Acta neurologica Taiwanica最新文献

Objective: To evaluate the effect of using acetylsalicylic acid (aspirin) together with lansoprazole in the secondary prevention of ischemic stroke.

Materials and methods: 199 patients with a diagnosis of ischemic stroke and transient ischemic attack (TIA) using 100 mg aspirin regularly were included in the study. All patients were evaluated for the presence of aspirin resistance before starting the study. 57 patients with aspirin resistance were excluded from the study. The remaining 142 patients were divided into two groups: the 1st group consisted of those with stomach discomfort and the 2nd group consisted of those without stomach discomfort. Patients in group 1 were given 30 mg of lansoprazole taken before breakfast in addition to aspirin therapy. All patients were re-evaluated for the presence of aspirin resistance at a one-month follow-up. The antiaggregant activity was evaluated by the impedance aggregometry method in both groups.

Results: Of 142 patients, 75 were in group 1, and 67 were in group 2. There was no difference between the two groups in terms of age and gender distribution of vascular risk factors. There was no statistically significant difference between the two groups in terms of aspirin efficacy. The dose of aspirin was increased in patients with aspirin resistance (AR).

Conclusion: The combination of 30 mg lansoprazole and 100 mg aspirin does not cause a decrease in antiaggregant activity in the early period, but chronic use was not evaluated in this study. Patients with AR may benefit from an increase in the dose of aspirin.

Purpose: The causes of acute stroke in patients with SLE are multifactorial. Antiphospholipid-associated hypercoagulability and inflammation-induced platelet activation are major causes of ischemic stroke in SLE patients. As such patients underwent intravenous thrombolysis and endovascular thrombectomy, they may have higher risk of complications and less favorable outcome.

Case report: A 30-year-old woman with underline SLE and Takayasu arteritis who presented with right CCA and MCA occlusion status post rtPA and endovascular thrombectomy. Twelve hours after the procedure, head CT was ordered due to anisocoria with loss of pupillary light reflex. The head CT showed partial obliteration of suprasellar and quadrigeminal cistern due to extensive brain edema, leading to her decompressive craniectomy. Two days later, patient's both pupil became dilated with head CT showing occlusion of the left MCA. Her condition drastically went downhill when complications such as central DI and myocardial stunning occurred.

Conclusion: Although autoimmune vasculitis is not listed as an absolute contraindication to endovascular thrombectomy, given the antecedent reports, it is prudent to disclose possible complications to both the patient and family while making the decision.

Purpose: Intracranial vertebrobasilar artery dissection (iVBD) is a potentially lethal disease, and progression of the dissected vessels is not uncommon. Our report is aimed at providing further clinical experience of the timing of follow-up vascular imaging or endovascular intervention in iVBD patients.

Case report: We report a case of iVBD with silent rapid progression. The 48-year-old woman presented as transient right limbs weakness. Brain MRI showed a small acute infarct over the left cerebellum, and MRA revealed a short segment of dissection over the left distal vertebral artery extending to proximal basilar artery. With no new clinical symptoms and signs, follow-up of vascular imaging within 1 week showed progressive critical narrowing of the dissected vertebrobasilar arteries. The blood flow of the vertebrobasilar system was restored by endovascular stenting.

Conclusion: iVBD might progress without clinical manifestations. Early follow-up of vascular imaging should be considered in the patients with high risk for progression.

Purpose: The three-dimensional (3D) measurement of vessel wall volume (VWV) and plaque volume is sensitive for predicting cardiovascular risk. We established the normal norms of carotid VWV.

Methods: We retrospectively enrolled 352 patients with normal findings of the carotid ultrasound studies. Two-dimensional carotid intima-media thickness (IMT) was measured online. Grayscale 3D images of both sides of the carotid arteries were analyzed offline for measurement of IMT (QIMT) and VWV.

Results: The median age of the enrollees was 59 years. The median carotid IMT, QIMT, and VWV was 0.61 mm, 0.72 mm, and 90 mm3, respectively. No differences in IMT and VWV were observed between men and women or between the right and left side. We stratified participants into four groups, namely young adults (≤50 years), middle-aged adults (51-65 years), older adults (66-75 years), and senior adults (≥75 years). All the values of measured variables increased with advancing age. The median VWV of each group was 84, 90, 100, and 112 mm3, respectively. The increment percentage from young to senior adults was similar in terms of IMT and VWV. Nevertheless, the difference in the value of VWV (28 mm3) was much larger than that in IMT (0.18 mm). All three measured variables exhibited a positive linear correlation with age.

Conclusion: Both IMT and VWV have positive linear correlations with age. The application of QIMT measurements was limited by its inconsistent accuracy. VWV not only has a strong correlation with IMT but also enables observation of dynamic vessel wall changes, which is valuable for clinical observational studies.

Purpose: Minor injury to head and neck is usually neglected for potential neurological consequences. We report a woman who suffered left Eagle syndrome due to styloid process fracture two years after a minor motorcycle collision.

