0°/180° phase shifts as the stimulating light sources and tested their efficacy in producing SSVEP responses with high signal-to-noise ratios (SNRs) while reducing the perceived flickering sensation.

MAIN RESULTS

The empirical results from ten healthy subjects showed that dual-colour lights flickering at 32 Hz/40 Hz with a 50% duty cycle and 180° phase shift achieved a greater than 90% detection accuracy with little or no flickering sensation.

SIGNIFICANCE

As a first step in developing an embedded SSVEP stimulus in commercial displays, this study provides a foundation for developing a combination of three primary colour flickering backlights with adjustable luminance proportions to create a subtle flickering polychromatic light that can elicit SSVEPs at the basic flickering frequency.

Association between Atrial Fibrillation and Three-Year Mortality in Nondiabetic Patients with Acute First-Ever Ischemic Stroke

BACKGROUND

Diabetes mellitus (DM) is a risk factor for atrial fibrillation (AF) and is known to be an important risk factor for death from stroke. The influence of AF on long-term outcomes in patients with ischemic stroke remains controversial. To clarify the exact influence of AF on stroke outcome and exclude the effect from DM, we investigated the influence of AF on the 3-year outcomes of nondiabetic patients with acute first-ever ischemic stroke.

METHODS

Five-hundred seventy-four nondiabetic patients with acute first-ever ischemic stroke were enrolled and had been followed for 3 years. Patients were divided into 2 groups according to whether AF was diagnosed or not. Clinical presentations, risk factors for stroke, laboratory data, comorbidities, and outcomes were recorded.

RESULTS

A total of 107 patients (18.6%) had AF. The age was significantly older in patients with AF. Total anterior circulation syndrome occurred more frequently among patients with AF (P < .001). The mean length of stay in the acute ward was significantly higher in patients with AF (P < .001). Furthermore, dependent functional status following discharge was higher in patients with AF (P < .001). Multivariate Cox regression revealed that AF is a significant predictor of 3-year all-cause mortality (hazard ratio = 1.98, 95% confidence interval = 1.07-3.67, P = .022).

CONCLUSIONS

AF is associated with increased risk of 3-year mortality in nondiabetic patients with acute first-ever ischemic stroke. Careful cardiac evaluation and treatment are essential in patients with AF and stroke.

Association between pneumonia in acute stroke stage and 3-year mortality in patients with acute first-ever ischemic stroke

The influence of pneumonia in acute stroke stage on the clinical presentation and long-term outcomes of patients with acute ischemic stroke is still controversial. We investigate the influence of pneumonia in acute stroke stage on the 3-year outcomes of patients with acute first-ever ischemic stroke. Nine-hundred and thirty-four patients with acute first-ever ischemic stroke were enrolled and had been followed for 3years. Patients were divided into two groups according to whether pneumonia occurred during acute stroke stage or not. Clinical presentations, risk factors for stroke, laboratory data, co-morbidities, and outcomes were recorded. The result showed that a total of 100 patients (10.7%) had pneumonia in acute stroke stage. The prevalence of older age, atrial fibrillation was significantly higher in patients with pneumonia in acute stroke stage. Total anterior circulation syndrome and posterior circulation syndrome occurred more frequently among patients with pneumonia in acute stroke stage (P<0.001 and P=0.009, respectively). Multivariate Cox regression revealed that pneumonia in acute stroke stage is a significant predictor of 3-year mortality (hazard ratio=6.39, 95% confidence interval=4.03-10.11, P<0.001). In conclusion, pneumonia during the acute stroke stage is associated with increased risk of 3-year mortality. Interventions to prevent pneumonia in acute stroke stage might improve ischemic stroke outcome.

Association between renal dysfunction and 3-year mortality in patients with acute first-ever ischemic stroke

OBJECTIVE

The influence of renal dysfunction on the clinical presentation and outcomes of patients with acute ischemic stroke is still controversial. We investigate the influence of renal dysfunction on the outcomes of patients with acute first-ever ischemic stroke.

METHODS

Nine-hundred thirty-four patients with acute first-ever ischemic stroke were enrolled and followed for 3 years. Renal function was assessed using the equation of the Modification Diet for Renal Disease for estimated glomerular filtration rate (eGFR). Serum creatinine levels were obtained within 3 days of acute stroke onset. Reduced eGFR was defined as eGFR<60ml/min/1.73m(2). Clinical presentation, risk factors for stroke, laboratory data, co-morbidities, and outcomes were recorded.

