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Palatal myoclonus (PM) is a rare disease that may induce dysphagia. Since dysphagia related to PM is unique and is characterized by myoclonic movements of the involved muscles, specific treatments are needed for rehabilitation. However, no study has investigated the treatment effectiveness for this condition. Therefore, the aim of this case report was to describe the benefit of combining behavioral treatment with valproic acid administration in patients with dysphagia triggered by PM. The two cases were treated with combined treatment. The outcomes evaluated by videofluoroscopic swallowing studies before and after the treatment showed significant decreases in myoclonic movements and improved swallowing function. We conclude that the combined treatment was effective against dysphagia related to PM.
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To evaluate the reliability of the practical life space in post-stroke patients using the Korean version of the Life-Space Assessment (K-LSA) questionnaire and to assess the relationships between the K-LSA and physical function, daily activity, quality of life, and post-stroke depression.
The LSA questionnaire was translated into Korean, and the translated version was authorized by the author of the LSA questionnaire. In a cross-sectional study, the performance of the K-LSA was evaluated in 34 stroke patients (20 males and 14 females; mean age 65.11±2.39 years) who were receiving physical and occupational therapy at the outpatient clinic in the rehabilitation medicine department of a university medical center at the time of evaluation. Performances were assessed twice by one examiner at a 2-week interval to test the reliability. The patients were evaluated using the Functional Ambulation Category (FAC) scale, Functional Independence Measure (FIM) scale, and mobility subscale of the FIM to assess their relationships with the K-LSA. They were also evaluated using the EuroQol 5 Dimensions questionnaire (EQ-5D) and Geriatric Depression Scale (GDS) to determine the relationship with quality of life and post-stroke depression.
Test-retest reliability at the first (62.20±32.14) and second (63.15±32.22) assessment was 0.993 (p<0.01). The K-LSA showed significant correlations with the FAC (r=0.848, p<0.01), FIM (r=0.765, p<0.01), mobility category of the FIM (r=0.764, p<0.01), GDS (r=-0.657, p<0.01), and EQ-5D (r=0.506, p<0.01).
This study suggests that the practical life space of post-stroke patients, assessed by the K-LSA, has a significant correlation with patients' functional mobility, independence in daily activity, quality of life, and depression.
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To determine the incidence and risk factors for medical complications in Korean patients suffering from stroke and the impact of such complications on post-stroke functional outcomes.
We assessed patients enrolled in a prospective cohort study. All recruited patients had suffered a first acute stroke episode and been admitted to nine university hospitals in Korea between August 2012 and June 2015. We analyzed patient and stroke characteristics, comorbidities, prevalence of post-stroke medical complications, and functional outcomes at time of discharge and 3, 6, and 12 months after stroke onset.
Of 10,625 patients with acute stroke, 2,210 (20.8%) presented with medical complications including bladder dysfunction, bowel dysfunction, sleep disturbance, pneumonia, and urinary tract infection. In particular, complications occurred more frequently in older patients and in patients with hemorrhagic strokes, more co-morbidities, severe initial motor impairment, or poor swallowing function. In-hospital medical complications were significantly correlated with poor functional outcomes at all time points.
Post-stroke medical complications affect functional recovery. The majority of complications are preventable and treatable; therefore, the functional outcomes of patients with stroke can be improved by providing timely, appropriate care. Special care should be provided to elderly patients with comorbid risk factors.
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To evaluate the reliability and validity of Korean version of AST (K-AST) as a bedside screening test of apraxia in patients with stroke for early and reliable detection.
AST was translated into Korean, and the translated version received authorization from the author of AST. The performances of K-AST in 26 patients (21 males, 5 females; mean age 65.42±17.31 years) with stroke (23 ischemic, 3 hemorrhagic) were videotaped. To test the reliability and validity of K-AST, the recorded performances were assessed by two physiatrists and two occupational therapists twice at a 1-week interval. The patient performances at admission in Korean version of Mini-Mental State Examination (K-MMSE), self-care and transfer categories of Functional Independence Measure (FIM), and motor praxis area of Loewenstein Occupational Therapy Cognitive Assessment, the second edition (LOTCA-II) were also evaluated. Scores of motor praxis area of LOTCA-II was used to assess the validity of K-AST.