Case report: A 53-year-old woman complained pain at her left upper neck, lower face and periauricular area after minor motorcycle collision at 2 years ago. The pain usually occurred spontaneously but was occasionally triggered or exacerbated by specific postural changes, including looking up or turning head to right side. Moreover, a foreign body sensation occurred at throat during swallowing. Physical examination provoked pain at the left submandibular area. Carotid bruit was absent. Otherwise, other neurological function was preserved. Computerized tomography revealed linear fracture at the middle of left styloid process. After inform, patient preferred conservative treatments including abortive non- steroidal anti-inflammatory drugs and an avoidance of rapid head rotations. Since afterwards, the frequency and intensity of neck pain greatly decreased and she could tolerate and maintain a normal daily living.

Conclusions: Asymptomatic or paucisymptomatic styloid process fracture may be neglected in case of minor injury to head and neck. A careful evaluation of neck should be completed in traumatic individuals to reveal underlying damage and prevent further harmful consequence.

The Treatment Guideline Subcommittee of the Taiwan Headache Society evaluated Taiwan's guidelines for the acute and preventive treatment of cluster headaches on the basis of the principles of evidence-based medicine. The subcommittee assessed the quality of clinical trials and levels of evidence and referred to the treatment guidelines of other countries. Over the course of several panel discussions, the subcommittee members reached a consensus regarding the major roles of, recommended levels of, clinical efficacy of, adverse events in, and clinical precautions for the acute and preventive treatment of cluster headaches. Thus, the subcommittee updated the previous version of the guidelines published in 2011. Most cluster headaches occurring in Taiwan are episodic, and very few patients develop chronic cluster headaches. Cluster headaches cause extreme pain over a short period and are accompanied by ipsilateral autonomic symptoms; therefore, immediate treatment can provide considerable relief. Treatment options can be categorized into acute and preventive types. Among the treatment methods currently available in Taiwan for cluster headaches, high-flow pure oxygen inhalation has demonstrated the best evidence and effectiveness for acute attacks, followed by triptan nasal spray; therefore, these are recommended as first-line treatments. Oral steroids and suboccipital steroid injections can be used as transitional preventative treatments. Verapamil is recommended as a first-line treatment for maintenance prophylaxis. Drugs such as lithium, topiramate, and calcitonin gene-related peptide (CGRP) monoclonal antibodies are recommended as secondline treatments. Noninvasive vagus nerve stimulation is the recommended instrumental therapy. The effectiveness of surgical treatment, such as sphenopalatine ganglion stimulation, is supported by a high level of evidence; nevertheless, because few patients have chronic cluster headaches in Taiwan, no clinical records are available for use as a reference. Transitional prophylaxis and maintenance prophylaxis can be used simultaneously according to the individual condition of the patient, and the transitional prophylaxis can be gradually discontinued once the maintenance prophylaxis takes effect. Steroids should not be used for more than 2 weeks as transitional prophylaxis. Maintenance prophylaxis should be administered until the end of the bout period (no attacks for 2 weeks) and then gradually tapered off. Key words: cluster headaches, oxygen therapy, triptans, steroids, CGRP monoclonal antibodies, noninvasive vagus nerve stimulation.

The Treatment Guideline Subcommittee of the Taiwan Headache Society evaluated the medications currently used for migraine prevention in Taiwan. The subcommittee assessed the results of recently published trials, meta-analyses, and guidelines. After expert panel discussions, the subcommittee reached a consensus on the preventive treatment of migraine in Taiwan, which includes recommendation levels, the strength of evidence, and essential prescription information (i.e., dosage and adverse effects) . The recent introduction of CGRP monoclonal antibodies has had a substantial effect on migraine treatment. Thus, the subcommittee updated the previous version of the treatment guideline published in 2017. Preventive medications for migraines can be divided into the following categories: ß-blockers, anticonvulsants, calcium channel blockers, antidepressants, onabotulinumtoxinA, anti-CGRP monoclonal antibodies, and complementary and alternative medicine. For episodic migraine prevention, propranolol, flunarizine, and topiramate are recommended as the first-line medications. Second-line medications for episodic migraine prevention include valproic acid, amitriptyline, and anti-CGRP monoclonal antibodies. Other treatment options could be used as third-line treatments. For chronic migraine prevention, topiramate, flunarizine, onabotulinumtoxinA, and anti-CGRP monoclonal antibodies are recommended as first-line therapies. Preventive medications for episodic migraine can also be used as second-line treatments for chronic migraine. For menstrual migraines, nonsteroidal anti-inflammatory drugs and triptans can be used for short-term prophylaxis. Indications for starting preventive treatment include a headache frequency of ≥4 days per month, profound disabilities, failure of or contraindication to acute therapies, a complicated migraine with debilitating (e.g., hemiplegic) auras, and migrainous brain infarction. The general principle for oral preventives is to "start low and go slow" while monitoring for adverse events and comorbid conditions. Physicians could consider gradually tapering the medications in patients with sustained improvement over 3 to 6 months in episodic migraine and 6 to 12 months in chronic migraine. Education about not overusing acute medications is also essential for all patients with migraine. Key words: migraine, preventive treatment, evidence-based medicine, guidelines, CGRP monoclonal antibodies, onabotulinumtoxinA, neuromodulation.

