Background and purposeAlthough parkinsonism after carbon monoxide (CO) intoxication is well known, neurotransmitter deficient networks that are responsible for the severity of parkinsonism have rarely been systemically evaluated.MethodsEighteen patients with CO‐related parkinsonism and nine age‐ and sex‐matched controls were enrolled for detailed neurological examinations, three‐dimensional T1‐weighted images, diffusion tensor imaging and 18F‐9‐fluoropropyl‐(+)‐dihydrotetrabenzazine (18F‐FP‐(+)‐DTBZ) positron emission tomography (PET). The structural analysis included voxel‐based morphometry to assess grey matter atrophy and tract‐based spatial statistics related to white matter involvement. For presynaptic monoaminergic assessment, volume of interest analysis in six subcortical regions and non‐parametric voxel‐wise comparison were performed on PET images with estimation of registration parameters from magnetic resonance images. All the imaging modalities were compared between the patients and controls. For the patients, a regression model for correlation with cognitive behaviour and Unified Parkinson's Disease Rating Scale (UPDRS) score was used.ResultsIn the patients, monoaminergic deficit networks were found in the caudate, anterior putamen, anterior insular, thalamus and anterior cingulate cortex. The UPDRS revealed significant correlations with the prefrontal white matter fractional anisotropy values and with the 18F‐FP‐(+)‐DTBZ uptake values in the caudate nucleus, insular, medial prefrontal and dorsomedial thalamus. The neuropsychiatric inventory score correlated with the 18F‐FP‐(+)‐DTBZ uptake values in the anterior cingulate cortex and dorsolateral prefrontal cortex.ConclusionsOur study demonstrated monoaminergic deficits and white matter damage networks in CO‐related parkinsonism that determined the severity of parkinsonism or behaviour changes. As the substantia nigra was spared, the monoaminergic topography of involvement suggests a different pathophysiology in CO‐related parkinsonism.

Background and purposeElevated plasma total homocysteine level (tHcy) is associated with increased risk of dementia via increased white matter changes or reduction in cortical volume. Whether tHcy has an independent impact on regional perfusion and if it can predict a more rapid cognitive decline in mild Alzheimer dementia (AD) warrants investigation.MethodsEighty AD patients with a clinical dementia rating of 1 were enrolled. Their Cognitive Ability Screening Instrument (CASI) scores on enrolment and after 1 year of follow‐up as well as their perfusion index (PI) from single photon emission computed tomography upon enrolment were analyzed.ResultsIn cross‐sectional analysis, elevated tHcy was associated with lower frontal PI independent of cerebrovascular risk factors (β = −0.35, P = 0.009). The CASI scores correlated with temporo‐parietal PI (Pearson r range 0.3–0.39, P < 0.01) but not with tHcy or frontal PI. By longitudinal analysis, only tHcy level was related to a more rapid cognitive decline (odds ratio for executive function score 1.82; odds ratio for total CASI score 1.74).ConclusionsCognitive performance in mild AD can be reflected by hypo‐perfusion of the temporo‐parietal region while frontal hypo‐perfusion may be mediated by tHcy. tHcy level is an independent risk factor for rapid cognitive decline, especially in the executive function.

Background: White matter hyper-intensities (WMHs) on magnetic resonance imaging (MRI) are commonly found in Alzheimer's disease (AD). Cerebro-vascular risk factors including plasma total homocysteine (tHcy) may result in WMHs. This study examined the association between tHcy and WMHs, and their effects on cognitive functions in AD patients over a two-year follow-up period.Methods: One hundred and fifty-seven AD patients with a clinical dementia rating of 1 or 2 were enrolled and follow-up for two years. tHcy, biochemistry tests, and mini-mental state examination (MMSE) scores were collected. WMHs were visually rated on brain MRI and classified as deep white matter hyper-intensities (DWMHs) or peri-ventricular white matter hyper-intensities (PWMHs). MMSEs were performed every six months to survey cognitive decline.Results: In the cross sectional study, tHcy was significantly associated with total WMHs especially in DWMHs even after adjusting for age and other cerebrovascular risk factors. Initial MMSE was inversely correlated with WMH severity but not with tHcy level. In the longitudinal analysis, no differences were found either in tHcy or WMHs score in the two AD groups defined by the cognitive decline rate.Conclusions: tHcy is an independent risk factor for developing moderate to severe DWMHs in AD but shows nonsignificant effect on cognitive performance. The close association between high WMH score and poor initial MMSE suggests an additive impact in AD. The long-term effect of elevated tHcy on cognitive decline was not conclusive in the twoyear follow-up period.

