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Objectives: Paradoxical insomnia, a type of sleep disorder, is characterized by misperception and underestimation of an individual’s sleep time. In this study, we investigated the percentage and clinical factors associated with paradoxical insomnia in patients with chronic insomnia, who underwent polysomnography.Methods: The study included 148 patients with chronic insomnia. The study population was categorized into paradoxical and non-paradoxical insomnia groups. The following criteria were used to define paradoxical insomnia: 1) total sleep time >390 min and sleep efficiency ≥85.0%, and 2) significant discrepancy of >1 hour between subjective and objective sleep measurements. We analyzed demographic data, polysomnographic parameters, and perceived sleep time in all patients.Results: Among 148 patients with chronic insomnia, 33 (22.6%) had paradoxical insomnia. We observed significant intergroup differences in age, sex, and the Insomnia Severity Index (ISI). Sleep architecture patterns were relatively better in the paradoxical than in the non-paradoxical insomnia group. Logistic regression analysis was performed to determine clinical factors associated with paradoxical insomnia. Female sex (odds ratio [OR] 2.96, 95% confidence interval [CI] 1.19–7.37), age (OR 0.97, 95% CI 0.94–0.99), and ISI (OR 1.18, 95% CI 1.05–1.31) were significantly associated with paradoxical insomnia.Conclusions: Approximately 20.0% of patients with chronic insomnia were classified into the paradoxical insomnia group, and female sex, age, and ISI were identified as clinical factors associated with this type of sleep disorder.

BACKGROUND Epilepsy is a neurological disorder, and accurate information about the condition is crucial for those affected. As natural language processing models such as ChatGPT become increasingly popular for accessing medical information, it is important to evaluate their accuracy and reliability. OBJECTIVE This study aimed to investigate the accuracy of ChatGPT in providing educational information related to epilepsy. METHODS We evaluated the accuracy and educational quality of ChatGPT's responses to 57 questions commonly asked by epilepsy patients or their caregivers using the “Epilepsy Patient and Caregiver Guide” from the Korean Epilepsy Society. The questions were divided into categories and entered into ChatGPT 4 version and 3.5 for comparison. Responses were evaluated by two epileptologists, with a third epileptologist serving as the final arbiter in cases of disagreement. ChatGPT 4's performance was compared to that of ChatGPT 3.5 and the official guide. Evaluations were categorized into four grades and compared using a standardized method in cases of disagreement. RESULTS Among the 57 questions, 40 responses had “sufficient educational value,” while 16 were “correct but inadequate.” Only one response was “mixed with correct and incorrect” information, and no responses were found to be “incorrect.” Comparison with ChatGPT 3.5 showed that GPT-4 performed better or similar in most questions, except for two instances where GPT-3.5 provided better answers. Compared to the official epilepsy guide, GPT-4 also had better or similar responses for most of the questions, with four exceptions where the official guide had better answers. CONCLUSIONS This study demonstrates the potential of ChatGPT-4 as a tool for providing accessible and helpful medical information related to epilepsy. Although there are many concerns about the use of GPT models for medical education, they can still be considered to decrease the burden on healthcare professionals with respect to patient education. More research is needed to fully understand the potential benefits and limitations of using language models such as ChatGPT in healthcare and medicine.

Introduction: The pathophysiology of migraine has been researched incessantly, and it has been suggested that calcitonin gene-related peptide (CGRP) is associated with migraine attacks. CGRP receptor blockers are attracting attention as potential agents for migraine prevention and treatment of acute episodes. This meta-analysis aimed to assess the effects of available CGRP receptor antagonists, focusing on their therapeutic doses for acute migraine treatment. Methods: We systematically searched MEDLINE and Embase from inception to March 27, 2021, for English-language publications using the keywords “migraine” and “calcitonin gene-related peptide”; the searches were limited to human studies. Results: Five studies that focused on examining the effects of CGRP receptor antagonists on acute migraine treatment met the eligibility criteria for this meta-analysis. A pooled analysis demonstrated that CGRP receptor antagonists significantly increased freedom from pain (odds ratio [OR] = 2.066, 95% confidence interval [CI] 1.766–2.418, I2 = 0%) and from bothersome symptoms in general (OR = 1.606, 95% CI = 1.408–1.830, I2 = 0%); reduced the intensity of pain (OR = 1.791, 95% CI = 1.598–2.008, I2 = 0%); and increased freedom from nausea (OR = 1.361, 95% CI = 1.196–1.548, I2 = 0%) compared to a placebo. Conclusions: CGRP receptor antagonists are effective for acute migraine treatment and are expected to be used clinically as emerging therapeutic agents.

Although genetic Creutzfeldt-Jakob disease (CJD) is a rare neurodegenerative disorder, cases of genetic CJD with E200K mutation are being increasingly reported in Korea. However, the clinical features and course of genetic CJD with E200K mutation in Korea remain unclear. We describe the clinical features and course of genetic CJD with E200K mutation in a patient who initially presented with rapid progressive memory impairment and myoclonus.

A 48-year-old woman presented with a 1-day history of aggressive behavior. Hashimoto encephalopathy was first suspected based on elevated levels of serum anti-thyroid peroxidase antibody. Her clinical symptoms did not improve despite treatment with intravenous corticosteroid. Abdominal computed tomography revealed liver cirrhosis, and brain T2-weighted magnetic resonance imaging revealed midbrain hyperintensity, and she was finally diagnosed with Wilson’s disease. The Wilson’s disease should be considered in the differential diagnosis in adults presenting with unexplained hepatic, neurological, or psychiatric abnormalities.

