Clinical and electromyographic features of radiation-induced lower cranial neuropathy

ObjectiveLower cranial neuropathy is a rare complication of radiation therapy for head and neck cancers. Little is known about the clinical and electromyographic features of this complication.MethodsThe records of six patients with radiation-induced lower cranial neuropathy who had undergone electromyographic study were reviewed. All patients were treated with radiation therapy for nasopharyngeal cancer. The total radiation dose was 6996–8280 cGy to the nasopharynx and 4680–7020 cGy to the neck. The dose per fraction was 180 or 212 cGy.ResultsSpinal accessory neuropathy occurred in all six patients, glossopharyngeal and vagus neuropathy in five patients, and hypoglossal neuropathy in five patients. The median latency between radiation therapy and lower cranial neuropathy was 61 months (range, 20–118 months). The lower cranial neuropathies developed insidiously and progressed slowly over a period of years in all patients. Myokymia was seen in three patients and myokymic discharges were demonstrated in five of six patients.ConclusionsMyokymia and myokymic discharges may be common and typical features of radiation-induced lower cranial neuropathy.SignificanceIt is important to make an effort to detect myokymia and myokymic discharges for symptomatic patients suggestive of radiation-induced lower cranial neuropathy.     

Suicide among the elderly and associated factors in South Korea

With the population of the elderly increasing, suicides among elderly people present a serious problem for global societies. However, there are few studies on suicide among elderly subjects, especially in Asia. The study aimed to determine the relationship between physical health, mental health, social environmental condition, and the suicide behavior among elderly subjects in the city of Suwon, located southeast of Seoul. We analyzed 1548 Korean aged over 60 years from baseline data of a larger prospective study called the Suwon Project. The study protocol included sociodemographic variables, mental health factors, and physical health factors. In the interview, the subjects were asked about suicide ideation and history of suicide attempt. Of the total subjects, 7.42% reported suicide ideation and 1.42% reported a history of suicide attempt. A logistic regression analysis showed that physical illness, five stroke warning signs, anxiety and depression associated with suicide ideation, and depression strongly corresponded to the suicide ideation. Anxiety, depression, and stroke warning signs were associated with history of suicide attempt among the elderly. Additionally, stroke warning signs and depression are independently associated with history of suicide attempt. This study revealed that stroke warning signs have a high correlation with history of suicide attempt in the elderly, independent from the depression factors. This study suggests that there is an independent relationship between physical health status and suicide behavior in the case of elders.     

Prevalence and Clinical Correlates of Insomnia in Depressive Disorders: The CRESCEND Study

Objective

To investigate the prevalence, clinical manifestations, and clinical correlates of insomnia in a large cohort of Korean patients with depressive disorders.

Methods

We recruited 944 patients with depressive disorders from the Clinical Research Center for Depression of South Korea (CRESCEND) study. Psychometric scales were used to assess depression (HAMD), anxiety (HAMA), psychotic symptoms (BPRS), global severity (CGI-S), and functioning (SOFAS). Insomnia levels were determined by adding the scores for all items on the HAMD insomnia subscale. The clinical characteristics of the patients with ''low insomnia'' (summed score ≤3 on the HAMD subscale) and ''high insomnia'' (score ≥4) were compared using statistical analyses. A logistic regression model was constructed to identify factors associated with ''high insomnia'' status.

Results

Symptoms of insomnia were present in 93% of patients, while simultaneous early, middle, and late insomnia affected 64.1%. The high insomnia patients were characterized by significantly greater age, higher symptom levels (including core, gastrointestinal somatic and anxiety symptoms, and suicidal ideation), higher global severity and incidence of physical disorders, and greater insight. Explanatory factors of ''high insomnia'' status were older age, higher gastrointestinal somatic and anxiety symptom levels, higher global severity, and greater insight.

Conclusion

In clinical psychiatry, insomnia has been significantly underdiagnosed and undertreated. It affects most patients with depressive disorders, and is indicative of the global severity of depression. Active efforts to diagnose and treat insomnia in patients with depressive disorders should be strongly encouraged. Further research is needed to improve the diagnosis and treatment of insomnia in depressive patients.     

Psychiatric Comorbidity and Quality of Life in Patients with Post-Stroke Emotional Incontinence

Objective

We aimed to investigate the associations of post-stroke emotional incontinence (PSEI) with various psychiatric symptoms and quality of life independent of potential covariates in survivors of acute stroke.

