Monocular gaze palsies which result from a supranuclear cerebral lesion are rare clinical manifestations. The prefrontal cortico-oculomotor pathways travel across the thalamus and mesodiencephalic junction terminating directly in oculomotor complexes. These pathways exist bilaterally and the contralateral oculomotor bundle exerts an inhibitory influence upon the oculomotor neurons, particularly those related to the medial rectus muscle. The acute disinhibition of these neurons by a posterior thalamic lesion results in a sustained but transient discharge of the medial rectus and tonic activation. Impairment of monocular projections in the contralateral posterior thalamus could result in a tonic activation of the medial rectus, analogous to the conjugate gaze deviation observed with a frontal lobe lesion. We describe two patients with an acute onset of esotropia and contralateral supranuclear lesions - thalamic hemorrhages.
Esotropia* ; Frontal Lobe ; Hemorrhage* ; Humans ; Intracranial Hemorrhages ; Neurons ; Paralysis ; Thalamus

Chronic acquired hepatocerebral degeneration (CAHD) is a progressive or episodic neurologic syndrome that occurs occasionally in patients who have chronic liver disease or portocaval shunt. The clinical features of CAHD include action and postural tremors, generalized chorea, asterixis, myoclonus, dystonia, resting tremor, gait ataxia, and variable impairments of intellectual function. We experienced 2 cases of CAHD with unusual neurologic manifestations, which were hypokinetic parkinsonian symptoms. Both cases had a history of liver cirrhosis and the same symptoms. They had masked faces, cogwheel rigidiy in both wrists, slurred speech, tongue tremor, bradykinesia, and gait ataxia. They had normal mental status and no pathologic reflex. Brain MRI showed abnormal, increased signal on T1-weighted images in the globus pallidus and mesencephalon bilaterally. The hypokinetic parkinsonian symptoms disappeared when given doses levodopa.
Brain ; Chorea ; Dyskinesias ; Dystonia ; Gait Ataxia ; Globus Pallidus ; Hepatolenticular Degeneration* ; Humans ; Hypokinesia ; Levodopa ; Liver Cirrhosis ; Liver Diseases ; Magnetic Resonance Imaging ; Masks ; Mesencephalon ; Myoclonus ; Neurologic Manifestations ; Reflex ; Tongue ; Tremor ; Wrist

Lentigo maligna melanoma and lentigo maligna are typically located on photo-exposed sites such as the head and neck, with the cheek being the most common site. Since lentigo maligna melanoma and lentigo maligna are found predominantly on such cosmetically-sensitive areas, it is critical to determine the exact histologic margin for maximal sparing of tissue and complete extirpation of the tumor. Since Mohs micrographic surgery has been recommended for tumors on cosmetically-sensitive locations where the tumor margin is indistinct, it appears to be a reasonable treatment modality for this type of tumor. We describe a case of lentigo maligna melanoma on the cheek, which was resected with Mohs micrographic surgery.
Cheek ; Head ; Hutchinson's Melanotic Freckle* ; Lentigo* ; Melanoma* ; Mohs Surgery* ; Neck

Signet-ring cells are cells in which the nucleus is crescentically compressed with a cellular border, so that the cell looks like a signet-ring. Many cutaneous signet-ring cell neoplasms originate from the stomach, lung and breast, and these appear to be the most common sites of origin. In skin, the appearance of signet-ring cells within a neoplasm can indicate metastatic adenocarcinoma of the stomach, lung and breast. Thus, the primary origin and other metastatic sites should be evaluated. A 44-year-old man presented with a six month history of cutaneous swelling on the left axillary and left supraclavicular area. Histopathologic findings of the axillary lesion showed signet-ring cells in the lymphatics. These clustered cells were PAS-positive, diastase-resistant, and stained with colloidal iron and CEA. During the work-up study to find the primary origin, we discovered advanced gastric cancer and multiple lymph node metastases.
Adenocarcinoma* ; Adult ; Breast ; Colloids ; Edema* ; Humans ; Iron ; Lung ; Lymph Nodes ; Neoplasm Metastasis ; Skin ; Stomach ; Stomach Neoplasms

A spontaneous dissecting Aneurysm of the posterior inferior cerebellar artery(PICA) is a very rare cause of subarachnoid hemorrhage(SAH) or ischemic stroke. We report a 53-year-old male patient with left PICA territory infarction due to the spontaneous dissection of the PICA. A Brain MRI revealed an infarction of the left PICA territory and an angiography showed spindle-shaped dilatations of the left PICA followed by an irregular luminal narrowing. An angiography taken 3 months later showed spontaneous resolution of the left PICA dissecting aneurysm. The management of the intracranial dissecting aneurysm is still controversial. Some authors recommend surgical approaches for the prevention of SAH while others present medical management. Our case showed spontaneous regression of the PICA dissecting aneurysm.
Aneurysm, Dissecting* ; Angiography ; Arteries* ; Brain ; Dilatation ; Humans ; Infarction ; Magnetic Resonance Imaging ; Male ; Middle Aged ; Phenobarbital ; Pica ; Stroke

Calvus, callus, plantar warts and piezogenic papules are well known to cause discomfort and disturbance of gait in ordinary physical and sports activities. Furthermore, calcifying aponeurotic fibroma, whose mass slowly grows on the palms and soles of children and young adults, leads to pain, disturbance of gait, and even to skeletal deformities. A 22-year-old woman noticed an elevated subcutaneous mass on the left plantar surface of her big toe, which was accompanied with pain, tenderness and gait disturbance. The histologic findings showed an ill-circumscribed fibroblastic proliferation with foci of calcification and chondroid differentiation. After total excision of the mass, the patient became free of the above symptoms and the lesion did not recur for 9 months.
Bony Callus ; Child ; Congenital Abnormalities ; Female ; Fibroblasts ; Fibroma* ; Gait* ; Humans ; Sports ; Toes ; Warts ; Young Adult

