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Valproate-induced Hyperammonemic Encephalopathy: A Case Report.

Brain & Neurorehabilitation.2013;6(2):86-89. doi:10.12786/bn.2013.6.2.86

Valproate is widely used because of broad spectrum of action, but it can produce an encephalopathy resulting from hyperammonemia even at the therapeutic range of valproate and is called as valproate-induced encephalopathy (VHE). Delay in recognition of VHE can result in the development of potentially life-threatening complications. Fortunately, it is reversible with discontinuing valproate. A 65-year-old man became progressively lethargic with impaired gait and poor cognitive function while taking valproate as alternative to zonisamide. Routine investigations of admission profiles were performed but revealed no abnormalities. Next, we checked serum ammonia level to identify other possible causes and detected hyperammonemia despite the therapeutic range of valproate in the absence of any abnormalities in liver enzymes. On cessation of valproate, he has achieved dramatic clinical improvement including the reversal of hyperammonemia. We confirmed the diagnosis of VHE. This emphasizes the importance of rapid diagnosis and proper management of VHE in order to prevent the neurological damage and minimize complications.
Aged ; Ammonia ; Gait ; Humans ; Hyperammonemia ; Isoxazoles ; Liver ; Valproic Acid

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A Case of Pathologic Nystagmus following Chemotherapy Using Carboplatin for Small Cell Lung Cancer: A Case Report.

Ji Yong KIM ; Jung Hyun PARK ; Jin Hyong LEE ; Hyoung Seop KIM

Brain & Neurorehabilitation.2013;6(2):82-85. doi:10.12786/bn.2013.6.2.82

A quadriparetic 62-year-old male patient completely cured from small cell lung cancer was admitted to the hospital. The patient complained of dizziness and spontaneous horizontal nystagmus was present in both eyes. He was tolerable during the cancer treatment, but 4 months later he became bed ridden status and totally dependent on all of the daily living activities. Brain metastasis of primary cancer and paraneoplastic syndrome were suspected first, however the brain MRI and paraneoplastic antibody study revealed negative result. With reviewing his medical history, he took chemotherapy including carboplatin. We suspected the ototoxicity induced by carboplatin, as carboplatin has a unique side effect including ototoxicity affecting the balance function while preserving the hearing function. Clinicians should keep in mind this adverse effect in any patient with chemotherapy including carboplatin and who subsequently develops nystagmus and functional level impairment. In such, we present this case with the related literatures.
Activities of Daily Living ; Brain ; Carboplatin ; Dizziness ; Eye ; Hearing ; Humans ; Lung ; Male ; Middle Aged ; Neoplasm Metastasis ; Nystagmus, Pathologic ; Paraneoplastic Syndromes ; Small Cell Lung Carcinoma

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The Effects of Additional Balance Training in Subacute Hemiplegic Stroke Patients.

Hwang Jae LEE ; Si Woon PARK ; Dal Yeon HWANG ; Yong Seok LEE

Brain & Neurorehabilitation.2013;6(2):73-81. doi:10.12786/bn.2013.6.2.73

OBJECTIVE: This study investigated the effects of additional balance training using three dimensional balance trainer on dynamic balance, gait symmetry and fall efficacy in subacute hemiplegic stroke patients. METHOD: This study designed pretest-posttest control group. Twenty subacute stroke patients were randomly assigned to an experimental or a control group. All patients had conventional physical therapy. In addition, 10 patients in experimental group was trained with the three dimensional balance trainer (BalPro(R)) for 30 min/day, 5 day/week for 4 weeks. All participants were assessed by: Berg Balance Scale (BBS), Timed Up and Go test (TUG), gait symmetry, and Fall efficacy scale-Korea (FES-K) before and after training. RESULTS: All participants of both group showed statistically significant improvements in dynamic balance, gait symmetry and fall efficacy. More improvements were shown significantly in experimental group than those in control group in BBS, TUG, step length symmetry (p<0.05) and single limb support symmetry (p<0.01). CONCLUSION: Additional balance training with conventional physical therapy is feasible and may be an effective tool to improve dynamic balance and gait symmetry in subacute patients.
Extremities ; Gait ; Humans ; Stroke

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Evaluation of Dysphagia.

Jin Woo PARK

Brain & Neurorehabilitation.2009;2(2):103-107. doi:10.12786/bn.2009.2.2.103

Dysphagia is common, especially in the elderly, and may cause dehydration, weight loss, aspiration pneumonia and airway obstruction. It may occur because of a wide variety of structural or functional conditions, including stroke, cancer, neurologic disease and gastroesophageal reflux disease. A thorough history and a careful physical examination are important in the diagnosis but investigations such as videofluoroscopic swallowing study (VFS), fiberoptic endoscopic examination of swallowing (FEES) and manometry are more useful for confirming diagnosis, identifying the pathophysiology of a swallowing disorder and testing the therapeutic and compensatory techniques. This article reviews various evaluating methods for dysphagia.

