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Multiple electrophysiologic studies have been conducted in the evaluation of facial neuropathy. In our study, the diagnostic and prognostic values of nerve conduction studies (NCSs) and transcranial magnetic stimulation (TMS) were compared for idiopathic unilateral facial neuropathy. We recruited patients with newly diagnosed idiopathic unilateral facial neuropathy and performed a blink reflex test, facial NCSs, and TMS. The amplitude of facial compound muscle action potential (CMAP) and motor evoked potential (MEP) between the affected and unaffected sides of the face was compared. A total of 30 patients were enrolled in the final analysis. TMS yielded a better detection rate, and MEP reduction rate was significantly higher than CMAP reduction rate, early in the course of the disease. Poor prognosis was positively associated with the CMAP reduction rate. The cutoff value of the CMAP reduction rate in the prediction of poor prognosis was established as 0.42. Facial TMS could detect idiopathic unilateral facial neuropathy with a high sensitivity when used as an early diagnostic tool. Facial NCS could predict prognosis, and the CMAP reduction rate was significantly associated with poor short-term prognosis.

Aim Chronic kidney disease (CKD) is associated with unfavorable outcomes in patients with ischemic stroke. One major metabolic derangement of CKD is dyslipidemia, which can be managed by statins. This study aimed to investigate whether the association of statins with post-stroke outcomes would be affected by renal function. Methods We evaluated the association of statin therapy at discharge with 3-month outcomes according to the estimated glomerular filtration rate (eGFR) of 50,092 patients with acute ischemic stroke from the Taiwan Stroke Registry from August 2006 to May 2016. The outcomes were mortality, functional outcome as modified Rankin Scale (mRS), and recurrent ischemic stroke at 3 months after index stroke. Results Statin therapy at discharge was associated with lower risks of mortality (adjusted hazard ratio [aHR], 0.41; 95% confidence interval [CI], 0.34 to 0.50) and unfavorable functional outcomes (mRS 3-5; aHR, 0.80; 95% CI, 0.76 to 0.84) in ischemic stroke patients. After stratification by eGFR, the lower risk of mortality associated with statins was limited to patients with an eGFR above 15 mL/min/1.73 m2. Using statins at discharge was correlated with a lower risk of unfavorable functional outcomes in patients with an eGFR of 60-89 mL/min/1.73 m2. Statin therapy in patients with an eGFR of 60-89 mL/min/1.73 m2 may be associated with a higher risk of recurrent ischemic stroke compared with nonusers (aHR, 1.29; 95% CI, 1.07 to 1.57). Conclusions In patients with acute ischemic stroke, the associations of statins with mortality and functional outcomes was dependent on eGFR.

Summary Objective This study used the Taiwan Stroke Registry data to evaluate the efficacy and safety of intravenous tissue plasminogen activator (tPA) in treating acute ischemic stroke in patients with renal dysfunction. Design We identified 3525 ischemic stroke patients and classified them into two groups according to the estimated glomerular filtration rate (eGFR) at the emergency department: ≥60, and Results Among patients with eGFR levels of Conclusions tPA for acute ischemic stroke could improve functional outcomes without increasing the risks of upper gastrointestinal bleeding for patients with or without renal dysfunction. The low eGFR was not a significant risk factor for intracerebral hemorrhage among patients receiving tPA treatment.

Status epilepticus may cause molecular and cellular events, leading to hippocampal neuronal cell death. Peroxisome proliferator-activated receptor &gamma, coactivator 1-&alpha, (PGC-1&alpha, ) is an important regulator of vascular endothelial growth factor (VEGF) and VEGF receptor 2 (VEGFR2), also known as fetal liver kinase receptor 1 (Flk-1). Resveratrol is an activator of PGC-1&alpha, It has been suggested to provide neuroprotective effects in epilepsy, stroke, and neurodegenerative diseases. In the present study, we used microinjection of kainic acid into the left hippocampal CA3 region in Sprague Dawley rats to induce bilateral prolonged seizure activity. Upregulating the PGC-1&alpha, pathway will increase VEGF/VEGFR2 (Flk-1) signaling and further activate some survival signaling that includes the mitogen activated protein kinase kinase (MEK)/mitogen activated protein kinase (ERK) and phosphatidylinositol 3-kinase (PI3K)/protein kinase B (AKT) signaling pathways and offer neuroprotection as a consequence of apoptosis in the hippocampal neurons following status epilepticus. Otherwise, downregulation of PGC-1&alpha, by siRNA against pgc-1&alpha, will inhibit VEGF/VEGFR2 (Flk-1) signaling and suppress pro-survival PI3K/AKT and MEK/ERK pathways that are also accompanied by hippocampal CA3 neuronal cell apoptosis. These results may indicate that the PGC-1&alpha, induced VEGF/VEGFR2 pathway may trigger the neuronal survival signaling, and the PI3K/AKT and MEK/ERK signaling pathways. Thus, the axis of PGC-1&alpha, /VEGF/VEGFR2 (Flk-1) and the triggering of downstream PI3K/AKT and MEK/ERK signaling could be considered an endogenous neuroprotective effect against apoptosis in the hippocampus following status epilepticus.