This study assessed whether patients with epilepsy have a higher level of impulsivity than healthy controls, and compared impulsivity among patients with different subtypes of epilepsy.The multicenter study included 108 subjects with epilepsy and 56 healthy volunteers. Subjects were evaluated by the Barratt Impulsiveness Scale-11 (BIS-11) and Patient Health Questionnaire-9, with BIS-11 scores analyzed as both dichotomized and continuous variables. High impulsivity was defined as a total BIS-11 score ≥ 67.Of the 108 subjects with epilepsy, 36 had idiopathic generalized epilepsy (IGE), 47 had temporal lobe epilepsy (TLE), and 25 had frontal lobe epilepsy (FLE). A significantly higher percentage of subjects with epilepsy (22.2%) than controls (1.8%) had BIS-11 scores ≥ 67 (p = 0.001), although mean BIS-11 scores were similar in subjects with epilepsy (59.5 ± 10.0) and controls (58.8 ± 4.6). Higher percentages of subjects with IGE and FLE had BIS-11 scores ≥ 67 than subjects with TLE and controls. Mean total BIS-11 scores did not differ between controls and subjects with IGE and FLE, but were lower in subjects with TLE than in controls. Differences in impulsivity among controls and subjects with epilepsy subtypes varied depending on BIS-11 subscale.Patients with epilepsy, particularly IGE and FLE, were more likely to have high impulsivity scores, defined by a certain cutoff on the BIS-11, than controls and subjects with TLE. However, mean impulsivity scores did not differ among controls and subjects with IGE and FLE. Dichotomizing BIS-11 scores may be necessary to avoid false negative results in subjects with epilepsy.

PURPOSE We investigated the moderating effect of sleep disturbance on the association between seizure recurrence and emotional instability in patients with epilepsy, independent of psychological distress. METHODS This was a cross-sectional study. Patients completed the short form of the Affective Lability Scale (ALS-18), Insomnia Severity Index (ISI), Patient Health Questionnaire-9 (PHQ-9), and Generalized Anxiety Disorder-7 (GAD-7). A stepwise linear regression analysis and an analysis of covariance with an interaction term were performed. RESULTS A total of 171 subjects (63.2% men) were included. The mean ALS-18 score was 15.6 ± 11.3. An ISI ≥ 15, PHQ-9 ≥ 10, and GAD-7 ≥ 7 were noted in 20.5%, 18.1%, and 23.4% of subjects, respectively. A stepwise linear regression analysis found that recurrent seizures in the last year, an ISI ≥ 15, a GAD-7 ≥ 7, and use of levetiracetam were significant and independent factors that were positively associated with higher ALS-18 scores. The coefficient of determination for the model was 0.331. The interaction between recurrent seizures and an ISI ≥ 15 had a significant effect on the ALS-18 scores (F = 6.812, p = 0.010, partial eta2 = 0.040). An ISI ≥ 15 was associated with ALS-18 scores in patients without seizure recurrence (p

Background Spontaneous intracranial hypotension and post-dural puncture headache are both caused by a loss of cerebrospinal fluid but present with different pathogeneses. We compared these two conditions concerning their clinical characteristics, brain imaging findings, and responses to epidural blood patch treatment. Methods We retrospectively reviewed the records of patients with intracranial hypotension admitted to the Neurology ward of the Pusan National University Hospital between January 1, 2011, and December 31, 2019, and collected information regarding age, sex, disease duration, hospital course, headache intensity, time to the appearance of a headache after sitting, associated phenomena (nausea, vomiting, auditory symptoms, dizziness), number of epidural blood patch treatments, and prognosis. The brain MRI signs of intracranial hypotension were recorded, including three qualitative signs (diffuse pachymeningeal enhancement, venous distention of the lateral sinus, subdural fluid collection), and six quantitative signs (pituitary height, suprasellar cistern, prepontine cistern, mamillopontine distance, the midbrain-pons angle, and the angle between the vein of Galen and the straight sinus). Results A total of 105 patients (61 spontaneous intracranial hypotension patients and 44 post-dural puncture headache patients) who met the inclusion criteria were reviewed. More patients with spontaneous intracranial hypotension required epidural blood patch treatment than those with post-dural puncture headache (70.5% (43/61) vs. 45.5% (20/44); p = 0.01) and the spontaneous intracranial hypotension group included a higher proportion of patients who underwent epidural blood patch treatment more than once (37.7% (23/61) vs. 13.6% (6/44); p = 0.007). Brain MRI showed signs of intracranial hypotension in both groups, although the angle between the vein of Galen and the straight sinus was greater in the post-dural puncture headache group (median [95% Confidence Interval]: 85° [68°-79°] vs. 74° [76°-96°], p = 0.02). Conclusions Patients with spontaneous intracranial hypotension received more epidural blood patch treatments and more often needed multiple epidural blood patch treatments. Although both groups showed similar brain MRI findings, the angle between the vein of Galen and the straight sinus differed significantly between the groups.

