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Purpose We describe the spectrum of acute neurological disorders among hospitalized patients who recently had COVID-19 mRNA vaccination. Method We performed a prospective study at 7 acute hospitals in Singapore. Hospitalized patients who were referred for neurological complaints and had COVID-19 mRNA vaccines, BNT162b2 and mRNA-1273, in the last 6 weeks were classified into central nervous system (CNS) syndromes, cerebrovascular disorders, peripheral nervous system (PNS) disorders, autonomic nervous system (ANS) disorders and immunization stress-related responses (ISRR). Results From 30 December 2020 to 20 April 2021, 1,398,074 persons (median age 59 years, 54.5% males) received COVID-19 mRNA vaccine (86.7% BNT162b2, 13.3% mRNA-1273); 915,344(65.5%) completed 2 doses. Four hundred and fifty-seven(0.03%) patients were referred for neurological complaints [median age 67(20–97) years, 281(61.5%) males; 95.8% received BNT162b2 and 4.2% mRNA-1273], classified into 73(16.0%) CNS syndromes, 286(62.6%) cerebrovascular disorders, 59(12.9%) PNS disorders, 0 ANS disorders and 39(8.5%) ISRRs. Eleven of 27 patients with cranial mononeuropathy had Bell's palsy. Of 33 patients with seizures, only 4 were unprovoked and occurred within 2 weeks of vaccination. All strokes occurred among individuals with pre-existing cardiovascular risk factors. We recorded 2 cases of cerebral venous thrombosis; none were vaccine-induced thrombotic thrombocytopenia. Five had mild flares of immune-mediated diseases. Conclusion Our observational study does not establish causality of the described disorders to vaccines. Though limited by the lack of baseline incidence data of several conditions, we observed no obvious signal of serious neurological morbidity associated with mRNA vaccination. The benefits of COVID-19 vaccination outweigh concerns over neurological adverse events.

BackgroundBiliary obstruction due to malignant disease causes debilitating symptoms and palliation of the disease involves placement of biliary stents. Covered self-expanding metal biliary stents may provide a longer patency and a lower risk of complications and dysfunction compared to uncovered stents, making them better for patients’ quality of life and cost effectiveness. This study aims to evaluate the indications and outcomes for a group of cases where expanded polytetrafluoroethylene/fluorinated ethylene propylene (ePTFE/FEP) covered metal stents were used to palliate malignant biliary obstruction.MethodsAll cases of ePTFE/FEP-covered Viabil stent implantation in a 4-year period in a single hospital were identified and details of indications and outcomes for stent placement were recorded. Kaplan-Meier estimator analysis was used to create plots for stent patency and survival time.ResultsThe median stent patency was 173 days (standard error of the mean, SE = 54) and the median survival time was 247 days (SE = 88). No complications of stent implantation were recorded and in seven cases no dysfunction was noted. In one case, tumour ingrowth was observed, and in one other case the stent was no longer found in situ on subsequent imaging.ConclusionThe use of the ePTFE/FEP-covered Viabil stent in the palliation of malignant obstruction where indicated is promising, providing a low rate of stent dysfunction and complications. More data need to be collected to conclusively ascertain whether covered stents have a longer patency and lower complication rate compared to uncovered stents.

To describe the spectrum of COVID-19 neurology in Singapore.We prospectively studied all microbiologically-confirmed COVID-19 patients in Singapore, who were referred for any neurological complaint within three months of COVID-19 onset. Neurological diagnoses and relationship to COVID-19 was made by consensus guided by contemporaneous literature, refined using recent case definitions.47,572 patients (median age 34 years, 98% males) were diagnosed with COVID-19 in Singapore between 19 March to 19 July 2020. We identified 90 patients (median age 38, 98.9% males) with neurological disorders; 39 with varying certainty of relationship to COVID-19 categorised as: i) Central nervous system syndromes-4 acute disseminated encephalomyelitis (ADEM) and encephalitis, ii) Cerebrovascular disorders-19 acute ischaemic stroke and transient ischaemic attack (AIS/TIA), 4 cerebral venous thrombosis (CVT), 2 intracerebral haemorrhage, iii) Peripheral nervous system-7 mono/polyneuropathies, and a novel group, iv) Autonomic nervous system-4 limited dysautonomic syndromes. Fifty-one other patients had pre/co-existent neurological conditions unrelated to COVID-19. Encephalitis/ADEM is delayed, occurring in critical COVID-19, while CVT and dysautonomia occurred relatively early, and largely in mild infections. AIS/TIA was variable in onset, occurring in patients with differing COVID-19 severity; remarkably 63.2% were asymptomatic. CVT was more frequent than expected and occurred in mild/asymptomatic patients. There were no neurological complications in all 81 paediatric COVID-19 cases.COVID-19 neurology has a wide spectrum of dysimmune-thrombotic disorders. We encountered relatively few neurological complications, probably because our outbreak involved largely young men with mild/asymptomatic COVID-19. It is also widely perceived that the pandemic did not unduly affect the Singapore healthcare system.

Background There has been increasing reports associating the coronavirus disease 2019 (COVID-19) with thromboembolic phenomenon including ischemic strokes and venous thromboembolism. Cerebral venous thrombosis (CVT) is a rare neurovascular emergency that has been observed in some COVID-19 patients, yet much remains to be learnt of its underlying pathophysiology. Objective We present a case series of local patients with concomitant COVID-19 infection and CVT; and aim to perform a systematic review of known cases in the current literature. Methods We describe two patients with concomitant COVID-19 infection and CVT from a nationwide registry in Singapore. We then conducted a literature search in PubMed and Embase using a suitable keyword search strategy from 1st December 2019 to 11th June 2020. All studies reporting CVT in COVID-19 patients were included. Results Nine studies and 14 COVID-19 patients with CVT were studied. The median age was 43 years (IQR=36-58) and majority had no significant past medical conditions (60.0%). The time taken from onset of COVID-19 symptoms to CVT diagnosis was a median of 7 days (IQR=6-14). CVT was commonly seen in the transverse (75.0%) and sigmoid sinus (50.0%); 33.3% had involvement of the deep venous sinus system. A significant proportion of patients had raised D-dimer (75.0%) and CRP levels (50.0%). Two patients reported presence of antiphospholipid antibodies. Most patients received anticoagulation (91.7%) while overall mortality rate was 45.5%. Conclusions The high mortality rate of CVT in COVID-19 infection warrants a high index of suspicion from physicians, and early treatment with anticoagulation should be initiated.

