To evaluate the usefulness of 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) in the management of cervical dystonia (CD) with botulinum toxin type A (BoNT-A) injection.
Thirty two subjects with CD were included. A BoNT-A injection was provided either by clinically targeting method (group 1) or by 18F-FDG PET/CT-assisted, clinically targeting method (group 2). In group 2, selection of target muscles and dosage of BoNT-A were determined according to the increased 18F-FDG uptake, in addition to physical examination and functional anatomy. The outcomes of BoNT-A injection was compared between the two groups, in terms of the number of subjects who had reinjection before and after 6 months, the number of reinjections, the interval of reinjections, the duration to the minimal Toronto Western Spasmodic Torticollis Rating Scale (TWSTRS), the number of adverse events, the reduction rate of TWSTRS at 1-3 months and 3-6 months after injection, and the probability of reinjection-free living.
The number of subjects who had reinjection within 6 months was significantly lower in group 2 than in group 1 (10 in group 1 vs. 3 in group 2). The reduction rate of TWSTRS after 3-6 months (37.8±15.7% of group 1 vs. 63.3±28.0% of group 2) and the probability of reinjection-free living were significantly higher in group 2 than in group 1.
These findings suggest that 18F-FDG PET/CT study could be useful in management of CD in terms of the identification of dystonic muscles if there is an increase in the 18F-FDG uptake in the cervical muscle of the images.
Citations
To investigate the effects of hippotherapy for adult patients with brain disorders.
Eight chronic brain disorder patients (7 males, mean age 42.4±16.6 years) were recruited. The mean duration from injury was 7.9±7.7 years. The diagnoses were stroke (n=5), traumatic brain disorder (n=2), and cerebral palsy (n=1). Hippotherapy sessions were conducted twice a week for eight consecutive weeks in an indoor riding arena. Each hippotherapy session lasted 30 minutes. All participants were evaluated by the Berg balance scale, Tinetti Performance-Oriented Mobility Assessment, 10 Meter Walking Test, Functional Ambulatory Category, Korean Beck Depression Inventory, and Hamilton Depression Rating Scale. We performed baseline assessments twice just before starting hippotherapy. We also assessed the participants immediately after hippotherapy and at eight weeks after hippotherapy.
All participants showed no difference in balance, gait function, and emotion between the two baseline assessments before hippotherapy. During the eight-week hippotherapy program, all participants showed neither adverse effects nor any accidents; all had good compliance. After hippotherapy, there were significant improvements in balance and gait speed in comparison with the baseline assessment (p<0.05), and these effects were sustained for two months after hippotherapy. However, there was no significant difference in emotion after hippotherapy.
We could observe hippotherapy to be a safe and effective alternative therapy for adult patients with brain disorders in improving balance and gait function. Further future studies are warranted to delineate the benefits of hippotherapy on chronic stroke patients.
Citations
To investigate the therapeutic effects of mechanical horseback riding for gait and balance parameters in post-stroke patients.
This study was a non randomized prospective positive-controlled trial over a 12 week period. From May 2011 to October 2011, 37 stroke patients were recruited from our outpatient clinic and divided into two groups. The control group received the conventional physiotherapy while the intervention group received the conventional physiotherapy along with mechanical horseback riding therapy for 12 weeks. Outcome measurements of gait included the Functional Ambulation Category (FAC) and gait part of the Performance Oriented Mobility Assessment (G-POMA) while those of balance included the Berg Balance Scale (BBS) and the balance part of the Performance Oriented Mobility Assessment (B-POMA). These measurements were taken before and after treatment.
There were no significant differences in the baseline characteristics and initial values between the two groups. When comparing baseline and 12 weeks post treatment in each group, the intervention group showed significant improvement on BBS (39.9±5.7 → 45.7±4.8, p=0.001) and B-POMA (10.4±2.6 → 12.6±2.1, p=0.001), but significant improvement on gait parameters. When comparing the groups, the dynamic balance category of BBS in post treatment showed significant difference (p=0.02).
This study suggests that mechanical horseback riding therapy may be an effective treatment tool for enhancing balance in adults with stroke.
Citations
To clarify factors affecting bone mineral density (BMD) in adults with cerebral palsy (CP).
Thirty-five patients with CP participated in this study. Demographic data including gender, age, body mass index (BMI), subtype according to neuromotor type and topographical distribution, ambulatory function, and functional independence measure (FIM) were investigated. The BMD of the lumbar spine and femur were measured using Dual-energy X-ray absorptiometry, and the factors affecting BMD were analyzed.