Background: The pathophysiology of migraine has been researched incessantly, and it has been suggested that calcitonin gene-related peptide (CGRP) is associated with migraine attacks. CGRP receptor blockers are attracting attention for migraine prevention and treatment of acute episodes, and CGRP receptor antagonists have been shown to be effective in treating acute migraine headaches. This meta-analysis aimed to assess the effect of available CGRP receptor antagonists, focusing on their therapeutic doses for acute migraine treatment.Methods: We performed a systematic search of MEDLINE (from inception to March 2021) and EMBASE (from inception to March 2021) for English publications using the keywords “migraine” and “Calcitonin gene-related peptide,” limited to human studies.Results: Five studies that focused on examining the effects of CGRP receptor antagonists on acute migraine treatment met the eligibility criteria for this meta-analysis. The pooled analysis demonstrated that the CGRP receptor antagonist improved freedom from pain (OR=2.066, 95% confidence interval [CI] 1.766–2.418, I2=0%), absence of bothersome symptoms (OR=1.606, 95% CI=1.408–1.830, I2=0%), pain relief (OR=1.791, 95% CI=1.598–2.008, I2=0%), and freedom from nausea (OR=1.361, 95% CI=1.196–1.548, I2=0%), significantly more than the placebo. Conclusions: CGRP receptor antagonists are effective for acute migraine treatment and are expected to be used clinically as emerging therapeutic agents.

We evaluated the relative contributions of emotional instability, impulsivity, and aggression to the presence of suicide risk in people with epilepsy after adjusting for depressive symptoms.This was a cross-sectional study that used the short form of the Affective Lability Scale (ALS-18), the Barratt Impulsiveness Scale Version 11 (BIS-11), the Brief Aggression Questionnaire (BAQ), and the Patient Health Questionnaire-9 (PHQ-9). Suicidality was assessed using the Mini International Neuropsychiatric Interview (MINI), and the presence of suicide risk was defined as a MINI suicidality score ≥1. Stepwise logistic regression and mediation analyses using a two-stage regression method were performed.Of the 171 subjects (63.2% men) included, suicide risk was present in 38 subjects (22.2%). The stepwise logistic regression analysis identified four variables that were independently associated with suicide risk: higher PHQ-9 score, higher BAQ score, longer duration of epilepsy, and unemployment. The univariate analysis showed that ALS-18 and BIS-11 scores were significantly associated with suicide risk; however, they were backward eliminated from the logistic model according to the criterion of p 0.1. The mediating effects of ALS-18 and BIS-11 scores on suicide risk via PHQ-9 scores (but not BAQ scores) were significant, with the proportion mediated 61.5% and 54.0% of the total effect, respectively.Alongside depressive symptoms, aggression may be a more useful concept than emotional instability and impulsivity for identifying suicidal risk in people with epilepsy.

Introduction Polymerase chain reaction (PCR)-based testing of cerebrospinal fluid (CSF) samples has greatly facilitated the diagnosis of central nervous system (CNS) infections. However, the clinical significance of Epstein-Barr virus (EBV) DNA in CSF of individuals with suspected CNS infection remains unclear. We wanted to gain a better understanding of EBV as an infectious agent in immunocompetent patients with CNS disorders. Methods We identified cases of EBV-associated CNS infections and reviewed their clinical and laboratory characteristics. The study population was drawn from patients with EBV PCR positivity in CSF who visited Pusan National University Hospital between 2010 and 2019. Results Of the 780 CSF samples examined during the 10-year study period, 42 (5.4 %) were positive for EBV DNA; 9 of the patients (21.4 %) were diagnosed with non-CNS infectious diseases, such as optic neuritis, Guillain-Barre syndrome, and idiopathic intracranial hypotension, and the other 33 cases were classified as CNS infections (22 as encephalitis and 11 as meningitis). Intensive care unit admission (13/33 patients, 39.3 %) and presence of severe neurological sequelae at discharge (8/33 patients, 24.2 %) were relatively frequent. In 10 patients (30.3 %), the following pathogens were detected in CSF in addition to EBV: varicella-zoster virus (n = 3), cytomegalovirus (n = 2), herpes simplex virus 1 (n = 1), herpes simplex virus 2 (n = 1), Streptococcus pneumomiae (n = 2), and Enterococcus faecalis (n = 1). The EBV-only group (n = 23) and the co-infection group (n = 10) did not differ in age, gender, laboratory data, results of brain imaging studies, clinical manifestations, or prognosis; however, the co-infected patients had higher CSF protein levels. Conclusion EBV DNA in CSF is occasionally found in the immunocompetent population; the virus was commonly associated with encephalitis and poor prognosis, and frequently found together with other microbes in CSF.

Short sleep duration has been known to be related to metabolic syndrome (MetS) . The aim of this study was to investigate the beneficial effects of weekend catch-up sleep (WCUS) on MetS in the Korean middle-aged population.For this cross-sectional study, 1,812 participants aged 35-60 years were selected from the 2016-2018 Korean National Health and Nutrition Examination Survey (mean age 46.94 years, 49% male). Short sleep duration was defined as6hrs on weekdays, and participants were divided into two groups: WCUS group and no weekend catch-up sleep group. Multiple logistic regression was performed to determine the association between WCUS and MetS prevalence. The covariates included age, sex, education, income, occupation, smoking, alcohol consumption, and physical activity.WCUS was significantly associated with lower MetS prevalence in the unadjusted model and in the model adjusted for socioeconomic and health behavior factors.These results support the beneficial effects of WCUS on lowering the risk of MetS among middle-aged chronic short sleepers.

