Showing papers by "Hyun Goo Kang published in 2019"

Metabolic Consequences of Obstructive Sleep Apnea Especially Pertaining to Diabetes Mellitus and Insulin Sensitivity

Abstract: Obstructive sleep apnea (OSA) and diabetes has been known to be closely related to each other and both diseases impact highly on the public health. There are many evidence of reports that OSA is associated with diabetes with a bidirectional correlation. A possible causal mechanism of OSA to diabetes is intermittent hypoxemia and diabetes to OSA is microvascular complication. However, OSA and diabetes have a high prevalence rate in public and shares the common overlap characteristic and risk factors such as age, obesity, and metabolic syndrome that make it difficult to establish the exact pathophysiologic mechanism between them. In addition, studies demonstrating that treatment of OSA may help prevent diabetes or improve glycemic control have not shown convincing result but have become a great field of interest research. This review outlines the bidirectional correlation between OSA and diabetes and explore the pathophysiologic mechanisms by approaching their basic etiologies.

Clinical significance of the internal carotid artery angle in ischemic stroke.

Abstract: The carotid artery plays a major role in stroke aetiology and is a good indicator of atherosclerosis. However, the clinical significance of internal carotid artery (ICA) anatomy remains unclear in patients with ischaemic stroke. This study examined the relationship between ICA angle and risk of ischaemic stroke. ICA angles of patients with acute ischaemic stroke were retrospectively compared with those of control patients between March 2014 and July 2014. Controls consisted of those with headaches but without ischaemic stroke. In both groups, ICA angles were measured using Maximum Intensity Projection images from computed tomography angiography, and the relationship between ICA angle and risk of ischaemic stroke was analysed. Of 128 screened patients with acute ischaemic stroke, 27 were enrolled, and 29 with headache were enrolled as controls. No differences were found in baseline characteristics between the two groups, but intracranial stenosis was more frequent in patients with stroke than in controls. Bilateral ICA angles were significantly larger in patients with stroke than in controls. Multiple logistic regression models showed that the right ICA angle was associated with risk of ischaemic stroke. Measuring the ICA angle may help assess the risk of ischaemic stroke.

Intimal flap detected by three-dimensional curved multiplanar reconstruction image in isolated posterior inferior cerebellar artery dissection: a report of two cases.

Abstract: Spontaneous isolated posterior inferior cerebellar artery (PICA) dissection has been reported more frequently since high-resolution vessel wall magnetic resonance imaging (HR vw-MRI) was introduced to the field. The intimal flap or double lumen, which is commonly reported to be a direct sign of the dissection, is not easily detectable on HR vw-MRI because the size of the PICA is very small and tortuous. Two patients with posterior circulation ischemic stroke due to spontaneous isolated PICA dissection underwent HR vw-MRI. The curved multiplanar reconstruction image reconstructed using three-dimensional (3D) HR vw-MRI (3D curved MPR imaging) is helpful to observe tortuous blood vessels such as the PICA because it can visualize the entire vessel course in a single plane. In this report, routine HR vw-MRI revealed only an intramural hematoma in both patients. However, 3D curved MPR imaging discovered the intimal flap which was not observed on the routine HR vw-MRI. Therefore, these two patients were diagnosed with spontaneous isolated PICA dissection due to the intimal flap that was observed on the 3D curved MPR image. HR vw-MRI is useful for the early diagnosis of isolated PICA dissection. Furthermore, we believe that 3D curved MPR imaging could improve the possibility of diagnosing the dissection early because it can easily confirm direct signs such as an intimal flap or double lumen.

Uremia presented as acute cranial neuropathy.

