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Thai

Journal

of

Neurology

วารสาร

ประสาทวทยา

แหงประเทศไทย

ISSN

2 2 2 8 - 9 8 0 1

คณะบรรณาธการของวารสารประสาทวทยาแหงประเทศไทย

บรรณาธการหลก

นพ.สมศกด เทยมเกา

สาขาวชาประสาทวทยา ภาควชาอายรศาสตร คณะแพทยศาสตร มหาวทยาลยขอนแกน

บรรณธการรวม

1. นพ.เมธา อภวฒนกล กลมงานประสาทวทยา สถาบนประสาทวทยา

2. นพ.สรตน ตนประเวช. สาขาวชาประสาทวทยา มหาวทยาลยเชยงใหม

3. นพ.พรชย สถรปญญา สาขาวชาประสาทวทยา มหาวทยาลยสงขลานครนทร

4. นพ.โยธน ชนวลญช สาขาวชาประสาทวทยา โรงพยาบาลพระมงกฎเกลา

5. นพ.เจษฎา อดมมงคล สาขาวชาประสาทวทยา โรงพยาบาลพระมงกฎเกลา

6. นพ.ชศกด ลโมทย สาขาวชาประสาทวทยา โรงพยาบาลจฬาลงกรณ

7. นพ.ดำารงวทย สขะจนตนากาญจน กลมงานประสาทวทยา โรงพยาบาลราชวถ

8. พญ.สรกลยา พลผล กลมงานประสาทวทยา โรงพยาบาลราชวถ

9. นพ.กองเกยรต กณฑกนทรากร สาขาวชาประสาทวทยา มหาวทยาลยธรรมศาสตร

10. นพ.สมบต มงทวพงษา สาขาวชาประสาทวทยา มหาวทยาลยธรรมศาสตร

11. นพ.นรงฤทธ เกษมทรพย สาขาวชาประสาทวทยา มหาวทยาลยขอนแกน

12. พญ.นาราพร ประยรววฒน สาขาวชาประสาทวทยา คณะแพทยศาสตร ศรราชพยาบาล

13. พญ.วรพรรณ เสนาณรงค สาขาวชาประสาทวทยา คณะแพทยศาสตร ศรราชพยาบาล

14. นพ.สพจน ตลยเดชานนท สาขาวชาประสาทวทยา คณะแพทยศาสตร โรงพยาบาลรามาธบด

คณะบรรณาธการ

ประธานวชาการสมาคมโรคลมชกแหงประเทศไทย

ประธานวชาการสมาคมหลอดเลอดสมองแหงประเทศไทย

ประธานวชาการสมาคมโรคสมองเสอมแหงประเทศไทย

ประธานวชาการชมรมโรคพารกนสนแหงประเทศไทย

ประธานวชาการชมรมศกษาโรคปวดศรษะ

ประธานวชาการชมรมโรคเสนประสาทรวมกลามเนอและเวชศาสตรไฟฟาวนจฉย

ประธานวชาการชมรม Multiple Sclerosis

สำานกงานสมาคมประสาทวทยาแหงประเทศไทย

เลขท 2 อาคารเฉลมพระบารม 50 ป ซอยศนยวจย ถ.เพชรบรตดใหม หวยขวาง บางกะป

กรงเทพฯ 10320 E-mail : [email protected]