RESULTS

Total 264 patients (28.3%) had a reduced eGFR. The prevalence of older age, hypertension, and atrial fibrillation was significantly higher in patients with a reduced eGFR. Total anterior circulation syndrome occurred more frequently among patients with a reduced eGFR (P=0.010). Multivariate Cox regression revealed that a reduced eGFR is a significant predictor of 3-year mortality (HR=1.67, 95% CI=1.06-2.62, P=0.026).

CONCLUSION

Reduced eGFR during the acute stroke stage is associated with increased risk of 3-year mortality. Furthermore, risk of acute complications and poor functional outcomes following discharge was significantly higher in patients with a reduced eGFR.

Habituation of steady-state visual evoked potentials in response to high-frequency polychromatic foveal visual stimulation

In an attempt to develop safe and robust methods for monitoring migraineurs' brain states, we explores the feasibility of using white, red, green and blue LED lights flickering around their critical flicker fusion (CFF) frequencies as foveal visual stimuli for inducing steady-state visual evoked potentials (SSVEP) and causing discernible habituation trends. After comparing the habituation indices, the multi-scale entropies and the time dependent intrinsic correlations of their SSVEP signals, we reached a tentative conclusion that sharp red and white light pulses flickering barely above their CFF frequencies can replace commonly used 13Hz stimuli to effectively cause SSVEP habituation among normal subjects. Empirical results showed that consecutive short bursts of light can produce more consistent responses than a single prolonged stimulation. Since these high frequency stimuli do not run the risk of triggering migraine or seizure attacks, further tests of these stimuli on migraine patients are warranted in order to verify their effectiveness.

Association of hyponatremia in acute stroke stage with three-year mortality in patients with first-ever ischemic stroke

BACKGROUND

Hyponatremia is the most common electrolyte disorder in hospitalized patients, and is frequently a marker of a significant underlying disease. The prognostic value of hyponatremia in patients with acute first-ever ischemic stroke is not known. We aimed to analyze whether hyponatremia in the acute stroke stage contributed to the risk of mortality or recurrent stroke in these patients.

METHODS

We studied 925 patients presenting with acute first-ever ischemic stroke between 2002 and 2004. Sodium levels were obtained on arrival at the emergency room within 3 days of acute stroke onset. Hyponatremia was defined as a serum sodium concentration of 134 mmol/l or less. Clinical presentation, stroke risk factors, associated medical disease, and outcome were recorded. All patients were followed for 3 years for survival analysis. A multivariate Cox proportional hazards model was used to identify risk factors for 3-year mortality in these patients. We also constructed Kaplan-Meier survival curves, and compared groups with hyponatremia and normonatremia by means of log rank tests for significant differences.

RESULTS

Among the patients with acute first-ever ischemic stroke, 107 (11.6%) were hyponatremic. Among stroke risk factors, the prevalence of diabetes mellitus was significantly higher among hyponatremic patients (p < 0.001). Prevalence of chronic renal insufficiency was also higher in the hyponatremic group (p = 0.002). Clinical presentations, such as the length of acute ward stay, initial impaired consciousness, and clinical course in acute stroke were similar among normo- and hyponatremic patients. Among the complications, pneumonia and urinary tract infection were significantly higher in hyponatremic than in normonatremic patients. After multivariate logistic regression analysis, diabetes mellitus and chronic renal insufficiency were associated with hyponatremia in these patients. Kaplan-Meier analysis indicated that the survival rate was significantly lower in hyponatremic patients than in normonatremic patients (log rank test; p value <0.001). After multivariate Cox proportional hazards model analysis, hyponatremia was a significant predictor of 3-year mortality in these patients after adjustment for related variables (p value = 0.003, hazard ratio = 2.23, 95% confidence interval: 1.30-3.82).

CONCLUSION

Hyponatremia in the acute stroke stage is a predictor of 3-year mortality in patients with acute first-ever ischemic stroke that is independent of other clinical predictors of adverse outcome.

