The number of reported cases with dual disability is increasing for the past few decades. Currently, dual disability of lower limb amputation and motor weakness after stroke became a strong issue in public concern. The functional levels of patients have shown in the wide range from independent community ambulation to non-ambulation. Thus, it indicates that favorable outcomes for dual disability may depend upon adopted rehabilitative strategies. We present the case of a man with left below-knee amputation and severe right-sided weakness following a huge putaminal hemorrhage. He had suffered from extreme pain and misfit of the prosthetic socket and the complicated residual limb for three years prior to the stroke. Forty days post-stroke, we performed a revision surgery to resolve the complications of bony overgrowth, verrucous hyperplasia, and neuroma and applied an ankle foot orthosis (AFO). Two years post-stroke, he was able to ambulate outside his home and negotiate stairs using a cane. This is the first case with the dual disability of lower limb amputation and contralateral hemiplegia to undergo revision surgery. The results suggest that an early revision surgery and use of an AFO are crucial for achieving a higher level of mobility in such cases.
Amputation ; Ankle ; Canes ; Extremities* ; Foot Orthoses ; Hemiplegia* ; Humans ; Hyperplasia ; Lower Extremity ; Neuroma ; Putaminal Hemorrhage ; Stroke ; Walking

OBJECTIVE: To determine the predictability of motor evoked potentials (MEP) in patients with putaminal hemorrhage (PH) according to the time of MEP from the onset of stroke. METHODS: Sixty consecutive patients with PH from January 2006 to November 2013 were retrospectively reviewed. Motor function of affected extremities was measured at onset time and at six months after the onset. Patients were classified into two groups according to the time of MEP from the onset of stroke: early MEP group (within 15 days from onset) and late MEP group (16-30 days from onset). Patients were also classified into two groups according to the presence of MEP on the affected abductor pollicis brevis (APB): MEP (+) group-patients (showing MEP in the affected APB) and MEP (-) group-patients (no MEP in the affected APB). Motor outcome was compared between the two early and late MEP groups or between the presence and absence of MEP in the affected APB groups. RESULTS: For patients with MEP (+), a larger portion in the late MEP group showed good prognosis compared to the early MEP group (late MEP, 94.4%; early MEP, 80%). In contrast, in patients with MEP (-), a larger portion of patients in the late MEP group showed bad prognosis compared to the early MEP group (late MEP, 80%; early MEP, 71.4%). No significant improvement of MI between MEP (+) and MEP (-) was observed when MEP was performed early or late. CONCLUSION: Our results revealed that the predictability of motor outcome might be better if MEP is performed late compared to that when MEP is performed early in patients with PH.
Evoked Potentials, Motor* ; Extremities ; Humans ; Hydrogen-Ion Concentration ; Prognosis ; Putaminal Hemorrhage* ; Recovery of Function ; Retrospective Studies ; Stroke* ; Transcranial Magnetic Stimulation

The most common etiology of spontaneous, non-traumatic intracerebral hemorrhage is hypertension. One of the most decisive factors for the determination of etiology is location of the hemorrhage. Here, we report on a 53-year-old female patient who was admitted with left putaminal hemorrhage. She did not have prominent vascular risk factors other than fundoscopic signs of hypertensive retinopathy. Magnetic resonance imaging and angiography revealed arteriovenous malformation (AVM) in the basal ganglia, which was fed by the lateral lenticulostriate artery. This case suggests that we should consider an AVM-related hemorrhage in relatively young stroke patients, regardless of hematoma location or presence of accompanying hypertension.
Angiography ; Arteries ; Arteriovenous Malformations ; Basal Ganglia ; Cerebral Hemorrhage ; Female ; Hematoma ; Hemorrhage ; Humans ; Hypertension ; Hypertensive Retinopathy ; Magnetic Resonance Imaging ; Middle Aged ; Putaminal Hemorrhage ; Risk Factors ; Stroke

OBJECTIVE: The purpose of this study was to investigate the factors affecting the surgical outcome and to compare the surgical results between transsylvian and transcortical approaches in patients with putaminal hematomas. METHODS: Retrospective review of charts and CT scan images was conducted in 45 patients (20 transsylvian and 25 transcortical approaches) who underwent open surgical evacuation of putaminal hematomas. Mean Glasgow coma scale (GCS) score and hematoma volume were 7.5+/-3.2 and 78.1+/-29.3 cc, respectively. The factors affecting the functional mortality were investigated using a multivariate logistic regression analysis. In addition, surgical results between transsylvian and transcortical approaches were compared. RESULTS: None of the patients had a good recovery after the surgery. Overall functional survival rate and mortality were 37.7% and 31%, respectively. The only risk factor for functional mortality was GCS motor score after controlling age, history of hypertension, side of hematoma, hematoma amount, midline shift, presence of intraventricular hemorrhage and surgical approach (p=0.005). Even though a transcortical approach was shorter in operative time (4.4 versus 5.1 hour) and showed a higher mortality rate (40% versus 20%) and lower functional survival (45% versus 35%) compared to the transsylvian approach, the differences were not statistically significant between the two groups. CONCLUSION: In patients who have large amounts of hematoma and require open surgical evacuation, the only significant risk factor for functional survival is the preoperative GCS score. Cortical incision methods such as transsylvian and transcortical approaches have no influence on the surgical outcome. To decompress the swollen brain rapidly, transcortical approach seems to be more suitable than transsylvian approach.
Brain ; Craniotomy ; Glasgow Coma Scale ; Hematoma ; Hemorrhage ; Humans ; Hypertension ; Logistic Models ; Operative Time ; Putaminal Hemorrhage ; Retrospective Studies ; Risk Factors ; Survival Rate