Objective: Based on its efficacy in treating neuropathic pain, gabapentin may be effective for the treatment of carpal tunnel syndrome (CTS). The purpose of this study was to evaluate the efficacy of gabapentin for symptom relief in CTS. Methods: We conducted a randomized, double-blinded, placebo-controlled trial recruiting patients with newly diagnosed idiopathic CTS of more than a period of three months. Diagnosis was based on characteristic symptoms with electrophysiological confirmation. Patients were randomly assigned to an active group receiving gabapentin (starting dose 300 mg once daily to a target of 900 mg daily) or a placebo group. Primary end-point was the global symptom score (GSS), which was measured at baseline, two, and eight weeks. Results: There was no significant difference in baseline variables between the two treatment groups. Hundred and forty patients were enrolled in the study, of whom 71 were randomly assigned to gabapentin group and 69 assigned to placebo group. Both gabapentin and placebo produced significant improvement in symptoms at two and eight weeks. The GSS at 2 and 8 weeks was 16.4 (SD 9.4) and 13.4 (SD 9.7), respectively, in the active group versus 14.9 (SD 9.0) and 12.5 (SD 8.9) in the control group (P

We present a case of cerebral venous sinus thrombosis (CVST) as a rare complication of herpes simplex virus (HSV) encephalitis. A young man with no pertinent medical history was diagnosed with HSV encephalitis. After initial treatment, he showed improvement in symptomatology until day 6 when he acutely developed new neurological deficits. An urgent MRI brain showed changes in left temporal lobe consistent with HSV encephalitis and lack of flow void in superior sagittal sinus. Subsequent magnetic resonance venography confirmed the diagnosis of superior sagittal sinus thrombosis along with thrombosis of bilateral frontoparietal cortical draining veins. Anticoagulation was immediately initiated and oral anticoagulation was continued for 1 year. He made complete recovery subsequently. Our case serves as a reminder for the treating clinicians to consider CVST in patients with HSV encephalitis who develop an unexpected new neurological deficits during early phase of appropriate treatment.

Summary Purpose: This study examined the profiles and prognosis of first acute symptomatic seizure (ASS). Because seizure recurrences may occur in the setting of a persisting or reemerging acute symptomatic cause or in the setting of an unprovoked seizure, we documented the prognosis of ASS in terms of acute symptomatic seizure (AS) or unprovoked seizure (US) recurrence. Methods: We conducted a prospective study of patients with suspected seizures between April 2004 and December 2005. Patients were classified according to medical history taking, routine clinical evaluation, and expert adjudication, and they were followed for a minimum of 2 years or until death. The Kaplan-Meier method and univariate/multivariate statistical analysis were used to determine prognosis. Results: One hundred five patients with first-ever ASS were identified. For many, first ASS was associated with status epilepticus (29.5%), multiple-onset (>1 seizure within 24 h on day of presentation) (35.2%), and multiple etiologies (22.9%), with a mortality of 30% at 2 years (Kaplan-Meier method). Using AS as outcome, the risk of recurrence following an ASS was 32% at 2 years [mean time to recurrence 20.5 days with epileptiform electroencephalography (EEG) being an independent predictor; p = 0.005, odds ratio (OR) 16, 95% confidence interval (CI) 4.09–62.7]. Using US as outcome, the risk of recurrence following an ASS was 12% at 2 years. Discussion: Although ASS did not associate with a high rate of US recurrence, we demonstrated that ASS was often followed by another AS. This may have implication for short- to medium-term antiepileptic agent therapy, especially when the acute symptomatic cause takes a long time to treat, is prone to reemergence, or is irreversible.

Summary Background Several specialist clinic-based epidemiology studies suggested low prevalence in Hong Kong Special Administrative Region (HKSAR) of China. Population-based epidemiological data for epilepsy is not available. We performed the first population-based epidemiological survey of epilepsy in this locality. Method We conducted a territory-wide survey. We randomly selected 9547 households from fixed-line telephone directory. We successfully surveyed 17,783 persons of 5178 households by telephone interview. All positive respondents 685 (3.85%) were invited for clinical validation. 127 subjects were validated by board-certified neurologists. Results Seizure disorders were confirmed in 28 subjects. The crude prevalence of active epilepsy and seizure disorder were estimated to be 3.94/1000 (95% confidence interval (CI): 2.10–6.74/1000) and 8.49/1000 (95% CI: 5.64–12.27/1000), respectively. Conclusions The prevalence of epilepsy in HKSAR is more common than previously thought. The data retrieved is useful for planning and allocation of health resources for patients with seizure disorders.

