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Objectives Ischemic stroke from acute intracranial distal internal carotid artery (ICA) occlusion usually carries a poor prognosis. Despite the intra-arterial revascularization therapies, the results are still unsatisfactory. The aim of this study was to compare the outcomes between two endovascular techniques, the modified Penumbra System (mPS) and mechanical clot disruption (MCD), and to confirm the influence of recanalization on the outcomes. Methods In a retrospective review of 39 consecutive cases of acute distal ICA occlusion, the recanalization rates and functional outcomes at 3 months of the two intra-arterial techniques during two consecutive periods (May 2006 to February 2009: MCD technique (n¼19) vs March 2009 to August 2010: mPS technique (n¼20)) were compared. Univariate and multivariate analyses were performed to determine the predictors of a favorable functional outcome. Results The rate of successful recanalization (Thrombolysis In Cerebral Infarction score 2 or 3) was significantly higher in the mPS group than in the MCD group (85% (17/20) vs 32% (6/19); p¼0.001). Favorable outcomes at 3 months (modified Rankin Scale score 0e2) were achieved in 9/20 and 3/19 in the mPS and MCD groups, respectively (45% vs 16%; p¼0.048). Binary logistic regression analysis showed that younger age and successful recanalization were independent predictors of a favorable functional outcome. Conclusions Forced-suction thrombectomy using the mPS technique may be a viable option for acute distal ICA occlusion and could result in more successful recanalization and a more positive clinical outcome.

a Neurology, b Neuroradiology, and c Daegu-Gyeongbuk Cardio-Cerebrovascular Abstract To date, the long-term effects of reperfusion on the salvaged brain tissues have not been addressed in the literature. We report 4 cases presenting subacute neurological deteriorations with selective axonal injury following reperfusion therapies for acute ischemic stroke. Our case series based on 4 patients showed common features distinct from those of early reperfusion injury in that (1) the neurological symptoms developed after 1-2 months of reperfusion therapies, (2) these symptoms were accompanied by the subcortical white matter changes on brain MRI, and (3) these findings were mostly reversible with time. This suggests that axons in the reperfused brain may be vulnerable to further neurological injury.

Background and Purpose: Co g n itive imp a irmen ts a re fre que n t c o n s e qu e n c e s o f e p ile p s y, with in te lle c tu a l a bility re p o r te dly bein g lo wer in p a tie n ts with id io p a thic g en er a lize d epi lepsi e s tha n in the g eneral p opul a tio n. Ho we ver, neuropsy c ho lo gi c al in vest ig at io ns ha ve be en r arel y p erf o rme d in p a tie n ts with ju ven ile myo c lo n ic ep ilep s y (JME). We a ime d to qu a n tify the c o g n itive fu n c tio n in JME p a tien ts u s in g va rio us n europsy c ho lo gi c al te st s . M et h ods: We c o mp a re d c o g n itive fu n c tio n in 27 JME p a tie n ts with tha t in 27 he al thy vo lun te ers u si n g te st s exa min in g c o g n itive p er fo rma n c e , s uc h a s the ve rba l a n d vis ua l me mo ry, fro nt a l fu nct io n, a tte nt io n, IQ s core, a nd mo o d . In the JME g ro u p , we e xa min e d ris k fa c to rs fo r c o g n itive fu n c tio n s uc h a s a g e , s ex, fa mily his to r y, ed u c a tio n le vel, a g e a t s e izur e o n s e t, s eizu re fr equ en c y, EEG a bn o rma lity , d is e a s e d u ra tio n , a n d p re vio u s in ta k e o f a n tiepi le pt ic d rugs. Resul t s: Ve rba l learni n g wa s s ig ni fic ant ly lo we r in JME p at ie nt s tha n i n c ont ro ls , a nd a tte nt io n a nd verb a l flu ency wer e imp a ir ed in JME p a tien ts c o mp a r ed with c o n tr o ls . Ho we ve r, g e n e ra l in telle c tu a l a bility a n d mo o d d id n o t d iffe r be twe en the g roups. Ea rly o nset o f s ei zur e a nd lo ng d urat io n o f dis ea s e wer e c lo s ely re la te d to imp a ir ed c o g n itive fu n c tio n . C oncl usi ons: JME p a tie n ts ma y exhibit imp a ire d c o g n itive fu n c tio n , in te rms o f memo ry a n d e xe c utio n , d es p ite ha vin g n o r ma l in tellig en c e a n d mo o d . J Clin Neurol 3(2):86-92, 2007

