Background and Purpose—The aim of this study was to investigate differences in risk factors and stroke mechanisms between intracranial atherosclerosis (ICAS) and extracranial atherosclerosis (ECAS) and between anterior and posterior circulation atherosclerosis. Methods—A multicenter, prospective, Web-based registry was performed on atherosclerotic strokes using diffusionweighted magnetic resonance imaging and magnetic resonance angiography. Stroke mechanisms were categorized as artery-to-artery embolism, in situ thrombo-occlusion, local branch occlusion, or hemodynamic impairment. Results—Onethousand patients were enrolled from 9 university hospitals. Age (odds ratio [OR], 1.033; 95% confidence interval [CI], 1.018–1.049), male gender (OR, 3.399; 95% CI, 2.335–4.949), and hyperlipidemia (OR, 1.502; 95% CI, 1.117–2.018) were factors favoring ECAS (vs ICAS), whereas hypertension (OR, 1.826; 95% CI, 1.274–2.618; P=0.001) and diabetes mellitus (OR, 1.490; 95% CI, 1.105–2.010; P=0.009) were related to posterio...

Risk Factors and Stroke Mechanisms in Atherosclerotic Stroke Intracranial Compared With Extracranial and Anterior Compared With Posterior Circulation Disease

The purpose of this study was to analyse MR imaging features and lesion patterns as defined by compromised vascular territories, correlating them to different clinical syndromes and aetiological aspects. In a 19.8-year period, clinical records and magnetic resonance imaging (MRI) features of 55 consecutive patients suffering from spinal cord ischemia were evaluated. Aetiologies of infarcts were arteriosclerosis of the aorta and vertebral arteries (23.6 %), aortic surgery or interventional aneurysm repair (11 %) and aortic and vertebral artery dissection (11 %), and in 23.6 %, aetiology remained unclear. Infarcts occurred in 38.2 % at the cervical and thoracic level, respectively, and 49 % of patients suffered from centromedullar syndrome caused by anterior spinal artery ischemia. MRI disclosed hyperintense pencil-like lesion pattern on T2WI in 98.2 %, cord swelling in 40 %, enhancement on post-contrast T1WI in 42.9 % and always hyperintense signal on diffusion-weighted imaging (DWI) when acquired. The most common clinical feature in spinal cord ischemia is a centromedullar syndrome, and in contrast to anterior spinal artery ischemia, infarcts in the posterior spinal artery territory are rare. The exclusively cervical location of the spinal sulcal artery syndrome seems to be a likely consequence of anterior spinal artery duplication which is observed preferentially here.

Spinal cord ischemia: aetiology, clinical syndromes and imaging features.

BACKGROUND AND PURPOSE: MR imaging features of HE have not been fully established The purpose of this study was to determine the topographic distribution and DWI findings of HE

MATERIALS AND METHODS: We retrospectively evaluated HE MR imaging ( n = 11) The topographic distribution of the lesions was evaluated on routine MR imaging, and DWI SI and ADC values were assessed The ADC value of involved lesions was compared with the noninvolved subcortical WM area by use of the paired t test

RESULTS: MR images demonstrated bilateral diffusion-restrictive lesions in the posterior limb of the IC ( n = 6), cerebral cortex ( n = 8), CR ( n = 7), CS ( n = 9), hippocampus ( n = 4), and BG ( n = 1) The mean ADC value of lesions was 44882 ± 9234 × 10−6 mm2/s compared with the mean ADC value of noninvolved lesions (83772 ± 6214 × 10−6 mm2/s); this difference was statistically significant ( P < 000) The lesions showed complete resolution on follow-up DWI for 6 patients Three patients with cortical involvement of ≥2 lobes showed partial recovery or death, but most of the other patients with WM involvement or cortical involvement in only 1 lobe experienced complete recovery

CONCLUSIONS: The topographic localization of the lesions was the posterior limb of the IC, cerebral cortex, CR, CS, hippocampus, and BG Most HE lesions probably correspond to areas of reversible cytotoxic edema as seen on DWI, which can predict the prognosis of HE according to the degree of lesion extent

ADC
: apparent diffusion coefficient
APN
: acute pyelonephritis
BG
: basal ganglia
BST
: blood sugar test
CC
: corpus callosum
CR
: corona radiata
CS
: centrum semiovale
DM
: diabetes mellitus
DWI
: diffusion-weighted image
FLAIR
: fluid-attenuated inversion recovery
FL
: frontal lobe
HE
: hypoglycemic encephalopathy
IC
: internal capsule
IN
: insular lobe
MCA
: middle cerebral artery
MRI
: MR imaging
NSA
: number of signals averaged
OC
: occipital lobe
PA
: parietal lobe
SI
: signal intensity
TL
: temporal lobe
WM
: white matter

pdf/diffusion-mr-imaging-of-hypoglycemic-encephalopathy-4l0bs45o8d.pdf

Diffusion MR imaging of hypoglycemic encephalopathy.