To investigate the proportion of Chinese patients with intractable seizures and the risk factors leading to refractory epilepsy.Consecutive patients over 14 years of age attending a Neurology clinic were evaluated. Patients with epilepsy were classified into two groups according to their seizure control: refractory or seizure-free. Epilepsy was classified as idiopathic as defined by age-related onset and typical electroclinical characteristics, symptomatic if secondary to a structural abnormality and cryptogenic if the cause was unknown. Age, sex, epilepsy syndrome classification, aetiology, presence of mental retardation and the number of drugs used were compared between patients with refractory epilepsy and those in remission.Among 260 adolescent and adult patients with a mean age of 34 years (range 15-79), complete seizure control was achieved in 157 (60%) cases. Multivariate binomial logistic regression analysis showed that patients with mesial temporal sclerosis (OR=7.6, 95% CI 3.53-16.4, p0.01) and the presence of mental retardation (OR=9.39, 95% CI 3.98-22.12, p0.01) were more likely to develop pharmacoresistant epilepsy.In adults the underlying aetiology is an important factor as to whether patients develop intractable seizures. Poor control was also associated with the presence of mesial temporal sclerosis and mental retardation.

Central nervous system toxicity following administration of beta-lactam antibiotics, of which penicillin is the prototype, is a potential cause of morbidity and mortality. In recent years, important advances have been made in the pathogenesis of antibiotic-related neurotoxicity. This review focuses on the experimental and clinical aspects of neurotoxicity caused by beta-lactam antibiotics. The purpose is to provide an update on the pathogenesis, mechanism, and clinical manifestations of the neurotoxicity, along with an overview of the relationship between antibiotic structure and convulsive action. In particular, some of the prevailing ideas about pathogenesis are highlighted, including theories of the mechanism of pathogenicity. A better understanding of antibiotic-related neurotoxicity, as derived from animal models and human clinical experience, would be of value in facilitating more efficient and safer use of antimicrobial compounds.

EPIDEMIOLOGY Carpal tunnel syndrome is the most common entrapment neuropathy encountered in electro-diagnostic laboratories. It is due to compression of the median nerve in the carpal tunnel. From the number of electrophysiologically confirmed cases in Canterbury, UK, the annual incidence is 120 per 100 000 for women and 60 per 100 000 for men (Bland & Rudolfer 2003). The incidence rises with age in men, but peaks in the 45–54 age group in women. Population surveys reveal a prevalence of 0.6–2% in men and up to 9% in women (De Krom et al . 1992; Atroshi et al . 1999). However, this sex ratio varies widely in the literature, from an excess of women of 23 : 1 in Korea to 2 : 1 in the UK. The relationship between carpal tunnel syndrome and work conditions is controversial. Early epidemiological studies produced divergent results, perhaps because they were methodologically flawed –

Objective: We studied the etiology, clinical features and outcome of patients with bacterial meningitis from an urban Chinese city over a 10-years period. Methods: We reviewed the files of all persons aged 15-years old or above diagnosed with community-acquired bacterial meningitis from a regional hospital. The clinical findings, relevant laboratory and imaging results as well as outcome were recorded in cases with microbiological evidence of meningitis. Neurosurgical and pediatric patients were excluded. Results: Sixty-five patients between the ages of 15 and 86 years of age (mean 52 years) were identified of whom 18 (28%) died. The four most common causes were Mycobacteria tuberculosis (46%), Streptococcus pneumoniae (11%), Streptococcus suis (9%) and Klebsiella pneumoniae (8%). Neisseria meningitidis and Haemophilus influenzae were rare pathogens. The annual incidence of community-acquired bacterial meningitis was 1.27/100,000 adults. Delay in treatment was associated with a poorer prognosis (p Conclusion: The causative organisms found in this region of China differ from that reported from Europe and the US; tuberculous meningitis is the most common cause of bacterial meningitis.

Background: Decompressive surgery and steroid injection are widely used forms of treatment for carpal tunnel syndrome (CTS) but there is no consensus on their effectiveness in comparison to each other. The authors evaluated the efficacy of surgery vs steroid injection in relieving symptoms in patients with CTS.Methods: The authors conducted a randomized, single blind, controlled trial. Fifty patients with electrophysiologically confirmed idiopathic CTS were randomized and assigned to open carpal tunnel release (25 patients) or to a single injection of steroid (25 patients). Patients were followed up at 6 and 20 weeks. The primary outcome was symptom relief in terms of the Global Symptom Score (GSS), which rates symptoms on a scale of 0 (no symptoms) to 50 (most severe). Nerve conduction studies and grip strength measurements were used as secondary outcome assessments.Results: At 20 weeks after randomization, patients who underwent surgery had greater symptomatic improvement than those who were injected. The mean improvement in GSS after 20 weeks was 24.2 (SD 11.0) in the surgery group vs 8.7 (SD 13.0) in the injection group (p < 0.001); surgical decompression also resulted in greater improvement in median nerve distal motor latencies and sensory nerve conduction velocity. Mean grip strength in the surgical group was reduced by 1.7 kg (SD 5.1) compared with a gain of 2.4 kg (SD 5.5) in the injection group.Conclusion: Compared with steroid injection, open carpal tunnel release resulted in better symptomatic and neurophysiologic outcome but not grip strength in patients with idiopathic carpal tunnel syndrome over a 20-week period.

Prediction of outcome after cardiac arrest has important ethical and socioeconomic implications. In general, delay in recovery of neurological function is associated with a worse prognosis. The presence of myoclonic seizures early after anoxia has been identified as a poor prognostic factor. We report a series of patients who developed postanoxic myoclonus status epilepticus (MSE), which was defined as continuous myoclonic seizure activity lasting 30 min or more. The results from 18 patients were retrieved, 11 men and 7 women, age ranging from 29 to 90 years. Myoclonus developed a mean of 11.7 h after cardiac arrest, persisting for a mean of 60.5 h. Sixteen (89%) died following MSE and the 2 survivors were highly dependent or remained in a persistent vegetative state, supporting the view that prognosis is poor in this condition.

Kennedy's disease is a X-linked neuromuscular disorder caused by an expanded trinucleotide repeat in the androgen receptor gene. To ascertain the clinical diagnosis of Kennedy's disease in a Chinese population, we used a rapid, accurate PCR-based sizing method for the CAG repeat allelotype. The clinical and electrophysiological features of affected patients are described. The CAG repeats ranged from 43 to 53 and were inversely correlated with the age of onset (r = -0.63; P < 0.005).