Introduction Osteoporotic vertebral compression fractures (VCF) are common in routine medical practice and usually heal without neurologic complications. However, vertebral bodies that are severely osteoporotic and located in thoracolumbar junction are more susceptible to non-healing with resultant intravertebral cleft formation (1). Recently, dynamic contrast enhanced magnetic resonance imaging (DCE -MRI) has been used for the evaluation of bone marrow perfusion (2, 3).In this study, we prospectively investigate the relationship between intraosseous clefts and bone marrow perfusion using dynamic contrast-enhanced magnetic resonance images (DCE-MRI) in patients with osteoporotic vertebral compression fractures. Material s and Methods Forty subjects referred for evaluation of vertebral compression fracture underwent DCE-MRI from T8 to sacrum. Bone marrow perfusion, as measured using the DCE-MRI time-intensity curve from a non-injured vertebrae was developed using 2 distinct parameters including peak enhancement ratio (PER) (which indicates tissue perfusion) and enhancement slope (which reflects vascularity). The ratio of the well-enhanced to the poorly-enhanced zone of each injured vertebra was calculated. Multiple logistic regression analysis was used to evaluate the relationships between baseline clinical factors, parameters of DCE-MRI and presence or absence of intraosseous clefts. Results and Discussions Twenty-nine injured vertebrae (72%) had intraosseous clefts. The cleft group showed significantly lower PER (p = 0.001) (Fig. 1 and Fig. 2) and a less well-enhanced zone ratio (p = 0.049) than the ‘no cleft’ group. Lower PER of the non-injured vertebrae was associated with higher poorly-enhanced zone ratio of the injured vertebrae (γ = -0.362, p = 0.017). Multivariate logistic regression analysis identified lower PER (hazard ratio, 0.000; 95% confidence interval, 0.000-0.096; p = 0.009) as an independent predictor of intraosseous clefts. A PER value less than 0.57 had a sensitivity of 80% and specificity of 90% for predicting intraosseous clefts (Fig. 3).

RESULTS: FA of patients with CO intoxication decreased in the corpus callosum, orbitofrontal WM, high frontal WM, parietal WM, and temporal lobes in comparison with the corresponding regions of healthy controls. FA of the WM in the occipital lobe and internal capsule of patients was not significantly different from that in controls. ADCs of all measured WM increased significantly in patients exposed to CO. High correlations were found between the FA of all selected WM and the Mini-Mental State Examina- tion score ( 0.631, P.016) and the digit span backward task ( 0.759, P.001). CONCLUSIONS: CO intoxication may cause FA decline in associated cortical areas. This observation indicates microstructural WM pathology in CO intoxication, which is related to delayed cognitive encephalopathy.

BACKGROUND AND PURPOSE: White matter (WM) injury in carbon monoxide (CO) intoxication is thought to be related to delayed cognitive sequelae. To determine if microstructural changes in WM are responsible for the delayed onset of cognitive symptoms, we performed diffusion tensor imaging (DTI) in patients with CO intoxication.MATERIALS AND METHODS: DTI was performed in 14 patients with delayed sequelae after CO intoxication and in 16 sex- and age-matched healthy volunteers, The fractional anisotropy (FA) and apparent diffusion coefficient (ADC) of several WM regions were measured. We also determined the correlation between FA of the selected WM and neuropsychological rating scores for the CO intoxication group.RESULTS: FA of patients with CO intoxication decreased in the corpus callosum, orbitofrontal WM, high frontal WM, parietal WM, and temporal lobes in comparison with the corresponding regions of healthy controls. FA of the WM in the occipital lobe and internal capsule of patients was not significantly different from that in controls. ADCs of all measured WM increased significantly in patients exposed to CO. High correlations were found between the FA of all selected WM and the Mini-Mental State Examination score (gamma = 0.631, P = .016) and the digit span backward task (gamma = 0.759, P = .001).CONCLUSIONS: CO intoxication may cause FA decline in associated cortical areas. This observation indicates microstructural WM pathology in CO intoxication, which is related to delayed cognitive encephalopathy.