Tai Chi has been shown to have significant benefits in improving muscle strength, balance, and quality of life. The purpose of this study was to design a sitting or lying Tai Chi model with a better playing posture that is easier to play, and with greater exercise efficiency for stroke patients. Eighteen stroke patients were recruited (> 6 months post-stroke; modified Rankin Scale: 2–4). The Direction-Oriented Motion and Short-Sitting and Lying Tai Chi (DOM-SSLTC) model was composed of nine typical Yang-style Tai Chi forms. All the subjects received 12 practice sessions (90 min per session) led by a Tai Chi master, and performed the DOM-SSLTC for 60 min per day for 3 months at home. The characteristics of the exercise patterns were quantified using a Tai Chi master’s motions. National Institutes of Health Stroke Scale, Modified Ashworth Scale, Modified Rankin Scale, Barthel Index, muscle endurance, and psychological evaluations were used to evaluate the effect of the Tai Chi exercise program on the stroke patients. The results showed that the rectus femoris and sternocleidomastoid muscles had larger contractions and also had larger trunk flexion in the deep breath with one leg stretched Tai Chi pattern. The 18 stroke patients had significantly decreased Depression Questionnaire scores and improvements in muscle power of knee stretching and sitting up after training. This newly developed Tai Chi model with one leg stretched allowed the stroke patients to practice with more intensive exercise, and resulted in improvements in muscle power and depression scale after 3 months exercise.

Background and aims Renal dysfunction is a potent risk factor for cardiovascular diseases, including stroke. This study aimed to evaluate the impact of admission estimated glomerular filtration rate (eGFR) levels on short-term (1-month) and long-term (1-year) mortality in patients with acute ischemic stroke. Methods From the Taiwan Stroke Registry data, we classified ischemic stroke patients, identified from April 2006 to December 2015, into 5 groups by eGFR at admission: ≥ 90, 60–89, 30–59, 15–29, and Results Among 52,732 ischemic stroke patients, 1480 died within one month. The 1-month mortality rate was over 5-fold greater in patients with eGFR Conclusions After acute ischemic stroke, patients with reduced eGFR are at elevated risks of short-term and long-term deaths in a graded relationship.

We investigated the impact of serum cholesterol levels on 30-day mortality after ischemic stroke in dialysis patients.From the Taiwan Stroke Registry data, we identified 46,770 ischemic stroke cases, including 1101 dialysis patients and 45,669 nondialysis patients from 2006 to 2013.Overall, the 30-day mortality was 1.46-fold greater in the dialysis group than in the nondialysis group (1.75 versus 1.20 per 1000 person-days). The mortality rates were 1.64, .62, 2.82, and 2.23 per 1000 person-days in dialysis patients with serum total cholesterol levels of 120 mg/dL, 120-159 mg/dL, 160-199 mg/dL, and ≥200 mg/dL, respectively. Compared to dialysis patients with serum total cholesterol levels of 120-159 mg/dL, the corresponding adjusted hazard ratios of mortality were 4.20 (95% confidence interval [CI] = 1.01-17.4), 8.06 (95% CI = 2.02-32.2), and 6.89 (95% CI = 1.59-29.8) for those with cholesterol levels of 120 mg/dL, 160-199 mg/dL, and ≥200 mg/dL, respectively.Dialysis patients with serum total cholesterol levels of ≥160 mg/dL or 120 mg/dL on admission are at an elevated hazard of 30-day mortality after ischemic stroke.