To prospectively evaluate accuracy of sonography for diagnosis of carpal tunnel syndrome (CTS) in patients clinically suspected of having the disease in one or both hands.A prospective cohort of 133 patients suspected of having CTS were referred to a teaching hospital between October 2001 and June 2002 for electrodiagnostic study. One hundred twenty patients (98 women, 22 men; mean age, 49 years; range, 19-83 years) underwent sonography within 1 week after electrodiagnostic study. Radiologist was blinded to electrodiagnostic study results. Seventy-five patients had bilateral symptoms; 23 patients, right-hand symptoms; and 22 patients, left-hand symptoms (total, 195 symptomatic hands). Cross-sectional area of median nerve was measured at three levels: immediately proximal to carpal tunnel inlet, at carpal tunnel inlet, and at carpal tunnel outlet. Flexor retinaculum was used as a landmark to margins of carpal tunnel. Optimal threshold levels (determined with classification and regression tree analysis) for areas proximal to and at tunnel inlet and at tunnel outlet were used to discriminate between patients with and patients without disease. Sensitivity, specificity, and false-positive and false-negative rates were derived on the basis of final diagnosis, which was determined with clinical history and electrodiagnostic study results as reference standard.For right hands, sonography had sensitivity of 94% (66 of 70); specificity, 65% (17 of 26); false-positive rate, 12% (nine of 75); and false-negative rate, 19% (four of 21) (cutoff, 0.09 cm(2) proximal to tunnel inlet and 0.12 cm(2) at tunnel outlet). For left hands, sensitivity was 83% (53 of 64); specificity, 73% (24 of 33); false-positive rate, 15% (nine of 62); and false-negative rate, 31% (11 of 35) (cutoff, 0.10 cm(2) proximal to tunnel inlet).Sonography is comparable to electrodiagnostic study in diagnosis of CTS and should be considered as initial test of choice for patients suspected of having CTS.

Microbleeds (MBs) detected by gradient-echo T2*-weighted MRI (GRE-T2*),white matter changes and lacunar infarcts may be regarded as manifestations of microangiopathy. The establishment of a quantitative relationship among them would further strengthen this hypothesis. We aimed to investigate the frequency and the number of MBs in patients hospitalized with lacunar infarcts and their quantitative relationship with the severity of white matter changes (WMC) and the number of old lacunar infarcts. We performed a hospital-based survey of patients with acute lacunar infarct. Eighty-two consecutive Chinese patients with acute lacunar infarcts on diffusion-weighted imaging were recruited in 2002. The number of MBs, number of old lacunar infarcts on T2-weighted imaging and the severity of WMC on MRI on admission were recorded. MBs were detected in 22 (27%) patients. The number of MBs ranged from 1 to 42 (mean 6.59, median 3). Advancing age and previous transient ischemic attacks or cerebrovascular accidents (TIA/CVA) were more common in patients with MBs than those without. There were significant correlations among the number of MBs, extent of WMC and number of lacunar infarcts: lacunar infarcts and MBs (r = 0.297, p = 0.007); lacunar infarct and WMC (r = 0.331, p = 0.002); WMC and MBs (r = 0.522, p < 0.0001). In conclusion, linear associations exist among MBs, WMC and lacunar infarcts. Our results suggest that all three may have a shared pathogenesis such as advanced microangiopathy.

Objectives: Although stroke associated with small vessel disease (SSVD) can induce both motor and cognitive impairment, the latter has received less attention. We aimed to evaluate the frequency of the varying severity levels of cognitive impairment, the determinants of severe cognitive impairment, and the association of cognitive impairment with functional outcome after SSVD. Methods: Consecutive patients admitted to hospital because of SSVD were assessed at 3 months after stroke. We performed a semi-structured clinical interview to screen for cognitive symptoms. Severity of cognitive symptoms was graded according to the Clinical Dementia Rating Scale (CDR). Performance on psychometric tests (Mini-Mental State Examination, Alzheimer’s Disease Assessment Scale (cognition subscale), Mattis Dementia Rating Scale (initiation/perseverence subscale; MDRS I/P)) of patients of different CDR gradings was compared with that of 42 healthy controls. Basic demographic data, vascular risk factors, stroke severity (National Institute of Health Stroke Scale; NIHSS), pre-stroke cognitive decline (Informant Questionnaire on Cognitive Decline in the Elderly; IQCODE), functional outcome (Barthel index; BI), Instrumental Activities Of Daily Living; IADL), and neuroimaging features (site of recent small infarcts, number of silent small infarcts, white matter changes) were also compared among the groups. Regression analyses were performed to find predictors of severe cognitive impairment and poor functional outcome. Results: Among the 75 included patients, 39 (52%) complained of cognitive symptoms. The number of patients in each CDR grading was as follows: 39 (52%) had a CDR of 0, 26 (34.7%) had a CDR of 0.5, 10 (13.3%) had a CDR of ⩾1. Pre-stroke IQCODE and previous stroke predicted CDR⩾1. The NIHSS was associated with more impaired BI. The NIHSS and MDRS I/P contributed most to impaired IADL. Conclusions: Half of the patients with SSVD complained of varying severity of cognitive problems 3 months after stroke. Pre-stroke cognitive decline and previous stroke predict severe cognitive impairment post stroke. Stroke severity and executive dysfunction contribute most to a poor functional outcome.

Neurological complications of antibiotics are relatively common in renal failure. Central nervous system neurotoxicity due to penicillin and beta-lactam antibiotics is best documented with fewer accounts of ototoxicity, peripheral nerve toxicity and neuromuscular blockade. In the context of risk stratification, the goal of this review is to explore the mosaic of factors in renal impairment that may contribute to susceptibility to antibiotic neurotoxicity. Improved knowledge of the pathogenesis of these formidable adverse events among the renal failure subjects should help prevent antibiotic neurotoxicity in the future.