Effect of neurotization upon degree of sensory recovery in toe-to-hand microvascular transplantation

The relationship between the number of myelinated nerve fibers from the hand that are reinnervating the distal glabrous skin of the toe and the number of myelinating nerve fibers originally innervating that toe target was investigated utilizing the toe-to-hand microvascular transplantation model. Digital nerve biopsy specimens suitable for morphometric analysis were obtained from the hand and toe at the time of surgery from 15 patients. Patients received sensory reeducation in the postoperative period to standardize rehabilitation. At a mean of 10.8 months after surgery, the degree of sensory recovery was determined by the hand therapist. Morphometric analysis was done by a neurologist blinded as to final sensory outcome. There was a statistically significant relationship between recovered moving two-point discrimination and ratio of the total number of reinnervating (neurotizing) finger axons compared with the original toe axons (r = 0.703, p < 0.003). A similar relationship was observed for static two-point discrimination (r = 0.802, p < 0.001). These results suggest that degree of sensory recovery in toe-to-hand transfer may be improved by increasing the number of reinnervating myelinated nerve fibers from the hand that neurotizes the free tissue transfer.

Oculopharyngeal muscular dystrophy --an under-diagnosed disease in China? Report a China-born Chinese with PABPN1 mutation and epidemiology review of the literature

BACKGROUND/PURPOSE

Most reports about oculopharyngeal muscular dystrophy (OPMD) have been contributed by occidental countries, and most of the victims of this disease are racially white. In contrast, this disorder is rarely seen in Asians and has only one African report. Consequently, OPMD has been regarded as a disease of the Western world. The purpose of this paper is to challenge the accuracy of this concept.

METHODS

In a Chinese immigrant family, 3 patients manifesting signs related to OPMD were examined. Electromyography, nerve conduction studies, muscle biopsy and genetic analysis were performed on the proband. All the 322 papers about OPMD were reviewed and their country of origin was labeled to perceive the approximate prevalence of OPMD. Countries were categorized into groups according to the continents to which they belonged.

RESULTS

The proband's muscle histopathology showed small angulated fiber with rimmed vacuoles, ultrastructural pathology exposed filamentous intranuclear inclusions, and genetic analysis of the polyadenylate binding protein nuclear 1(PABPN1) gene revealed 13 GCG trinucleotide repeats in one allele (GCG)13 while being normal in the other. The survey of the country of origin of OPMD reports showed that 80% of these papers were contributed by occidental countries and that the number of publications of OPMD among countries of Americas and Asia were unequal, when compared to those of European countries, which were fairly proportioned. An epidemiologic review of the literature is presented and the prevalence of OPMD is discussed.

CONCLUSION

This is a China-born Chinese patient with both morphologically and genetically proven of OPMD. The very low OPMD report rate in developing countries of East Asia is due to the unfamiliarity of medical workers to OPMD and the unavailability of medical supplies to confirm the diagnosis. In addition, the present and previous reports provide clear evidence that OPMD in these areas is underdiagnosed.

Microneurosurgical planning in toe-to-hand transplantation: axonal population of digital nerves in the fingers and toes

Although toe-to-hand microvascular transplantation is now an accepted and successful reconstructive strategy for the thumb, there remains varying success in recovery of sensibility. The purpose of the present study was to provide an anatomic basis for analyzing neurotization of the great toe or the second toe with the digital nerves of the fingers and hand. Axon counts were obtained from donor and recipient nerves during reconstructive procedures. Sixty-seven upper- and eighty lower-extremity nerves were analyzed. No statistical difference was found between the mean number of axons between the thumb and the index finger; however, the thumb had significantly more (p < 0.001) axons than the middle or the ring finger. The great toe had significantly more axons than the second toe (p < 0.001). The common plantar digital nerve had significantly more axons than a digital nerve (p < 0.001). The thumb had significantly more axons than the great toe (p < 0.001). The thumb had significantly more axons than the second toe (p < 0.001). Numerical data are now available for strategic planning of toe transplantation, and direct neurotization from the dorsum of the hand to the digits.