Purpose: We here report an uncommon cause of recurrent subdural hematoma in a female with thrombocytopenia.

Case report: The patients'detailed workup revealed a diagnosis of chronic disseminated intravascular coagulation. Subsequently, her bone marrow biopsy indicated bone marrow suppression and computed tomography of the abdomen showed carcinoma of the gallbladder with vertebral metastasis.

Conclusion: If a patient present with recurrent subdural hematoma, adequate investigations and timely management should be pursued to avoid further complications.

Purpose Alzheimer disease (AD) is an irreversible neurodegenerative disease that causes progressive cognitive decline. Co-existing thymoma should be considered when rapid deterioration of cognition was noted in AD patients and removal of thymoma may improve cognition in AD. Case report We report a 72-year-old woman with initial complaints of memory impairment for 2 years. After detailed history taking, neuropsychological tests, brain magnetic resonance imaging, and positive amyloid positron emission tomography, she was diagnosed as having dementia of the Alzheimer type. At the time of diagnosis, her dementia condition was mild (clinical dementia rating [CDR] is equal to 1, CDR sum of boxes [CDR-sb] = 4.5, Mini-Mental State Examination (MMSE) is equal to 21 divided by 30). She needed moderate assistance in performing daily life activities. One year after AD diagnosis, her condition deteriorated drastically, and she experienced frequent falls and severe weakness apart from cognitive symptoms. Concurrent myasthenia gravis (MG) with thymoma was found later, and thymectomy was performed. Her symptoms related to MG alleviated after the operation. Notably, her cognitive symptoms also improved 4 months after the operation, and her dementia reversed to mild cognitive impairment. Conclusion Although the role of neuroinflammation in AD has been widely discussed, it remains elusive. Removal of the co-existing thymoma not only alleviated the patient's MG symptoms but also improved her cognitive performance. We supposed that this effect may have been a direct result of the decrease in acetylcholine receptor antibody or reduction in the degree of neuroinflammation. Keywords Alzheimer disease, thymoma, neuroinflammation, central cholinergic effects, acetylcholine receptor antibody.

Here we present a case of Japanese encephalitis with an interesting MRI image. The patient is a previously healthy 27 years old male living around a hog farm. Initially, he went to a local hospital and was treated with Levofloxacin as a pneumonia infection. He presented with fever and headache for two days before he sought medical assistance. For two days, his symptoms didn't improve, and progressive consciousness declining was noted. Hence the family decided to transfer to our hospital for further evaluation. On examination, his consciousness was stupor, cannot obey orders, and febrile. The pupils were equal with preserved light reflex. His muscle powers were symmetric bilaterally near his baseline. CSF examination showed normal opening pressure, elevated WBC count with 196 nucleated cells/mm3, normal glucose, and elevated protein level. Brain MRI showed left medial thalamic hyperintensity on T2WI and DWI (Figure 1). Finally, the patient was diagnosed with Japanese encephalitis based on the positive result of the Nucleic acid amplification test. The patient received supportive care with a gradual recovery of his consciousness and became able to obey commands. However, subtle learning problems persisted after one week. Based on the literature review, the MRI or CT finding on thalamic lesions on imaging has high specificity, which could be an assistance tool diagnosis of Japanese encephalitis.[1] The typical Japanese MRI feature consists of hyperintense lesions on T2WI or DWI, and the thalamus was the most commonly involved region. [2][3][4] Although the majority of Japanese encephalitis had bilateral thalamic lesions, the unilateral lesion is uncommon. [4][5] Thus the case presented here provides a rare image of reference for Japanese encephalitis with a unilateral thalamic lesion Reference 1. Dung NM, et al. An evaluation of the usefulness of neuroimaging for the diagnosis of Japanese encephalitis. J Neurol. 2009;256(12): 2052-60. 2. Maschke M, et al. Update on neuroimaging in infectious central nervous system disease. Curr Opin Neurol. 2004;17(4):475-80. 3. Sunwoo, J.-S., et al., Clinical Characteristics of Severe Japanese Encephalitis: A Case Series from South Korea. The American journal of tropical medicine and hygiene, 2017. 97(2): p. 369-375. 4. Phukan, P., et al., MRI Spectrum of Japanese Encephalitis in Northeast India: A Cross-Sectional Study. Journal of neurosciences in rural practice, 2021. 12(2): p. 281-289. 5. Yakushiji, Y., et al., [A case of Japanese encephalitis presenting with unilateral lesions in diffusion-weighted MRI]. Rinsho Shinkeigaku, 2001. 41(9): p. 602-5.