Clinical research regarding impulsivity in patients with epilepsy is limited. The present study investigated the associations between impulsivity and seizure-related factors or suicidality in patients with epilepsy, independent of depression and anxiety.The multicenter study included 146 subjects (63% men). We utilized the Barratt Impulsiveness Scale-11 (BIS-11), Patient Health Questionnaire-9 (PHQ-9), Generalized Anxiety Disorder-7 (GAD-7), and suicidality module of the Mini International Neuropsychiatric Interview (MINI). Stepwise regression analyses and an analysis of covariance with interaction terms were performed.The mean BIS-11 score was 59.3 (SD = 10.7). Psychiatric pathologies, including suicidality, were reported in relatively large proportions of patients, including PHQ-9 score ≥ 10 in 29 (19.9%) patients, GAD-7 score ≥ 7 in 35 (24.0%) patients, and MINI suicidality score ≥ 6 in 15 (10.3%) patients. Stepwise linear regression revealed that BIS-11 score was positively associated with the PHQ-9 scores (p 0.001), antiseizure medication polytherapy (p 0.001), use of lamotrigine (p = 0.009), and recurrence of generalized or focal to bilateral tonic clonic seizures (p = 0.010). The coefficient of determination for the model was 0.397. Generalized or focal to bilateral tonic clonic seizure recurrence tended to be positively associated with total BIS-11 scores in men but not in women. In subscale analyses, somewhat different variables were associated with different BIS-11subscales. A trend for a positive association between BIS-11 score and suicidality was found (p = 0.066).This study identified a positive association between clinical seizure severity and impulsivity, and found that this association tended to be sex-specific, occurring only in males. Impulsivity could potentially be weakly associated with suicidality in patients with epilepsy.

The familial Creutzfeldt-Jakob disease (fCJD) usually has similar clinical and neuroimaging features as sporadic CJD (sCJD). A 57-year-old man presented with a four-month history of rapidly progressive dementia (RPD). Laboratory tests for RPD were all normal. Brain MRI demonstrated diffuse cortical atrophy and no abnormal cortical or striatal hyperintensities on fluid-attenuated inversion recovery (FLAIR)/diffusion weighted imaging (DWI). Electroencephalography revealed intermittent slow waves in the bilateral hemispheres. Cerebrospinal fluid (CSF) examination showed elevated cell counts and protein concentrations. After 10 days of empirical treatment with antiviral agents, the patient was eventually diagnosed with fCJD with M232R mutation based on the results of positivity for 14-3-3 protein, CSF PrPsc in real-time quaking-induced conversion assay and genetic test for PRNP gene. The striatal or cortical FLAIR/DWI hyperintensities are reliable radiographic markers in the diagnosis of both sCJD and fCJD. However, this case suggests that clinical work-up for CJD including genetic test is essential to do a differential diagnosis of RPD, regardless of FLAIR/DWI findings.

Three α-herpesviruses are known to be associated with central nervous system (CNS) infection; however, there are limited data on the incidence and clinical characteristics of α-herpesviruses CNS infections. This study aimed to assess the clinical manifestations, laboratory findings, and outcomes in patients with human herpes simplex virus 1 (HSV-1), human herpes simplex virus 2 (HSV-2), and varicella-zoster virus (VZV) CNS infections. We identified cases of HSV-1, HSV-2, and VZV CNS infections and reviewed their clinical and laboratory characteristics. The study population was drawn from patients with HSV-1, HSV-2, and VZV polymerase chain reaction positivity in cerebrospinal fluid (CSF) who visited Pusan National University Hospital between 2010 and 2018. During the 9-year study period, a total of 727 CSF samples were examined, with 72.2% (525/727) patients identified as having a CNS infection. Of 471 patients with aseptic meningitis and encephalitis, the causative virus was identified in 145 patients, and no virus was detected in 337 patients. A total of 15.2% (80/525) were diagnosed with one of the 3 herpesviruses as causative agents, 59 patients had meningitis, and 21 patients had encephalitis. Eleven patients with HSV-1, 27 patients with HSV-2, and 42 patients with VZV CNS infections were included. The distribution of cases by age showed different patterns depending on the type of herpesvirus infection. Compared with the HSV-1 group, the median age in the HSV-2 group was younger (HSV-1: 58 years; HSV-2: 38 years; P = .004), and patients with VZV infections showed a bimodal age distribution. Encephalitis was more common in the HSV-1 group, and HSV-1 infection was associated with a poor prognosis at discharge. CSF white blood cell counts were significantly lower in patients infected with HSV-1 (117 × 106 cells/L) than in patients infected with VZV (301 × 106 cells/L) (P = .008). These 3 herpesviruses are important causes of CNS infections regardless of immunologic status. HSV-1 infection was commonly associated with encephalitis and poor prognosis; HSV-2 and VZV CNS infections were associated with a low risk of mortality and neurological sequelae.