Background and purpose:Dementia remains an exclusion criterion in diagnosing multiple system atrophy (MSA). This study aimed to determine the cognitive changes and brain atrophy patterns in the Parkinsonian (MSA-P) and cerebellar (MSA-C) variants of MSA.Methods:Voxel-based morphometry (VBM) of magnetic resonance imaging (MRI) and neuro-psychological tests were applied to 10 MSA-C and 13 MSA-P patients, and compared to 37 age-matched controls. Correlation analyses were performed between cognitive test results and morphometric data extracted from the VBM data.Results:In neuro-psychological testing, the 23 MSA patients scored lower in the Stroop interference test and took longer in the trail-making test as compared with the controls, whereas MSA-C performed worse than MSA-P in the memory scores, Stroop test, and time to complete the trail-making test. MSA, as a group, showed atrophy in the cerebellum, insular cortex, fusiform gyrus, inferior orbito-frontal gyrus, superior temporal gyrus, and caudate nucleus. Memory scores correlated well with pre-frontal lobe atrophy but not in the insular area.Conclusion:In conclusion, although dementia is not a typical presenting feature of MSA and is regarded as a sub-cortical movement disorder, frontal atrophy, cognitive changes, and dementia are identifiable as MSA progresses.

To analyze the clinical features of hepatocellular carcinoma (HCC) in patients with signs and symptoms of nervous system involvement as the initial presentation. Over a period of 11 years (January 1993 to December 2003), 15,008 HCC patients were identified at the Chang Gung Memorial Hospital in Kaohsiung, Taiwan. Amongst them, 42 cases had nervous system involvement, of which six had nervous system involvement as their initial presentation. These six cases were enrolled in this study and their clinical and laboratory data were analyzed. The clinical features of the other 36 HCC cases with nervous system involvement were also analyzed for comparison. The six cases were all males, aged 36-68 years old. The involved parts of the nervous system were the cerebellar hemisphere (one), the frontal lobe (one), the sphenoid sinus, sellar turcica, and cavernous sinus (one), the cervical spine (one), and the thoracic spine (two). Their corresponding neurologic presentations were back pain, headache, consciousness disturbance, visual disturbance, and limb weakness. Whilst three out of six patients presenting with nervous system manifestations were found to have concurrent systemic metastases in other expected sites (lung, bone), three had isolated nervous system involvement even after extensive work up. The associated medical conditions of the six cases included hepatitis B (three), hepatitis C (one), liver cirrhosis (two), portal vein thrombosis (three), and diabetes mellitus (two). All the six died within 9 months after the detection of nervous system involvement. The prevalence of nervous system involvement in HCC patients is 0.28% (42/15,088), with 0.04% (6/15,088) having this as their initial presentation. The prognosis of HCC with nervous system involvement is grave. Their clinical and laboratory data are not unique but the diagnosis could only be confirmed by hepatic and nervous system imaging studies, histopathologic examination, and serum alpha-fetoprotein detection. This consideration should be emphasized especially in areas that are hyperendemic for HCC and if the original focus of metastatic lesion is obscure.

To evaluate the cerebral hemodynamics in cryptococcal meningitis (CM) patients using non‐invasive studies. Serial trans‐cranial color‐coded sonography (TCCS) and magnetic resonance angiography (MRA) studies were performed to measure the cerebral vasculopathy of 12 HIV‐negative CM patients. With TCCS, 8 of the 22 middle cerebral arteries (MCAs) showed stenotic velocities, whereas the time‐mean velocity (Vmean) of the 20 anterior cerebral arteries (ACAs), 22 posterior cerebral arteries (PCAs), and 12 basilar arteries (BAs) did not. In total, five patients had stenotic velocities, three of whom had bilateral M1 stenosis (<50%), whilst two had unilateral M1 stenosis (<50%). The Vmean of MCA increased from day 1 to day 35 and substantially decreased thereafter. The mean Pulsatility Index (PI) in the studied vessels was higher during the study period. A mismatch of the findings between TCCS and MRA studies were also demonstrated. There was a high incidence and a longer time‐period of disturbed cerebral hemodynamics during the clinical course of CM. However, because of the limited case numbers for this study, further large‐scale studies are needed to delineate the clinical characteristics and therapeutic influence of cerebrovascular insults in HIV‐negative CM patients.