Inter-rater reliabilities were 0.983 (p<0.001) at the first assessment and 0.982 (p<0.001) at the second assessment. For intra-rater (test-retest) reliabilities, the values of four raters were 0.978 (p<0.001), 0.957 (p<0.001), 0.987 (p<0.001), and 0.977 (p<0.001). K-AST showed significant correlation (r=0.758, p<0.001) with motor praxis area of LOTCA-II test. K-AST also showed positive correlations with the total FIM score (r=0.694, p<0.001), the selfcare category of FIM (r=0.705, p<0.001) and the transfer category of FIM (r=653, p<0.001).
K-AST is a reliable and valid test for bedside screening of apraxia.
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Bilateral paramedian thalamic infarction is a rare subtype of stroke caused by occlusion of the artery of Percheron, an uncommon variant originating from one of the posterior cerebral arteries. This type of stroke has several major clinical presentations: altered mental status, behavioral amnestic impairment, aphasia or dysarthria, ocular movement disorders, motor deficits, cerebellar signs, and others. Few cases of bilateral paramedian thalamic infarction-related pseudobulbar palsy characterized by dysarthria, dysphagia, and facial and tongue weakness have been reported. We report here a rare case of acute severe pseudobulbar palsy as a manifestation of bilateral paramedian thalamic infarction.
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To determine the supratentorial area associated with poststroke dysphagia, we assessed the diffusion tensor images (DTI) in subacute stroke patients with supratentorial lesions.
We included 31 patients with a first episode of infarction in the middle cerebral artery territory. Each subject underwent brain DTI as well as a videofluoroscopic swallowing study (VFSS) and patients divided were into the dysphagia and non-dysphagia groups. Clinical dysphagia scale (CDS) scores were compared between the two groups. The corticospinal tract volume (TV), fractional anisotropy (FA) and apparent diffusion coefficient (ADC) values were calculated for 11 regions of interest in the supratentorial area—primary motor cortex, primary somatosensory cortex, supplementary motor cortex, anterior cingulate cortex, orbitofrontal cortex, parieto-occipital cortex, insular cortex, posterior limb of the internal capsule, thalamus, and basal ganglia (putamen and caudate nucleus). DTI parameters were compared between the two groups.
Among the 31 subjects, 17 were diagnosed with dysphagia by VFSS. Mean TVs were similar across the two groups. Significant inter-group differences were observed in two DTI values: the FA value in the contra-lesional primary motor cortex and the ADC value in the bilateral posterior limbs of the internal capsule (all p<0.05).
The FA value in the primary motor cortex on the contra-lesional side and the ADC value in the bilateral PLIC can be associated with dysphagia in middle cerebral artery stroke.
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A 50-year-old man with liver cirrhosis and esophageal varix for 3 years was diagnosed with hematemesis and treated for a bleeding varix. However, bleeding recurred 11 days later, and he developed drowsiness with left hemiparesis. His left upper and lower extremity muscle strengths based on the manual muscle test at the onset were grade 2/5 and 1/5, respectively. The Babinski sign was positive. His serum ammonia level was elevated to 129.9 µg/dL (normal, 20-80 µg/dL). Magnetic resonance imaging revealed restriction on diffusion and T2-hyperintensities with decreased apparent diffusion coefficient values in the bilateral frontoparietooccipital cortex. The effect was more severe in the right hemisphere and right parietooccipital cortices, which were compatible with hepatic encephalopathy. Although the patient's mental status recovered, significant left-sided weakness and sensory deficit persisted even after 6 months. Diffusion tensor tractography (DTT) performed 3 months post-onset showed decreased volume of the right corticospinal tract. We reported a patient with hepatic encephalopathy involving the corticospinal tract by DTT.
Apraxia of eyelid opening (AEO) is a syndrome characterized by the patient's difficulty in initiating eyelid elevation spontaneously. Most of the reported cases were associated with extrapyramidal diseases. We report a case of AEO presented after traumatic brain injury, not with extrapyramidal diseases, and improved by dopaminergic treatment. A 49-year-old man underwent a traffic accident and was transferred to the emergency room in an unconscious state. Brain computed tomography (CT) revealed a subdural and epidural hemorrhage at right temporal and bilateral frontal lobes, and he received burr-hole trephination. After receiving comprehensive treatment including occupational therapy, cognition and mobility gradually improved, but he could not open his eyes voluntarily. With dopaminergic treatment (levodopa/benserazide 200/50 mg), he started to open his eyes spontaneously, especially when eating and undergoing physical training. This case showed that AEO may occur after brain injury and that dopaminergic treatment is beneficial also in AEO patients without extrapyramidal diseases.