The BMD had no significant association with factors such as gender, age, and subtype in adults with CP. However, BMI was significantly correlated with the BMD of lumbar spine and femur (p<0.05). The FIM score was also positively correlated with the BMD of femur (p<0.05). Moreover, CP patients with higher ambulatory function had significantly higher BMD of femur (p<0.05).
These findings suggest that BMI and functional levels such as FIM and ambulatory function can affect BMD in adults with CP. The results might be used as basic data, suggesting the importance of treatment including weight bearing exercise and gait training in adults with CP.
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To evaluate the effects of physical properties of foods on the changes of viscosity and mass as well as the particle size distribution after mastication.
Twenty subjects with no masticatory disorders were recruited. Six grams of four solid foods of different textures (banana, tofu, cooked-rice, cookie) were provided, and the viscosity and mass after 10, 20, and 30 cycles of mastication and just before swallowing were measured. The physical properties of foods, such as hardness, cohesiveness, and adhesiveness, were measured with a texture analyzer. Wet sieving and laser diffraction were used to determine the distribution of food particle size.
When we measured the physical characteristics of foods, the cookie was the hardest food, and the banana exhibited marked adhesiveness. Tofu and cooked-rice exhibited a highly cohesive nature. As the number of mastication cycles increased, the masses of all foods were significantly increased (p<0.05), and the viscosity was significantly decreased in the case of banana, tofu, and cooked-rice (p<0.05). The mass and viscosity of all foods were significantly different between the foods after mastication (p<0.05). Analyzing the distribution of the particle size, that of the bolus was different between foods. However, the curves representing the particle size distribution for each food were superimposable for most subjects.
The viscosity and particle size distribution of the bolus were different between solid foods that have different physical properties. Based on this result, the mastication process and food bolus formation were affected by the physical properties of the food.
Citations
To investigate the clinical characteristics of dysphagic elderly Korean patients diagnosed with aspiration pneumonia as well as to examine the necessity of performing a videofluoroscopic swallowing study (VFSS) in order to confirm the presence of dysphagia in such patients.
The medical records of dysphagic elderly Korean subjects diagnosed with aspiration pneumonia were retrospectively reviewed for demographic and clinical characteristics as well as for VFSS findings.
In total, medical records of 105 elderly patients (81 men and 24 women) were reviewed in this study. Of the 105 patients, 82.9% (n=87) were admitted via the emergency department, and 41.0% (n=43) were confined to a bed. Eighty percent (n=84) of the 105 patients were diagnosed with brain disorders, and 68.6% (n=72) involved more than one systemic disease, such as diabetes mellitus, cancers, chronic cardiopulmonary disorders, chronic renal disorders, and chronic liver disorders. Only 66.7% (n=70) of the 105 patients underwent VFSS, all of which showed abnormal findings during the oral or pharyngeal phase, or both.
In this study, among 105 dysphagic elderly patients with aspiration pneumonia, only 66.7% (n=70) underwent VFSS in order to confirm the presence of dysphagia. As observed in this study, the evaluation of dysphagia is essential in order to consider elderly patients with aspiration pneumonia, particularly in patients with poor functional status, brain disorders, or more than one systemic disease. A greater awareness of dysphagia in the elderly, as well as the diagnostic procedures thereof, particularly VFSS, is needed among medical professionals in Korea.
Citations
To investigate the inter-rater agreement using the Videofluoroscopic Dysphagia Scale (VDS).
The present study was designed as a multicenter, single-blind trial. A Videofluoroscopic Swallowing Study (VFSS) was performed using the protocol described by J.A Logemann. Thick-fluid, pureed food, mechanically altered food, regularly textured food, and thin-fluid boluses were sequentially swallowed. Each participant received a 3 ml bolus followed by a 5 ml bolus of each food material, in the order mentioned above. All study procedures were video recorded. Discs containing these video recordings in random order were distributed to interpreters who were blinded to the participant information. The video recordings were evaluated using a standardized VDS sheet and the inter-rater reliability was calculated.
In total, 100 patients participated in this study and 10 interpreters analyzed the findings. Inter-rater reliability was fair in terms of lip closure (κ: 0.325), oral transit time (0.253), delayed triggering of pharyngeal swallowing (0.300), vallecular residue (0.275), laryngeal elevation (0.345), pyriform sinus residue (0.310), coating of the pharyngeal wall (0.310), and aspiration (0.393). However, other parameters of the oral phase were lower than those of the pharyngeal phase (0.06-0.153). Moreover, the summation of VDS reliability (intraclass correlation coefficient: 0.556) showed moderate agreement.