Purpose Religiosity can be important in the everyday life of persons with epilepsy (PWE). How PWE live with religiosity can be influenced by their cultural background. We determined whether religiosity is associated with anxiety, depressive symptoms, and well-being in Korean adults with epilepsy. Methods This multicenter cross-sectional study was conducted in the outpatient clinics of five university hospitals in Korea. Religiosity was assessed using the five-item Duke University Religion Index (DUREL). The WHO-Five Well-Being Index (WHO-5) and Hospital Anxiety Depression Scale were used. The participants were categorized into three subgroups bounded by the 33rd and 66th percentiles of their DUREL scores. Results Of a total of 226 participants, 61.1% declared that they had religious affiliation. The median DUREL score was 11 (interquartile ranges 6, 18). All three subscales of the DUREL were significantly related to WHO-5 (p Conclusions Religiosity is significantly associated with anxiety, depressive symptoms, and well-being in Korean adults with epilepsy.

Purpose Obsessive–compulsive disorder (OCD) is a common but underrecognized psychiatric condition comorbid with epilepsy. We thus investigated clinical factors associated with obsessive–compulsive symptoms (OCS) in adults with epilepsy. Methods This was a cross-sectional multicenter study in Republic of Korea. Obsessive–compulsive symptoms were assessed using the Obsessive–Compulsive Inventory—Revised (OCI-R). Clinical factors that were assessed included age, sex, seizure-related variables, and the number and use of antiepileptic drugs (AEDs) prescribed. Data were analyzed by stepwise linear regression and adjusted according to anxiety and depressive symptoms as assessed by Hospital Anxiety Depression Scale (HADS). Results The study population comprised 221 adults with epilepsy (42.1% male, 39.7 ± 11.9 years of age). The mean OCI-R score was 18.0 (standard deviation, 12.7), and an OCI-R score of ≥ 21 was obtained for 40.3% of the study sample. On a stepwise linear regression analysis, epilepsy severity, temporal lobe seizures, the use of topiramate, and the use of lamotrigine were identified as independent factors associated with OCI-R score after adjusting for anxiety according to the HADS. All factors except topiramate usage were positively associated with OCS. The total explained variance was 37.3%. Conclusions Obsessive–compulsive symptoms are common in persons with epilepsy and are associated with severe epilepsy, temporal lobe seizures, and the use of topiramate and lamotrigine. Specifically, the use of lamotrigine may aggravate OCS, whereas the use of topiramate may have beneficial effects on OCS.

The aim of this study was to examine social anxiety in South Korean adults with epilepsy and to identify associated factors.This was a cross-sectional, multicenter study in South Korea. Social anxiety was assessed using short forms of the Social Phobia Scale (SPS-6) and Social Interaction Anxiety Scale (SIAS-6). The SPS-6 scores ≥9 and SIAS-6 scores ≥12 were considered indicative of social phobia and social interaction anxiety, respectively. The Patient Health Questionnaire-9 (PHQ-9); Stigma Scale-Revised (SS-R); Disclosure Management Scale; Family Adaptation, Partnership, Growth, Affection, Resolve (F-APGAR) scale; and a questionnaire assessing knowledge about epilepsy were also used.Of a total of 219 patients with epilepsy, 21% and 11% had SPS-6 scores ≥9 and SIAS-6 scores ≥12, respectively. In logistic regression analysis, SPS-6 scores ≥9 were independently associated with SS-R scores of 4-9 (odds ratio [OR]: 8.626, 95% confidence interval [CI]: 2.515-29.587, p = .001), SS-R scores 1-3 (OR: 5.496, 95% CI: 1.757-17.197, p = .003), and PHQ-9 scores ≥10 (OR: 4.092, 95% CI: 1.823-9.185, p = .001). In contrast, SIAS-6 scores ≥12 were related only to PHQ-9 scores ≥10 (OR: 8.740, 95% CI: 3.237-23.599, p .001). Belonging to a dysfunctional family and lack of knowledge about epilepsy tended to be associated with social phobia (p = .071) and social interaction anxiety (p = .090), respectively. Epilepsy-related variables were not related to social anxiety.Social anxiety is not rare in patients with epilepsy. In this study, social phobia was associated with perceived stigma and depressive symptoms, whereas social interaction anxiety was related only to depressive symptoms in patients with epilepsy.

Background & objective Although iron accumulation is thought to be associated with neurodegenerative processes, the timing of putaminal iron deposition during the disease course of multiple system atrophy (MSA) remains unclear. We sought to investigate the temporal pattern of iron deposition in the putamen of MSA patients by calculating the conditional probabilities (CPs) of multimodal MRI changes. Methods We simultaneously measured putaminal R2*, volume and MD values of 39 probable MSA patients and 22 control subjects. The presence of significant MRI changes was defined as higher R2* and MD values, or lower volumes than cut-off values derived from mean values in control putamen. The CPs of R2* changes without MD or volume changes were then compared with those of MD or volume changes without R2* changes. Results Regardless of the cut-off values, the CPs of R2* increments without MD or volume changes were significantly lower than those for MD or volume changes without R2* increments. The associations of R2* with volume and MD values appeared in non-linear exponential and quadratic patterns, respectively. Conclusions Our findings suggest that putaminal iron accumulation would occur under volume atrophy or MD increments. Thus, iron deposition in the putamen of MSA patients is likely a secondary byproduct of neurodegeneration.