Background and Purpose: Lo w-d ose to pi ra ma te (TP M) mo not her apy ha s r ecent ly be en fo und effe c tive fo r s eizu re c o n tro l in n e wly d ia g n o s ed e p ile p s y. In hig he r do s a g e s , TP M ha s bee n a s s o c ia ted with re la tive ly hig h r a tes o f a d ve rs e c o g n itive e ffec ts ; s imila r s ide effe c ts ha ve be e n s ee n a fte r ra p id titr a tio n o r p o lyther a p y. Ho weve r, its c o g n itive effe c ts d ur in g lo w-d o s e mo n o the ra p y ha ve n o t bee n e s t a blis he d . We eva lu a te d the c o g n itive e ffec ts o f lo w-do s e TP M c o mp a r ed with o xc a rba ze p in e (OXC), a d ru g tha t d o e s n o t a p p e a r to a ffe c t c o g n itive fu n c tio n . M et h ods: Co g n itive te s ts a n d s u bje c tive c o mp la in ts o f 30 p a tien ts with lo w-do s e TP M mo n o the ra p y (50-200 mg /da y) wer e re tr o s p e c tively c o mp a re d with tho s e o f 30 p a tien ts with OXC mo not he rapy a t 1 ye ar o f me di c at io n. The two g ro u p s d id n o t d iffer with r es p e c t to e p ile p s y-re le va n t va ri a ble s, n or o n ba sel in e n europsy c ho lo gi c al te st s . Resul t s: The TP M g ro u p s ho wed a s ig n ific a n t d iffer en c e in the p e rfo r ma nc e o f d e la yed wo rd re c a ll (P

Immunoglobulin G (IgG) anti-GD1a ganglioside antibody is an important marker of Guillain–Barre syndrome (GBS). This antibody is highly associated with disease severity, the need for mechanical ventilation, and axonal degeneration of peripheral nerves. We report a 46-year-old female patient manifesting the IgG anti-GD1a antibody with polycranial neuropathy and sensory ataxia as a variant of GBS. She presented with slurred speech, swallowing difficulties, and gait disturbance following diarrhea. Decreased sensations of vibration and position were found in her distal limbs and she had an ataxic gait with a positive Romberg sign. Her serum was positive for IgG anti-GD1a ganglioside antibody (1:640). Her neurological examination at the third month after intravenous Ig treatment showed complete recovery.

We report two patients with an ocular tilt reaction (OTR) due to unilateral caudal cerebellar lesion. One patient had a caudal cerebellar hemorrhage, the other a posterior inferior cerebellar artery territory infarct. There was head tilt in both patients which had not been reported previously. These findings support the previous proposal that the mechanism of a tonic contraversive OTR with unilateral cerebellar lesion is an increased tonic resting activity in the ipsilesional vestibular nucleus due to a loss of inhibition from the lesioned nodulus.

Background and PurposezzLevetiracetam (LEV) is a new antiepileptic drug that has been found to be effective as an adjunctive therapy for uncontrolled partial seizures. However, the results of several studies suggested that LEV has negative psychotropic effects, including irritability, aggressiveness, suicidality, and mood disorders. We investigated the impact of adjunctive LEV on psychiatric symptoms and quality of life (QOL) in patients with drug-refractory epilepsy (DRE) and determined the risk factors provoking psychiatric adverse events. MethodszzA 24-week, prospective, open-label study was conducted. At enrollment, we interviewed patients and reviewed their medical charts to collect demographic and clinical information. They were asked to complete self-report health questionnaires designed to measure various psychiatric symptoms and QOL at enrollment and 24 weeks later. ResultszzSeventy-one patients were included in the study, 12 patients (16.9%) of whom discontinued LEV therapy due to serious adverse events including suicidality. The risk factor for premature withdrawal was a previous history of psychiatric diseases (odds ratio 4.59; 95% confidence interval, 1.22-17.32 ). LEV intake resulted in significant improvements in Beck Anxiety Inventory score (p