VDS shows a moderate rate of agreement for evaluating the swallowing function. However, many of the parameters demonstrated a lower rate of agreement, particularly the oral phase parameters.
Citations
To determine the associating factors of fear of falling (FOF) and the correlations between FOF and quality of life (QOL) on subacute stroke patients in Korea.
Fifty hemiplegic subacute stroke patients in our clinic were recruited. We directly asked patients with their fear of falling and interviewed them with the Korean version of falls efficacy scale-international (KFES-I). We divided the participants into two groups; with FOF and without FOF. We compared these groups with the strength of hemiplegic hip abductor, knee extensor, ankle plantar flexor, functional ambulation category (FAC) scale, stroke specific quality of life (SSQOL), and hospital anxiety depression scale (HADS).
Thirty-four participants were enrolled, and more than half of the patients with subacute stroke had FOF. We compared the patients with and without FOF. According to the results, FOF was associated with the strength of hemiplegic hip abductor, knee extensor and ankle plantar flexor, FAC, total SSQOL, and domains (energy, mobility, self care, upper extremity function) of SSQOL (p<0.05). FOF was also associated with the anxiety score of HADS (p<0.05). KFES-I had a significant negative correlation with the strength of hemiplegic hip abductor, knee extensor and ankle plantar flexor, FAC, total SSQOL, and domains (energy, mobility, self care, upper extremity function) of SSQOL (p<0.01).
The FOF was associated with not only QOL but also with the physical and psychological factors, and in particular, anxiety. Therefore, further concerns about FOF in subacute stroke patients might be required.
Citations
To evaluate the feasibility of the ICF for initial comprehensive evaluation of early post-acute spinal cord injury.
A comprehensive evaluation of 62 early post-acute spinal cord injury (SCI) patients was conducted by rehabilitation team members, such as physicians, physical therapists, occupational therapists, nutritionists, medical social-workers, and nurses. They recorded each of their evaluation according to the ICF first level classification. The contents of the comprehensive evaluation were linked to the ICF second level categories, retrospectively. The linked codes were analyzed descriptively and were also compared with the brief ICF core set for early post-acute SCI.
In the evaluation of early post-acute SCI patients based on the ICF first level categories, 19 items from the body functions domain, such as muscle power functions (b730) and urination functions (b620), 15 items from the body structures domain, including spinal cord and related structures (s120), 11 items from the activities and participation domain, such as transferring oneself (d420) and walking (d450), and 9 items from the environmental factors domain, e.g., health professionals (e355), were linked to the ICF second level categories. In total, 82.4% of all contents were linked to the brief ICF core set. Prognosis insight, a personal factor not linkable to an ICF code, was mentioned in 29.0% of all patients.
First level ICF categories can provide a structural base for a comprehensive evaluation in early post-acute spinal cord injury. However, frequently linked items, including the brief core set, as well as personal factors should be considered via a checklist in order to prevent the omission of significant contents.
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To investigate whether higher resilience level predicts low levels of psychological distress in chronic SCI patients living in the community.
Thirty seven patients (mean age 41.5±10.9, male : female=28 : 9) with chronic spinal cord injury (duration 8.35±7.0 years) living in the community are included, who were hospitalized for annual checkups from November, 2010 to May, 2011. First, their spinal cord injury level, completeness and complications were evaluated. The patients completed questionnaires about their educational status, religion, employment status, marital status, medical and psychological history and also the following questionnaires: Hospital Anxiety and Depression Scale (HADS), Connor-Davidson Resilience Scale (CD-RISC), Alcohol Use Disorders Identification Test-alcohol consumption questions (AUDIT-C) and Health-related quality of life (EQ-5D). The patients were divided into two subgroups: patients with HADS ≥13 are classified as high psychological distress group and others as low psychological distress group. We compared the two groups to find statistically significant differences among the variables.
CD-RISC, EQ-5D and employment status are significantly different between two groups (p<0.05). In a forward stepwise regression, we found that EQ-5D had a greater contribution than CD-RISC to the psychological distress level.
In addition to health-related quality of life, resilience can be suggested as a possible predictor of psychological distress in chronic SCI patients.
