Acta neurologica Taiwanica最新文献

Purpose: Migraine is a common, debilitating, primary headache disorder that can cause and be affected by odontalgia.

Case report: A 49-year-old woman(Patient 1) presented with pulsating pain in the left maxillary molar area, and a history of unsuccessful root canal treatment. She was ultimately diagnosed with menstrually related migraine without aura and zolmitriptan was prescribed, which reduced her headache and toothache together. A 45-year-old woman (Patient 2) presented with throbbing pain in the right maxillary molar and cheek area. Past repeated endodontic therapy had been unsuccessful. She was then diagnosed with menstrually related migraine without aura, and sumatriptan significantly reduced her headache and toothache. A 40-year-old woman (Patient 3) presented with pulsating pain near the left maxillary molar region. Pulpectomy was performed after she had previously received a diagnosis of pulpitis in the left maxillary second molar, but her pain did not subside. Patient 2 and 3 were misdiagnosed as pulpitis by dental practitioners and the pain did not relive after pulpectomy. All patients were diagnosed as migraine by headache specialists and were treated with triptans, which resulted in satisfactory pain relief.

Conclusion: A thorough history and examination, as well as an understanding of migraine headaches, is necessary to differentiate odontogenic pain and migraine headaches. Key Words: menstrually related migraine, orofacial pain, ICHD-3, headache.

Medication adherence, by definition,(2) is "the extent to which a patient acts in accordance with the prescribed interval and dose of a dosing regimen." Poor medication adherence can interfere with the ability to treat many diseases, leading to greater complications and a lower quality of life.(3) In this issue of Acta Neurologica Taiwanica, Chen et al.(4) presented the inverse association between adherence of antithrombotic agents and poor outcomes after a first-ever ischemic stroke. The findings were consistent with Sung, et al.(5) that medication nonadherence are prevalent in young adults with a firstever stroke. The results by Chen, et al.(4) highlighted the importance of developing strategies to improve antithrombotic adherence. Besides, the risk-benefit profile of medication treatment must be considered and monitored for optimizing prescription in secondary stroke prevention. For those purposes, real-world data (RWD) derived from administrative claims database is becoming an efficient source of information.(6) The US Food and Drug Administration has also recognized the use of RWD to monitor post-marketing safety and adverse events and to make regulatory decisions of medicinal products.(7) Nonetheless, deriving RWD from administrative claims database should be held to an even higher scientific standard because of the greater potential for bias.(6) For example, the ascertainment of cases, coding for comorbidities, and handling of unmeasured confounders (e.g. disease severity) should follow those previously wellvalidated methods.(8-10) Besides, we should note that the adherence measured using claims data is the proportion of days covered with filled prescription. It might not be exactly equal to the real medication adherence behavior of the patients, as mentioned by Chen, et al.(4) Linking administrative claims database with other validated clinical databases (e.g. stroke registry) may improve the validity of a RWD study.(11) In the era of data science and artificial intelligence, we neurologists should endeavor to make the best use of all available electronic healthcare datasets, creating more useful RWD for our patients with strokes, as well as other neurological diseases.

A 77-year-old woman with a history of hypertension developed acute onset of aphasia and right hemiplegia and hemisensory loss. She was urgently referred to emergency department. Cerebral multidetector computed tomographic angiography (MD-CTA) revealed an acute ischemic stroke due to the occlusion of the left middle cerebral artery (Figure 1). Since the symptoms started three hours previously, the patient was candidate for mechanical thrombectomy. The patient then performed a selective digital subtraction angiography (DSA) of the left internal carotid artery that confirmed occlusion of the ipsilateral middle cerebral artery (Figure 2) and subsequently successfully performed the endovascular mechanical thrombectomy (Figure 2). Her clinical course has shown neurological symptoms improvement over time. Acute ischemic stroke can be caused by several factors, but the main ones are arterial and cardiac embolism, arterial wall disease or variants(1-4). The National Institutes of Health Stroke Scale (NIHSS) score, is widely used as clinical assessment for neurological deficits related to ischemic stroke(1). MDCTA and Magnetic Resonance Imaging are the two gold standard methods for diagnosis in acute ischemic stroke patients(1-5). Thrombolytic therapy of this pathological state began in the fifties, while the endovascular mechanical thrombectomy was defined as a new standard of care in 2015(1,5,6). This recent technique have added tissue window" to the existing "time window" (5,6). So, nowadays patients with small ischemic core, large penumbra, and good collaterals vessel may benefit from endovascular mechanical thrombectomy(1,5,6); even if they arrive within 6-24 h of stroke onset(5.