Objective The purpose of the study was to delineate how affective symptoms (AS) influence quality of life (QOL) for individuals with drug-refractory epilepsy (DRE) and those with well-controlled epilepsy (WCE) independently. Methods All subjects participating in the study were asked to complete reliable and validated self-report health questionnaires, including AS, measured with the Korean versions of the Beck Depression Inventory, Beck Anxiety Inventory, and Quality of Life in Epilepsy Inventory-31 (QOLIE-31). We examined predictors of QOLIE-31 scores among the various demographic and clinical factors. We compared the effects of AS on QOL between patients with DRE and those with WCE and investigated the differential effects of seizure control and AS on QOL. Results Two hundred forty-nine patients with DRE or WCE were included in the study. The strongest predictor of QOL was AS, followed by seizure control and MRI abnormality. Affective symptoms had almost two times the effect of seizure control and six times the effect of MRI abnormality. Poorest QOL was noted in patients with DRE with AS, followed by those with WCE with AS, DRE without AS, and WCE without AS. Conclusion The major determinant of QOL in patients with epilepsy is AS rather than DRE or WCE status.

Background: The aim of this study was to examine the rate of early neurological deterioration (END) and favorable outcomes after acute lacunar stroke following the use of intravenous recombinant tissue plasminogen activator (IV rtPA). Methods: A total of 76 acute lacunar stroke patients (Results: END/favorable outcomes were observed in 24/31% of the subjects in group A and 21/23% in group B (p = 0.77/0.46). Subgroup analysis of the etiologic subtype of small-vessel occlusion showed that END/favorable outcomes were observed in about 33/33% and 15/19% of the patients in groups A and B, respectively (p = 0.21/0.34). Conclusions: The authors showed that the use of rtPA in cases of no lysible clots might not affect the END and favorable outcomes.

Background and Purpose: Zo n is a mid e (ZNS) is a us e fu l a n tie p ile p tic d ru g with a bro a d the ra p eu tic s p e c tr um. Ho we ver , the re is limite d in fo rma tio n o n the lo n g -ter m us e o f Z NS a s a mo not he rapy . This s tud y in ve st ig at e d the lo n g -ter m effe c ts o f ZNS a s a mo n o the ra p y fo r the tre a tmen t o f epi le psy . Met h ods: We r etro s p ec tive ly a n a lyze d the re c o rd s o f e p ile p s y p a tien ts tr ea te d with ZNS mo n o ther a p y a t o u r c lin ic . We id e n tifie d o u tc o mes fo r p a tien ts tre a ted with ZNS mo not he rapy fo r a min imu m o f 6 mo nt hs . Effic acy wa s qu a n tifie d a s the p er c en ta g e c ha n g e in s e izur e fre qu e n c y, a n d s af e ty wa s a ssessed by the fre que ncy a nd typ es of a dv e rse eve nt s . Resul t s: Sixty p a tie n ts who re c e ive d ZNS fo r a min imu m o f 6 mo n ths we re in cl u ded. The me an d urat io n o f tre a tmen t wa s 19.8 mo n ths (r a n g e , 6-37 mo n ths ), a n d the mea n ZNS d o s a g e wa s 255 mg /d a y (ra n g e , 100-500 mg /da y). Twe n ty-s e ven p a tien ts (45%) we re s eizu re -fre e, a n d a n a d d itio n a l 20 p a tien ts (33%) ha d a bo ve 50% s eizu re fre qu e n c y re du c tio n a t the la s t fo llo w-u p vis it. P a rtial s e izur es with o r witho ut s e c o n d a ry g e n e ra liza tio n a n d g e n e ra lized s e izu re s we re we ll c o n tr o lle d by ZNS, wher ea s c o mp l ex p art ia l s eizu res were n ot . Fo rty-e ig ht p at ie nt s (80%) re port e d mild-to -mo derat e a dv erse e vent s , in cl u din g memo r y lo s s (35%), a tte n tio n de fic it (27%), a n d we ig ht lo ss (20%). Concl usi ons: Lo n g -te rm ZNS mo n o ther a p y is e ffec tive a t tre a tin g a bro a d s p ec tru m o f s ei zu re d is ord e rs , exc ept complex partial seizures. However, a specific adverse event, such as cognitive impairment, is common and long-lasting.