Background Approximately 5% of combat-related injuries include burns. Previous studies have shown similar mortality rates between military and civilian burn casualties; but causes of death were not detailed. Study Design We retrospectively reviewed autopsy reports of patients with burns treated at the US Army Institute of Surgical Research Burn Center from 2004 to 2007. Results Of 1,255 admissions, 100 (8%) died, with autopsies performed on 74 (36 burned during military operations). Causes of death included infection (61%); disorders of the pulmonary (55%), cardiac (36%), renal (27%), gastrointestinal (27%), and central nervous (11%) systems; and multiorgan dysfunction (15%). Patients burned as a result of military operations were younger men with more associated inhalation injuries, greater severity of injury, and longer time from injury to admission and to death. They died more frequently of infection (notably fungus, Pseudomonas , and Klebsiella ) and gastrointestinal complications; and those not burned in military operations had greater numbers of cardiac and renal causes of death. Conclusion Casualties of military operations are clinically different and die from different causes than patients not burned during military operations. The differences are likely reflective of a younger population, with greater severity of illness and longer times from injury to admission. Therapeutic interventions should focus on prevention of infection and gastrointestinal catastrophes in military burn casualties, which are similar to younger burn patients in the US, and minimizing cardiac complications in civilian burn casualties, who are typically older patients and possibly reflective of patients with more comorbidities.

Causes of Mortality by Autopsy Findings of Combat Casualties and Civilian Patients Admitted to a Burn Unit

Posterior circulation ischaemia is a clinicopathological condition with complex symptomatology associated with an infarction within the vertebrobasilar arterial system. Posterior circulation strokes account for about 20-25% of all ischemic strokes and remain a significant cause of patient disability and mortality. Diagnosis can be challenging because presenting symptoms are often non-focal and because there is a substantial overlap in symptoms and signs of ischaemia in the anterior circulation. Despite better imaging techniques, diagnosis and treatment of life-threatening conditions, such as basilar artery occlusions, are often delayed. Therefore, early detection of symptoms and causes of posterior circulation ischaemia is essential for choosing the most appropriate therapy. In this review, we summarise the anatomy, aetiology, typical presentations and characteristic findings of common strokes resulting from disease in the vertebrobasilar arterial system.

Posterior circulation ischaemic stroke—a review part I: anatomy, aetiology and clinical presentations

To understand the characteristics of posterior circulation ischemic stroke (PCS) in the Korean population better, we retrospectively reviewed the data from the Hallym Stroke Registry (HSR). We analyzed the demographic features, risk factors, stroke subtypes, lesion distributions and clinical outcomes of 591 consecutive patients with PCS, enrolled in HSR between January 1996 and July 2002. PCS was 39.8% of all ischemic strokes. Mean age of PCS patients was 63.4 years and 55.7% were men. Hypertension was the most common risk factor (69.9%). However, potential cardioembolic sources were found only in 11.0%. The most frequent stroke subtype was large artery disease (50.0%), followed by small vessel disease (33.8%). Only 5.2% of patients were classified as affected with cardioembolism. The most common location of infarcts was in the middle territory (36.5%), followed by distal (28.1%), proximal (19.0%), and multiple territories (16.4%). The hospital mortality rate (4.1%) and discharge outcome of PCS were comparable with those of the anterior circulation stroke (ACS). In conclusion, the etiology and lesion topography of PCS in the Korean population appeared to be different from those of the Caucasians.

Posterior circulation ischemic stroke in Korean population.