www.neurothai.org

คณะกรรมการบรหารสมาคมประสาทวทยาแหงประเทศไทย

สมยวาระ พ.ศ.2560-2562

1. ศ.พญ.รวพรรณ วทรพณชย ทปรกษา

2. พลตร.พญ.จตถนอม สวรรณเตมย ทปรกษา

3. ศ.นพ.นพนธ พวงวรนทร ทปรกษา

4. รศ.พญ.ศวาพร จนทรกระจาง ทปรกษา

5. ศ.นพ.กมมนต พนธมจนดา ทปรกษา

6. นายแพทยสมศกด ลพธกลธรรม ทปรกษา

7. นายแพทยสมชาย โตวณะบตร ทปรกษา

8. รศ.พญ.นาราพร ประยรววฒน ทปรกษา

9. นพ.ไพโรจน บญคงช น นายกสมาคม

10. ผศ.นพ.สพจน ตลยาเดชานนท อปนายก คนท 1

11. ศ.พญ.นจศร ชาญณรงค อปนายก คนท 2

12. พญ.ทศนย ตนตฤทธศกด เลขาธการ

13. ศ.นพ.กองเกยรต กณฑกนทรากร ประธานฝายวชาการ

14. พนโท พญ.พาสร สทธนามสวรรณ เหรญญก

15. รศ.นพ.สมศกด เทยมเกา บรรณาธการวารสาร ประสาทวทยา

16. รศ.พญ.กนกวรรณ บญญพสฎฐ ประธานฝายฝกอบรมและสอบ

17. ศ.นพ.รงโรจน พทยศร ประธานฝายวจย และวเทศสมพนธ

18. ดร.นพ.จรงไทย เดชเทวพร รองประธานฝายวชาการ และฝายกจกรรมพเศษ

19. นพ.สรตน ตนประเวช นายทะเบยน

20. รศ.นพ.สมบต มงทวพงษา รองเลขาธการ และงานฝายกฏหมาย

21. พนเอก นพ.เจษฎา อดมมงคล ประชาสมพนธ

22. รศ.พญ.วรพรรณ เสนาณรงค ปฏคม

23. พญ.สญสณย พงษภกด รองเลขาธการ และงานฝายกฏหมาย

24. รศ.นพ.พรชย สถรปญญา ตวแทนภาคใต และผชวยฝายวจย

25. นพ.อาคม อารยาวชานนท ตวแทนภาคตะวนออกเฉยงเหนอ และผชวยฝายกจกรรมพเศษ

26. นพ.วฑรย จนทรโรทย ตวแทนภาคตะวนออก และผชวยปฏคม

คณะกรรมการบรหารชมรมโรคพารกนสนไทย ภายใตสมาคมประสาทวทยาแหงประเทศไทย

สมยวาระ พ.ศ. 2560-2562

1. พนโท นพ.ปานศร ไชยรงสฤษด ประธานชมรม

2. นพ.อครวฒ วรยเวชกล รองประธานชมรม

3. พญ.ณฎลดา ลโมทย เหรญญก

4. ผศ.นพ.ประวณ โลหเลขา ประธานวชาการ

5. นพ.ไพโรจน บญคงชน ทปรกษาคณะกรรมการบรหาร

6. นพ.อภชาต พศาลพงศ ทปรกษาคณะกรรมการบรหาร

7. ศ.นพ.รงโรจน พทยศร ทปรกษาคณะกรรมการบรหาร

8. พญ.จรดา ศรเงน เลขานการทปรกษาคณะกรรมการบรหาร

9. พญ.อรพร สทธบรณะ กรรมการ

10. พญ.ปรยา จาโกตา กรรมการ

11. พญ.อรอนงค จตรกฤษฎากล กรรมการ

12. รศ.พญ.สวรรณา เศรษฐวชราวนช กรรมการ

13. นพ.วฑรย จนทรโรทย กรรมการ

14. นพ.อาคม อารยาวชานนท กรรมการ

15. นพ.สรตน ตนประเวช กรรมการ

16. นพ.สทธ เพชรรชตะชาต กรรมการ

17. นพ.สรตน สงหมณสกลชย กรรมการ

18. นพ.ปรชญา ศรวานชภม กรรมการ