Methods

A total of 423 stroke patients were assessed within 2 weeks of the index event. Psychiatric symptoms were assessed by the Symptom Checklist-90-Revised (SCL-90-R), which has nine domains comprising Somatization, Obsessive-Compulsive, Interpersonal Sensitivity, Depression, Anxiety, Hostility, Phobic Anxiety, Paranoid Ideation, and Psychoticism. Quality of life was measured using the World Health Organization Quality of Life abbreviated form (WHOQOL-BREF), which has four domains related to physical factors, psychological factors, social relationships, and environmental context. Associations of PSEI with scores on the SCL-90-R and WHOQOL-BREF were investigated using pairwise logistic regression model adjustment for potential sociodemographic and clinical covariates.

Results

PSEI was present in 51 (12.1%) patients. PSEI was associated with the Obsessive-Compulsive, Interpersonal Sensitivity, and Hostility symptom dimensions of the SCL-90-R and with the psychological factors and social relationships domains of the WHOQOL-BREF independent of important covariates including previous stroke, stroke severity, and physical disability.

Conclusion

PSEI causes some aspects of psychiatric distress and negatively affects psychological and interpersonal quality of life. For patients with PSEI, special attention to psychiatric comorbidity and quality of life is needed, even in the acute stage of stroke.     

The Usefulness of the Ivy Sign on Fluid-Attenuated Intensity Recovery Images in Improved Brain Hemodynamic Changes after Superficial Temporal Artery-Middle Cerebral Artery Anastomosis in Adult Patients with Moyamoya Disease

Objective

MR perfusion and single photon emission computerized tomography (SPECT) are well known imaging studies to evaluate hemodynamic change between prior to and following superficial temporal artery (STA)-middle cerebral artery (MCA) anastomosis in moyamoya disease. But their side effects and invasiveness make discomfort to patients. We evaluated the ivy sign on MR fluid attenuated inversion recovery (FLAIR) images in adult patients with moyamoya disease and compared it with result of SPECT and MR perfusion images.

Methods

We enrolled twelve patients (thirteen cases) who were diagnosed with moyamoya disease and underwent STA-MCA anastomosis at our medical institution during a period ranging from September of 2010 to December of 2012. The presence of the ivy sign on MR FLAIR images was classified as Negative (0), Minimal (1), and Positive (2). Regions were classified into four territories: the anterior cerebral artery (ACA), the anterior MCA, the posterior MCA and the posterior cerebral artery.

Results

Ivy signs on preoperative and postoperative MR FLAIR were improved (8 and 4 in the ACA regions, 13 and 4 in the anterior MCA regions and 19 and 9 in the posterior MCA regions). Like this result, the cerebrovascular reserve (CVR) on SPECT was significantly increased in the sum of CVR in same regions after STA-MCA anastomosis.

Conclusion

After STA-MCA anastomosis, ivy signs were decreased in the cerebral hemisphere. As compared with conventional diagnostic modalities such as SPECT and MR perfusion images, the ivy sign on MR FLAIR is considered as a useful indicator in detecting brain hemodynamic changes between preoperatively and postoperatively in adult moyamoya patients.     

Delayed Unilateral Soft Palate Palsy without Vocal Cord Involvement after Microvascular Decompression for Hemifacial Spasm

Microvascular decompression is a very effective and relatively safe surgical modality in the treatment of hemifacial spasm. But rare debilitating complications have been reported such as cranial nerve dysfunctions. We have experienced a very rare case of unilateral soft palate palsy without the involvement of vocal cord following microvascular decompression. A 33-year-old female presented to our out-patient clinic with a history of left hemifacial spasm for 5 years. On postoperative 5th day, patient started to exhibit hoarsness with swallowing difficulty. Symptoms persisted despite rehabilitation. Various laboratory work up with magnetic resonance image showed no abnormal lesions. Two years after surgery patient showed complete recovery of unitaleral soft palate palsy. Various etiologies of unilateral soft palate palsy are reviewed as the treatment and prognosis differs greatly on the cause. Although rare, it is important to keep in mind that such complication could occur after microvascular decompression.     

Surgical Outcomes and Complications after Occipito-Cervical Fusion Using the Screw-Rod System in Craniocervical Instability

Objective

Although there is no consensus on the ideal treatment of the craniocervical instability, biomechanical stabilization and bone fusion can be induced through occipito-cervical fusion (OCF). The authors conducted this study to evaluate efficacy of OCF, as well as to explore methods in reducing complications.