Citations
To determine whether there is side to side difference of the trunk rotation muscle in Korean male professional golf players. Healthy controls who did not play golf were also evaluated and compared with professional golf players.
Fifty-one professional golf players and 50 healthy controls participated in this study. Bilateral isokinetic trunk rotation strength that represented the aiming side and non-aiming side trunk rotator function in a golf swing and other parameters were evaluated using the Biodex System III Isokinetic Dynamometer at angular velocities of 30, 60, and 120 degree per second.
The professional golf players' peak torque and total work on their aiming sides were significantly higher than on their non-aiming side at all angular velocities. Additionally, the golf players' peak torque on their aiming side was significantly higher than those of the healthy controls only at the 60 degree per second angular velocity, but there was a slight and consistent trend in the others. Finally, the difference between the aiming side and the non-aiming side of the professional golf players and the healthy controls was also significant.
The aiming side rotation strength of the male professional golf players was higher than that of non-aiming side. The controls showed no side-to-side differences. This finding is attributed to the repetitive training and practice of professional golf players. A further study is needed to investigate if the strengthening of the trunk rotation muscle, especially on the aiming side, could improve golf performance.
Citations
To explore the relationship between a number of clinically relevant variables and sonographic imaging data in respect to the level of impairment experienced in the affected and unaffected shoulders of hemiplegic stroke patients.
Fifty-one hemiplegic stroke patients (32 males, 19 females; 29 right-sided hemiplegics, 22 left-sided hemiplegics) participated in this study. A musculoskeletal radiologist conducted a sonographic exam on both the affected and unaffected shoulders of all patients and two physicians classified the severity of the injury on a six-point rating scale. Clinical variables including age, sex, duration of injury, spasticity and muscle power of the hemiplegic side, and level of functional activity of the shoulder were assessed.
The sonographic rating scores of hemiplegic shoulders were positively correlated with age (p<0.01) and negatively correlated with level of muscle spasticity (p<0.05). The sonographic rating scores of unaffected shoulders were positively correlated with duration of injury (p<0.01). Affected shoulders received sonographic rating scores that reflected significantly more impairment than those of unaffected shoulders (p<0.001), and pre-morbid handedness did not affect the relationship between impairment rating and shoulder injury status.
Hemiplegic stroke influences not only affected shoulders, but also unaffected sides. Proper management of spasticity, enhancement of motor recovery, and avoidance of unaffected shoulder overuse should be considered to prevent shoulder problems following strokes which result in hemiplegia.
Citations
To reveal the relationship between depression and WMSD.
Five physiatrists participated in the workplace musculoskeletal survey and diagnosed 724 office workers with WMSD by performing detailed history taking and physical examination. All subjects were asked to answer the Korean version of the Beck depressive inventory (K-BDI), and to express their pain according to the visual analogue scale (VAS) score. We categorized the subjects into 4 groups, myofascial pain syndrome (MPS), herniated intervertebral disk (HIVD), tenosynovitis, and others, and investigated the prevalence of depression in desk workers and relationship between WMSD and depression, and we compared pain intensity between the depression and non-depression groups. Correlation analysis was carried out between K-BDI and VAS scores in each group.
The mean K-BDI score were 8.7±6.68. The prevalence of depression was higher in females than in male, and there was no relationship between age and depression. There was a significant connection between HIVD and depression (p<0.05). However, the other groups did not have significant connection to depression. The VAS score (5.02) of the depression group was significantly higher than that (4.10) of the non-depression group. In addition, there was a significant difference of VAS scores between the depression group and non-depression group in each disease group.
The mean VAS score of the depression group in WMSD was significantly higher than in the non-depression group. The correlation between BDI and VAS scores in the subjects was present, and the highest was in the HIVD group.
Citations
To investigate Botulinum toxin type B (BNT-B) injection's effect and duration depending on dose for patients with brain lesion.
Twenty one patients with brain lesion and severe drooling were included and divided into three groups. All patients received conventional dysphagia therapy. Group A patients (n=7) received an injection of 1,500 units and group B patients (n=7) received an injection of 2,500 units of BNT-B in submandibular gland under ultrasound guidance. Group C patients (n=7) received conventional dysphagia therapy. Saliva secretion was assessed quantitatively at baseline and at weeks 1, 2, 4, 8, and 12. The severity and frequency of drooling was assessed using the Drooling Quotient (DQ) by patients and/or caregivers.