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Normal Swallowing Mechanism on Neurophysiogical Basis.

Ju Kang LEE

Brain & Neurorehabilitation.2009;2(2):98-102. doi:10.12786/bn.2009.2.2.98

Swallowing, known scientifically as deglutition, is the process in the human or animal body that makes something pass from the mouth, to the pharynx, into the esophagus, with the shutting of the epiglottis. If this fails and the object goes through the trachea, then choking or pulmonary aspiration can occur. In the human body it is controlled by the swallowing reflex. The nose and pharynx serves as a pathway for air in breathing. During swallowing, the pharynx is isolated from the nasal cavity and lower airway by velopharyngeal and laryngeal closure during the pharyngeal swallow. Normal swallowing process is complex neuromuscular activities consisting of three phases, an oral, pharyngeal and esophageal phase. The oral phase is usually voluntary process and mainly controlled by the fronto-temporal cerebral cortex with contributions from the motor cortex and other cortical areas. The pharyngeal phase is controlled by swallowing center in the medulla and pons. It is initiated mainly by the receptors of the posterior upper pharyngeal wall and "swallowing reflex" occurred. The food bolus is advanced from the pharynx to the esophagus through sequential contraction of the constrictor muscles. During swallowing reflex, the respiratory center of the medulla is inhibited by swallowing center accompanied by velopharyngeal and laryngeal closure to prevent airway aspiration. The esophageal phase, which is passive process, started from relaxation of upper esophageal sphincter. The autonomic system network coordinates the smooth muscles of pharynx and esophagus sequentially pushes the bolus through the esophagus into the stomach.

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Post-Stroke Dysphagia: Incidence, Complications and Pattern Relates to Brain Lesion.

Don Kyu KIM

Brain & Neurorehabilitation.2009;2(2):91-97. doi:10.12786/bn.2009.2.2.91

Dysphagia is commonly observed in stroke patients. The precise locations of lesion and its effect that produce swallowing disorder remain to be determined. Unilateral hemispheric lesion as well as bilateral lesions and brainstem, which has nucleus for lower cranial nerves and neurons in swallowing centers, is also associated with dysphagia. Though the reported incidence of dysphagia is different among studies because of evaluation methods, up to half of acute stroke patients are affected by dysphagia, where its presence has been associated with risk of complications, such as pneumonia, malnutrition, dehydration etc. These complications are also related with prolonged hospital stay and poor functional outcome. Most of the dysphagic patients will make a functional recovery and return to pre-stroke diet patterns after acute period but about twenty percent of patient would have significant problems in swallowing even after 6 months according to previous studies. This suggests that intensive management and serial follow up evaluation as well as early screening of dysphagia is one of the important treatment strategies in the management of stroke.

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A Case of Hyponatremia Associated with Paroxetine: A case report.

Min Kyun SOHN ; Seon Lyul HWANG ; Hyun Tak SONG ; Jun Ho LIM

Brain & Neurorehabilitation.2012;5(1):43-46. doi:10.12786/bn.2012.5.1.43

Paroxetine is a selective serotonin reuptake inhibitor (SSRI) widely used for depression in brain damaged patients as it is known for its few affects on cognition or psychomotor function. Major side effects observed for paroxetine are vertigo, headache and tremor. It is reported that hyponatremia is also rarely observed. In 69 year-old male with left hemiplegia due to cerebral infarction had started taking 20 mg/day of paroxetine for depression. Next day the patient showed severe generalized weakness and decreased consciousness. Laboratory tests showed that serum sodium level was decreased to 102 mEq/L. Paroxetine administration was stopped and 3% sodium and oral furosemide were administered under the diagnosis of syndrome of inappropriate secretion of antidiuretic hormone (SIADH). We report a case of patient with severe hyponatremia due to SIADH within 2 days after use of paroxetine. This case emphasizes the need to monitor serum sodium level routinely at the initial treatment to prevent hyponatremia.
Brain ; Cerebral Infarction ; Cognition ; Consciousness ; Depression ; Furosemide ; Headache ; Hemiplegia ; Humans ; Hyponatremia ; Inappropriate ADH Syndrome ; Male ; Organothiophosphorus Compounds ; Paroxetine ; Serotonin ; Sodium ; Tremor ; Vertigo

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Effect of Botulinum Toxin A on Trismus after Pons Infarction: A case report.