OBJECTIVE: The aim of this study is to describe the surgical outcome and determine prognostic factors of hypertensive putaminal hemorrhage in the elderly patients. METHODS: In a retrospective study, we analyzed the surgical outcome of 61 patients under 50 year-old (the younger group) and 57 patients over 70 year-old (the older group) with hypertensive putaminal hemorrhage treated from April 1998 to May 2002 in our institution. Neurological condition, brain computed tomography characteristics, and previous disease were analysed to select prognostic factors. The Glasgow Outcome Scale after six months was used for comparison of outcome. RESULTS: Of 16 patients with an initial GCS of 3-6, six of the younger group (86%) and nine of the older group (100%) had poor outcomes (p=0.062). Of 64 patients with an initial GCS of 7-11, 24 of the younger group (73%) and 23 of the older group (74%) had good outcomes. Of 38 patients with an initial GCS of 12-15, 20 of the younger group (95%) and 16 of the older group (94%) had good outcomes. Of 58 patients with moderate hematoma (30-50ml), 23 of the younger group (79%) and 22 of the older group (76%) had good outcomes. Of 30 patients with large hematoma (>50ml), 6 of the younger group (40%) and 5 of the older group (33%) had good outcomes (P=0.144). Of 21 patients with intraventricular hemorrhage, 6 of the younger group (60%) and 10 of the older group (91%) had poor outcomes (2.6 versus 1.8: p=0.016). Of 13 patients with hydrocephalus, 4 of the younger group (67%) and 7 of the older group (100%) had poor outcomes (2.5 versus 1.4: p=0.006). The surgical outcome of hypertensive putaminal hemorrhage showed no significant difference in the older group compared with the younger group. Outcome was worse in the older group with intraventricular hemorrhage or hydrocephalus. CONCLUSION: We conclude that surgical treatment for hypertensive putaminal hemorrhage in the elderly patients without intraventricular hemorrhage or hydrocephalus is needed. Poor prognosis in elderly patients is significantly associated with intraventricular hemorrhage and hydrocephalus.
Aged* ; Brain ; Glasgow Outcome Scale ; Hematoma ; Hemorrhage ; Humans ; Hydrocephalus ; Middle Aged ; Prognosis ; Putaminal Hemorrhage* ; Retrospective Studies

OBJECTIVE: The purpose of this study is to prove and quantify motor tract disruption and to correlate with motor weakness and its recovery in thalamic and putaminal hemorrhage using diffusion tensor magnetic resonance(MR) image. METHODS: We studied 24 patients with thalamic and putaminal hemorrhage with motor weakness who did not underwent surgery(hematoma volume < 25ml). We performed diffusion tensor MR image within a week, and then calculated FA(fractional anisotropy) index and FA ratio of posterior limb of internal capsule. We checked motor power of the patients at initial, 2 weeks, 1 month, 3 months and 6 months after hemorrhage. We divided patients into three groups according to FA ratio(group A: FA ratio < 50.0%, group B: FA ratio 50.0~75.0%, group C: FA ratio > 75.0%)and compared means of motor power at each time. RESULTS: The means of FA ratio were 42.5% in group A, 63.0% in group B and 88.2% in group C. The means of motor power were 1.1, 2.3 and 3.7 at initial. After 6 months the means of motor power were 3.0, 4.0 and 4.5. The group of lower FA ratio had more severe motor weakness and showed worse motor recovery clinically than the group of higher FA ratio(P < 0.01). Though patients had severe motor weakness initially, the patients with high FA ratio showed good recovery. CONCLUSION: In thalamic and putaminal hemorrhage, diffusion tensor MR image can prove the degree of motor tract damage and predict the degree of motor recovery.
Diagnosis* ; Diffusion* ; Extremities ; Hemorrhage ; Humans ; Internal Capsule ; Magnetic Resonance Imaging* ; Putaminal Hemorrhage*