Group A and B reported a distinct improvement of the symptoms within 2 weeks after BNT-B injection. Compared to the baseline, the mean amount of saliva decreased significantly throughout the study. However, there was no meaningful difference between the two groups. The greatest reductions were achieved at 2 weeks and lasted up to 8 weeks after BNT-B injection. Group C did not show any differences.
Local injection of 1,500 units of BNT-B into salivary glands under ultrasonic guidance proved to be a safe and effective dose for drooling in patient with brain lesion, as did 2,500 units.
Citations
To evaluate the effect of neuromuscular electrical stimulation (NMES) on cardiopulmonary function in healthy adults.
Thirty-six healthy adults without a cardiac problem were enrolled. All patients were randomly assigned to either a control (17 subjects, mean age 29.41) or an electrical stimulation group (19 subjects, mean age 29.26). The electrical stimulation group received NMES on both sides of quadriceps muscle using a Walking Man II® in a sitting position for 30 minutes over 2 weeks. Maximum oxygen consumption (VO2max), metabolic equivalent (MET), resting, maximal heart rate (RHR, MHR), resting, maximal blood pressure (RBP, MBP), and maximal rate pressure product (MRPP), exercise tolerance test (ETT) duration were determined using an exercise tolerance test and a 6 minute walk test (6MWT) before and after treatment.
The electrical stimulation group showed a significant increase in VO2max (p=0.03), 6MWT (p<0.01), MHR (p<0.04), MsBP (p<0.03), ETT duration (p<0.01) and a significant decrease in RsBP (p<0.02) as compared with the control group after two weeks. NMES induced changes improved only in RsBP (p<0.049) and ETT duration (p<0.01). The effects of NMES training were stronger in females.
We suggest that NMES is an additional therapeutic option for cardiopulmonary exercise in disabled patients with severe refractory heart failure or acute AMI.
Citations
Warfarin is a frequently prescribed anticoagulant in rehabilitation patients. Adverse drug reactions of warfarin were reported as bleeding and cutaneous microvascular thrombosis. Major bleeding, such as intracranial hemorrhage and psoas hematoma, in patients receiving anticoagulation therapy is a rare condition, but sometimes very serious complication that can even be fatal. Patient-specific factors (eg, age, body size, race, concurrent diseases, and medications) explain some of the individual variability in warfarin dose, but genetic factors, which influence warfarin response, explain a significantly higher proportion of the variability in the dose. There are two identified genes that are responsible for the main proportion of the genetic effect: CYP2C9, which codes for the enzyme cytochrome P450 2C9 that metabolizes S-warfarin, and VKORC1, which codes for warfarin's target, vitamin K epoxide reductase. We report a case of intolerance to warfarin dosing, due to impaired drug metabolism in a patient with CYP2C9*1/*3 and VKORC 1173TT. Fortunately, there are no severe complications.
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Cerebral hemorrhage is one of the most common causes of dysphagia. In many cases, dysphagia gets better once the acute phase has passed. Structural lesions such as thyromegaly, cervical hyperostosis, congenital web, Zenker's diverticulum, neoplasm, radiation fibrosis, and retropharyngeal abscess must be considered as other causes of dysphagia as well. Retropharyngeal abscess seldom occur in adults and if it does so, a search for a prior dental procedure, trauma, head and neck infection is needed. The symptoms may include neck pain, dysphagia, sore throat, and in rare cases, dyspnea accompanied by stridor. We present a case and discuss a patient who had dysphagia and neck pain after a cerebral hemorrhage. Testing revealed a retropharyngeal abscess. The symptoms were successfully treated after the administration of antibiotics.
Citations
The mechanisms and functional anatomy underlying the early stages of speech perception are still not well understood. Auditory agnosia is a deficit of auditory object processing defined as a disability to recognize spoken languages and/or nonverbal environmental sounds and music despite adequate hearing while spontaneous speech, reading and writing are preserved. Usually, either the bilateral or unilateral temporal lobe, especially the transverse gyral lesions, are responsible for auditory agnosia. Subcortical lesions without cortical damage rarely causes auditory agnosia. We present a 73-year-old right-handed male with generalized auditory agnosia caused by a unilateral subcortical lesion. He was not able to repeat or dictate but to perform fluent and comprehensible speech. He could understand and read written words and phrases. His auditory brainstem evoked potential and audiometry were intact. This case suggested that the subcortical lesion involving unilateral acoustic radiation could cause generalized auditory agnosia.
