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Hemiplegia is a rare complication accompanied with hypoglycemia. We reported three cases of hypoglycemic hemiplegia (HH). Case 1: A 74-year-old female had medication for diabetes mellitus (DM). She had right hemiplegia and aphasia. Case 2: A 72-year-old male had DM, and was admitted to our hospital having loss of consciousness and right hemiplegia. Case 3: An 82-year-old female suffered from consciousness disturbance with tetraplegia, and had left hemiparesis later. She had no DM, but suffered from iatrogenic hypoglycemia. The brain CT of these three cases showed atrophy, and MRI demonstrated multiple infarction. The angiography of case 1 showed the stenosis of bilateral internal carotid artery and the origin of the left vertebral artery. The angiography of case 2 showed severe stenosis of the left internal carotid artery. The cases above had hypoglycemia at admission. The value of the case 1 was 48 mg/dl, case 2 was 35 mg/dl and case 3 was 38 mg/dl. But these symptoms of the three cases disappeared rapidly after glucose infusion. The literature regarding HH was reviewed, and the pathogenesis was discussed. We emphasize the importance of checking blood sugar levels for the emerging patients with hemiplegia, because it is difficult to discriminate by clinical history or neurological findings.
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PMID:[Hypoglycemic hemiplegia: a report of three cases]. 1180 22

We report a 67-year-old man with mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS), successfully treated with eicosapentaenoic acid ethyl ester (EPA-E) for about eight months. He showed bilateral auditory disturbance and slowly progressive gait ataxia at age 50 during treatment of diabetes mellitus (DM) with subcutaneous injection of insulin since age 29. At age 58 he manifested an acute hemiparesis of right extremities for one week with no abnormal findings on neuroradiological examinations. A permanent pacemaker was implanted at age 61 to treat frequent syncopal attacks due to complete atrioventricular block. On admission to our hospital, neurological examinations revealed dementia, auditory disturbance, severe cerebellar ataxia and mild atrophy of proximal muscles with systemic hyporeflexia. Based on a point mutation in position 3243 of mitochondrial DNA, he was diagnosed as having MELAS with severe DM, auditory disturbance and cardiac conduction block. After initiation of treatment with EPA-E at a dose of 2,700 mg/day he showed temporarily an improvement in auditory disturbance, blood glucose control and cerebellar ataxia. In objective evaluations for cerebellar ataxia, we could find significant decreases in times for 20 m walking and heel-knee patting in the ninth month, and in time for tracing of a whirl from the third to the ninth month, compared with those before treatment of EPA-E (p < 0.0001). Because EPA-E is taken into mitochondrial membranes and activates electron transmission enzyme complexes, it might be a candidate for therapy of mitochondrial encephalomyopathy, including MELAS.
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PMID:[A case of mitochondrial myopathy, encephalopathy, lactic acidosis and stroke-like episodes (MELAS), showing temporary improvement during the treatment with eicosapentaenoic acid ethyl ester]. 1199 86

A 71-year-old female complicating Parkinson disease and diabetes mellitus was admitted to our medical center for urinary tract infection one month after burr hole irrigation and drainage of left chronic subdural hematoma. Klebsiella pneumonia was detected in the bacterial culture of her urine. As antibiotic therapy started, her condition and peripheral white blood cell counts were improved. But consciousness level got worsened and right hemiparesis appeared. A CT scan showed re-accumulation of left subdural fluid so an emergent irrigation was performed. The old hematoma with slightly yellowish, bloody purulent fluid was found and an intracapsular drain was inserted. Klebsiella pneumonia was detected from the bacterial culture of the hematoma. After 10 days, a CT scan showed subdural fluid collection again, so, total hematoma capsule removal was performed. After the operation, her neurological and serological condition improved and she was discharged without any neurological deficits. Klebsiella pneumonia existing urinary tracts rarely infected subdural hematoma cavity via hematogenous dissemination. We must keep in mind this complication may occur when we see compromised host like this case. Total removal of infected hematoma capsule is considered as radical treatment.
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PMID:[A case of infected subdural hematoma following chronic subdural hematoma irrigation]. 1235 83