This study was a prospective, randomized, open-label investigation of the long-term effects of zonisamide (ZNS) monotherapy on cognition and mood of patients with epilepsy. Forty-three patients with epilepsy received ZNS, with final dose groups of 100, 200, 300, and 400 mg/day. Cognitive and mood tests were done twice, at baseline and 1 year after starting medication. Nine patients were withdrawn prior to their follow-up tests. Three patients (33%) dropped out during the titration period because of cognitive and mood problems. Thirty-four patients completed follow-up neuropsychological tests. After 1 year of treatment, 16 patients (47%) complained of cognitive deficits. Only 5 patients (15%) experienced mood changes. Although ZNS decreased seizure frequency and EEG abnormalities and did not elicit significant mood changes, it had negative effects on several cognitive tests. Worse performance on delayed word recall, Trail Making Test Part B, and verbal fluency was related to dose. In conclusion, ZNS has adverse effects on cognition even after 1 year of treatment.

The present study was conducted to evaluate the long-term effects of low-dose topiramate (TPM) monotherapy on the cognitive function of epilepsy patients. Forty-seven epilepsy patients received TPM, with target doses of 50, 75, and 100 mg/day. Cognitive tests were performed twice, at baseline and 1 year after starting medication. Thirty-six patients completed the follow-up neuropsychological tests. After a year of treatment, 16 patients (44%) complained of cognitive problems. Although it improved seizure frequency and EEG abnormalities, TPM had significantly negative effects on the digit span and verbal fluency tests. These cognitive effects were dose-related and significantly improved after withdrawal from TPM and substitution with older antiepileptic drugs. In conclusion, even at a low dose, TPM has long-term, negative effects on working memory and verbal fluency.

In a patient receiving 5-fluorouracil and levamisole, neurologic deficits suggest the cerebral demyelinating syndrome as a differential diagnosis. The authors report a patient diagnosed as multifocal inflammatory leukoencephalopathy for which thallium-201 (201Tl) single photon emission computed tomography (SPECT) and proton magnetic resonance spectroscopy (MRS) were employed as noninvasive diagnostic tools. 201Tl SPECT study was negative and proton MRS showed an increase of choline and lactate and well preserved N-acetylaspartate. These findings support histopathologic findings of multifocal inflammatory leukoencephalopathy revealing demyelination with relative axonal sparing in the patient.

a ; Soon-Hak Kwon, MD, PhD b Background and PurposezzThe risk of suicide or suicide attempts is reported higher in peo- ple with epilepsy (PWE) than in the general population. Although epileptic, psychiatric, and psy- chosocial factors are known risk factors for suicide or suicide attempt, no studies have evaluated the predictors of the severity of suicidal ideation-which is a warning sign for suicide attempts-in PWE. Therefore, we measured the severity of suicidal ideation and its risk factors. MethodszzConsecutive PWE who were medicated with antiepileptic drugs (AEDs) and attended epilepsy clinic were included in the study. The subjects completed self-reported questionnaires, which included the Beck Depression Inventory (BDI), Beck Anxiety Inventory (BAI), Symptom Checklist-90-Revised (SCL-90-R), and Scale for Suicide Ideation-Beck (SSI-Beck). We com- pared the patients' demographic and clinical variables, and BDI, BAI, and SCL-90-R scores with their SSI-Beck score, and used our findings to determine the predictors for suicidal ide - ation. ResultszzIn total, 257 PWE were enrolled in the study. SSI-Beck scores correlated strongly with several seizure-related variables, duration of education, IQ, BDI and BAI scores, and nine domains of the SCL-90-R questionnaire. However, the strongest predictor for suicidal ideation was BDI score (β=0.41, p