Seon Jeong OH ; Sun IM ; Jeehae OH ; Seok Ha HONG ; Geun Young PARK

Brain & Neurorehabilitation.2012;5(1):39-42. doi:10.12786/bn.2012.5.1.39

We report a 77-year-old woman with bilateral pons infarction who presented with severe trismus, which was responsive to botulinum toxin-A injection. She was unable to open her mouth and showed anterior displacement of her temporo-mandibular (TM) joint on MRI findings. She was fed via nasogastric tube because of mouth opening limitation. There was no improvement of her mouth opening after range of motion exercise. She underwent closed reduction of the TM joints under general anesthesia but there was no significant improvement. Electromyography studies revealed continuous muscle activities on masseter and temporalis muscles during mouth opening. Botulinum toxin-A (Botox(R)) was injected into both the masseter and left temporalis muscles under ultrasonographic guidance. There was some improvement in mouth opening at post-injection 5 days. The inter-incisal distance improved gradually, and she could start oral feeding after 18 days. She could maintain an inter-incisal distance of 1.8 cm with favorable response during post-injection 4 months.
Aged ; Anesthesia, General ; Botulinum Toxins ; Displacement (Psychology) ; Electromyography ; Female ; Humans ; Infarction ; Joints ; Mouth ; Muscles ; Pons ; Range of Motion, Articular ; Trismus

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Effects of the Balance Control Training in Chronic Hemiplegic Stroke Patients.

Seung Deuk BYUN ; Dong Hyun CHO ; Won Duck CHOI ; Yong Ho HONG ; Zee Ihn LEE ; Yang Soo LEE

Brain & Neurorehabilitation.2012;5(1):32-38. doi:10.12786/bn.2012.5.1.32

OBJECTIVE: To investigate the training effects on balance and gait ability using balance control trainer combined with partial weight-bearing system in chronic hemiplegic stroke patients. METHOD: A prospective crossover clinical trial was designed. The subjects consisted of 16 chronic hemiplegic stroke patients. All patients had a stroke more than six months. In addition to conventional physical therapy (PT), 8 patients in group A were trained with the balance control trainer for 30 min/day, 5 day/week, for first 2 weeks and then received only conventional physical therapy for 2 weeks. The other 8 patients in group B received only conventional PT for first 2 weeks and then were trained with the balance control trainer for 30 min/day, 5 day/week, for next 2 weeks, with additional conventional PT. We evaluated with clinical tests including functional ambulation categories (FAC), Berg balance scale (BBS), 6 min walking distance (6mWT), timed up and go (TUG), Korean-modified barthel Index (K-MBI) and muscle strengthening of knee extensor (MMTknee) before training, 2 weeks and 4 weeks after training in those patients. RESULTS: After training, subjects in experimental period (2weeks period of conventional PT+Balance control trainer in group A&B) showed more improvement than those in control period (2 weeks period of only conventional PT in group A&B) in FAC, BBS, 6mWT, TUG, K-MBI (p<0.05). CONCLUSION: We think the balance control trainer combined with the partial weight-bearing system can be a useful tool for improving balance and gait ability in chronic hemiplegic stroke patients.
Gait ; Humans ; Knee ; Muscles ; Prospective Studies ; Stroke ; Walking ; Weight-Bearing

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Motor Evoked Potentials and Somatosensory Evoked Potentials of Upper and Lower Extremities for Prediction of Functional Recovery in Stroke.

Se Won KIM ; Seung Beom KIM ; Su Young LEE ; Seong Eun KOH ; Jong Min LEE ; Joo Young LEE

Brain & Neurorehabilitation.2012;5(1):24-31. doi:10.12786/bn.2012.5.1.24

OBJECTIVE: The aim of this study was to evaluate the relationship between motor evoked potentials (MEPs) or somatosensory evoked potentials (SSEPs) and the recovery of function in acute or subacute stroke patients. METHOD: Twenty one hemiplegic stroke patients were examined with MEPs of extensor carpi radialis, abductor pollicis brevis, tibialis anterior and abductor hallucis and SSEPs of median and tibial nerves. A separate score was defined for upper and lower extremities within the Fugl-Meyer assessment and Korean-modified Barthel index. Motor performances were evaluated simultaneously with the evoked potential assessments and at 2 weeks after the first examination. RESULTS: The second motor function of upper extremity was significantly higher in patients with the presence of MEP or SSEP (p<0.05). The improvement of self care was correlated with the responsiveness in SSEP. Motor function of lower extremity was significantly associated with the responsiveness in MEP or SSEP (p>0.05). MEP in tibialis anterior or tibial SSEP were correlated with the mobility. CONCLUSION: MEP in tibialis anterior is useful in predicting in mobility after stroke. SSEP is predictive for activities in daily living after stroke.
Activities of Daily Living ; Evoked Potentials ; Evoked Potentials, Motor ; Evoked Potentials, Somatosensory ; Humans ; Lower Extremity ; Recovery of Function ; Self Care ; Stroke ; Tibial Nerve ; Upper Extremity

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