19. พญ.พทธมน ปญญาแกว กรรมการ

20. ดร.สรสา โคงประเสรฐ กรรมการ

คณะกรรมการทปรกษา

1. พลตรหญง ศ.คลนก พญ.จตถนอม สวรรณเตมย

2. ศ.พญ.รวพรรณ วทรพณชย

3. ศ.นพ.นพนธ พวงวรนทร

4. รศ.พญ.ศวาพร จนทรกระจาง

5. นพ.สมศกด ลพธกลธรรม

6. ศ.นพ.กมมนต พนธมจนดา

7. นพ.สมชาย โตวณะบตร

8. รศ.พญ.นาราพร ประยรววฒน

คณะกรรมการบรหารชมรมศกษาโรคปวดศรษะ ภายใตสมาคมประสาทวทยาแหงประเทศไทย

สมยวาระ พ.ศ.2560-2562

1. ศ.นพ.กมมนต พนธมจนดา ทปรกษา


3. ศ.นพ.อนนต ศรเกตรตขจร ประธานชมรม

4. นพ.สรตน ตนประเวช ประธานฝายวชาการ

5. นพ.วฒนชย โชตนยวตรกล กรรมการ

6. พญ.เพชรรตน ดสตานนท กรรมการ

7. ผศ.นพ.ธนนทร อศววเชยรจนดา กรรมการ

8. ผศ.ดร.วระ สพรศลปชย กรรมการ

9. ผศ.ดร.ศภางค มณศรเลอกรอง กรรมการ

10. นพ.กรตกร วองไววาณชย เลขานการ

คณะกรรมการชมรมโรคเสนประสาทรวมกลามเนอ และเวชศาสตรไฟฟาวนจฉย

ภายใตสมาคมประสาทวทยาแหงประเทศไทย สมยวาระ พ.ศ. 2560-2562

1. ศ.นพ.ประเสรฐ บญเกด ทปรกษา

2. ศ.พญ.รวพรรณ วทรพณชย ทปรกษา


4. รศ.พญ.ตมทพย แสงรจ ทปรกษา

5. ศ.นพ.กองเกยรต กณฑกนทรากร ประธานชมรม

6. รศ.พญ.กนกวรรณ บญญพสฏฐ รองประธาน

7. ดร.นพ.จรงไทย เดชเทวพร เลขาธการ และประธานวชาการ

8. ผศ.นพ.ชยยศ คงคตธรรม เหรญญก

9. นพ.นฤพชร สวนประเสรฐ ปฏคม และทะเบยน

10. ศ.ดร.นพ.ธรธร พลเกษ กรรมการ

11. ผศ.นพ.ณฐ พสธารชาต กรรมการ

12. พญ.สญสณย พงษภกด กรรมการ

13. ผศ.พญ.อรณ แสนมณชย กรรมการ

14. นพ.ธเนศ เตมกลนจนทน กรรมการ

15. พญ.จนทมา แทนบญ กรรมการ

อนกรรมการพจารณาใหความเหนจรยธรรมทางการแพทย สมยวาระ พ.ศ.2560-2562

1. นายแพทยสมศกด ลพธกลธรรม ประธานอนกรรมการ

2. นายแพทยกมมนต พนธมจนดา อนกรรมการ

3. นายแพทยสมชาย โตวณะบตร อนกรรมการ

4. แพทยหญงนาราพร ประยรววฒน อนกรรมการ

5. นายแพทยสามารถ นธนนทน อนกรรมการ

6. นายแพทยสพจน ตลยาเดชานนท อนกรรมกา

7. แพทยหญงสญสณย พงษภกด อนกรรมการ

8. นายแพทยสมบต มงทวพงษา อนกรรมการและเลขานการ

บทบรรณาธการ

เรยน สมาชกสมาคมประสาทวทยาแหงประเทศไทย

สวสดทานสมาชกสมาคมประสาทวทยาและทานผสนใจทกทานวารสารฉบบนเปนวารสารทจดทำาลวงหนา

เพอเผยแพรบทคดยอผลงานวจยของแพทยประจำาบานประจำาปการศกษา2561จำานวน39เรองซงทกๆการศกษานน