Higher leukocyte count is associated with higher risk of 3-year mortality in non-diabetic patients with first-ever ischemic stroke

Leukocyte count predicted the risk of first-time myocardial infarction and ischemic stroke. The aim of this study was to determine the role of elevated leukocyte count in non-diabetic patients admitted for acute first-ever ischemic stroke on clinical presentation and 3-year mortality. We studied 462 patients with acute first-ever ischemic stroke without diabetes mellitus or active infection at admission. Patients were classified into 2 groups according to their leukocyte count. A white blood cell (WBC) count ≥ 10,000/μL was defined as an elevated leukocyte count, otherwise as normal. Clinical presentation, risk factors for stroke, laboratory data, co-morbidities, and outcomes were recorded. 64 patients (13.9%) had elevated leukocytes. Multivariate logistic regression showed that an elevated platelet count was positively associated with the elevated leukocyte count, while a low serum sodium level was negatively associated with an elevated leukocyte count (P=0.008, P=0.003, respectively). An elevated leukocyte count was associated with a higher risk of a stroke in evolution (P=0.021). Multivariate Cox regression analysis revealed that an elevated leukocyte count is a significant predictor of 3-year mortality [P=0.010, HR=3.26 (1.33-7.98)]. In conclusion, higher leukocyte counts during the acute stroke stage are associated with increased risk of 3-year mortality in patients with acute, first-ever ischemic stroke.

SNR analysis of high-frequency steady-state visual evoked potentials from the foveal and extrafoveal regions of human retina

With brain-computer interface (BCI) applications in mind, we analyzed the amplitudes and the signal-to-noise ratios (SNR) of steady-state visual evoked potentials (SSVEP) induced in the foveal and extra-foveal regions of human retina. Eight subjects (age 20-55) have been exposed to 2° circular and 16°-18° annular visual stimulation produced by white LED lights flickering between 5Hz and 65Hz in 5Hz increments. Their EEG signals were recorded using a 64-channel NeuroScan system and analyzed using non-parametric spectral and canonical convolution techniques. Subjects' perception of flickering and their levels of comfort towards the visual stimulation were also noted. Almost all subjects showed distinctively higher SNR in their foveal SSVEP responses between 25Hz and 45Hz. They also noticed less flickering and felt more comfortable with the visual stimulation between 30Hz and 45Hz. These empirical evidences suggest that lights flashing above the critical flicker fusion rates (CFF) of human vision may be used as effective and comfortable stimuli in SSVEP BCI applications.

The impact of smoking on the severity of acute ischemic stroke

OBJECTIVES

This study investigated the impact of smoking on the initial severity of acute ischemic stroke and examined its subsequent outcome.

METHODS

Patient data was collected from the Stroke Registry in the Chang Gung Healthcare System (SRICHS). A total of 2650 patients admitted for acute ischemic stroke from January to December 2009 were included. Baseline characteristics were compared between smokers and non-smokers. Factors affecting the initial severity and the recovery from neurological deficit were examined by logistic regression analysis. The patients were further divided according to stroke mechanism for subgroup analysis.

RESULTS

The total number of smokers and non-smokers was 817 (31.9%) and 1833 (69.1%), respectively. Univariate analysis showed that smokers had lower NIHSS scores on admission than did non-smokers (P<0.001). In subgroup analysis, smokers with small-vessel occlusions frequently had higher NIHSS scores on admission than did non-smokers (P=0.001). However, smokers with cardioembolic stroke had lower NIHSS scores on admission as compared to non-smokers (P=0.024). No subgroup had smoking as a significant factor for neurological recovery during hospitalization.

CONCLUSIONS

Smoking correlated with higher NIHSS scores on admission for small-vessel occlusion. Conversely, it was associated with lower NIHSS scores on admission for cardioembolism.

Autosomal dominant late-onset quadriceps myopathy: three patients of a Taiwanese kindred

OBJECTIVE

Primary quadriceps weakness/atrophy is a rare disorder with variable etiologies; therefore, this disorder has been regarded as a clinical syndrome rather than a distinct entity. However, three affected patients of a Taiwanese family demonstrate a uniform pattern of quadriceps weakness and atrophy, their clinical manifestations and pattern of inheritance may suggest a new disease entity.

PATIENTS AND METHODS

Three patients in a Taiwanese kindred with selective quadriceps weakness and atrophy, which began after age 40 years, were examined. To disclose the confines of this disorder, muscle CT scans, electromyography, nerve conduction studies and muscle biopsies were performed; and to unravel and better understand the nature of this disorder, histopathological, ultrastructural, immunocytochemical and genetic studies were carried out.