Objectives: Frontal Assessment Battery (FAB) is a valid and reliable screening test for evaluating executive dysfunction among whites with frontal and subcortical degenerative lesions. We studied the properties of a Chinese version of FAB (CFAB) in evaluating executive dysfunction among Chinese stroke patients with small subcortical infarct. Methods: Concurrent validity was evaluated using Wisconsin Card Sorting Tst (WCST) and Mattis Dementia Rating Scale– Initiation/Perseveration Subset (MDRS I/P) among 41 controls and 30 stroke patients with small subcortical infarct. Discriminant validities of CFAB and its subitems were compared with those of MiniMental State Examination (MMSE). Internal consistency, test-retest, and interrater reliability of CFAB were evaluated. Results: The CFAB had low to good correlation with various executive measures: MDRS I/P (r = 0.63, p < 0.001), number of category completed (r = 0.45, p < 0.001), and number of perseverative errors (r = �0.37, p < 0.01) of WCST. Among the executive measures, only number of category completed had significant but small contribution (6.5%, p = 0.001) to the variance of CFAB. A short version of CFAB using three items yielded higher overall classification accuracy (86.6%) than that of CFAB full version (80.6%) and MMSE (77.6%). Internal consistency (alpha = 0.77), test-retest reliability (rho = 0.89, p < 0.001), and interrater reliability (rho = 0.85, p < 0.001) of CFAB were good. Conclusion: Although CFAB is reliable, it is only moderately valid in evaluating executive dysfunction among Chinese stroke patients with small subcortical infarct. The clinical use of CFAB in the evaluation of executive dysfunction among this group of patients cannot be recommended at this stage.

Background: Small subcortical infarct (SSI) occurs more frequently among Chinese than Caucasians. Apart from small vessel disease, SSI is also associated with intracranial large artery disease. We aimed to study the frequency of SSI with and without intracranial large artery disease among Chinese stroke patients. Methods: Magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and diffusion weighted imaging (DWI) were performed among consecutive Chinese stroke patients admitted to our acute stroke unit over a 6-month period. Results: Among the 257 patients with ischemic stroke, 71 patients (27.6%) had SSI. Twelve patients (16.9%) had relevant intracranial large artery disease and three patients (4.2%) had lone relevant extracranial carotid artery disease. No patient had an identifiable cardiac embolic source or other miscellaneous cause. Excluding patients with relevant intracranial large artery disease and extracranial carotid artery disease, the frequency of SSI associated with presumed small vessel disease among patients with ischemic stroke was 21.7%. Patients with SSI associated with intracranial large artery disease had greater number of acute infarcts and slightly greater stroke severity and cognitive impairment than those with presumed small vessel disease. Conclusion: Our present study suggests that the higher frequency of SSI among Chinese may be in part related to a higher frequency of intracranial large artery disease rather than to a higher frequency of small vessel disease.

The authors reviewed the clinical and electrophysiological features in 20 consecutive adult patients with Guillain-Barre Syndrome (GBS) admitted to a regional hospital in Hong Kong from 1993 to 1998. The majority of cases in this locality consists of the demyelinating form of GBS; epidemic, acute motor axonal neuropathy is not the predominant form. The incidence of GBS in this region of China was 0.44 per 100,000.

Over half of the estimated 50 million people with epilepsy live in Asia, but there has been limited information on the epidemiology, aetiology and management of epilepsy from this region. In this article, we summarise some of the main problems faced by patients and the current treatment options available in an urban area of China.

The purpose of this study was to investigate the long-term prognosis of patients with carpal tunnel syndrome (CTS). We prospectively followed-up patients with CTS for 80 weeks. Thirty cases had been treated with a single injection of methylprednisolone acetate and another 30 with a 10-day course of prednisolone. At the end of the follow-up period, there were no significant differences in symptoms as measured by global symptom score and in the proportion of patients who progressed to decompressive surgery. Few patients who were not operated on (11.4%) remain asymptomatic.

We report a case of a woman who underwent in-vitro fertilisation embryo transfer treatment for infertility and developed an acute stroke (left hemiparesis and headache). The stroke was caused by cerebral venous thrombosis due to ovarian hyperstimulation syndrome. We review the current background about this uncommon disorder.

The authors compared the effectiveness of low-dose, short-term oral prednisolone vs local methylprednisolone injection in a prospective, double-blinded, parallel treatment study of carpal tunnel syndrome (CTS). A single injection of 15 mg methylprednisolone resulted in significant improvement in global symptom scores over a 12-week period. This study demonstrated the superiority of local steroid injection to oral steroid in the treatment of CTS.

Background and purpose Concurrent small vessel, intracranial and extracranial large artery disease (SLAD) is common in Asian but its impact on cognitive and functional outcomes is unclear. We aimed to evaluate the clinical, cognitive and functional outcomes in ischemic stroke patients with SLAD. Methods Chinese ischemic stroke patients with diffuse white matter lesions (WMLs) were recruited as part of the VITATOPS Trial. They were studied with MRI and MRA of brain. Various neuropsychiatric batteries were used to assess the cognitive functions. Results Totally 97 patients with acute ischemic stroke and diffuse WMLs were included, of whom 44 (45%) had SLAD. Patients with SLAD had lower Mini Mental State Examination (MMSE) when compared with the patients without SLAD. They had more behavioral symptoms and caused more stress in caregivers as assessed by the Neuropsychiatric Inventory (NPI). Multivariate regression analysis showed SLAD contributed significantly to MMSE, NPI Patient (NPI P) and NPI Care Giver (NPI CG). Among 44 patients with SLAD, 30 (68%) had severe cognitive impairment. They were older and less educated. They had more diabetes and poorer performance in neuropsychiatric tests including Mattis Dementia Rating Scale Initiation/Perseveration subset (MDRS I/P) and Clinical Dementia Rating (CDR). They also had poorer functional outcomes as assessed by Barthel Index (BI) and Instrumental activities of daily living (IADL). Conclusions This was the first MRA-based study to take into consideration the clinical, cognitive and functional outcomes in ischemic stroke patients with SLAD. Patients with SLAD had poorer cognitive and functional outcomes when compared to patients without SLAD.