Status epilepticus is a severe neurological disease associated with substantial mortality and health-care cost. Treatment of status epilepticus should proceed without delay even in the pre-hospital setting because prolonged generalized convulsive seizures may lead to neuronal injury, pharmacoresistance, and poor prognosis. These concepts have led to the establishment of an updated treatment algorithm emphasizing a more rapid escalation to third-line therapy for refractory convulsive status epilepticus. This article reviews the guidelines and current evidence for the management of status epilepticus.

Purpose We evaluated the course of perceived stigma and the factors associated with perceived stigma over the first year in newly diagnosed people with epilepsy (PWE). Methods We recruited newly diagnosed PWE from 12 tertiary hospitals in Korea. The perceived stigma of epilepsy was assessed using the Stigma Scale at baseline and one year later. At the time of diagnosis, demographic, clinical seizure-related, and psychological data were collected. The predictive factors for perceived stigma over one year were analyzed using logistic regression analyses. Results Two hundred eighteen newly diagnosed PWE were included at baseline, and 153 completed the study. The percentage of participants who felt stigmatized decreased from 30.7% at the time of diagnosis to 17.6% at the end of follow-up. Introverted personality and a high level of anxiety were independent factors contributing to stigma at the time of epilepsy diagnosis. At the one-year follow-up, introverted personality and lower economic status were predictive of the development of perceived stigma. Conclusion Introverted personality was an important factor contributing to the development of perceived stigma at the time of diagnosis and at one year after diagnosis. In addition, a high level of anxiety and a low economic status were independently related to feelings of stigma at baseline and at one year after diagnosis, respectively. There may be a decrease in the perception of stigma over one year in newly diagnosed PWE.

Purpose Literature regarding family stigma related to epilepsy is scarce. This study investigated the prevalence of family stigma and depressive symptoms and the associated factors among the family members of patients with epilepsy. Methods In a cross-sectional study, Stigma Scale–Revised score ≥ 4 and Patient Health Questionnaire-9 score ≥ 10 were considered indicative of moderate-to-severe stigma and depressive symptoms, respectively. Stepwise logistic regression analyses were performed. Results Of the 482 family members, a mean age was 47.1 ± 9.4 years, and 73.4% were female. Of the patients, a mean age was 25.5 ± 16.7 years, and 45.0% were female. Idiopathic generalized epilepsy and focal epilepsy were noted in 22.4% and 65.6% of patients, respectively. Family stigma and depressive symptoms were noted in 10.0% and 11.2% of family members, respectively. Family stigma was significantly associated with high seizure frequency and being a sibling or offspring of a patient independent of their depressive symptoms. By contrast, depressive symptoms in family members were significantly associated with polytherapy, being parents of a patient, and neurological comorbidities independent of family stigma. In a subset of patients and their family, patients had higher proportion of stigma and depressive symptoms than their family. Depressive symptoms and stigma among patients were significantly correlated with those among parents, but not spouse. Conclusion Family stigma is common in families with epilepsy and is closely related to depressive symptoms. Frequent seizures, polytherapy, neurological comorbidities, and the relationship to a patient may be factors that are independently associated with family stigma and depressive symptoms in family members.

Purpose The purpose of this study was to evaluate differences in stigma, disclosure management of epilepsy, and knowledge about epilepsy between patients with epilepsy who recognized and did not recognize the new Korean term for epilepsy. Methods This was a cross-sectional, multicenter study. The Stigma Scale-Revised, the Disclosure Management Scale, the Patient Health Questionnaire-9, and a questionnaire assessing knowledge about epilepsy were used. The set of questionnaires had two versions, using either the old or new name for epilepsy. Multivariate logistic regression analyses were used. Results A total of 341 patients with epilepsy and 509 family members were recruited. Approximately 62% of patients felt some degree of epilepsy-related stigma. Mild stigma, severe concealment of epilepsy diagnosis, and increased knowledge about epilepsy were independently identified as factors associated with recognition of the new term in patients. Recognition of the new term was more prevalent in patients and family members with higher education, female family members, and family members having patients with younger age at seizure onset and shorter duration of epilepsy. There were no significant differences between the two types of questionnaires. About 81% of patients and 93% of family members had a positive attitude about renaming epilepsy. Conclusion The use of the new Korean term for epilepsy (cerebroelectric disorder) increased knowledge about epilepsy but did not reduce stigma and concealment of epilepsy diagnosis in Korean adults with epilepsy. Higher education may be an important factor for knowing the new term in patients and family members.

To determine whether obstructive sleep apnea syndrome (OSAS) patients with mixed sleep apnea (MSA) have different clinical, polysomnographic, and continuous positive airway pressure (CPAP) titration findings compared to OSAS patients without MSA.We retrospectively reviewed the records of OSAS patients who had undergone CPAP titration and categorized them into pure-OSA and mixed-OSA groups. Demographic features, daytime sleepiness, and apnea severity were compared between the two groups using univariate and multivariate analyses. CPAP titration findings were also compared between the two groups.One hundred and ninety-five subjects (n=126 pure-OSA; n=69 mixed-OSA) were included in the analysis. Compared to the pure-OSA group, the mixed-OSA group had a higher percentage of males (p=0.003) and a higher body mass index (p=0.044), Epworth Sleepiness Scale score (p=0.028), and apnea-hypopnea index (AHI) (p0.001). In logistic regression analysis, older age, male sex, and higher body mass index were independently associated with mixed-OSA before PSG study. When using AHI as a covariable, the higher AHI with older age, male sex, and daytime sleepiness was independently related to mixed-OSA. The mixed-OSA group had a higher percentage of patients with complex sleep apnea, a lower percentage of patients with optimal titration, and a higher titrated pressure than the pure-OSA group.Severe OSA, older age, male sex, obesity, and daytime sleepiness were related to mixed-OSA. Complex sleep apnea, less optimal titration, and a higher titrated CPAP were also associated with MSA in OSAS patients.