Background and Purpose: This s tud y c o mp a re d the c o g n itive e ffec ts o f 1 ye a r o f tre a tmen t with la mo trig in e (LTG) a nd o xc arb a ze pi n e (OXC) in e pi le psy p at ient s . Met h ods: This r et ro spect ive s tu dy in ve st ig at e d 60 e pi le psy p at ie nt s u nd ergoi n g n europsy c ho lo gi c al test s who were e ither n ew ly dia gnosed o r u nt re at e d in the p recedi n g 6 mo n ths . The c o g n itive fu n c tio n in 30 p a tie n ts re c e ivin g LTG mo not he rapy a nd 30 a ge- ma tc he d p at ie nt s r ecei vin g OXC mo not he ra py wa s c om p ared a fte r 1 year . The neuropsy c ho lo gi c al s cores a t ba sel in e a nd a ll o f the epi lepsy -r el e va nt va ria bles e xc ept s ei zu re typ e did n ot d iffer be twe en the g ro u p s . The mea n d a ily d o s a g es o f LTG a n d OXC a t 1 ye ar we re 93 mg a nd 825 mg , re spect ively. Resul t s: The p o s ttre a tmen t lis t-le a r n in g p er fo rma n c e wa s bette r in the LTG g roup tha n in the OXC g roup (p

Background Creutzfeldt-Jakob disease (CJD) is a rare transmissible disease that typically causes a rapidly progressive dementia and leads to death in less than 1 year. Although a few anecdotal reports suggest that diffusion-weighted magnetic resonance imaging may help substantiate premortem diagnosis of CJD, detailed correlation between radiographic data and clinical, electrophysiologic, and metabolic parameters is not available. Methods Signal abnormalities on diffusion-weighted images in 3 consecutive patients with probable CJD were correlated with psychometric features, electroencephalographic findings, and functional images with either positron emission tomography or single photon emission computed tomography. Results Focality of abnormalities on diffusion-weighted image, not apparent on routine magnetic resonance images, correlated closely with clinical manifestations of CJD. The topographic distribution of signal abnormality on diffusion-weighted image corresponded with abnormal metabolism or perfusion on positron emission and single photon emission computed tomographic scans. In 2 cases, the laterality of diffusion abnormalities correlated with periodic sharp wave activity on electroencephalograms. Conclusion These findings extend previous observations that suggested a diagnostic and localizing utility of diffusion-weighted imaging in CJD.

We previously reported the presence of stationary negative potentials (N3, N6, N9) over the arm ipsilateral to the side of median nerve stimulation. In this study, we examined the effect of different arm positions upon these stationary peaks in 12 normal subjects. When arm position was changed from elbow extended to elbow flexed 90 degrees, we recorded a new negative peak, N4. The peak latency of N4 corresponded to the traveling impulse reaching the distal biceps brachii. With the elbow flexed, N3, N6 and N9 peak latencies significantly shortened compared to those recorded with the arm in the usual elbow extended position. In contrast, with the arm abducted at the shoulder, N6 and N9 latencies were significantly prolonged while N3 remained unchanged. Corresponding latency shifts were also observed in the bipolarly recorded traveling impulse. We consider 2 possible factors for N4 enhancement by elbow flexion. One is the change in conducting volume surrounding the nerve, i.e., increased muscle bulk of biceps brachii. The other is the change in axial orientation of the propagating nerve impulse by 90 degrees. We also propose that the latency shifts of the stationary potential as well as of a traveling wave can be attributed primarily to relaxation or stretching of the nerve trunk with change in arm position.