Background Dual transcranial direct current stimulation (tDCS) to the bilateral primary motor cortices (M1s) has potential benefits in chronic stroke, but its effects in subacute stroke, when behavioural effects might be expected to be greater, have been relatively unexplored. Here, we examined the neurophysiological effects and the factors influencing responsiveness of dual-tDCS in subacute stroke survivors. Methods We conducted a randomized sham-controlled crossover study in 18 survivors with first-ever, unilateral subcortical ischaemic stroke 2–4 weeks after stroke onset and 14 matched healthy controls. Participants had real dual-tDCS (with an ipsilesional [right for controls] M1 anode and a contralesional M1 [left for controls] cathode; 2 mA for 20mins) and sham dual-tDCS on separate days, with concurrent paretic [left for controls] hand exercise. Using transcranial magnetic stimulation (TMS) and magnetoencephalography (MEG), we recorded motor evoked potentials (MEPs), the ipsilateral silent period (iSP), short-interval intracortical inhibition, and finger movement-related cortical oscillations before and immediately after tDCS. Results Stroke survivors had decreased excitability in ipsilesional M1 with a relatively excessive transcallosal inhibition from the contralesional to ipsilesional hemisphere at baseline compared with controls, as quantified by decreased MEPs and increased iSP duration. Dual-tDCS led to increased MEPs and decreased iSP duration in ipsilesional M1. The magnitude of the tDCS-induced MEP increase in stroke survivors was predicted by baseline contralesional-to-ipsilesional transcallosal inhibition (iSP) ratio. Baseline post-movement synchronization in α-band activity in ipsilesional M1 was decreased after stroke compared with controls, and its tDCS-induced increase correlated with upper limb score in stroke survivors. No significant adverse effects were observed during or after dual-tDCS. Conclusions Task-concurrent dual-tDCS in subacute stroke can safely and effectively modulate bilateral M1 excitability and inter-hemispheric imbalance and also movement-related α-activity.

Additional file 1. Table A.1, Table A.2, Table A.3, Table A.4, Table A.5. Full statistic values of analysis of variance.

Bipolar disorder (BD) is one of the most serious psychiatric disorders in the world, but its pathophysiology is still unclear. Regulation of neurotrophic factors have been thought to play a role in this process. There have been inconsistent findings regarding the differences in blood neurotrophin-3 (NT-3) and neurotrophin-4/5 (NT-4/5) between patients with BD and healthy controls (HCs). The aim of the current meta-analysis is to examine the changes in the levels of NT-3 and NT-4/5 in BD patients at different affective states. Eight articles (including 465 BD patients and 353 HCs) were included in the analysis, and their results were pooled by using a random effects model. We found the levels of both NT-3 (p = 0.0046) and NT-4/5 (p = 0.0003) were significantly increased in BD patients, compared to HCs. Through subgroup analysis, this increase persisted only in patients in depressed state (p = 0.0038 for NT-3 and p = 0.0001 for NT-4/5), but not in manic or euthymic state. In addition, we found the differences in NT-3 and NT-4/5 were significantly associated with the duration of illness, but not by the mean age or female proportion. Our results suggest a state-dependent increase in NT-3 and NT-4/5 levels in patients with BD. Further studies are needed to examine dynamic changes of these neurotrophins in BD patients along the disease course.

Importance Tinnitus has a prevalence of 10% to 25% and is frequently associated with numerous complications, such as neuropsychiatric disease. Traditional treatments have failed to meet the needs of patients with tinnitus. Noninvasive brain stimulation (NIBS) can focally modify cortical functioning and has been proposed as a strategy for reducing tinnitus severity. However, the results have been inconclusive. Objective To evaluate the association between different central NIBS therapies and efficacy and acceptability for treatment of tinnitus. Data Sources ClinicalKey, Cochrane CENTRAL, Embase, ProQuest, PubMed, ScienceDirect, and Web of Science databases were searched from inception to August 4, 2019. No language restriction was applied. Manual searches were performed for potentially eligible articles selected from the reference lists of review articles and pairwise meta-analyses. Study Selection Randomized clinical trials (RCTs) examining the central NIBS method used in patients with unilateral or bilateral tinnitus were included in the current network meta-analysis. The central NIBS method was compared with sham, waiting list, or active controls. Studies that were not clinical trials or RCTs and did not report the outcome of interest were excluded. Data Extraction and Synthesis Two authors independently screened the studies, extracted the relevant information, and evaluated the risk of bias in the included studies. In cases of discrepancy, a third author became involved. If manuscript data were not available, the corresponding authors or coauthors were approached to obtain the original data. This network meta-analysis was based on the frequentist model. Main Outcomes and Measures The primary outcome was change in the severity of tinnitus. Secondary outcomes were changes in quality of life and the response rate related to the NIBS method in patients with tinnitus. Results Overall, 32 unique RCTs were included with 1458 unique participants (mean female proportion, 34.4% [range, 0%-81.2%]; mean age, 49.6 [range, 40.0-62.8] years; median age, 49.8 [interquartile range, 48.1-52.4] years). The results of the network meta-analysis revealed that cathodal transcranial direct current stimulation over the left dorsolateral prefrontal cortex combined with transcranial random noise stimulation over the bilateral auditory cortex was associated with the greatest improvement in tinnitus severity (standardized mean difference [SMD], –1.89; 95% CI, –3.00 to –0.78) and quality of life (SMD, –1.24; 95% CI, –2.02 to –0.45) compared with the controls. Improvement in tinnitus severity ranked more favorably for continuous theta-burst stimulation (cTBS) over both auditory cortices (SMD, −0.79; 95% CI = −1.57 to −0.01) than cTBS over only the left auditory cortex (SMD, −0.30; 95% CI, −0.87 to 0.28), compared with controls. Repetitive transcranial magnetic stimulation with priming had a superior beneficial association with tinnitus severity compared with the strategies without priming. None of the investigated NIBS types had a significantly different dropout rate compared with that of the control group. Conclusions and Relevance This network meta-analysis suggests a potential role of NIBS interventions in tinnitus management. Future large-scale RCTs focusing on longer follow-up and different priming procedure NIBS are warranted to confirm these findings.