Abstract: Dear Sir, A 61-year-old patient who had been receiving hemodialysis three times per week due to end-stage renal disease (ESRD) for 10 years visited a nearby hospital due to upper respiratory tract infection symptoms 4 days before visiting our hospital. The patient was diagnosed with pneumonia and started treatment with 3rd-generation cephalosporin administration while hemodialysis was discontinued. On the third day of antibiotic treatment, dysphagia and dysarthria occurred, and consequently, the patient was transferred to our hospital. In the neurologic examination, the patient was not able to swallow and drooled because of partial lower facial diplegia and paralysis of the soft palate and pharynx (Fig. 1a). All other neurologic examinations were normal, except for decreased bilateral ankle jerk. Left vocal cord palsy was confirmed by laryngoscopy (Fig. 1b). Abnormal findings were not observed on contrast-enhanced brain magnetic resonance imaging (MRI) and a diffusion-weighted image. In laboratory tests, the electrolyte levels were normal and blood urea nitrogen (BUN) (60 mg/dL), creatinine (13.29 mg/dL), and ammonia (75 μg/dL) were increased. The glomerular filtration rate (GFR) was 4.7 ml/min. The results of the cerebrospinal fluid (CSF) test showed clear color, pressure of 150 mmH2O, white blood cells (WBC) count 2/mm, glucose concentration 63 mg/dL, and protein concentration 69 mg/dL. The results of facial nerve conduction studies (NCS) revealed bilateral facial nerve abnormalities. NCS in the upper and lower limbs did not show abnormal findings. Hemodialysis was performed daily from the day of admission. From the third day of admission, the dysphagia of the patient had partially improved. Therefore, the patient was able to eat a liquid diet, and the number of hemodialysis sessions was reduced to three times per week.We could not exclude the possibility of multiple cranial nerve palsy caused by viral infection, and as a result, the patient began to take valacyclovir from the third day of admission. However, dysphagia began to worsen from the 7th day of admission, and the patient showed drowsy mentation from the 8th day. The results of the laboratory test hadworsened again (BUN = 73.1mg/dL, creatinine = 9.84 mg/dL, and GFR = 5.99 ml/min). Hemodialysis was again conducted daily, immediately after stopping the administration of valacyclovir. The patient was recovered to alert mentation from the 10th day of admission. After that, the facial palsy and dysphagia were gradually resolved, and the patient was able to carry out independent activities. Viral markers, blood and CSF cultures, and autoimmune and demyelinating markers were all negative (Fig. 2). Therefore, the patient was discharged. The presented case reports a patient who, under hemodialysis due to ESRD, suddenly developed facial, glossopharyngeal, and vagal neuropathy during discontinuation of hemodialysis. The possibility of various diseases that could show acute neurological symptoms had to be excluded, but no test showed abnormal findings. The patient symptoms were improved by hemodialysis alone. Therefore, the subject was diagnosed with uremic cranial neuropathy (CNP). Neurologic complications of CKD are classified as central/ cortical neurologic complications, neuropathy, myopathy, and Wook Hur and Ji Yeon Chung contributed equally to this work.

Postoperative Cheek Cyst Mimicking Trigeminal Neuralgia.

Abstract: A 55-year-old woman visited our clinic due to headache, pain on the left side of the face, a “tingling” feeling in the mouth, and toothache. She experienced severe pain mostly on the left cheek and upper gingiva area. When the symptom worsened, she felt the pain on the left temporal area. The patterns of pain were sometimes lancinating pain but sometimes were no more than a tingling sensation. Particularly, when she brushed her teeth and chewed food by the left-side cheek, the severity of pain was aggravated. The pain worsened up to 8 points on visual analog scale (VAS). The patient provided consent for the writing up of this case report. She did not have any significant past medical history except for maxillary sinus surgery for sinusitis 12 years prior to presentation. We suspected trigeminal neuralgia based on clinical symptoms; therefore, brain magnetic resonance imaging (MRI) was performed to determine the presence of neurovascular compression (NVC). However, we could not find any abnormalities other than left maxillary sinusitis. Paranasal sinus computed tomography revealed a postoperative expansile cyst in the left maxillary sinus (Fig. 1). She was diagnosed with a postoperative cheek cyst (POCC) and thus underwent endoscopic sinus surgery. All symptoms improved 3 months postoperatively. POCC is caused by a disordered healing mechanism after a Caldwell-Luc operation. It usually occurs >10 years postoperatively. Osteoclasia due to POCC is, in particular, an uncommon manifestation. The anterior and inner walls of the maxillary sinus are invaded frequently. When POCC occurs beneath the maxillary sinus, it can be misdiagnosed as trigeminal neuralgia because it can affect the superior alveolar nerve. The presence of NVC is commonly confirmed using brain MRI to identify problems of the trigeminal neuralgia pathway. When Headache doi: 10.1111/head.13531 © 2019 American Headache Society Published by Wiley Periodicals, Inc. ISSN 0017-8748

Different imaging patterns of PCNSL and IVL: a case report.