RESULTS

In two patients with long-standing disease, muscle imaging showed marked atrophy and fat replacement of the anterior thigh muscles and electromyography showed a mixture of myopathic and neuropathic changes. Muscle histopathology on the mildly affected tibialis anterior showed myopathic changes with myofibrillar degeneration and secondary neurogenic alterations. Immunocytochemical staining was not diagnostic but excluded the dystrophinopathies and other well-known muscular dystrophies.

CONCLUSION

All previously identified diseases resulting in quadriceps weakness and atrophy have been ruled out and the present disorder appears to be a new disease entity of autosomal dominant late onset quadriceps myopathy.

Pituitary adenoma apoplexy with initial presentation mimicking bacterial meningoencephalitis: a case report

Pituitary apoplexy is a rare but life-threatening disorder. Clinical presentation of this condition includes severe headache, impaired consciousness, fever, visual disturbance, and variable ocular paresis. Signs of meningeal irritation are very rare. However, if present and associated with headache, fever, and pleocytosis, meningeal irritation may lead to misinterpretation as infectious meningoencephalitis. To the best of our knowledge, pituitary apoplexy with an initial presentation mimicking infectious meningoencephalitis had rarely been reported in the literature. Here, we report a 57-year-old man who had acute severe headache, high fever, neck stiffness, disturbance in consciousness, and left ocular paresis. Laboratory data showed leukocytosis, an elevated C-reactive protein level, and neutrophilic pleocytosis in the cerebrospinal fluid. Because bacterial meningoencephalitis was suspected, empiric antibiotic therapy was administered but in vain. Further examinations indicated a diagnosis of pituitary adenoma with apoplexy. After the immediate administration of intravenous corticosteroid supplement and surgical decompression, the patient recovered.

Predictive factors of outcome and stroke recurrence in patients with unilateral atherosclerosis-related internal carotid artery occlusion

BACKGROUND

Clinical outcome of internal carotid artery (ICA) occlusion is highly variable and the reason is uncertain.

AIM

To study the predictive factors of clinical outcome and stroke recurrence in patients with ischemic stroke associated with unilateral atherosclerosis-related ICA occlusion.

SETTINGS AND DESIGN

Prospective study in neurology department of a single hospital.

MATERIALS AND METHODS

We prospectively studied 66 patients who suffered from first-ever ischemic stroke associated with unilateral atherosclerosis-related ICA occlusion over a period of two years. The end point was death or stroke recurrence.

STATISTICAL ANALYSIS

Chi-square or Fisher's exact test was used to analyze predictors of early functional outcome. Multivariate analysis was used to analyze predictors of death or stroke recurrence within two years.

RESULT

Higher age (>or=70 years) predicted a worse functional outcome (P=0.049). Total anterior circulation syndrome (TACS) was associated with a poor functional outcome (P<0.001), but lacunar syndrome had a better outcome (P=0.001). Stroke in evolution predicted a poor outcome (P=0.001), while those with symptom improvement had a better outcome (P=0.016). Pneumonia predicted a poor outcome (P=0.021). Five patients expired and 22 patients suffered from recurrent stroke in the following 24 months. Previous transient ischemic attack (TIA) and anemia were associated with a higher risk of death or recurrent stroke within two years (P=0.036, P=0.012).

CONCLUSION

High age, TACS, stroke in evolution and pneumonia were predictors for poor functional outcome. Previous TIA and anemia were predictors for death and recurrent stroke within two years.

Synthesis and properties of 9,9-diarylfluorene-based triaryldiamines

[reaction: see text] 9,9-Diaryl-2,7-dibromofluorene was synthesized by a triflic acid promoted Friedel-Crafts reaction. Introduction of diarylamino groups at its C2 and C7 positions by a Pd-catalyzed amination results in the formation of a novel class of triaryldiamines. The 9,9-diaryl substituents at the central linkage play a less important role in the photophyscial properties but affect the oxidation potential and improve the morphological stability of these new triarylamines.

Herniated blastomere following chemically assisted hatching may result in monozygotic twins

OBJECTIVE

To explore a possible mechanism of the increasing incidence of monozygotic twins following assisted hatching of human embryos.

DESIGN

Case report.

SETTING

Clinical research center in a medical school teaching hospital.

PATIENT

A 37-year-old infertile woman with repeated IVF failures.

INTERVENTION(S)

Assisted hatching of the day 3 embryos using acidic Tyrode's solution.

