Occipital lobes are not usually implicated in the current proposed pathways of pathological laughter. We present a case of occasional pathological laughter associated with pontine infarct. Brain SPECT revealed hypoperfusion of bilateral occipital lobes in addition to an underlying abnormal regulation of the cortico-pontine-cerebellar pathway. The cause of bilateral occipital hypoperfusion was thought to be due to vertebrobasilar stenosis in our patient. The co-existence of bilateral occipital lobe hypoperfusion in our patient suggest that occipital lobes may also be involved in the generation of pathological laughter.

Neurogenic pulmonary edema (NPE) is defined as acute pulmonary edema develops after a significant central nervous system insult. Although NPE has been recognized for a long time, it is still underdiagnosed in clinical practice. The exact mechanism remains unclear, but the activation of sympathetic nervous system and a catecholamine surge play important roles. Common clinical presentations are dyspnea, hypoxia and pink frothy sputum. The mortality rate is high, but recovery is usually good in surviving patients. Here we report a 62-year-old woman presenting with abrupt onset respiratory distress during thrombolytic therapy after acute ischemic stroke involving the left insular and fronto-temporo-parietal lobes. Diagnosis of NPE following acute ischemic stroke was made. Review of literature showed that NPE following ischemic stroke is rare, with only few cases previously reported in the literature.

Background and Objectives: Atrial fi brillation (AF) is an important, independent risk factor for stroke. The value of antithrombotic therapy to prevent stroke is well established in numerous randomized controlled trials. The objectives of this study were to determine the rate and the factors associated with the prescription of antithrombotic treatment before fi rst-ever ischemic stroke in patients with known AF; and to assess the association between preadmission antithrombotic therapy and stroke severity, death or disability. Methods: Consecutive patients with acute fi rst-ever ischemic stroke and AF admitted to Mackay Memorial Hospital from July 2005 to June 2007 were included in the study. We reviewed the use of antithrombotic agents before stroke onset, the international normalized ratio at admission and coexisting illness. The severity of stroke was graded using the National Institute of Health Stroke Scale. Disability was measured at discharge and during 90 days follow-up according to modifi ed-Rankin Scale. Results: A total of 1,952 patients were admitted with ischemic stroke during the study period. Of these, 152 patients with AF experienced fi rst-ever ischemic stroke. Of 152 patients, 124 (82%) were known to have AF and 28 (18%) were diagnosed with AF during admission. Before stroke, 69 out of 124 patients with known AF (56%) were not on antithrombotic therapy, 30 (24%) were receiving antithrombotic treatment but inadequately treated, and 25 (20%) were adequately treated according to the current guidelines. Younger age (<75 years), history of ischemic heart disease, diabetes mellitus and congestive heart failure were associated with the use of antithrombotic therapy before stroke onset. At discharge and during 90 days follow-up, 28% of the adequately treated patients died or were severely disabled compared with 57% of those inadequately treated. Conclusion: Antithrombotic treatment was underutilized before stroke onset, and this underuse is associated with increased mortality or disability in ischemic stroke patients with AF.

Background and Objectives: Anticoagulation clinics are widely used for anticoagulation management in many countries, but have only recently began to gain acceptance in Taiwan. Our service model is a physician-managed outpatient clinic collaborating with clinical pharmacist and nurse. This study aimed to evaluate the adequacy of anticoagulation and rates of warfarin-related complications before and after referral to our collaborative anticoagulation clinic (CAC). Methods: Stroke patients taking warfarin from the neurology department were identifi ed and referred to the CAC during the 12-month period from February 2009 to January 2010. Quality markers include percentage of international normalized ratio (INR) values in the therapeutic range, frequency of INR monitoring, and frequency of follow-up visits and the mean interval of next INR monitoring after non-therapeutic INRs were compared one year before and after management in the CAC. Using studied patients as self-control, they were included in the analysis if patients had at least 3 months follow-up or 3 INR values both before and after referral. Results: A total of 44 stroke patients were included: mean age of 75.0 ± 9.7 years, with a CHADS2 score of 3.71 ± 0.69. The adequacy of anticoagulation was signifi cantly greater during CAC care compared with the period before referral; the percentage of INR within expanded therapeutic range was 60.9% versus 53.7%, respectively (p=0.049). Reduction in sub-therapeutic INR values from 31.8% to 24.2% (p=0.023) contributed mostly to the improved quality of care. The time interval of next INR monitoring after non-therapeutic INRs ( 4.0 or 1.5) was also signifi cantly shorter. However, there was no signifi cant difference in the rates of thromboembolic and hemorrhagic events which may be attributed to a small sample size. Conclusion: Based on results of our study, a CAC may be the optimal structure for anticoagulation management service in the future.

BACKGROUND: A prospective, double blind study was performed to compare the clinical effect of vertical infraclavicular and supraclavicular brachial plexus block using a nerve stimulator for upper limb surgery. METHODS: One hundred patients receiving upper limb surgery under infraclavicular or supraclavicular brachial plexus block were enrolled in this study. The infraclavicular brachial plexus block was performed using the vertical technique with 30 ml of 0.5% ropivacaine. The supraclavicular brachial plexus block was performed using the plumb bob technique with 30 ml of 0.5% ropivacaine. The block performance-related pain was evaluated. This study observed which nerve type was stimulated, and scored the sensory and motor block. The quality of the block was assessed intra-operatively. The duration of the sensory and motor block as well as the complications were assessed. The patient's satisfaction with the anesthetic technique was assessed after surgery. RESULTS: There were no significant differences in the block performance-related pain, frequency of the stimulated nerve type, evolution of sensory and motor block quality, or the success of the block. There were no significant differences in the duration of the sensory and motor block. There was a significant difference in the incidence of Horner's syndrome. Two patients had a pneumothorax in the supraclavicular approach. There were no significant differences in the patient's satisfaction. CONCLUSIONS: Both infraclavicular and supraclavicular brachial plexus block had similar effects. The infraclavicular approach may be preferred to the supraclavicular approach when considering the complications.
Amides ; Brachial Plexus ; Double-Blind Method ; Horner Syndrome ; Humans ; Incidence ; Pneumothorax ; Prospective Studies ; Upper Extremity