Epilepsy and spreading depolarization (SD) are both episodic brain disorders and often exist together in the same individual. In CA1 pyramidal neurons of mouse hippocampal slices, induction of SD evoked epileptiform activities, including the ictal-like bursts, which occurred during the repolarizing phase of SD, and the subsequent generation of paroxysmal depolarization shifts (PDSs), which are characterized by mild depolarization plateau with overriding spikes. The duration of the ictal-like activity was correlated with both the recovery time and the depolarization potential of SD, whereas the parameters of PDSs were not significantly correlated with the parameters of SD. Moreover, we systematically evaluated the effects of multiple anti-epileptic drugs (AEDs) on SD-induced epileptiform activity. Among the drugs that are known to inhibit voltage-gated sodium channels, carbamazepine, phenytoin, valproate, lamotrigine, and zonisamide reduced the frequency of PDSs and the overriding firing bursts in 20–25 min after the induction of SD. The GABA uptake inhibitor tiagabine exhibited moderate effects and partially limited the incidence of PDSs after SD. AEDs including gabapentin, levetiracetam, ethosuximide, felbamate, and vigabatrin, had no significant effect on SD-induced epileptic activity. Taken together, these results demonstrate the effects of AEDs on SD and the related epileptiform activity at the cellular level.

Background and purpose Physical activity is associated with a reduced incidence of first-time stroke. However, few studies have examined the effect of pre-stroke physical activity on post-stroke complications and clinical outcomes. Methods A total of 39 835 cases of stroke registered in the nationwide stroke registry system of Taiwan between 2006 and 2009 were analyzed according to five levels of severity as determined by National Institutes of Health Stroke Scale score upon hospital admission. Pre-stroke physical activity was defined in the Taiwan Stroke Registry as dedicated leisure-time physical activity for at least 30 min/day for 3 days/week for more than 6 months. A Cox model was used to compare complications and outcomes between active and inactive groups. Results The active and inactive groups were similar in age distribution and stroke type distribution, but the active group had better National Institutes of Health Stroke Scale scores upon admission. The active group also had significantly fewer post-stroke complications. Active patients had lower hospital mortality and better functional outcomes upon discharge as per the modified Rankin Scale. Improved functional status in the active group was significant at 1, 3 and 6 months post-stroke. Conclusion Dedicated leisure-time physical activity for at least 30 min/day, at least three times per week for more than 6 months was associated with decreased stroke severity, fewer post-stroke complications, lower mortality and better outcomes.

Internal responsiveness of HRQoL in the stable patient group. (DOCX 20 kb)

Objectives Generic and disease-specific health-related quality of life (HRQoL) instruments may reflect different aspects of lives in patients with Parkinson’s disease (PD) and thus be associated with different determinants. We used the same cluster of predictors for the generic and disease-specific HRQoL instruments to examine and compare the determinants of HRQoL. Method HRQoL was measured in 92 patients with PD by the 36-item Short-Form Health Survey (SF-36) and the 39-item Parkinson’s Disease Questionnaire (PDQ-39). The predictors included demographic and disease characteristics, and motor and non-motor symptoms. Multiple regression analyses were used to identify HRQoL determinants. Results Depressive symptoms and motor difficulties of daily living were the first two significant determinants for both instruments. The other significant determinant for the SF-36 was fatigue and non-motor difficulties of daily living, and for the PDQ-39 was motor signs of PD. Conclusions The results suggest the importance of the evaluation and intervention focused on depressive symptoms and motor difficulties of daily living in patients with PD. In addition, the SF-36 seems more related to non-motor symptoms, while the PDQ-39 appears more associated with motor symptoms. This information is important for understanding results from these two instruments and for choosing which to use.