A N 82-YEAR-OLD WOMAN PRESENTED TO THE emergency department with altered mental status. Her son had conversed with her by telephone 36 hours before the onset, but he could not reach her by telephone 24 hours after that. She had a medical history of right hemiparesis and dysarthria 14 years earlier and had been taking medication for hypertension as well as aspirin. She was diagnosed as having type 1 diabetes mellitus and began taking medication for her diabetes 1 month prior to this onset. Her blood glucose level during the emergency department visit was 12 mg/dL (0.7 mmol/L). Her initial blood pressure was 173/76 mm Hg and oxygen saturation was 91.3%. Diffusion-weighted magnetic resonance (MR) imaging and T2-weighted MR imaging showed diffuse cortical high signal (Figure). The brainstem, cerebellum, and thalamus were spared. Despite prolonged hypoglycemia, the dorsofrontal cortex and occipital poles were also spared. The signal changes on the hippocampus were relatively small. On T2-weighted MR imaging, a focal high-signal lesion was seen in the thalamus bilaterally (with more prominence on the left side) and in the centrum semiovale. Diffuse white matter lesions were seen on T2-weighted MR imaging. Considering her medical history and the diffusion-weighted MR image, it seems more likely we were looking at an old ischemic lesion and hypertensive change. She died 3 days after hospital admission. Diffusion-weighted MR imaging may help differentiate acute hypoglycemic lesions from old ischemic lesions and diffuse white matter changes. Unlike hypoxic damage, the occipital cortex, dorsofrontal cortex, and hippocampus may be more resistant to prolonged hypoglycemia.

Severe Hypoglycemia and Vulnerability of the Brain

Background: The significance of silent infarcts (SIs) is unknown in very elderly patients with first-ever acute ischemic stroke. Methods: Fifty patients aged 80 y

Significance of silent infarcts in acute ischemic stroke patients aged 80 years and older.

Leprosy is a disease characteristically involving the skin and peripheral nerves. Leprosy is diagnosed typically by observation of representative skin lesions and the presence of acid-fast bacilli (AFB) in a skin smear or a skin biopsy; deepnerve biopsies such as a sural nerve biopsy are not routine procedures. Therefore, very few reports of sural nerve biopsies that yield a pathologic finding of leprosy are available; moreover, electron microscopic studies are still rarer. A nerve conduction study (NCS) and sural nerve biopsy are the gold standards for the diagnosis of chronic inflammatory polyneuropathy (CIDP). NCS findings that indicate leprosy are known as mononeuropathy pattern or mononeuritis multiplex pattern and these findings distinguish leprosy from demyelinating polyneuropathies such as CIDP. In non-endemic areas such as Korea, leprosy is not the most likely diagnosis to account for subacute peripheral nerve lesions. We report a case of lepromatous leprosy neuropathy that was misdiagnosed as CIDP after a nerve conduction study and a sural nerve biopsy.

Leprotic neuropathy misdiagnosed as chronic inflammatory demyelinating polyneuropathy

JO N 2 95 2 insulin therapy Although the precise role of insulin is not well understood, all relevant studies have reported the development of acute painful neuropathy associated with rapid glycaemic control following the initiation of insulin therapy Here, we report a case of acute painful neuropathy that developed in a patient under regular insulin treatment on increasing the insulin dose A 30-year-old male presented with a burning sensation in his feet, which had persisted for 3 weeks He had been diagnosed with type 1 diabetes mellitus 15 years earlier Until 4 weeks prior to presentation, he had been receiving intermediate-acting (Lente) insulin at a dosage of 24 units/day and the short-acting insulin (Lispro) 6–14 units/time, 3 times/day; however, his HbA1c level was determined to be more than 11 %, and the fasting glucose level was up to 300 mg/dl The intermediate-acting insulin dosage was increased up to 30 units/day during the last 4 weeks prior to presentation His HbA1c level decreased to 88 % and the fasting glucose decreased to 127 mg/dl Subsequently, he developed dizziness and sweating, and his blood sugar level frequently dropped below 45 mg/dl One week after the dose was increased; he experienced a severe burning sensation in the soles and a tingling sensation in the dorsum of the feet Physical and neurological examinations did not reveal any specific findings An electrophysiological test revealed a mild reduction in the motor and sensory nerve conduction velocity but normal sensory and compound nerve action potentials Amitryptine was used for pain control, and the pain subsided after a month Insulin therapy itself has been reported to cause arteriovenous (A-V) shunting and to increase the epineurial blood flow [5] This reKi-Bong Song Soo-Jin Cho Yang-Ki Minn Ki-Han Kwon Min-Keun Park

A case of insulin neuritis that developed in a patient under regular insulin treatment on increasing the insulin dose. Insulin neuritis: is it a misnomer?

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