นาสนใจอยางยงผมหวงวาผลงานวจยฉบบสมบรณของงานวจยเหลานจะไดตพมพเผยแพรเพอใหผสนใจไดศกษา

เพมเตมอยางละเอยด

ในชวงเวลา6ปทผานมานผมเหนการพฒนางานวจยของแพทยประจำาบานทมคณภาพสงขนทกๆป

มาอยางตอเนอง ซงเปนการบงชวาคณภาพการฝกอบรมดานการวจยของแพทยประจำาบานประสาทวทยาสงขน

อยางไรกตามเปาหมายสงสดของการฝกอบรมแพทยประจำาบานนนคอการสรางประสาทแพทยทดสามารถใหการ

รกษาผปวยระบบประสาทและผปวยอนๆอยางดดงนนผมมความหวงวาแพทยประจำาบานทกคนทจบการฝกอบรม

ในปนจะเปนประสาทแพทยทดชวยเหลอผปวยใหหายจากความเจบปวย

รศ.นพ. สมศกด เทยมเกา

บรรณาธการ

แกคำาผดวารสารฉบบท2ป2562เดอนเมษายน-มถนายนหนาท17ดงน

บดภทรวรฐตอนนตอายรแพทยระบบประสาท กลมงานอายรกรรมโรงพยาบาลนครปฐมเปน

บดภทรวรฐตอนนตแพทยเวชศาสตรฉกเฉน กลมงานอบตเหตและฉกเฉนโรงพยาบาลนครปฐม

คำาแนะนำาสำาหรบผนพนธในการสงบทความทางวชาการเพอรบการพจารณาลงในวารสารประสาทวทยาแหงประเทศไทย

(Thai Journal of Neurology)

วารสารประสาทวทยาแหงประเทศไทย หรอ

Thai Journal of Neurology เปนวารสารทจดทำาขน

เพอเผยแพรความรโรคทางระบบประสาทและความร

ทางประสาทวทยาศาสตรในทกสาขาทเกยวของ เชน

การเรยนรพฤตกรรมสารสนเทศความปวดจตเวชศาสตร

และอนๆตอสมาชกสมาคมฯแพทยสาขาวชาทเกยวของ

นกวทยาศาสตร ผสนใจดานประสาทวทยาศาสตร

เปนสอกลางระหวางสมาชกสมาคมฯและผสนใจเผยแพร

ผลงานทางวชาการและผลงานวจยของสมาชกสมาคมฯ

แพทยประจำาบานและแพทยตอยอดดานประสาทวทยา

นกศกษาสาขาประสาทวทยาศาสตร และเพอพฒนา

องคความร ใหม สง เสรมการศกษาตอเ นอง โดย

กองบรรณาธการสงวนสทธในการตรวจทางแกไขตนฉบบ

และพจารณาตพมพตามความเหมาะสม บทความ

ทกประเภท จะไดรบการพจารณาถงความถกตอง

ความนาเชอถอความนาสนใจตลอดจนความเหมาะสมของ

เนอหาจากผทรงคณวฒจากในหรอนอกกองบรรณาธการ

วารสารมหลกเกณฑและคำาแนะนำาทวไปดงตอไปน

1. ประเภทของบทความบทความทจะไดรบการ

ตพมพในวารสารอาจเปนบทความประเภทใดประเภทหนง

ดงตอไปน

1.1 บทบรรณาธการ (Editorial)เปนบทความ

สนๆทบรรณาธการและผทรงคณวฒทกองบรรณาธการ

เหนสมควร เขยนแสดงความคดเหนในแงมมตาง ๆ

เกยวกบบทความในวารสารหรอเรองทบคคลนนเชยวชาญ

1.2 บทความทวไป (General article) เปน

บทความวชาการดานประสาทวทยาและประสาท

วทยาศาสตรและสาขาวชาอนทเกยวของ

1.3 บทความปรทศน (Review article) เปน

บทความทเขยนจากการรวบรวมความรในเรองใดเรอง

หนงทางประสาทวทยาและประสาทวทยาศาสตร และ

สาขาวชาอนทเกยวของ ทผเขยนไดจากการอานและ

วเคราะหจากวารสารตาง ๆควรเปนบทความทรวบรวม

ความรใหม ๆ ทนาสนใจทผอานสามารถนำาไปประยกต

ไดโดยอาจมบทสรปหรอขอคดเหนของผเขยนดวยกได

1.4 นพนธตนฉบบ (Original article) เปนเรอง

รายงานผลการศกษาวจยทางประสาทวทยาและประสาท

วทยาศาสตรและสาขาวชาอนทเกยวของของผเขยนเอง

ประกอบดวยบทคดยอ บทนำา วสดและวธการ ผลการ

ศกษาสรปแบะวจารณผลการศกษาและเอกสารอางอง

1.5 ยอวารสาร (Journal reading) เปนเรองยอ

ของบทความทนาสนใจทางประสาทวทยาและประสาท


1.6 วทยาการกาวหนา (Recent advance)