Carotid-cavernous fistulae (CCFs) are classified into the direct and indirect types, which can be attributed to trauma, atherosclerosis, hypertension, diabetes mellitus, pregnant or postmenopausal status(1). Cerebral angiography is the gold standard for the diagnosis of CCFs. Doppler ultrasound, which typically reveals increased blood flow velocity and decreased resistance index (RI) in the feeding arteries, can assist in the diagnosis(2-3). We herein report a case of indirect CCF presenting with high RI in the feeding arteries, which is mainly attributed to the generalized atherosclerotic change, and is regarded as a diagnostic pitfall of the CCFs.

Purpose: Sporadic hemiplegic migraine (SHM) is characterized by a prolonged motor aura that accompanies a migraine attack, and its underlying pathophysiology remains unclear. Functional image during the event can help to explore the mechanism.

Case report: We report a finding of 18-fluorodeoxyglucose positron emission tomography (FDG-PET) in a 15-year-old female with SHM. She presented with recurrent right arm weakness and pain with migrainous headache. A video electroencephalogram showed no evidence of epilepsy during the events. Subtraction of ictal-interictal FDG-PET coregistered to magnetic resonance imaging was performed for the image analysis. In comparison with the interictal state, the FDG-PET image showed decreased glucose metabolism in the bilateral dorsal lateral frontal cortices and bilateral occipital cortices, whereas increased metabolism in the left precentral motor cortex and right premotor cortex.

Conclusion: These findings reveal an increase in metabolism in the motor cortex during general cortical dysfunction in the frontal and occipital cortices in SHM. Key words: FDG-PET, hemiplegic migraine, migraine, positron emission tomography, SISCOM.

Objective: Various numbers of factors such as oxidative stress, neurotoxins, and pesticides have been implicated in its pathophysiology of Parkinson's disease (PD). Paraoxonas1 (PON1) metabolizes xenobiotics, including pesticides. Therefore, we surveyed the relationship between PON1 polymorphisms with its activities in the pathogenesis of Parkinson's disease..

Methods: We investigated polymorphisms of the PON1 (L55M and Q192R) by PCR-RFLP assays; we also measure the levels of PON1, TAC (total antioxidant capacity) and TOS (total oxidant status) with ELISA (Enzyme-linked immunosorbent assay) and spectrophotometric method for their activities.

Results: Paraoxonase and arylesterase activity of PON1 as well as their concentrations were lower in patients with PD compared with control group, but from the view of the specific activity, it was not significant between two groups. In the compare of TAC, TOS, and OSI, the TOS and OSI were higher in the patients than controls, while patients had lower levels of TAC compared with controls. Serum PON1 concentrations and activities were higher in LL (comparison with LM and MM) and RR (comparison with QR and QQ) genotypes while we did not observe any significant differences in arylesterase levels among mentioned polymorphisms.

Conclusion: In the current study, we reported associations between PON1 polymorphisms (55, 192) and enzyme activities in Parkinson's disease as there was a significant reduction in PON1 levels in patients with Parkinson compared with healthy. Taken together, paraoxonase enzyme in subjects with different genotypes could be a potential biomarker for determining the severity and prognosis of Parkinson. However, more studies are needed to clarify its clinical values. Key words: Parkinson's disease; paraoxonase1; Polymorphism.

Abtract Objective: The auditory brainstem response (ABR) has been reported as normal in patients with vitamin B12 deficiency, but there have also been reported cases of interference in amplitude responses. However, studies investigating the effects of vitamin B12 on auditory response are limited in patients with tinnitus. The aim of this study was to investigate the ABR findings in patients with tinnitus together with vitamin B12 deficiency.

Material and methods: Twenty-eight patients with tinnitus-related vitamin B12 deficiency were included in the study. Their serum vitamin B12 levels were lower than 200 pg/ml. Patients were between 19 and 58 years with a mean age of 36.82 ± 11.19 (ratio: male/female, 6/22). ABR was performed in all patients. Latencies ( I, II, III, IV, V), interpeak latencies (I-III, III-V, I-V) and amplitudes were evaluated. Neurologic and ear physical examinations were evaluated and brain magnetic resonance imaging (MRI) was also performed in all patients.

Results: Neurologic,ear-auditory physical examinations and brain MRI findings were normal in all patients. Wave latencies and interpeak latencies were normal in all patients. Six patients (21.42 %) had low amplitude in their ABR. In one of them, the left-sided response showed a mild amplitude decrease in all waves compared to the right-side. Bilateral mild low amplitude was observed in 4 (66.6 %) patients in ABR findings.

Conclusion: These results support that ABR findings can be influenced in vitamin B12 deficiency patients having tinnitus. More detailed studies are needed in tinnitus associated with vitamin B12 deficient patients. Key words: Auditory brainstem response, Tinnitus, Vitamin B12 deficiency, Neurophysiology, Low amplitude.