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To investigate the intra-rater and inter-rater reliability and usefulness of the Korean version of the Scale for the Assessment and Rating of Ataxia (K-SARA) in ataxic stroke patients.
The original SARA was translated into Korean, back translated to English, and compared to the original version. Stroke patients (n=60) with ataxia were evaluated using the K-SARA by one physiatrist and one occupational therapist. All subjects were rated twice. We divided the subjects into 5 groups by Functional Ambulation Category (FAC) and 3 groups based on the ataxia subscale of the National Institutes of Health Stroke Scale (NIHSS). The mean K-SARA scores representing each group of FAC and the ataxia subscale of NIHSS were compared.
The test-retest correlation coefficient of the K-SARA was 0.997 by the therapist and 1.00 by the physiatrist (p<0.001). The inter-rater correlation coefficient of the K-SARA was 0.985 (p<0.001). The ataxia subscale of NIHSS did not correlate with K-SARA. There was a significant difference in the mean K-SARA score by FAC (p<0.001).
K-SARA is a reliable and valid measure of ataxia in stroke patients in Korea.
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The postoperative infectious spondylitis has been reported to occur among every 1% to 12%. It is difficult to early diagnose in some cases. If the diagnosis is delayed, it can be a life-threatening condition. We report a 32-year-old male patient with postoperative infectious spondylitis. He had surgical treatments for traumatic intervertebral disc herniations in L3-4 and L4-5. Three weeks after surgery, he complained for fever and paraplegia. Cervicothoracic magnetic resonance imaging showed the collapsed T2 and T3 vertebral body with changes of bone marrow signal intensity. Moreover, it showed anterior and posterior epidural masses causing spinal cord compressions which suggested infectious spondylitis. After the use of antibiotics and surgical decompressions T2-T3, his general conditions were improved and muscle power of lower extremities began to be gradually restored. However, we could not identify the exact organisms that may be the cause of infectious spondylitis. It could be important that the infectious spondylitis, which is presented away from the primary operative level, should be observed in patients with fevers of unknown origin and paraplegia.
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The intrathecal chemotherapy with methotrexate and cytarabine arabinoside is used for the treatment and prophylaxis of the primary central nervous system lymphoma. The therapy may induce neurotoxicity including the cauda equina syndrome. We report a case of a 58-year-old man with the diffuse large B-cell lymphoma, who developed the cauda equina syndrome after the administration of intrathecal methotrexate and cytarabine arabinoside, as diagnosed by the electrodiagnostic, urodynamic, and radiologic approaches.
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To investigate the factors affecting rehabilitation outcomes in children with congenital muscular torticollis (CMT).
We retrospectively reviewed the medical records of 347 patients who were clinically suspected as having CMT and performed neck ultrasonography to measure sternocleidomastoid (SCM) muscle thickness. Fifty-four patients met the inclusion criteria. Included were demographic characteristics as well as measurements of cervical range of motion (ROM), SCM muscle thickness, and the abnormal/normal (A/N) ratio, defined as the ratio of SCM muscle thickness on the affected to the unaffected side.
Subjects were divided into three groups depending on degree of cervical ROM (group 1A: ROM>60, n=12; group 1B: 60≥ROM>30, n=31; group 1C: ROM≤30, n=11), the SCM muscle thickness (Th) (group 2A: Th<1.2 cm, n=23; group 2B: 1.2≤Th<1.4 cm, n=18; group 2C: Th≥1.4 cm, n=13), and the A/N ratio (R) (group 3A: R<2.2, n=19; group 3B: 2.2≤R<2.8, n=20; group 3C: R≥2.8, n=15). We found that more limited cervical ROM corresponded to longer treatment duration. The average treatment duration was 4.55 months in group 1A, 5.87 months in group 1B, and 6.50 months in group 1C. SCM muscle thickness and the A/N ratio were not correlated with treatment duration.
Infants with CMT who were diagnosed earlier and had an earlier intervention had a shorter duration of rehabilitation. Initial cervical ROM is an important prognostic factor for predicting the rehabilitation outcome of patients with CMT.