Abstract: Primary central nervous system lymphoma (PCNSL) is a rare, malignant, non-Hodgkin’s lymphoma of the brain, leptomeninges, and rarely the spinal cord. PCNSL has characteristic magnetic resonance imaging (MRI) findings, and effective treatment strategies are available. It is characterized predominately by neurological symptoms, which are caused by tumor infiltration into the nervous system as well as ischemia. Chemotherapy is an effective treatment, if started prior to the ischemic damage. A 62-year-old male patient with PCNSL presented with altered mental status. The initial brain MRI revealed high signal intensity on the T2-weighted images (T2WIs) of the putamen area of the right basal ganglia, and the clinical symptoms improved after steroid administration. However, the symptoms were later deteriorated, we considered the possibility of autoimmune encephalitis and, consequently, conducted an immunomodulatory therapy. In a follow-up brain MRI, enlargement lesions of T2WI in basal ganglia and pons were simultaneously enhanced. Subsequently, the patient’s mental status deteriorated to a semi-coma and PCNSL was diagnosed after a surgical biopsy. Chemotherapy was started immediately; however, the patient died. Effective treatments are available for PCNSL and intravascular lymphoma; thus, their prognosis is generally good if they are diagnosed early. Herein, we report the case of a patient suspected with autoimmune encephalitis after brain MRI and treated with immunomodulation therapy. However, PCNSL was confirmed by a surgical biopsy. It is, therefore recommended to consider lymphoma in patients with neurological symptoms that are difficult to localize and rapidly progressive enhancing lesions showing a mass effect on brain MRI.

Asymptomatic Brain Abscess with Intracerebral Hemorrhage

Abstract: Dear Editor, A 44-year-old man with hypertension and diabetes presented with an acute headache and left hemiparesis. He reported recent inadequate control of blood pressure and diabetes. At the time of admission, his blood pressure was 240/130 mmHg, but fever and myalgia were absent. Immediate computed tomography (CT) revealed a right frontotemporal lobe intracerebral hemorrhage (ICH), and some areas of ICH appeared to be associated with other lesions (Fig. 1). Immediate surgery was performed because of rapidly deteriorating consciousness. After insertion of a catheter to the nearest ICH site, white purulent discharge was observed and irrigation was performed. Blood tests revealed unremarkable findings, with the exception of a slightly increased C-reactive protein level (0.12 mg/L). Staphylococcus saprophyticus was detected on culture, and vancomycin was given for 21 days. Postoperative CT confirmed that the fluid level disappeared and problems caused by the mass as a spaceoccupying lesion had nearly resolved (Fig. 2). The patient became more alert, and the left hemiparesis gradually improved. Brain abscess typically presents with various neurological symptoms and is associated with high mortality [1]. It sometimes occurs in association with ICH, but may occur due to hematogenous spread from distal foci [2]. In a case of brain abscess, prompt diagnosis, timely surgical treatment, and antibiotic therapy are important for improving prognosis. In this patient, a brain abscess developed with ICH. It was thought that the abscess was caused by hematogenous spread from an unknown site and that uncontrolled diabetes contributed to abscess generation or exacerbation. Moreover, it is possible that the abscess was overlooked on initial brain imaging because of hemorrhage into the abscess cavity. Treatment for the abscess might have been delayed, but fortunately, the fluid level in the abscess cavity raised the suspicion of an abscess. This case demonstrates that an abscess can be overlooked when ICH invades the abscess cavity, although an abscess should be suspected in the presence of a fluid level and differences in density of the brain parenchyma around the ICH.