OBJECTIVES:Tuberculous and cryptococcal meningitis are two of the most common types of chronic meningitis. The study was performed to assess whether the occurrence of intracranial arterial stenosis is a risk factor for poor outcome in tuberculous and cryptococcal meningitis.METHODS:The clinical relevance of intracranial arterial stenoses in tuberculous and cryptococcal meningitis was studied using transcranial color-coded sonography (TCCS) and magnetic resonance angiography (MRA) over the period of 1 year (2003). A comparison was made between patients with and those without intracranial arterial stenoses during hospitalization.FINDINGS:There were 12 males and three females. Four patients (27%, 4/15) exhibited a stenosis of at least one cerebral artery, of which three had bilateral middle cerebral artery (MCA) stenosis and one had unilateral MCA stenoses. The stenoses were demonstrable during the whole observation period. After 6 months of follow-up, fatality rate was 50% (2/4) in those with intracranial arterial stenosis and 9% (1/11) in those without. Risk of poor outcome at a 6-month endpoint had an odds ratio of 5.3 for patients with intracranial arterial stenoses than those without (reference group).CONCLUSIONS:Intracranial arterial stenoses imply danger of cerebrovascular complications for the treatment of chronic meningitis during hospitalization. This study demonstrates that the frequency of intracranial stenosis in patients affected by chronic meningitis is high (27%) and it may be associated with poorer outcomes.

BACKGROUND There is no agreement on the optimal management of patients initially presenting with metastatic nasopharyngeal carcinoma. This study was performed to investigate the treatment outcomes and to assess whether radiotherapy to the primary tumors has survival benefits. METHODS From 1993 to 2001, 806 consecutive patients with histology-proven nasopharyngeal carcinoma were registered at our department. Among them, 125 patients had distant metastases and fulfilled the criteria for stage IVC of the 1997 American Joint Committee on Cancer staging system. Tumor histology according to the World Health Organization classification was Type 2 in 67 patients and Type 3 in 58 patients. The most common site of initial metastasis was bone. A total of 28 patients refused any treatment, 39 received chemotherapy alone and 58 had radiotherapy to the primary tumor sites alone. RESULTS The 1 year overall survival rates were 25, 36 and 48% for patients with no treatment, chemotherapy and radiotherapy, respectively. In multivariate analysis, age of diagnosis and treatment modality were confirmed as independent prognostic factors for overall survival. CONCLUSIONS Based on our results, radiotherapy to the primary tumor sites could be considered for patients with stage IVC nasopharyngeal carcinoma. A combination of radiotherapy and chemotherapy might have potential survival benefits. Further randomized prospective study is necessary to explore the optimal treatment strategy.

To determine the factors predictive of fatality in massive middle cerebral artery (MCA) territory infarction and outcome of decompressive hemicraniectomy, 62 patients who were retrospectively verified with first event massive MCA infarctions were enrolled in this study. Amongst them, 21 received decompressive hemicraniectomy during hospitalization. Clinical data between early and late hemicraniectomy groups were also compared. Significant deterioration occurred in 40 cases, 21 of whom received decompressive hemicraniectomy. The other 19 received conservative treatment. The mortality rate of these 40 cases between decompressive hemicraniectomy and conservative treatment was 29% (six of 21) and 42% (eight of 19), respectively. Factors that predicted fatalities in our massive MCA infarction patients with or without decompressive hemicraniectomy were total scores of baseline GCS at the time of admission, associated with coronary artery diseases, and significant deterioration during hospitalization. This study confirms the lifesaving procedure of hemicraniectomy that prevents death in patients deteriorating because of cerebral edema after infarction, although it may produce severe disability with an unacceptably poor quality of life in survival. Despite high mortality and morbidity, decompressive hemicraniectomy to prevent cerebral herniation when significant deterioration is demonstrated are essential for maximizing the potential for survival.