MAIN OUTCOME MEASURE(S)

The morphology of the zona-drilled embryos and the pregnancy outcome.

RESULT(S)

After assisted hatching, a herniated blastomere through an oversized opening in the zona pellucida was found in one embryo. The transfer of two zona-drilled embryos resulted in a triplet pregnancy.

CONCLUSION(S)

Large openings in the zona pellucida following chemically assisted hatching may cause premature hatching of the blastomeres and may be implicated in the occurrence of monozygotic twins.

Concurrent thrombosis of cerebral and femoral arteries in a patient with nephrotic syndrome

Although venous thrombosis is a frequently encountered problem in nephrotic syndrome, the occurrence of arterial thrombosis is much less common, and is usually associated with a poor prognosis. To the best of our knowledge, there has been only one reported case of concurrent cerebral and femoral artery thrombosis, that of a 23-year-old male who finally died. Herein, we report a case of a 35-year-old woman with nephrotic syndrome. She developed cerebral and femoral arterial thrombosis simultaneously when the nephrotic syndrome relapsed. Immediate thrombectomy of the femoral artery, followed by anticoagulation and immunosuppressive therapy, were employed. The patient recovered completely and is now doing well. Our experience indicates that multiple artery thrombosis in nephrotic patients may not necessarily carry a poor outcome if early and aggressive treatment can be undertaken.

Baclofen toxicity in patients with severely impaired renal function

OBJECTIVE

To report the toxic effects of baclofen in patients with severely impaired renal function.

DATA SOURCES

From 1991 to 1995, nine patients with severely impaired renal function (2 not receiving dialysis, 1 undergoing continuous ambulatory peritoneal dialysis [CAPD], and 6 receiving maintenance hemodialysis), who exhibited clinical toxicity after baclofen therapy at our hospital were included for analysis. Another seven cases from the literature obtained by computerized (MEDLINE) and manual (Index Medicus) search methods published between 1980 and 1995 were also reviewed.

INTERVENTION

Among our nine patients, the six undergoing chronic hemodialysis and one not undergoing dialysis received early (< 48 h) hemodialysis after toxic symptoms developed. The patient undergoing CAPD received late hemodialysis (> 72 h), and the other patient who had not undergone dialysis received only supportive care.

RESULTS

A review of these 16 cases revealed that most patients received only small doses and very short-term baclofen therapy. Altered consciousness was the major presenting feature. Severe acute complications, such as seizures and respiratory depression, were relatively uncommon among patients with severely impaired renal function. However, abdominal pain, which has previously rarely been reported, was noted in five of our nine patients. Most patients showed clinical improvement after hemodialysis. An analysis of these nine patients revealed that those who received early hemodialysis had a shorter recovery time than the patient who received only supportive care (2.71 +/- 0.42, respectively, vs. 9 d; p < 0.01). A lag of several hours between the end of the hemodialysis session and an improvement in the level of consciousness was noted.

DISCUSSION

As most patients with severely impaired renal function developed toxic symptoms soon after initiating a low-dose baclofen regimen, the accumulated dosage was small and severe complications were less common. Abdominal pain may have occurred as a result of the gamma-aminobutyric acid-mediated cholinergic effect exerted by baclofen. The delay in conscious recovery after hemodialysis may be due to a delay in the clearance of baclofen from the central nervous system.

CONCLUSIONS

Patients with severely impaired renal function generally develop baclofen intoxication soon after the initiation of low-dose therapy. Thus, the administration of baclofen, regardless of the dosage, in these patients is not appropriate. Abdominal pain, in addition to altered consciousness, is a common presenting feature in patients with renal failure who have baclofen intoxication. Hemodialysis is effective in alleviating the clinical symptoms and shortening the recovery time for such patients.

Coexistence of cerebral venous sinus and internal carotid artery thrombosis associated with exogenous sex hormones. A case report

A forty-six year-old premenopausal woman developed headache, nausea and vomiting, left hemiparesis and seizure two days after parenteral use of progesterone and estradiol. Diabetes mellitus (DM) was found during admission. Computed tomography showed a hemorrhagic infarct in the right frontal lobe and increased density in the superior sagittal sinus (SSS). Left carotid angiography found occlusion of the left internal carotid artery (ICA). Right carotid angiograms failed to show the SSS and inferior sagittal sinus, suggestive of venous sinus thrombosis. Coexistence of the cerebral artery and the venous sinus occlusion has been described infrequently. In this case, the authors postulate that the use of estradiol and progesterone and the underlying DM increased vascular thrombogenicity, which provided a common denominator for thrombosis of both the ICA and the venous sinus.