Purpose: PACNS has a broad spectrum of clinical manifestations without typical features, and its clinical diagnosis is challenging. We report an elderly patient of cerebellar PACNS (Primary angiitis of central nervous system) presented as a brain tumor by MRI, and primary angiitis was proven by pathology.

Case report: We report an 81-year-old female who complained about vertigo for 3 weeks with right arm dysmetria. There were no other neurologic symptoms/signs, and the patient was free from headache. Brain CT showed a space-occupying lesion over the right cerebellum, and a high-grade glioma was suspected by brain MRI and MRS. The pathologic result of brain biopsy showed granulomatous variant of PACNS. The patient received immunosuppressant therapy as long-term therapy, and had favorable response during a 2-year follow up.

Conclusion: Due to variations in clinical presentation and nonspecific findings on imaging studies, PACNS is not easily diagnosed, especially in the aged population. PACNS should be considered as one of the differential diagnoses of any CNS dysfunction. PACNS is also an exclusionary diagnosis, so although brain biopsy is limited for its low sensitivity, its application is still important to exclude the possibility of other diseases. Although there have been reports of fulminant cases, PACNS can be treated successfully with immunosuppressant as maintaining therapy.

Cannabis plant has the scientific name called Cannabis sativa L. Cannabis plant has many species, but there are three main species including Cannabis sativa, Cannabis indica and Cannabis ruderalis. Over 70 compounds isolated from cannabis species are called cannabinoids (CBN). Cannabinoids produce over 100 naturally occurring chemicals. The most abundant chemicals are delta-9-tetrahydrocannabinol (THC) and Cannabidiol (CBD). THC is psychotropic chemical that makes people feel "high" while CBD is nonpsychotropic chemical. However, cannabinoid chemicals are not found only in the cannabis plant, they are also produced by the mammalian body, called endocannabinoids and in the laboratory, called synthesized cannabinoids. Endocannabinoids are endogenous lipid-based retrograde neurotransmitters that bind to cannabinoid receptors, and cannabinoid receptor proteins that are expressed throughout the mammalian central nervous system including brain and peripheral nervous system. There are at least two types of endocannabinoid receptors (CB1 and CB2) which are G-protein coupled receptors. CB1 receptors are particularly abundant in the frontal cortex, hippocampus, basal ganglia, hypothalamus and cerebellum, spinal cord and peripheral nervous system. They are present in inhibitory GABA-ergic neurons and excitatory glutamatergic neurons. CB2 receptor is most abundantly found on cells of the immune system, hematopoietic cells and glia cells. CB2 is mainly expressed in the periphery under normal healthy condition, but in conditions of disease or injury, this upregulation occurs within the brain, and CB2 is therefore expressed in the brain in unhealthy states. Cannabis and cannabinoid are studied in different medical conditions. The therapeutic potentials of both cannabis and cannabinoid are related to the effects of THC, CBD and other cannabinoid compounds. However, the "high" effect of THC in cannabis and cannabinoid may limit the clinical use, particularly, the study on the therapeutic potential of THC alone is more limited. This review emphasizes the therapeutic potential of CBD and CBD with THC. CBD has shown to have benefit in a variety of neuropsychiatric disorders including autism spectrum disorder, anxiety, psychosis, neuropathic pain, cancer pain, HIV, migraine, multiple sclerosis, Alzheimer disease, Parkinson disease, Huntington disease, hypoxic-ischemic injury and epilepsy. CBD is generally well tolerated. Most common adverse events are diarrhea and somnolence. CBD also shows significantly low abuse potential.

Purpose: Mitochondrial encephalomyopathy, lactic acidosis and stroke-like episodes (MELAS) syndrome primarily affects the young and may not be considered first in an older adult with infection-like encephalopathy. Here, we present the case of a patient who suffered from the acute onset of fever, delirium, and epilepsy, mimicking herpes simplex encephalitis (HSE).

Case report: A 52-year-old woman with diabetes and end stage renal disease (ESRD) regularly took oral anti-diabetic drugs (OADs) and received hemodialysis. She presented with an acute onset of fever, delirium, and epilepsy, mimicking HSE. Further investigation showed a persistent elevated lactate level in the cerebrospinal fluid (CSF). A mitochondrial DNA analysis revealed a point mutation at nucleotide 3243.

Conclusion: The clinical presentation and imaging studies of MELAS in adults are variable and may mimic those of HSE. Antiviral therapy should be administered until the diagnosis of MELAS is definitive. Infection and metformin may have also precipitated MELAS manifestation in this patient. Clinicians should avoid potential mitochondrial-toxic drugs in these patients.