Methods

A total of 16 cases with craniocervical instability underwent OCF since the year 2002. The mean age of the patients was 51.5 years with a mean follow-up period of 34.9 months. The subjects were compared using lateral X-ray taken before the operation, after the operation, and during last follow-up. The Nurick score was used to assess neurological function pre and postoperatively.

Results

All patients showed improvements in myelopathic symptoms after the operation. The mean preoperative Nurick score was 3.1. At the end of follow-up after surgery, the mean Nurick score was 2.0. After surgery, most patients'' posterior occipito-cervical angle entered the normal range as the pre operation angle decresed from 121 to 114 degree. There were three cases with complications, such as, vertebral artery injury, occipital screw failure and wound infection. In two cases with cerebral palsy, occipital screw failures occurred. But, reoperation was performed in one case.

Conclusion

OCF is an effective method in treating craniocervical instability. However, the complication rate can be quite high when performing OCF in patients with cerebral palsy, rheumatoid arthritis. Much precaution should be taken when performing this procedure on high risk patients.     

Fatal Septic Internal Jugular Vein-Sigmoid Sinus Thrombosis Associated with a Malpositioned Central Venous Catheter

Objective

The aim of this study is to assess outcomes during first one year for patients with severe motor weakness caused by lumbar disc herniation that underwent surgical or nonsurgical treatment.

Methods

The 46 patients with motor weakness because of lumbar disc herniation who were treated at neurosurgical department and rehabilitation in our hospital from 2006 to 2010, retrospectively. Each group had 26 surgical treatments and 20 conservative treatments. We followed up 1, 3, 6 months and 12 month and monitored a Visual Analogue rating Scale (VAS) of back and leg pain, Oswestry Disability Index (ODI) and degree of motor weakness. We analyzed the differences between surgical and nonsurgical groups using Mann-Whitney U test and repeat measure ANOVA in each follow-up periods.

Results

In the recovery of motor weakness, surgical treatment uncovered a rapid functional recovery in the early periods (p=0.003) and no difference between groups at the end of follow-up period was found (p>0.05). In VAS of back and leg, the interaction between time and group was not found (p>0.05) and there was no difference between groups (p>0.05). In ODI, the interaction between time and group was not found (p>0.05) and there was no difference between groups (p>0.05).

Conclusion

Surgical treatment for motor weakness caused by herniated intervertebral disc resulted in a rapid recovery in the short-term period, especially 1 month. We think early and proper surgical treatment in a case of motor weakness from disc herniation could be a good way for providing a chance for rapid alleviation.     

Effect of the Refrigerator Storage Time on the Potency of Botox for Human Extensor Digitorum Brevis Muscle Paralysis

Background and Purpose

It is recommended that Botox be used within 5 hours of reconstitution, which results in substantial quantities being discarded. This is not only uneconomic, but also inconvenient for treating patients. The aim of this study was to determine the potencies of Botox used within 2 hours of reconstitution with unpreserved saline, the same Botox refrigerated (at +4℃) 72 hours after reconstitution, and during the next 4 consecutive weeks (weeks 1, 2, 3, and 4). This comparison was used to determine the length of refrigeration time during which reconstituted Botox will maintain the same efficacy as freshly reconstituted toxin.

Methods

Individual paralysis rates in the extensor digitorum brevis (EDB) compound muscle action potential (CMAP) amplitude and area were measured 1 week after injecting fresh reconstituted 2.5 MU of Botox on one side of the foot, and when the same quantity of Botox that had been refrigerated for a designated time (i.e., 72 h, or 1, 2, 3, or 4 weeks) into the other side of the foot. The EDB CMAP amplitude and area at 12 and 16 weeks postinjection were also measured to compare the efficacy durations in all five comparative groups.

Results

Ninety-four volunteers were divided into five groups according to the refrigerator storage time of the second Botox injection. The paralysis of the EDBs was significant for each injection of Botox, both fresh and refrigerated, with no statistically significant differences between them, regardless of the refrigeration time. There was a tendency toward increased CMAP amplitude and area at 12 or 16 weeks postinjection (p<0.0001). The duration of effective muscle paralysis did not differ significantly throughout the 16-week follow-up period between all five groups.

Conclusions

The potency of reconstituted Botox is not degraded by subsequent refrigeration for 4 weeks. However, there are definite concerns regarding its sterility, and hence its safety, since multiple withdrawals from the same vial over long periods can introduce bacterial contamination.