BACKGROUND AND PURPOSE 18F-fluoromisonidazole (FMISO) positron emission tomography (PET) is used to image metabolically compromised but viable hypoxic tissue. We hypothesized that FMISO PET might predict early infarct growth in acute ischemic stroke patients with perfusion-diffusion mismatch in magnetic resonance imaging (MRI). METHODS We prospectively enrolled acute ischemic stroke patients who visited the emergency room within 48 hours after stroke onset and had perfusion-diffusion mismatch (>20%), as shown MRI. Infarct growth was defined as >20% increase of initial infarct volume or >5 mL in follow-up diffusion-weighted image 5 ± 2 days after stroke. The association between FMISO uptake and infarct growth was explored. RESULTS Of 19 enrolled patients, 10 (52.6%) showed increased FMISO uptake, with 8 of the latter showing infarct growth. None of the 9 patients who did not show FMISO uptake had infarct growth. FMISO uptake was significantly associated with infarct growth (Fisher's exact test; P < .01). FMISO PET scan had a sensitivity of 100% and a specificity of 82% (AUC = .909) in predicting infarct growth. CONCLUSIONS FMISO PET scan can predict early infarct growth in acute ischemic stroke patients with perfusion-diffusion mismatch in MRI.

Address for correspondence Sang-Ahm Lee, MD, PhD Division of Epilepsy and Sleep, Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea Tel: +82-2-3010-3445 Fax: +82-2-474-4691 E-mail: salee@amc.seoul.kr Objectives: Some patients with obstructive sleep apnea syndrome (OSAS) experience development of central sleep apnea (CSA) during continuous positive airway pressure (CPAP) application (complex sleep apnea, compSA). We reviewed the prevalence and polysomnographic characteristics of compSA in patients with a primary diagnosis of OSAS. Methods: Total 198 patients with OSAS who performed CPAP titration at the Asan Medical Center were studied retrospectively from year 2006 to 2009. compSA was defined as presenting central sleep apnea ≥5 /h, during CPAP titration to eliminate upper airway obstruction. Demographic profiles and polysomnography (PSG) variables were compared between compSA and NoncompSA. Results: The prevalence of compSA was 17 of 198 (8.6%) with male predominance (n=17). Among compSA, 11 patients showed persistent CSA during entire titration and 6 patients showed newly developed CSA above certain pressure level (mean 7.2 cmH2O). At near optimized CPAP levels, obstructive sleep apnea index (OAI) was not significantly different between two groups (compSA; 0.52±0.74 /h vs. NoncompSA; 0.32±0.80 /h) but the level of apnea hypopnea index (AHI), mixed apnea index (MAI), central apnea index (CAI), and hypopnea index (HI) were greater in compSA than Non-compSA (compSA: AHI; 15.23±9.85 /h, MAI; 0.97±1.83 /h, CAI; 8.22±7.96 /h, HI; 5.52±4.98 /h vs. Non-compSA: AHI; 2.20±2.25 /h, MAI; 0.08±0.27 /h, CAI; 0.48±0.89 /h, HI; 5.52±4.98 /h). At baseline PSG, the value of CAI and MAI was higher in compSA (CAI; 3.78±3.92 /h vs. 1.03±1.97 /h, MAI; 6.71±7.50 /h vs. 4.33±9.59 /h) but there were no differences in AHI, OAI, HI, and demographic profiles between two groups. Conclusions: In this study, early indicators of developing compSA in baseline PSG was CAI and MAI. J Korean Sleep Res Soc 2013;10:51-55

Received September 16, 2013 Revised December 8, 2013 Accepted December 9, 2013 Address for correspondence Sang-Ahm Lee, MD, PhD Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea Tel: +82-2-3010-3445 Fax: +82-2-474-4691 E-mail: salee@amc.seoul.kr REM sleep behavior disorder (RBD) is a sleep disorder characterized by loss of normal voluntary muscle atonia during REM sleep associated with complex motor behavior while dreaming. Dream-enacting behaviors can also occur in patients with other sleep disorders such as obstructive sleep apnea (OSA). This clinical situation has been termed “pseudo-RBD”. In contrast, OSA causes frequent arousal, which may consequently result in masking of RBD symptoms. We reported two patients with severe OSA, who were initially diagnosed with “pseudo-RBD” but on continuous positive airway pressure (CPAP) titration, rediagnosed with “true-RBD”. When RBD is clinically suspected but is not confirmed by diagnostic overnight polysomnography, we have to keep in mind that RBD could be detected during CPAP titration. J Korean Sleep Res Soc 2013;10:62-65