This study examined the profiles and prognosis of first acute symptomatic seizure (ASS). Because seizure recurrences may occur in the setting of a persisting or reemerging acute symptomatic cause or in the setting of an unprovoked seizure, we documented the prognosis of ASS in terms of acute symptomatic seizure (AS) or unprovoked seizure (US) recurrence.We conducted a prospective study of patients with suspected seizures between April 2004 and December 2005. Patients were classified according to medical history taking, routine clinical evaluation, and expert adjudication, and they were followed for a minimum of 2 years or until death. The Kaplan-Meier method and univariate/multivariate statistical analysis were used to determine prognosis.One hundred five patients with first-ever ASS were identified. For many, first ASS was associated with status epilepticus (29.5%), multiple-onset (1 seizure within 24 h on day of presentation) (35.2%), and multiple etiologies (22.9%), with a mortality of 30% at 2 years (Kaplan-Meier method). Using AS as outcome, the risk of recurrence following an ASS was 32% at 2 years [mean time to recurrence 20.5 days with epileptiform electroencephalography (EEG) being an independent predictor; p = 0.005, odds ratio (OR) 16, 95% confidence interval (CI) 4.09-62.7]. Using US as outcome, the risk of recurrence following an ASS was 12% at 2 years.Although ASS did not associate with a high rate of US recurrence, we demonstrated that ASS was often followed by another AS. This may have implication for short- to medium-term antiepileptic agent therapy, especially when the acute symptomatic cause takes a long time to treat, is prone to reemergence, or is irreversible.

Cross-sectional studies have suggested that valproate treatment may be associated with hyperinsulinemia and hyperandrogenism in women. Few prospective data are available. We evaluated the reproductive endocrine and insulin-related metabolic parameters in men and women with untreated epilepsy randomized to valproate (n = 44) or lamotrigine (n = 37) monotherapy for 12 months. On treatment, there was no significant difference in fasting serum insulin concentrations between the two groups. In women (n = 40), there was no significant difference between the two groups in change from baseline in serum total testosterone, dehydroepiandrosterone sulfate, luteinizing hormone, or follicle-stimulating hormone. In men (n = 41), follicle-stimulating hormone concentration significantly decreased in patients taking valproate compared with those on lamotrigine as early as 3 months after treatment. Greater attention should be paid to investigate the potential impact of valproate on reproductive function in men.

PURPOSE. Bilateral visual field constriction has been reported following the use of the antiepileptic drug (AED) vigabatrin. The incidence of retinal toxicity is variable and there are limited data in Asian populations. The authors report the results of ophthalmologic examination in Chinese patients taking this drug. METHODS. The authors identified two groups of patients with refractory epilepsy: one group on vigabatrin and another cohort of patients taking other AEDs. The authors recorded the medical history and performed visual acuity testing, intraocular pressure measurement, slit lamp biomicroscopy, and conventional automated perimetry with Humphrey Visual Field Analyzer II in all patients. RESULTS. Eighteen patients - 8 men and 10 women - with a mean age of 23.8 years who were taking vigabatrin were reviewed. Length of treatment with this drug ranged from 13 months to 5 years and the mean daily dosage was 1581 mg. None of the patients in either group had a history of coexisting optic nerve diseases or other neurotoxic drug use. Twenty of 36 (55.6%) eyes of the vigabatrin users showed significant bilateral visual field defects with 80% showing a concentric pattern, compared with none in the control group. CONCLUSIONS. The authors confirmed a high prevalence of visual field constriction associated with vigabatrin in Chinese patients. The use of alternative novel techniques such as measurement of the retinal nerve fibre layer thickness and perimetry may detect early retinal damage and result in even higher incidences. Visual field monitoring is recommended in patients who continue to take this drug. (Eur J Ophthalmol 2008; 18: 624-7)

Background: Differentiating between first seizure, epilepsy and a non-epileptic event is a challenging clinical exercise for many physicians as it may lead to different therapeutic implications. This study aims to investigate the agreement between the initial diagnosis at the accident and emergency (A&E) department and the final diagnosis following inpatient neurological evaluation of seizure disorders. Method: A prospective observational study between April 2004 and June 2005 in a regional hospital in Hong Kong recruited 1701 patients from the A&E to neurology/medical wards with initial diagnoses/labels matching any one of 12 predefined keywords which were categorised as either “seizure specific” or “non-specific”. Results: Among the 1170 patients with “non-specific” initial diagnoses/labels, 58 (5%) were finally diagnosed as having had a first seizure or epilepsy. Among 531 patients with “seizure specific” initial diagnoses/labels, 27 (5.1%) were subsequently diagnosed as having had non-epileptic events. The κ value for agreement between the initial and final diagnosis was 0.88. Of the 154 patients with a final diagnosis of first seizure, 34 (22%) had “non-specific” initial labels. Among these patients, components of the evaluation contributing to revision of diagnosis included retrieval of witness accounts (47%), epileptiform discharges on EEG (47%), short term monitoring in patients suspected of acute symptomatic seizures (28%) and panel discussion of cases (22%). Conclusion: There was generally a high degree of agreement between the initial and final diagnosis, but first seizures were often missed initially. Careful history taking, judicious use of EEG, selective short term monitoring and liaison with specialists are important in reaching an accurate diagnosis.