Background Asians have higher frequency of intracranial arterial stenosis. The present study aimed to compare the clinical features and outcomes of ischemic stroke patients with and without middle cerebral artery (MCA) stenosis, assessed by transcranial sonography (TCS), based on the Taiwan Stroke Registry (TSR). Methods Patients with acute ischemic stroke or transient ischemic attack registered in the TSR, and received both carotid duplex and TCS assessment were categorized into those with stenosis (≥50%) and without (

Changed scores of measures in three groups. (DOCX 17 kb)

The relationship between cholesterol level and hemorrhagic stroke is inconclusive. We hypothesized that low cholesterol levels may have association with intracerebral hemorrhage (ICH) severity at admission and 3-month outcomes. This study used data obtained from a multi-center stroke registry program in Taiwan. We categorized acute spontaneous ICH patients, based on their baseline levels of total cholesterol (TC) measured at admission, into 3 groups with 200 mg/dL of TC. We evaluated risk of having initial stroke severity, with National Institutes of Health Stroke Scale (NIHSS) >15 and unfavorable outcomes (modified Rankin Scale [mRS] score >2, 3-month mortality) after ICH by the TC group. A total of 2444 ICH patients (mean age 62.5±14.2 years; 64.2% men) were included in this study and 854 (34.9%) of them had baseline TC 15), with an adjusted odds ratio [aOR] of 1.80; 95% confidence interval [CI], 1.41-2.30), and 3-month mRS >2 (aOR, 1.41; 95% CI, 1.11-1.78) using patients with TC >200 mg/dL as reference. Those with TC >160 mg/dL and body mass index (BMI)

Vertebral compression fracture is one of the frequent complications of osteoporosis. Percutaneous vertebroplasty (PVP) has been applied in the treatment of osteoporotic vertebral compression fractures, multiple myelomas and vertebral metastatic lesions. Complications of the procedure include bleeding at the puncture site, local infection, cement leakage in the vertebral canal and intervertebral foramen. Cerebrospinal fluid leakage after the procedure was rarely mentioned in the literature.A 51-year-old healthy female patient has no neurologic or orthopedic illness before. She suffered from severe low back pain since 10 days ago after some exercise. She has back pain with radiating to bilateral subcostal areas. The pain aggravated by bending forward. X ray of spine showed T12 vertebral body compression fracture. MRI demonstrated compression fracture at T12 with bone marrow edema and increased bone marrow enhancement. Bone mineral density checked by Dualenergy X-ray absorptiometry revealed osteopenia. The symptoms were not relieved by conservative treatments and she received vertebroplasty for pain relief. The operation course was smooth, but she started to suffer from orthostatic headache after the procedure. Spinal MRI revealed fluid accumulation at posterior epidural space of T11-12-L1 and CSF leakage was impressed. Intracranial hypotension related to CSF leakage was diagnosed according to the Diagnostic criteria formulated by Schievink, et al (2008). After hydration and bed-rest, her symptoms improved gradually without epidural blood patch.Our report highlights the possibility and importance of intracranial hypotension related to CSF leakage after vertebroplasty. Clinicians should be alert to this complication.

This study evaluated the differences in surgical changes and post-surgical changes between bi-cortical and mono-cortical osteosynthesis (MCO) in the correction of skeletal Class III malocclusion with bilateral sagittal split osteotomies (BSSOs). Twenty-five patients had bi-cortical osteosynthesis (BCO), 32 patients had mono-cortical fixation. Lateral and postero-anterior cephalometric radiographs, taken at the time of surgery, before surgery, 1 month after surgery, and on completion of orthodontic treatment (mean 9.9 months after surgery), were obtained for evaluation. Cephalometric analysis and superimposition were used to investigate the surgical and post-surgical changes. Independent t-test was performed to compare the difference between the two groups. Pearson's correlations were tested to evaluate the factors related to the relapse of the mandible. The sagittal relapse rate was 20% in the bi-cortical and 25% in the mono-cortical group. The forward-upward rotation of the mandible in the post-surgical period contributed most of the sagittal relapse. There were no statistically significant differences in sagittal and vertical changes between the two groups during surgery and in the post-surgical period. No factors were found to correlate with post-surgical relapse, but the intergonial width increased more in the bi-cortical group. The study suggested that both methods of skeletal fixation had similar postoperative stability.

Few studies have addressed intracerebral hemorrhage (ICH) in younger adults. We studied spontaneous ICH in adults

Summary: Purpose: Prolonged and continuous epileptic seizure (status epilepticus) results in cellular changes that lead to neuronal damage. We investigated whether these cellular changes entail mitochondrial dysfunction and ultrastructural damage in the hippocampus, by using a kainic acid (KA)-induced experimental status epilepticus model. Methods: In Sprague–Dawley rats maintained under chloral hydrate anesthesia, KA (0.5 nmol) was microinjected unilaterally into the CA3 subfield of the hippocampus to induce seizure-like hippocampal EEG activity. The activity of key mitochondrial respiratory chain enzymes in the dentate gyrus (DG), or CA1 or CA3 subfield of the hippocampus was measured 30 or 180 min after application of KA. Ultrastructure of mitochondria in those three hippocampal subfields during KA-induced status epilepticus also was examined with electron microscopy. Results: Microinjection of KA into the CA3 subfield of the hippocampus elicited progressive build-up of seizure-like hippocampal EEG activity. Enzyme assay revealed significant depression of the activity of nicotinamide adenine dinucleotide cytochrome c reductase (marker for Complexes I+III) in the DG, or CA1 or CA3 subfields 180 min after KA-elicited temporal lobe status epilepticus. Conversely, the activities of succinate cytochrome c reductase (marker for Complexes II+III) and cytochrome c oxidase (marker for Complex IV) remained unaltered. Discernible mitochondrial ultrastructural damage, varying from swelling to disruption of membrane integrity, also was observed in the hippocampus 180 min after hippocampal application of KA. Conclusions: Our results demonstrated that dysfunction of Complex I respiratory chain enzyme and mitochondrial ultrastructural damage in the hippocampus are associated with prolonged seizure during experimental temporal lobe status epilepticus.