Purpose The efficacy and safety of the anti-convulsive drug levetiracetam (LEV) has been well documented but few clinical studies have investigated tolerance to LEV. The aim of this study was to evaluate the loss of the initial efficacy of LEV in adult patients with refractory partial-onset seizures. Methods We enrolled patients with refractory partial epilepsy who were started on add-on LEV treatment. The efficacy of LEV was evaluated every three months and the seizure frequency was decided by the average number of monthly seizures. A responder was defined as a patient with a ≥50% reduction in seizure frequency from the baseline. Seizure freedom was defined as a seizure-free status from the beginning of LEV treatment to the evaluation period. Loss of the initial efficacy was defined as a shift from responder status during the first three months of LEV treatment to non-responder status during the follow-up period. Results A total of 95 epilepsy patients were analyzed. During the first three months of LEV treatment, 50 (52.6%) of the 95 patients were responders with a ≥50% seizure reduction. Nine patients (18.0%) showed a loss of initial efficacy during the second three-month period. In contrast, only two (4.0%) of the non-responders during the first three months became responders during the next three months. However, this difference did not reach statistical significance ( P =0.054). Based on Kaplan–Meier survival estimates, 49.2% of the patients who initially responded to LEV treatment during the first three months were predicted to lose this response at 42 months. Loss of the initial efficacy of LEV treatment occurred mostly within 18 months. Conclusion This study suggests that the occurrence of tolerance is more common than late gain of efficacy of treatment although larger prospective studies would have to be carried out to prove this observation.

Received April 3, 2012 Revised May 27, 2012 Accepted May 27, 2012 Address for correspondence Sang-Ahm Lee, MD, PhD Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea Tel: +82-2-3010-3445 Fax: +82-2-474-4691 E-mail: salee@amc.seoul.kr Sleep related eating disorder (SRED) is a parasomnia with recurrent episodes of involuntary eating during an arousal from nighttime sleep with adverse consequences. The mechanism of SRED is still uncertain but it has been suggested to be related to dopaminergic dysfunction. A few cases of SREDs in association with zolpidem have been reported worldwide, but not yet reported in Korea. We report zolpidem-induced SRED in a patient with underlying restless leg syndrome, periodic leg movement and obstructive sleep apnea. J Korean Sleep Res Soc 2012;9:15-18

Received June 30, 2011 Revised October 11, 2011 Accepted October 11, 2011 Address for correspondence Sang-Ahm Lee, MD Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea Tel: +82-2-3010-3440 Fax: +82-2-474-4691 E-mail: salee@amc.seoul.kr Propriospinal myoclnus is uncommon disorder characterized by arrhythmic jerk arising in muscles corresponding to a myelomere and spreading rostrally and caudally. Propriospinal myoclnus occurring only in the relaxation period preceding sleep was first described in 1997, and is extremely rare. Myoclonus showed a striking relationship with vigilance level. We report a case of propriospinal myoclnus at sleep onset with a polysomnographic and electromyographic studies, who is the first case in Korea to the best of our knowledge. J Korean Sleep Res Soc 2011;8:48-51

Received March 27, 2012 Revised May 30, 2012 Accepted May 30, 2012 Address for correspondence Sang-Ahm Lee, MD, PhD Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, 88 Olympic-ro 43-gil, Songpa-gu, Seoul 138-736, Korea Tel: +82-2-3010-3445 Fax: +82-2-474-4691 E-mail: salee@amc.seoul.kr Exploding head syndrome (EHS) is a rare phenomenon of unknown etiology, characterized by a sense of an explosive noise in the head usually in the wake-sleep transition. The sufferers experience a loud bang in their head that seems to originate from inside the head. We describe a 55-year old male with symptoms of a loud bang, spark and electrical current running like noise at sleep onset for one year. On video-electroencephalography monitoring, the events occurred during sleep-wake transition. We diagnosed him to EHS based on typical clinical features. J Korean Sleep Res Soc 2012;9:19-21

The purpose of this study is to determine the diagnostic cutoff for the proportion of rapid eye movement (REM) sleep with tonic and phasic activities of the submentalis muscle activity that can be used to diagnose REM sleep behavior disorder (RBD). Seventeen patients clinically diagnosed as idiopathic RBD and 15 age- and gender-matched controls were studied. Surface electromyography was recorded from the submentalis muscle, and two sleep technologists manually identified epochs with tonic and phasic activities during REM sleep. Receiver operating characteristic (ROC) curves were constructed to find the optimal cutoff values for diagnosing RBD using the proportion of REM sleep with tonic and phasic activities of the submentalis muscle. Cohen’s kappa coefficient was calculated to evaluate interrater reliability. The cutoff value with the optimal sensitivity and specificity was 6.5 % for the proportion of REM sleep with tonic activity (sensitivity, 94.1 %; specificity, 93.3 %; area under the ROC curve, 0.976) and 9.5 % for the proportion of REM sleep with phasic activity (sensitivity, 94.1 %; specificity, 93.3 %; area under the ROC curve, 0.992). The cutoff value required to achieve a specificity of 100 % was 8.9 % for tonic activity and 11.1 % for phasic activity. Cohen’s kappa coefficient between two scorers was 0.96 (95 % confidence interval, 0.95−0.97) and 0.95 (95 % confidence interval, 0.94−0.95) for tonic and phasic activities, respectively (both p

In this paper we introduce optical configurations of single-polarizer non-twisted liquid crystal cells for high-contrast reflective displays that can be applied to vertical-switching modes as well as horizontal-switching modes. In particular, optical configurations that can provide high contrast without using a wide-band quarter-wave film are proposed. By fabricating reflective cells with the introduced configurations, we demonstrate their optical performance.