Citations
Spinal cord injury (SCI) without radiographic abnormality (SCIWORA) is estimated to account for 1-9% of the occurrence of SCI. Of these, cervical SCIWORA in children is common, but thoracic SCIWORA delayed onset in adult is much less common. We experienced a case of 38-years old male patient with lower extremity weakness; he had fallen down a week earlier before the investigation. At the time of admission, motor grade was 4 with voiding incontinence and ambulated with cane. He presented progressive weakness from G4 to G3 and hypoesthesia was below T8 dermatome and ambulated with wheelchair. Whole spine and lumbar MRI findings showed no abnormality and electrodiagnostic findings showed normal NCS, however, abnormal SEP on both the tibial nerves. After steroid therapy and proper rehabilitation program for 2 weeks, lower extremity strength was improved from G4 to G3, voiding was continent, and ambulation reached cane gait.
Citations
Tracheo-innominate artery fistula (TIAF) is rare, yet the most fatal complication after tracheostomy. In the absence of immediate diagnosis and surgical management, the mortality rate is very high, because the complication can lead to sudden massive tracheal hemorrhage. Tracheal obstruction and hypovolemic shock are the major life threatening conditions. The 46-year-old woman received tracheostomy tube insertion after stroke. Three months later, there was occurrence of active bleeding at the site of tracheostomy in the patient, who participated in comprehensive rehabilitation program. Immediately, the patient received an endotracheal tube insertion into the tracheostomy site and thus massive bleeding was controlled. The patient was transferred to the intensive care unit, where her breathing was maintained by mechanical ventilation. Based on computed tomography and laryngoscopy, no remarkable findings about TIAF were detected. Nevertheless, transfemoral angiography findings revealed that innominate artery made small luminal outpouching to trachea at the carotid artery and at the subclavian artery bifurcation level, based on which a diagnosis of TIAF was made. She had an operation for TIAF, tracheoplasty with bypass graft. Subsequently, she was discharged after 15 weeks. In the present report, we describe a case of TIAF, which can occur in the patients with tracheostomy tube during rehabilitation.
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Nephrogenic systemic fibrosis (NSF) is a rare fibrosing disorder of the skin and joints that occurs in patients with advanced renal insufficiency. This condition is progressive and can be seriously disabling. Gadolinium based contrast agent (GBCA) has been identified as a potential cause of this condition. A 56-years-old man in hemodialysis developed stiffness and contracture of the whole limbs eight years after frequent GBCA exposure for cervical magnetic resonance imaging. For the first time in Korea, we report late-onset nephrogenic systemic fibrosis after GBCA exposure and performed an electrophysiologic study of this condition.
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Central pontine myelinolysis is a rare neurologic disorder that is defined by demyelination of longitudinally descending tracts and transversly crossing fibers in the basis pontis. Frequently observed clinical manifestations of this disorder include sudden weakness, dysphagia, loss of consciouness and locked-in syndrome. However, there have been a few studies that reported a benign course of this disease, which include cerebellar signs, such as ataxia, intention tremor, and dysarthria. Here we report on a 53-year-old male with a history of liver cirrhosis who showed the cerebellar type of central pontine myelinolysis. The patient was diagnosed with central pontine myelinolysis based on clinical presentations and magnetic resonance imaging findings after a liver transplantation. Conventional magenetic resonance imaging (MRI) revealed the preservation of the corticospinal tract and abnormal pontocerebellar fibers. However, these findings were not sufficient to define the pathophysiology of our patient. Electrophysiologic analysis and diffusion tensor imaging (DTI) were performed to investigate cerebellar signs in this case. Delayed central motor conduction time (CMCT) to the tibialis anterior muscle with transcranial magnetic stimulation (TMS) was observed, which indicated demyelination of the corticospinal tract. Also, diffusion tensor imaging showed abnormal pontocerebellar fibers, which might have been caused by cerebellar dysfunction in our patient. A combination of TMS and DTI was also used to determine the pathophysiology of this disease.
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Typical venous malformations are easily diagnosed by skin color changes, focal edema or pain. Venous malformation in the skeletal muscles, however, has the potential to be missed because their involved sites are invisible and the disease is rare. In addition, the symptoms of intramuscular venous malformation overlaps with myofascial pain syndrome or muscle strain. Most venous malformation cases have reported a focal lesion involved in one or adjacent muscles. In contrast, we have experienced a case of intramuscular venous malformation that involved a large number of muscles in a lower extremity extensively.
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