Ginseng-associated cerebral arteritis

We report a 28-year-old woman who had a severe headache after ingesting a large quantity of ethanol-extracted ginseng. Cerebral angiograms showed "beading" appearance in the anterior and posterior cerebral and superior cerebellar arteries, consistent with cerebral arteritis. The close temporal association between intake of ginseng and cerebral arteries suggests a causal relationship.

Successful treatment of hereditary progressive dystonia--a case report

Hereditary progressive dystonia or Segawa disease is a very rare disease. Diagnosis depends on typical clinical features with remarkably good response to levodopa and normal laboratory findings. Here, we report on a unique case of Segawa disease with a fixed equinovarus foot. The patient was a twenty one year old female with the typical clinical manifestations since eight years of age who became wheel-chair dependent at the age of fifteen. The dystonia responded well to levodopa except for the foot deformities. The foot deformities were successfully corrected by use of the Ilizarov apparatus and she ambulated freely at follow up. Since several similar foot deformities appeared in the early stage of a progressive neurological degenerative disease, the treatable Segawa disease should be added to the differential diagnosis when facing a patient with pes equinovarus.

Vertebrobasilar insufficiency related to cervical spondylosis. A case report and review of the literature

A 64-year-old man suffered from symptoms of vertebrobasilar insufficiency (VBI) while turning his head to the left. Roentgenograms of the cervical spines showed severe spondylosis. Cerebral angiography demonstrated compression of the left vertebral artery by osteophytes of the cervical spine when the patient turned his head to the left. He was treated surgically by fixation of the vertebral bodies with good relief of symptoms during one year of follow-up. VBI induced by spondylotic compression of the vertebral artery is uncommon. We therefore reviewed the literature and suggested a more simple method of operation.

Immunohistochemical study of dystrophin in neuromuscular disorders

Dystrophin, a protein product of the gene that is affected in Duchenne/Becker muscular dystrophy (DMD/BMD), is localized on the sarcolemma of muscle fibers. We tried to study various neuromuscular disorders, including DMD/BMD and their carriers, by the immunohistochemical method with two types of anti-dystrophin antibodies. No dystrophin stain was found on the muscles of cases of DMD. In cases of BMD, partial deficiency or a mosaic appearance of dystrophin was found. In members of DMD/BMD families, polyclonal antibody stains did not show definite membrane abnormality. However, partial deficiency or a mosaic appearance of dystrophin on muscle membranes was found in the carriers by a monoclonal anti C-terminal antibody stain. The explanation may be: 1) more non-specific antigen-antibody cross reactions occurred in the polyclonal antibody stain; and 2) a partial defect exists, such as a segmental deletion of the C-terminal portion of dystrophin. Dystrophin study in muscle diseases is a helpful tool for the following reasons: 1) it improves diagnostic accuracy and helps to differentiate variant types of muscle disorders; 2) it makes an early diagnosis possible before the onset of the symptoms of DMD/BMD; and 3) it detects nonsymptomatic carriers of DMD/BMD. However, without the aid of a genetic study, dystrophin antibody stains cannot absolutely rule out the diagnosis of carriers.

Peripheral nerve involvement in Werdnig-Hoffmann disease

The number of large myelinated axons was markedly decreased in almost all the intramuscular nerve bundles included in 32 muscle biopsies from patients with Werdnig-Hoffmann disease compared to that in normals. The morphometric analysis of peripheral nerves in 5 epon-embedded sections also showed a selective loss of larger myelinated fibers. The ultrastructural findings of the nerves were similar to those seen in Wallerian degeneration including axonal degeneration, myelin breakdown with phagocytosis, Schwann cell proliferation forming Schwann cell columns, axonal sprouting and probable remyelination. The earlier and more striking peripheral nerve involvement than that previously believed was not different from that seen in amyotrophic lateral sclerosis (ALS). The earlier damage to the peripheral nerves probably resulted from a degeneration of the anterior horn cells or anterior spinal roots as in ALS rather than from a dying-back process.