Many Chinese like to drink alcohol soaked with creatures for promoting health. This study reports a 49-year-old male who presented with multiple focal neuropathies of the upper limbs, coagulopathy, erythematous swelling of the bilateral upper extremities and trunk with bullous skin lesions, and rhabdomyolysis associated with acute renal failure after drinking alcohol soaked with centipede. Soaking a centipede, Scolopendra subspinipes mutilans, in 53% alcohol, produced the wine. Supportive treatment was administered, and the skin lesions and renal failure improved with subsequent neurologic deficit during the week following initial presentation. Alcohol binge or immobilization was the likely cause of neuropathy, bullous skin lesions and rhabdomyolysis in the patient. However, there is a possibility that centipede venom also contributed to the illness in this patient.

Background Discharge disposition planning is vital for poststroke patients. We investigated clinical factors associated with discharging patients to nursing homes, using the Taiwan Stroke Registry data collected from 39 major hospitals. Methods We randomly assigned 21,575 stroke inpatients registered from 2006 to 2008 into derivation and validation groups at a 3-to-1 ratio. We used the derivation group to develop a prediction model by measuring cumulative risk scores associated with potential predictors: age, sex, hypertension, diabetes mellitus, heart diseases, stroke history, snoring, main caregivers, stroke types, and National Institutes of Health Stroke Scale (NIHSS). Probability of nursing home care and odds ratio (OR) of nursing home care relative to home care by cumulative risk scores were measured for the prediction. The area under the receiver operating characteristic curve (AUROC) was used to assess the model discrimination against the validation group. Results Except for hypertension, all remaining potential predictors were significant independent predictors associated with stroke patient disposition to nursing home care after discharge from hospitals. The risk sharply increased with age and NIHSS. Patients with a cumulative risk score of 15 or more had an OR of 86.4 for the nursing home disposition. The AUROC plots showed similar areas under curves for the derivation group (.86, 95% confidence interval [CI], .85-.87) and for the validation group (.84, 95% CI, .83-.86). Conclusions The cumulative risk score is an easy-to-estimate tool for preparing stroke patients and their family for disposition on discharge.

The relationship between low estimated glomerular filtration rate (eGFR) and the outcome of ischemic stroke remains controversial, despite the close association between kidney dysfunction and atherosclerosis.This study conducted subgroup analysis using data from the prospective Taiwan Stroke Registry to investigate the relationship between eGFR at the time of admission and 6-month functional outcomes in patients with the large artery atherosclerotic (LAA) subtype of acute ischemic stroke. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS), and outcomes were defined as modified Rankin Scale and mortality status at 6 months post stroke.Of the 8052 patients with the LAA subtype of acute ischemic stroke in this study, 3312 (41.1%) had eGFR60 mL/min/1.73 m(2). The adjusted odds ratios of worse functional outcomes following a stroke were 1.10 (95% confidence interval [CI], 0.95-1.28), 1.60 (95% CI, 1.22-2.11) and 1.60 (95% CI, 1.10-2.33) in patients with eGFR 30-59, 15-29, and15 as compared with those with eGFR 60-119 mL/min/1.73 m(2), respectively. Increased risk of mortality was closely and independently related to high NIHSS scores and low eGFR levels. Stroke severity and eGFR were also synergistically related to 6-month mortality, with an adjusted hazard ratio of 21.19 (95% CI, 9.69-46.35) in patients with NIHSS15 and eGFR15 mL/min/1.73 m(2), compared with those with NIHSS 0-5 and eGFR 60-119 mL/min/1.73 m(2).Low eGFR was significantly and independently associated with 6-month functional outcomes and mortality in patients with the LAA subtype of acute ischemic stroke. The deleterious relationship between low eGFR levels and mortality following stroke was exacerbated by its synergistic association with stroke severity.