Simultaneous occurrence of aneurysmal subarachnoid hemorrhage (SAH) and hypertensive intracerebral hemorrhage (ICH) is very rare and only two cases have been previously reported in the literatures. We present a case of 68-yr-old man with a history of untreated hypertension, who suffered from sudden onset of headache followed by right hemiparesis. Computed tomographic (CT) scan revealed SAH in the basal cistern and remote ICH at the left putamen. Cerebral angiography showed a saccular aneurysm at the anterior communicating artery. No other vascular anomaly could be found at left putaminal area. Nine days after the ictal attack of SAH, the neck of aneurysm was clipped via the left frontotemporal craniotomy. Because of the ICH at the left frontal lobe and intraventricular hematoma on postoperative CT, we performed hematoma removal and external ventricular drainage 3 hours after the first operation. Postoperative neurological status had been improved to be drowsy and he was discharged in a severely disabled state 4 weeks after surgery. We suggest that the rupture of aneurysm possibly caused a rapid increase in blood pressure and subsequently resulted in hypertensive ICH.
Aged ; Aneurysm, Ruptured/*complications/radiography/surgery ; Carotid Arteries/radiography ; Humans ; Intracranial Hemorrhage, Hypertensive/*complications/radiography/surgery ; Male ; Putaminal Hemorrhage/*complications/radiography/surgery ; Subarachnoid Hemorrhage/*etiology/radiography/surgery ; Tomography, X-Ray Computed

OBJECTIVE: The purpose of this study is to investigate the risk factors for hematoma enlargement(HE) in the patients with spontaneous putaminal hemorrhage. METHODS: Among the 620 patients with putaminal hemorrhage admitted to our hospital during the period of 1990-2000, sixty patients(9.7%) had HE on the second computed tomographic(CT) scan at the interval of mean 38 hours after attack(range 1.8-168 hours). Clinical features and CT findings of these 60 patients with HE were compared with those of the remaining 560 patients without HE. RESULTS: Multivariate logistic regressional analysis revealed that the independent risk factors for HE were CT finding showing the separation of hematoma(odds ratio[OR] 3.5, 95% confidence interval [CI] 1.7-7.3, p=0.0006) or the hypodensity around or within hematoma(OR 2.5, 95% CI 1.2-5.6, p=0.0194), alcoholism(OR 4.8, 95% CI 2.0-11.7, p=0.0004), hematoma volume of 20-39cc(OR 2.54, 95% CI 1.0-6.3, p=0.0424), Glasgow Coma Scale(GCS) score of 8-11(OR 3.1, 95% CI 1.4-6.9, p=0.0046) and glutamic-pyruvic transaminase>50 IU/L(OR 6.54, 95% CI 2.1-20.5, p= 0.0013). CONCLUSION: Alcoholism and liver dysfunction appear to increase the risk of HE in putaminal hemorrhage. Particularly, careful observation for HE is needed in the patients who are GCS score of 8-11 at the time of admission, who have hematoma volume of 20-39cc and the CT finding showing the separation of hematoma or the hypodensity around or within hematoma.
Alcoholism ; Coma ; Hematoma ; Humans ; Liver Diseases ; Logistic Models ; Putaminal Hemorrhage* ; Risk Factors*

Bilateral putaminal hemorrhages rarely occur simultaneously in hypertensive patients. The association of intracerebral hemorrhage with cerebral edema (CE) has been rarely reported in diabetic patients. We present a patient with bilateral putaminal hemorrhage (BPH) and CE during the course of hyperglycemic hyperosmolar syndrome (HHS). A 40-year-old man with a history of diabetes mellitus and chronic alcoholism was admitted with acute impaired mentality. His blood pressure was within the normal range on admission. Laboratory results revealed hyperglycemia and severe metabolic acidosis without ketonuria. After aggressive treatment, plasma sugar fell to 217 mg/dl, but brain CT showed BPH and diffuse CE. Our case demonstrated that HHS should be considered as a cause of BPH with CE. Initial brain imaging study may be recommended for patients with diabetic coma.
Adult ; Brain/pathology ; Brain Edema/*etiology ; Case Report ; Human ; Hyperglycemic Hyperosmolar Nonketotic Coma/*complications ; Male ; Putaminal Hemorrhage/*etiology ; Tomography, X-Ray Computed

OBJECTIVE: The aim of this study was to find out the factors related to the recovery of hand motor function in patients with subcortical hemorrhage. METHOD: We investigated 21 patients with subcortical hemorrhage prospectively. We used their CT and/or MR imaging for the localization and estimation of the size of lesion. The Hand Movement Scale (HMS) was used for evaluation of the hand function. Proprioception, initial shoulder and hand recovery were also measured every month for at least 6 months during the follow up periods. RESULTS: There are 13 patients with putaminal hemorrhage and 8 patients with thalamic hemorrhage. There is no difference in general characteristics between the two groups. When recovery began within 4 weeks after onset, only thalamic hemorrhage patients showed significantly good recovery. Initial shoulder shrug, especially within 4 weeks after onset, could be one of the prognostic factors of good hand motor recovery. Putaminal hemorrhage patients, who had higher scores on the hand movement scale, showed early recovery of proprioceptive function. CONCLUSION: Among many other factors which can be involved in the recovery of hand function in patients with subcortical hemorrhage, the time of initial hand motor recovery, the time of initial shoulder shrug, and proprioceptive function were most important.
Follow-Up Studies ; Hand* ; Hemorrhage* ; Humans ; Magnetic Resonance Imaging ; Proprioception ; Prospective Studies ; Putaminal Hemorrhage ; Shoulder