To evaluate and review the clinical spectrum of anterior cerebral artery (ACA) territory infarction, we studied 48 consecutive patients who admitted to our stroke unit over a 6-year period. We performed magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) in all patients, and diffusion magnetic resonance imaging (DWI) in 21. In our stroke registry, patients with ACA infarction represented 1.3% of 3705 patients with ischemic stroke. The main risk factors of ACA infarcts was hypertension in 58% of patients, diabetes mellitus in 29%, hypercholesterolemia in 25%, cigarette smoking in 19%, atrial fibrillation in 19%, and myocardial infarct in 6%. Presumed causes of ACA infarct were large-artery disease and cardioembolism in 13 patients each, small-artery disease (SAD) in the territory of Heubner's artery in two and atherosclerosis of large-arteries (<50% stenosis) in 16. On clinico-radiologic analysis there were three main clinical patterns depending on lesion side; left-side infarction (30 patients) consisting of mutism, transcortical motor aphasia, and hemiparesis with lower limb predominance; right side infarction (16 patients) accompanied by acute confusional state, motor hemineglect and hemiparesis; bilateral infarction (two patients) presented with akinetic mutism, severe sphincter dysfunction, and dependent functional outcome. Our findings suggest that clinical and etiologic spectrum of ACA infarction may present similar features as that of middle cerebral artery infarction, but frontal dysfunctions and callosal syndromes can help to make a clinical differential diagnosis. Moreover, at the early phase of stroke, DWI is useful imaging method to locate and delineate the boundary of lesion in the territory of ACA.
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PMID:Spectrum of anterior cerebral artery territory infarction: clinical and MRI findings. 1245 77

Angiography by means of iodinated contrast material, before endovascular or surgical treatment, may result in serious complications in patients with renal insufficiency or previous anaphylactoid reaction to iodine. Alternative techniques, such as magnetic resonance angiography or carbon dioxide angiography, have their own limitations. We report effectiveness and safety of cerebral angiography using gadolinium for a patient with right vertebral artery and basilar artery occlusion and renal insufficiency. A 66-year-old woman with diabetes under medical treatment suffered loss of consciousness and left hemiparesis following dehydration for 24 hours. She was transferred to our hospital. Emergent MRI suggested brain stem and cerebellar infarction due to vertebral artery occlusion with diffusion-perfusion mismatch. Because of renal insufficiency, the digital subtraction cerebral angiography using gadolinium was performed. Appropriate diagnosis was achieved by angiography using gadolinium of 0.4 mmol/kg. There was no any complication including deterioration of renal function. Gadolinium appears to be a safe and useful intraarterial contrast agent in patients with renal insufficiency.
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PMID:[Experience of cerebral angiography using gadolinium for renal insufficiency]. 1268 99

Neurotoxic side effects of chemotherapy occur frequently and are often a reason to limit the dose of chemotherapy. Since bone marrow toxicity, as the major limiting factor in most chemotherapeutic regimens, can be overcome with growth factors or bone marrow transplantation, the use of higher doses of chemotherapy is possible, which increases the risk of neurotoxicity. Chemotherapy may cause both peripheral neurotoxicity, consisting mainly of a peripheral neuropathy, and central neurotoxicity, ranging from minor cognitive deficits to encephalopathy with dementia or even coma. In this article we describe the neurological adverse effects of the most commonly used chemotherapeutic agents. The vinca-alkaloids, cisplatin and the taxanes are amongst the most important drugs inducing peripheral neurotoxicity. These drugs are widely used for various malignancies such as ovarian and breast cancer, and haematological cancers. Chemotherapy-induced neuropathy is clearly related to cumulative dose or dose-intensities. Patients who already have neuropathic symptoms due to diabetes mellitus, hereditary neuropathies or earlier treatment with neurotoxic chemotherapy are thought to be more vulnerable for the development of chemotherapy-induced peripheral neuropathy. Methotrexate, cytarabine (cytosine arabinoside) and ifosfamide are primarily known for their central neurotoxic side effects. Central neurotoxicity ranges from acute toxicity such as aseptic meningitis, to delayed toxicities comprising cognitive deficits, hemiparesis, aphasia and progressive dementia. Risk factors are high doses, frequent administration and radiotherapy preceding methotrexate chemotherapy, which appears to be more neurotoxic than methotrexate as single modality. Data on management and neuroprotective agents are discussed. Management mainly consists of cumulative dose-reduction or lower dose-intensities, especially in patients who are at higher risk to develop neurotoxic side effects. None of the neuroprotective agents described in this article can be recommended for standard use in daily practise at this moment, and further studies are needed to confirm some of the beneficial effects described.
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PMID:Neurotoxic complications of chemotherapy in patients with cancer: clinical signs and optimal management. 1288 62