Otolaryngology–Head and Neck SurgeryVolume 134, Issue 5 p. 883-885 Case Report Basaloid Squamous Cell Carcinoma of the Sinonasal Tract: Report of two Cases Sheng-Yun Lu MD, Sheng-Yun Lu MD Department of Pathology, University and Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, TaiwanSearch for more papers by this authorHock-Liew Eng MD, Hock-Liew Eng MD Department of Pathology, University and Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, TaiwanSearch for more papers by this authorChao-Cheng Huang MD, Chao-Cheng Huang MD Department of Pathology, University and Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, TaiwanSearch for more papers by this authorChih-Yen Chien MD, Chih-Yen Chien MD Department of Otolaryngology, University and Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, TaiwanSearch for more papers by this authorChun-Chung Lui MD, Chun-Chung Lui MD Department of Pathology, University and Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, Taiwan Radiology Chang Gung University and Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, TaiwanSearch for more papers by this authorJui-Wei Lin MD, Corresponding Author Jui-Wei Lin MD [email protected] Department of Pathology, University and Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, TaiwanDepartment of Pathology, Chang Gung Memorial Hospital, Kaohsiung Medical Center, 123, Ta-Pei Road, Niao-sung, Kaohsiung 833, Taiwan. E-mail address: [email protected].Search for more papers by this author Sheng-Yun Lu MD, Sheng-Yun Lu MD Department of Pathology, University and Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, TaiwanSearch for more papers by this authorHock-Liew Eng MD, Hock-Liew Eng MD Department of Pathology, University and Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, TaiwanSearch for more papers by this authorChao-Cheng Huang MD, Chao-Cheng Huang MD Department of Pathology, University and Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, TaiwanSearch for more papers by this authorChih-Yen Chien MD, Chih-Yen Chien MD Department of Otolaryngology, University and Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, TaiwanSearch for more papers by this authorChun-Chung Lui MD, Chun-Chung Lui MD Department of Pathology, University and Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, Taiwan Radiology Chang Gung University and Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, TaiwanSearch for more papers by this authorJui-Wei Lin MD, Corresponding Author Jui-Wei Lin MD [email protected] Department of Pathology, University and Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, TaiwanDepartment of Pathology, Chang Gung Memorial Hospital, Kaohsiung Medical Center, 123, Ta-Pei Road, Niao-sung, Kaohsiung 833, Taiwan. E-mail address: [email protected].Search for more papers by this author First published: 17 May 2016 https://doi.org/10.1016/j.otohns.2005.03.049Read the full textAboutPDF ToolsExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article. Volume134, Issue5May 2006Pages 883-885 RelatedInformation

Eight patients who had sensorineural hearing loss (SNHL) associated with cryptococcal meningitis were studied. After a minimum 3-year follow-up, one had died. Among the seven survivors, three had improved, two stabilized, and two progressed. Predictive factors included visual disturbance, meningeal enhancements on MRI, and a CSF cryptococcal antigen titer of >1:1,024. SNHL accounted for 30.8% (8/26) of cryptococcal meningitis patients in our study.

Cortical lesion might elicit restricted acral sensory deficit but a disparity of topographies in cheiro-oral-pedal syndrome is very rare. We report the first case of cheiro-oral-pedal syndrome due to a contralateral parasagittal hemangioma involving the supplement sensory area in parietal lobe. This unusual link between neuroanatomy and neurological feature is discussed.

To analyze the prognostic factors and therapeutic outcome of adult patients with isolated symptomatic stenosis of the middle cerebral artery (MCA). Forty-nine patients were retrospectively verified with isolated symptomatic stenosis of the MCA through both magnetic resonance angiogram and transcranial color-coded duplex sonography. Therapeutic outcome at 1 year or more was determined using a modified Barthel index (BI). For the purpose of analysis, the patients were divided into two groups: a good outcome group (BI > or = 12) and a poor outcome group (BI < 12 or recurrent stroke). The association between different therapeutic regimens and the percent free of recurrent stroke after the first event of cerebral infarction was assessed with Kaplan-Meier plots compared by a log-rank test. These patients accounted for 2.8% of all patients with the first event of cerebral infarction during the same period. At follow-up of 1 year or more, 63% had good outcomes whilst the other 37% had poor outcomes. Overall, 26.5% suffered from recurrent strokes during the follow-up period. According to the statistical analysis, the stepwise logistic regression revealed that only the National Institutes of Health Stroke Scale (NIHSS) at the time of admission was independently associated with a poor outcome. Furthermore, Kaplan-Meier analysis showed a significantly higher percentage of patients free of recurrent stroke events amongst those who were treated with warfarin. The NIHSS at the time of admission was a predictor of outcome amongst our patients, and stenosis of the MCA implies the danger of recurrent cerebral events. Our study also demonstrates the efficacy of oral anticoagulants in the secondary prevention in this specific group of patients. Therefore, we look forward to more prospective multicenter investigations in evaluating the efficiency of therapy in the future.

We report an unusual pericallosal lipoma presenting as scalp mass at birth. The patient had no obvious neurological deficit, but CT and MRI revealed a striking lipoma extending extracranially into the scalp from the interhemispheric fissure via the anterior fontanelle. The corpus callosum was distorted but not dysplastic.