Common etiologies of acute acquired cerebellar ataxia include cerebrovascular diseases, toxin or drugs, infections/para-infections, and autoimmune diseases. It is a rare manifestation of Sjögren's syndrome, which is a common autoimmune disease but is often missed as a differential diagnosis.This is a report of a patient with acute onset cerebellar ataxia for one month. She also had massive neck lymphadenopathy. After a series of studies and the exclusion of other common causes of acute cerebellar ataxia, she was diagnosed as having Sjögren's syndrome. Patients with Sjögren's syndrome have higher risk for lymphoma, which leads to poorer prognosis. After lymph node biopsy, the patient was proven to have sinus histiocytosis, which is another rare finding in Sjögren's syndrome.For patients with acute acquired cerebellar ataxia, immune-mediated cerebellar ataxia should be an important differential diagnosis aside from the more common causes like stroke or drugs.

Background Tolosa-Hunt syndrome (THS) manifests as a benign or an inflammatory type disease. The nosography differences between these types remain to be elucidated. We aimed to analyze and compare the clinical presentations of benign and inflammatory THS. Methods The ward patients who presented with THS from January 1990 to May 2011 were retrospectively reviewed. THS was diagnosed according to the recommendations of the International Headache Society. Results Of the 53 THS cases (49 patients), 30 (56.6%) were classified as benign and 23 (43.4%) as inflammatory THS. There were strong similarities between the groups in terms of clinical manifestations, laboratory findings, responses to glucocorticoid treatment, and outcomes. However, patients with inflammatory THS tended to be younger (mean age, 43.4 years; p 0.5 mg/kg/day) and low-dose (≤0.5 mg/kg/day) prednisolone were equally effective in relieving symptoms in both groups ( p > 0.05). Conclusion Benign and inflammatory THS were highly similar in terms of nosography. The responses to glucocorticoid treatment were generally good except in patients with orbital pseudotumors.

This study designed a series of polyanionic nanocarriers based on biodegradable and biocompatible poly (aspartic acid)s for oral administration. First, polysuccinimide (PSI) was synthesized from L-aspartic acid using acid-catalyzed bulk thermal polycondensation and acid-catalyzed thermal polycondensation in a mixture of mesitylene/sulfolane. PSI-C16 was then synthesized by aminolysis with nucleophile, hexadecylamine to react with PSI known as nucleophilic addition. Finally, a series of partially esterified poly (aspartic acid)s was produced by alkaline treatment to afford an amphiphilic polyanion, poly (sodium aspartate-g-hexadecyl aspartate) (Na-PASP-g-C16-PASP). 1HNMR, FTIR, DSC and GPC were utilized to demonstrate and characterize the polymers. The synthesized polyanion could be self-assembled into the nano-scaled micelles and be independent of pH in phosphoric buffer solutions. The hydrodynamic diameter and zeta potential were measured using the dynamic light scattering (DLS) method, and the critical micelle concentration (CMC) was determined using the fluorescence spectrophotometer. The micellar morphologies were examined using transmission electron microscopy (TEM), and atomic force microscopy (AFM) to present the nano-dimensional sphere. The stability of size transition at different pH levels, from strong acid to alkaline, proved that the micelles could stably transport from the stomach to intestinal lumen prior to arriving in the epithelium of the small intestine.

We report a family with familial amyloid polyneuropathy (FAP), showing an early-onset and a fatal outcome before age 30. Transthyretin (TTR) gene analysis showed one point mutation (T C change) in the second base of codon 55, and the corresponding amino acid substitution of proline (Pro) for leucine (Leu) was confirmed at the protein level. This is the first FAP family of Taiwanese origin demonstrating a causative gene abnormality, and FAP with TTR-Pro55 was considered to be more serious compared with other forms of FAP. © 1994 John Wiley & Sons, Inc.

Vertebral artery dissection (VAD), although uncommon, is an important cause of ischemic stroke in young adults. Without prompt diagnosis and treatment, it may cause mortality and morbidity. Spontaneous VAD related to abrupt neck position change, sudden sneezing, or severe cough and vomiting after fish bone choking are rarely reported. This report describes three cases of spontaneous VAD due to seemingly harmless events.The first patient developed vertebro-basilar ischemic symptoms after suddenly turning his head to the left during an argument with a colleague. The second suffered from right lateral medullary infarction after sudden sneezing. The third developed left lateral medullary syndrome after she tried to extract a fish bone in her throat, which induced severe cough and vomiting. The three cases all presented with acute severe neck pain with posterior circulation ischemic symptoms and signs. Magnetic resonance imaging (MRI), magnetic resonance angiogram (MRA), and conventional angiography confirmed the diagnosis. The first patient was treated with warfarin and recovered well. The other two cases received heparinization and then oral anticoagulant therapy, and recovered without residual neurologic deficits.In conclusion, VAD should be among the differentials considered when encountering young patients presentation with such clinical symptoms.