A 49-year-old female with a history of systemic hypertension and diabetes mellitus suffered transient right hemiparesis. Carotid angiography with arch-aortography detected severe stenosis of the proximal portion of the left common carotid artery. The left carotid bifurcation was surgically exposed and retrograde catheterization was performed to approach the proximal common carotid artery stenosis. The lesion was dilated with a balloon catheter and successfully stented without complications. The left internal carotid artery was clamped during the procedure to avoid embolism. Retrograde carotid stenting for stenosis of the proximal common carotid artery is a safe and effective alternative to conventional surgery in selected patients.
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PMID:Retrograde carotid stenting for isolated stenosis of the proximal common carotid artery--case report. 1470 21

The authors experienced 55 cases of anesthetic management in 52 elderly surgical patients, 14 men and 38 women, aged 90 to 101 years with an average of 92.1 +/- 2.1 years for the past ten years. Surgical procedures included 38 cases of orthopedic, 14 cases of general surgical and 3 cases of ophthalmic operations. Thirteen cases out of them were emergency. General, epidural, spinal, and local anesthesia were applied in 34 cases, 18 cases, 2 cases, and one case out of these elderly patients, respectively. These general anesthesia consisted of total intravenous anesthesia with propopol, fentanyl and ketamine in 27 cases, sevoflurane with nitrous oxide in 4 cases, isoflurane with nitrous oxide or air in 2 cases, and thiopental anesthesia in one case. The elderly patients had past history of heart disease, dementia, hypertension, cerebral infarction/hemorrhage, diabetes mellitus and others. Their preoperative examinations revealed anemia, hypoproteinemia, renal hypofunction, serum electrolytes imbalance, and others. Vasopessors were given to 42% of the patients during anesthesia and surgery. Their postoperative complications included myocardial infarction, paroxysmal atrial fibrillation, hypotension following anemia, transient hemiparesis, delirium and so on. Two patients developed myocardial infarction postoperatively and died thereafter. The authors suggest that appropriate anesthetic management for elderly patients aged 90 years or older requires proper preoperative evaluation, sufficient vigilance of hemodynamics with direct arterial pressure measurement, reliable preparation of medical agents, and awareness of impairment of circulatory function and others by aging.
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PMID:[Anesthetic management of elderly patients aged 90 years or older]. 1501 25

Unlike the case in adult-onset diabetes, neurologic complications in children with type 1 diabetes are uncommon. We report a case of a 14-year-old boy with type 1 diabetes who presented at our emergency unit with acute hemiparesis and intense headache without hypoglycaemia. Two hours after onset, the symptoms had subsided. It is the intention of the authors to increase the awareness of this association, whose prognosis is almost invariably good.
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PMID:Acute hemiparesis in a boy with type 1 diabetes. 1512 Jun 88

Dominant hand dysfunction due to cerebrovascular accident or fracture makes it more difficult to self-inject insulin. This would likely lead to diminishing a patient's quality of life. We made a new device to introduce self-injection of insulin by a patient's non-dominant hand and tested it. This device was built into a 600-g block of wood 11.5 cm x 8 cm x 8 cm, to be used with the InnoLet insulin kit system (Novo Nordisk Pharmaceuticals Inc., Bagsvaerd, Denmark). It had an insulin injector clamp on the front and a needle holder on the top. The bottom and the back were covered with silicon rubber, which allows the device's own weight to affix it on a table. The insulin injector is placed upright in a holder and fastened with a bar. A needle is installed on the insulin injector with a needle cap. After this cap was removed, the patient could remove any air bubbles by pushing 2 units of insulin through the needle. After the insulin injector was unfastened from the device, the patient injected the insulin subcutaneously into his abdomen or thigh. Then, the insulin injector was removed from the device. We introduced this device in a 59-year-old man with type 2 diabetes mellitus who had suffered from ischemic cerebral infarction in the left middle cerebral artery distribution, resulting in complete right hemiparesis. Our patient mastered this procedure within a few days. At the time of discharge, he could self-inject regular human insulin in a dose of 16 units in the morning, 6 units at noon, and 8 units in the evening. Two weeks after he was admitted to our hospital, he continued independent insulin self-injection three times per day without any help. His hemoglobin A(1c) level gradually decreased until it reached 5.7%. The self-injection of insulin may be introduced with a new device by the non-dominant hand in a patient with diabetes having a disabled dominant hand.
Diabetes Technol Ther 2004 Aug
PMID:A new device to introduce self-injection of insulin by his non-dominant hand in a patient with hemiplegia. 1532 Oct 7


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