We reported an 80-year-old Chinese woman on chronic stable dose of warfarin who experienced two episodes of an elevated international normalized ratio (INR) after drinking herbal tea containing Lycium barbarum L. Our case illustrated the potential herbal-drug interaction between warfarin and L. barbarum L. in keeping with a previous case report. Enquiry about herbal intake may be a crucial part in the management of anticoagulation in this locality.

This paper aimed to assess the usefulness and safety of video-EEG (video-electroencephalography) monitoring in patients with refractory epilepsy. We analysed the video-EEG recordings of consecutive patients over a 3-year period from 2002 to 2005. The pre-admission diagnosis, demographic information, number of ictal episodes, adverse events, and final diagnosis were recorded in all patients. The diagnostic labels before and after monitoring were compared in order to assess whether it had led to a change in diagnosis and management. Of the 100 patients who underwent video-EEG, 227 clinical events were recorded in 62 cases. The most common events were complex partial seizures followed by non-epileptic attacks. Video-EEG allowed a diagnosis to be made in 81 patients and the diagnosis at discharge was altered in 19 cases. Major injuries and status epilepticus did not occur during monitoring. In our experience video-EEG is safe and provides important clinical information in over 80% of patients.

We evaluated the efficacy and safety of topiramate for migraine prophylaxis among Chinese patients in a multicenter prospective observational study. We found that topiramate at low doses was effective in preventing migraine headache in Chinese patients and was generally well tolerated. There was no difference in baseline headache frequency or intensity between responders and nonresponders.

Status epilepticus is a medical emergency and is secondary to a range of insults to the central nervous system. The authors reviewed the current management of this disorder in light of the latest developments from recent trials and guidelines. Important principles in management include early recognition of status epilepticus, identification of the underlying cause and prompt treatment to terminate seizures and reduce complications. The role of electroencephalographic monitoring and different treatment regimens are examined.

There is accumulating evidence to suggest that overexpression of efflux drug transporters at the blood-brain barrier, by reducing antiepileptic drug (AED) accumulation in the seizure foci, contributes to drug resistance in epilepsy. P-glycoprotein, encoded by the ABCB1 gene, is the most studied drug transporter. There are conflicting data as to whether the CC genotype of the ABCB1 3435C>T polymorphism is associated with drug resistance in Caucasian patients with epilepsy. We investigated this association in ethnic Chinese. ABCB1 3435C>T was genotyped in 746 Han Chinese patients with epilepsy and 179 controls. Patients with drug-resistant epilepsy were more likely to have the TT genotype compared with those with drug-responsive epilepsy (16.7% vs 7.4%, odds ratio=2.5, 95% confidence interval=1.4-4.6, P=0.0009). Our results contrast with those of studies of Caucasians, and highlight the complexity of the possible role of this polymorphism in AED response in different ethnic populations.

Background: Lateral epicondylitis is a common condition for which botulinum toxin has been reported to have a therapeutic role in uncontrolled studies. Objective: To determine if an injection of botulinum toxin is more effective than placebo for reducing pain in adults with lateral epicondylitis. Design: Randomized, double-blind, placebo-controlled trial conducted from September 2002 to December 2004. Setting: Outpatient clinics at a university hospital and a district hospital in Hong Kong. Participants: 60 patients with lateral epicondylitis. Measurements: The primary outcome was change in subjective pain as measured by a 100-mm visual analogue scale (VAS) ranging from 0 (no pain) to 10 (worst pain ever) at 4 weeks and 12 weeks. All patients completed post-treatment follow-up. Interventions: A single injection of 60 units of botulinum toxin type A or normal saline placebo. Results: Mean VAS scores for the botulinum group at baseline and at 4 weeks were 65.5 mm and 25.3 mm, respectively; respective scores for the placebo group were 66.2 mm and 50.5 mm (between-group difference of changes, 24.4 mm [95% Cl, 13.0 to 35.8 mm]; P < 0.001). At week 12, mean VAS scores were 23.5 mm for the botulinum group and 43.5 mm for the placebo group (between-group difference of changes, 19.3 mm [Cl, 5.6 to 32.9 mm]; P = 0.006). Grip strength was not statistically significantly different between groups at any time. Mild paresis of the fingers occurred in 4 patients in the botulinum group at 4 weeks. One patient's symptoms persisted until week 12, whereas none of the patients receiving placebo had the same complaint. At 4 weeks, 10 patients in the botulinum group and 6 patients in the placebo group experienced weak finger extension on the same side as the injection site. Limitations: The trial was small, and most participants were women. The blinding protocol may have been ineffective because the 4 participants who experienced paresis of the fingers could have correctly assumed that they received an active treatment. Conclusions: Botulinum toxin injection may improve pain over a 3-month period in some patients with lateral epicondylitis, but injections may be associated with digit paresis and weakness of finger extension.

The proportion of elderly people in China is projected to increase rapidly but there is limited information on status epilepticus (SE) in this population. We evaluated retrospectively the etiology, response to treatment, outcome and predictors of mortality in a group of elderly patients with generalized tonic-clonic SE in Hong Kong, China. Factors for increased mortality were analyzed using a logistic regression model. Of the 80 acute admissions for SE from two large urban hospitals over a seven-year period, 1996-2002, the two leading causes were attributed to cerebral infarct (n=28, 35%) and cerebral haemorrhage (n=14, 17.5%). The mean age was 74.2 years (range 60-93 years). At six months from the onset of seizures, 26 patients (32.5%) had made a good recovery but another 28 (35%) had died. Results showed that mortality was associated with increasing age (OR 1.08, 95% CI 1.01-1.16) and SE due to an acute symptomatic disturbance (OR 4.90, 95% CI 1.17-13.67). SE is associated with significant morbidity and mortality in this age group.