Background and Methods. To research the pathophysiology of the Eustachian tube (ET), electromyographies (EMG) of the tensor and levator veli palatini muscles (TVP and LVP) in 46 fresh specimens of nasopharyngeal carcinoma (NPC) were studied. Results. Sixty-eight percent of the of TVP on the symptomatic side had abnormal EMG. Normal EMG recordings were noted in all TVP on the asymptomatic side. The abnormal TVP EMG observed most often was poor interference pattern or decreased interference with swallowing, and not uncommonly, there were some abnormal motor unit action potentials of serrated or large polyphasic waveforms found on motor unit potential analysis. This is strong evidence of neurogenic abnormality of the TVP caused by the NPC invasion. Despite the large polyphasic or serrated action potentials often being recorded on the symptomatic sides of LVP, the abnormal EMG finding also was found in 12 LVP on the asymptomatic sides. Conclusions. There was no evidence that an ET dysfunction could be caused solely by an abnormal LVP function. This investigation and the study of ET function of these patients demonstrate that functional obstruction induced by the invasion of NPC to the nerve of TVP, rather than mechanical obstruction caused by the tumor mass effect on the ET, gives rise to the ear symptoms and signs of these patients. The authors suggest that the LVP action has little or no role in the function of the ET.

Seizures originating in the occipital areas are relatively uncommon. They are usually characterized by visual hallucinations and illusions or other symptoms related to the eyes and vision.In a 54-year-old woman with occipital lobe epilepsy, complex visual hallucinations, illusions, and migraine-like headache constitute the major clinical manifestations. During focal status epilepticus, ictal electroencephalography revealed rhythmic focal spikes in the right occipital region, rapidly propagating to the right parietal and contralateral occipital areas. Ictal brain single-photon emission computed topography revealed hyperperfusion of the right occipital region. Using a full-field pattern-shift visual evoked potential (VEP) study, we found that the P100 responses on both sides were markedly attenuated in amplitude during occipital focal status epilepticus, whereas the latencies of the VEPs were normal. The amplitude and morphology of P100 responses on both sides, however, returned to the normal range 7 days after cessation of the seizures.In addition to clinical seizure semiology, scalp EEG, SPECT and neuroimaging studies, VEP studies may be used as a supplementary examination tool to provide further information in the patients with occipital lobe seizures or epilepsies.

Cervical N13 potential in response to the median nerve stimulation can be recorded either from upper (Cv2) or lower (Cv6) neck with almost equal amplitudes and latencies. It has long been debated whether they represent the same or different generator sources. Using a conditioning-test paired stimuli paradigm, we examined the differences of recovery function of Cv2- and Cv6-N13, anterior neck (AN)-P13, and scalp recorded P13/P14 in 6 healthy subjects. All cervical electrodes were referenced to the non-cephalic site. Scalp response was recorded with linked ear reference. The inter-stimulus intervals ranged from 4 to 20 ms with 2 ms increments. Throughout 4 to 18 ms ISI, Cv6-N13, AN-P13 and scalp P13/P14 were suppressed, whereas Cv2-N13 was facilitated. All but scalp P13/P14 returned close to the control at 20 ms ISI. The findings indicate that Cv2-N13, Cv6-N13 and scalp P13/P14 are independent each other and arise from different generator sources. The suppression of Cv6-N13 is consistent with a postsynaptic nature of this potential and may indeed be mediated through dorsal horn interneurons creating a current field orientation in the posterior-anterior direction. The facilitation of Cv2-N13 suggests that this is a presynaptic potential and may travel through the dorsal column with vertical orientation. The longer period of suppression of scalp P13/P14 suggests it to be of polysynaptic origin and to arise at least rostral to the cuneate nucleus.

One of the factors that induces eustachian tube dysfunction caused by the invasion of nasopharyngeal carcinoma is paralysis of the tensor veli palatini muscle. Electromyography (EMG), computed tomography (CT), and/or magnetic resonance imaging (MRI) were used to study the tensor muscle and the related paratubal structures and parapharyngeal space. This study, from 44 patients with nasopharyngeal carcinoma, showed that 67% of tensor muscles on the side of the symptomatic ear yielded abnormal electromyographic waveforms, which usually indicated a neurogenic disorder. In the majority of the abnormal EMG cases, CT or MRI often revealed that the pharyngobasilar fascia and the tensor muscle were compressed anterolaterally and the upper prestyloid parapharyngeal space was infiltrated. It was found that an abnormal electromyogram of the tensor muscle generally suggested a more advanced T stage and eustachian tube dysfunction. Otitis media with effusion in the stage I cases was usually not caused by paralysis of the tensor muscle. The invasion of some early cancers, especially localized on the torus tubarius, could also cause the effusion.