BACKGROUND: Cilostazol leads to inhibition of platelet aggregation and to vasodilatation. It is widely used for the secondary prevention of cerebral infarction. However, headache is a well-known adverse effect of cilostazol, and these headaches may be caused by the vasodilation of the cerebral artery. The goal of our study was to assess the frequency and severity of headaches following cilostazol treatment and to evaluate factors related to the development of these headaches. METHODS: Seventy patients with cerebral infarction were included in this study. We measured the carotid intima media thickness (IMT), the distensibility of the carotid artery (CAD), the brachial ankle index (ABI), and the brachial ankle pulse wave velocity (PWV) in order to quantify the degree of atherosclerosis and arterial stiffness. Patients were then given 100 mg of cilostazol in tablet form twice daily. For three days, we evaluated headache incidence and severity using a verbal rating scale (0-10). RESULTS: Twenty three (32.9%) patients reported headache during cilostazol medication and 7 patients had severe headache. Women were more likely to develop headaches than men (p=0.03). In addition, the mean IMT was lower in subjects with cilostazol-induced headache than in the headache-free subjects (0.8+/-0.1 vs 1.01+/-0.2 mm, p=0.001), while CAD was higher in these subjects (0.3+/-0.1 vs 0.25+/-0.1, p=0.03). There was no difference in PWV and ABI. CONCLUSIONS: Lower carotid IMT, increased CAD, and female gender may be associated with the development of cilostazol-induced headache in patients with cerebral inafarction, but not the systemic arterial stiffness.
Animals ; Ankle ; Atherosclerosis ; Carotid Arteries ; Carotid Intima-Media Thickness ; Cerebral Arteries ; Cerebral Infarction ; Female ; Headache ; Humans ; Incidence ; Male ; Platelet Aggregation ; Pulse Wave Analysis ; Secondary Prevention ; Tetrazoles ; Vascular Stiffness ; Vasodilation

Primary mucinous carcinoma of the skin is a rare adnexal neoplasm with sweat gland differentiation. Mucinous carcinoma can occur in noncutaneous visceral sites and may metastasize in the skin. Thus it is important to exclude the possibility of a noncutaneous visceral primary tumor before diagnosing primary mucinous carcinoma of the skin. This tumor has a tendency for slow growth, local recurrence, and infrequent metastasis. To decrease local recurrence, Mohs micrographic surgery can be used to treat primary mucinous carcinoma of the skin. We describe a case of primary mucinous carcinoma of the skin which was resected by Mohs micrographic surgery.
Adenocarcinoma, Mucinous* ; Mohs Surgery ; Mucins* ; Neoplasm Metastasis ; Recurrence ; Skin* ; Sweat Glands

BACKGROUND AND PURPOSE: We examined the characteristics of sleep disturbances and sleep patterns in the caregivers of patients with amnestic mild cognitive impairment (aMCI) and dementia. METHODS: We prospectively studied 132 patients (60 with aMCI and 72 with dementia) and their caregivers, and 52 noncaregiver controls. All caregivers and controls completed several sleep questionnaires, including the Pittsburgh Sleep Quality Index (PSQI). The patients were administered neuropsychological tests and the neuropsychiatric inventory to evaluate their behavioral and neuropsychiatric symptoms of dementia (BPSD). RESULTS: The PSQI global score was 6.25+/-3.88 (mean+/-SD) for the dementia caregivers and 5.47+/-3.53 for the aMCI caregivers. The Insomnia Severity Index (ISI) and short form of the Geriatric Depression Scale (GDS-S) predicted higher PSQI global scores in aMCI caregivers, and higher scores for the ISI, Epworth Sleepiness Scale (ESS), and GDS-S in dementia caregivers. BPSD, including not only agitation, depression, and appetite change in dementia patients, but also depression, apathy, and disinhibition in aMCI patients, was related to impaired sleep quality of caregivers, but nighttime behavior was not. Age and gender were not risk factors for disturbed sleep quality. CONCLUSIONS: Dementia and aMCI caregivers exhibit impaired quality of sleep versus non-caregivers. ISI, GDS-S, and ESS scores are strong indicators of poor sleep in dementia caregivers. In addition, some BPSD and parts of the neuropsychological tests may be predictive factors of sleep disturbance in dementia caregivers.
Alzheimer Disease ; Apathy ; Appetite ; Caregivers* ; Dementia* ; Dementia, Vascular ; Depression ; Dihydroergotamine ; Humans ; Mild Cognitive Impairment* ; Neuropsychological Tests ; Prospective Studies ; Risk Factors ; Sleep Initiation and Maintenance Disorders ; Surveys and Questionnaires

It is controversial whether isolated lesions of mammillothalamic tract (MTT) produce significant amnesia. Since the MTT is small and adjacent to several important structures for memory, amnesia associated with isolated MTT infarction has been rarely reported. We report a patient who developed amnesia following an infarction of the left MTT that spared adjacent memory-related structures including the anterior thalamic nucleus. The patient s memory deficit was characterized by a severe anterograde encoding deficit and retrograde amnesia with a temporal gradient. In contrast, he did not show either frontal executive dysfunction or personality change that is frequently recognized in the anterior or medial thalamic lesion. We postulate that an amnesic syndrome can develop following discrete lesions of the MTT.
Aged ; Amnesia/*etiology ; Cerebral Infarction/*complications ; Humans ; Male ; Mamillary Bodies/*physiopathology ; Neuropsychological Tests ; Thalamus/*physiopathology