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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.
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To determine the relation between postvoid residual (PVR) and the occurrence of urinary tract infection (UTI) in stroke patients.
One hundred and eighty-eight stroke patients who were admitted to an inpatient rehabilitation unit and who did not have UTI on admission (105 males, 83 females, mean age 67.1 years) were included in this study. The PVR was measured 3 times within 72 hours after admission. Mean PVR, demographic variables, K-MMSE (Korean Mini-Mental State Examination), initial K-MBI (Korean Modified Barthel Index), Foley catheter indwelling time and stroke type were defined and the relation to the occurrence of UTI was analyzed.
UTI occurred in 74 patients (39.4%) during admission to the rehabilitation unit. There were significant differences between the UTI and non-UTI groups in K-MMSE, K-MBI, Foley catheter indwelling time (p<0.01). However, age, gender, stroke location and type were not associated. The occurrence of UTI was 4.87 times higher in the patients with a mean PVR over 100 ml than in those with a mean PVR <100 ml. The mean PVR was 106.5 ml in the UTI group, while it was 62.7 ml in the non-UTI group (p<0.01). PVR was not associated with age.
The UTI rate is higher when the mean PVR is over 100 ml irrespective of gender and age. Close monitoring of PVR and appropriate intervention is needed to reduce the occurrence of UTI in stroke patients.
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To determine abnormal MRI findings in adults hospitalized with acute severe axial LBP.
Sixty patients with back pain were divided into 3 groups consisting of 1) 23 adults with acute axial severe LBP who could not sit up or stand up for several days, but had not experienced previous back-related diseases or trauma (group A), 2) 19 adults who had been involved in a minor traffic accident, and had mild symptoms but not limited mobility (group B), and 3) 18 adults with LBP with radicular pain (group C)., Various MRI findings were assessed among the above 3 groups and compared as follows: disc herniation (protrusion, extrusion), lumbar disc degeneration (LDD), annular tear, high intensity zone (HIZ), and endplate changes.
The MRI findings of A group were as follows: disc herniation (87%), LDD (100%), annular tear (100%), HIZ (61%), and end plate changes (4.4%). The findings of disc herniation, annular tear, HIZ, and LDD were more prevalent in A group than in B group (p<0.01). HIZ findings were more prevalent in A group than in group B or group C (p<0.05).
Patients with acute severe axial LBP were more likely to have disc herniation, LDD, annular tear, HIZ. Among LBP groups, there was a significant association of HIZ on MRI with acute severe axial LBP.
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Cefepime is a fourth-generation cephalosporin that is active against both gram-positive and gram-negative organisms. It is administered parenterally for the treatment of severe infections. Approximately 85% of the drug is excreted unchanged by the kidneys. Neurotoxicity in patients with renal failure who are treated with cefepime has been reported sporadically. We report on two senile patients with renal impairment who developed neurotoxicity including lethal outcome after treatment with cefepime.
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To examine the usefulness of the Scale for the Assessment and Rating of Ataxia (SARA) in ataxic stroke patients.
This was a retrospective study of 54 patients following their first ataxic stroke. The data used in the analysis comprised ambulation status on admission and scores on the SARA, the Korean version of the Modified Barthel Index (K-MBI) and the Berg Balance Scale (BBS). The subjects were divided into four groups by gait status and into five groups by level of dependency in activities of daily living (ADLs) based on their K-MBI scores. Data were subjected to a ROC curve analysis to obtain cutoff values on the SARA for individual gait status and levels of activity dependency. The correlations between the SARA, K-MBI and BBS scores were also computed.
There was significant correlation between the SARA and the K-MBI scores (p<0.001), and this correlation (r=-0.792) was higher than that found between the BBS and the K-MBI scores (r=0.710). The SARA scores of upper extremity ataxia categories were significantly related to the K-MBI scores of upper extremity related function (p<0.001). The SARA scores were also significantly correlated negatively with ambulation status (p<0.001) and positively with ADL dependency (p<0.001). In the ROC analysis, patients with less than 5.5 points on the SARA had minimal dependency in ADL, while those with more than 23 points showed total dependency.
SARA corresponds well with gait status and ADL dependency in ataxic stroke patients and is considered to be a useful functional measure in that patient group.
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