Simple partial status epilepticus (SPSE) is uncommon compared with generalized tonic-clonic status epilepticus. We evaluated the clinical profile and predictors of poor outcome in a group of Chinese patients with this condition. We identified 32 patients above the age of 14 years with SPSE from a large urban hospital over an eleven-year period. Factors for poor outcome, defined as death or morbidity, were analyzed. The most common underlying causes were due to cerebrovascular disease (46.9%), CNS infection (15.6%), metabolic derangement (12.5%) and tumor (12.5%). At 30 days from the onset of seizures, 13(40.5%) patients had recovered fully and seven (21.9%) had died. Poor outcome was associated with the presence of an acute symptomatic injury.

The majority of patients with epilepsy live in developing countries but there is limited information on status epilepticus (SE) from these regions. We evaluated the clinical profile and predictors of poor outcome in a group of Chinese patients with SE. Patients with SE were ascertained from the medical, intensive care and emergency departments of a large urban hospital from 1996 to 2001. Factors for poor outcome, defined as death or morbidity as measured by deterioration in functional status using the Glasgow Outcome Score were analysed in a multivariate logistic regression model. A total of 107 episodes of SE occurring in Chinese patients were studied. The three most common underlying causes were cerebrovascular disease, metabolic derangement and anti-convulsant withdrawal but alcohol-related SE was infrequent. Twenty-six percent had worsened functional ability and the mortality rate was 16%. Predictors of poor outcome were older age (odds ratio (OR)=1.04, 95% CI 1.01–1.07), delay in treatment (OR=3.52, 95%CI 1.01–12.18), SE due to cerebrovascular disease (OR=9.73, 95% CI 1.58–59.96) and CNS infection (OR=30.27, 95% CI 3.14–292.19).

We reviewed 42 cases of cefepime-induced neurotoxicity and 12 cases of ceftazidime-induced neurotoxicity from the literature and our institution. Clinical characteristics and timing of diagnosis were examined. Common findings were confusion with temporospatial disorientation (96% of patients), myoclonus (33%), and seizures (13%). These neurologic disorders frequently are encountered in uremic and elderly patients, who often are in a confused state when they visit their physician. The risk of delayed diagnosis was greater with cefepime than ceftazidime neurotoxicity. The median interval between symptom onset and diagnosis of cefepime versus ceftazidime neurotoxicity was 5 and 3 days, respectively (p=0.005). Delayed diagnosis of cefepime neurotoxicity may be due to lack of awareness of the adverse effect. Data gathered since these two broad-spectrum antibiotics were first marketed underscore the potential for neurologic adverse events secondary to their administration. Thus, clinicians' awareness must be increased so that the time between symptom onset and diagnosis can be reduced.

Objective Sonographic examination of the median nerve has been suggested as a useful alternative to electrophysiologic study in the diagnosis of carpal tunnel syndrome. To determine its usefulness and the best diagnostic criterion, sonograms of patients with the disease were compared with sonograms of healthy subjects in a case–control study. Methods Patients with carpal tunnel syndrome and asymptomatic controls who were matched for age and sex were enrolled and underwent sonography of the wrists. Eight separate sonographic criteria were analyzed in each wrist. Data from the patient group and the control group were compared to establish optimal diagnostic criteria for carpal tunnel syndrome, using receiver operating characteristic analytic techniques. Results Thirty-five patients with carpal tunnel syndrome and 35 asymptomatic controls were examined. Increased cross-sectional area of the median nerve was found to be the most predictive measure of carpal tunnel syndrome, proximal to the tunnel inlet, at the tunnel inlet, and at the tunnel outlet, with significant differences between patients and controls. Using a receiver operating characteristic curve, a cut-off value >0.098 cm2 at the tunnel inlet provided a diagnostic sensitivity of 89% and a specificity of 83%. Conclusion Sonographic measurement of the median nerve cross-sectional area is both sensitive and specific for the diagnosis of carpal tunnel syndrome.

This report describes nonconvulsive status epilepticus (NCSE) in four patients with end-stage renal disease (ESRD) on peritoneal dialysis therapy. All patients presented with acute confusion or stuporous state without clinical motor seizures. Three patients had active systemic infections and were being administered antibiotics. Diagnoses were confirmed in all cases by electroencephalogram (EEG), which showed characteristic diffuse sharp waves and spikes. The EEG appearance improved after anticonvulsant therapy. All patients had satisfactory control of their electrical seizure activity and made varying degrees of mental recovery. To our knowledge, this is the first reported series of NCSE in patients with ESRD on peritoneal dialysis therapy. It shows NCSE as a differential diagnosis for acute confusion. We emphasize the need for nephrologists to consider NCSE as a differential diagnosis for uremic encephalopathy.

Summary: Purpose: There is wide variation in the reported prognosis after a first unprovoked generalized tonic-clonic convulsion and in the risk factors that are associated with recurrence. Estimates for the risk of recurrence range from 26 to 71%. We investigated the likelihood of a second attack in Hong Kong Chinese patients. Methods: One hundred thirty-two patients with a first convulsion that was unexplained by acute neurological or medical causes were retrospectively ascertained. Patients’ demographic details, potential risk factors for recurrence, and current seizure status were recorded. Survival analysis was performed using the Kaplan-Meier procedure. Results: The cumulative probability of a second attack at 1, 2, 3, and 4 years was 30, 37, 42, and 47%, respectively. Seizures in patients with abnormal computer tomography scans of the brain were associated with an increased risk of recurrence on multivariate analysis. Conclusions: Thirty percent of the sample population experienced a second seizure after 1 year. An additional 17% continue to be at risk of a second convulsion during the next 3 years. Key Words: First seizure—Recurrence rate—Chinese population—Risk factors—Prognosis.