เปนบทความสน ๆ ทนาสนใจแสดงถงความร ความ

กาวหนาทางวชาการดานประสาทวทยาและประสาท


1.7 จดหมายถงบรรณาธการ (Letter to the

editor) อาจเปนขอคดเหนเกยวกบบทความทตพมพไป

แลวในวารสารและกองบรรณาธการไดพจารณาเหนวาจะ

เปนประโยชนตอผอานทานอนหรออาจเปนผลการศกษา

การคนพบความรใหมๆทสนและสมบรณในตว

1.8 กรณศกษานาสนใจ (Interesting case)

เปนรายงานผปวยทนาสนใจหรอผปวยทมการวนจฉยท

พบไมบอยผอานจะไดเรยนรจากตวอยางผปวย

1.9 บทความอน ๆ ทกองบรรณาธการเหน

สมควรเผยแพร

2. การเตรยมตนฉบบ

2.1 ใหพมพตนฉบบในกระดาษขาวขนาดA4

(8.5 x 11นว) โดยพมพหนาเดยวเวนระยะหางระหวาง

บรรทด2ชวง(doublespace)เหลอขอบกระดาษแตละ

ดานไมนอยกวา1นวและใสเลขหนากำากบไวทกหนา

2.2 หนาแรกประกอบดวย ชอเรอง ชอผเขยน

และสถานททำางานภาษาไทยและภาษาองกฤษ และ

ระบชอผเขยนทรบผดชอบในการตดตอ(corresponding

author) ไวใหชดเจนชอเรองควรสนและไดใจความตรง

ตามเนอเรอง

2.3 เนอเรองและการใชภาษาเนอเรองอาจเปน

ภาษาไทยหรอภาษาองกฤษถาเปนภาษาไทยใหยดหลก

พจนานกรมฉบบราชบณฑตยสถานและควรใชภาษาไทย

ใหมากทสดยกเวนคำาภาษาองกฤษทแปลแลวไดใจความ

ไมชดเจน

2.4 รปภาพและตาราง ใหพมพแยกตางหาก

หนาละ1รายการโดยมคำาอธบายรปภาพเขยนแยกไวตาง

หากรปภาพทใชถาเปนรปจรงใหใชรปถายขาว-ดำาขนาด

3”x5”ถาเปนภาพเขยนใหเขยนดวยหมกดำาบนกระดาษ

มนสขาวหรอเตรยมในรปแบบdigitalfileทมความคมชด

สง

2.5 นพนธตนฉบบใหเรยงลำาดบเนอหาดงน

บทคดยอภาษาไทยและภาษาองกฤษพรอม

คำาสำาคญ(keyword)ไมเกน5คำาบทนำา(introduction)

วสดและวธการ(materialandmethods)ผลการศกษา

(results)สรปและวจารณผลการศกษา(conclusionand

discussion) กตตกรรมประกาศ (acknowledgement)

และเอกสารอางอง(references)

2.6 เอกสารอางองใชตามระบบVancouver’s

InternationalCommittee ofMedical Journal โดยใส

หมายเลขเรยงลำาดบทอางองในเนอเรอง (superscript)

โดยบทความทมผเขยนจำานวน3คนหรอนอยกวาใหใส

ชอผเขยนทกคนถามากกวา3คนใหใสชอเฉพาะ3คน

แรกตามดวยอกษรetalดงตวอยาง

วารสารภาษาองกฤษ

LeelayuwatC,HollinsworthP,PummerS,etal.

Antibody reactivity profiles following immunisation

withdiversepeptidesof thePERB11(MIC)family.

ClinExpImmunol1996;106:568-76.

วารสารทมบรรณาธการ

SolbergHe.Establishmentanduseofreference

valueswithanintroductiontostatisticaltechnique.

In:TietzNW,ed.FundamentalsofClinicalChemistry.

3rd.ed.Philadelphia:WBSaunders,1987:202-12.

3. การสงตนฉบบ

สงตนฉบบ1ชดของบทความทกประเภทในรปแบบ

ไฟลเอกสารไปท อเมลลของ รศ.นพ.สมศกด เทยมเกา

[email protected] พรอมระบรายละเอยดเกยวกบ

โปรแกรมทใชและชอไฟลเอกสารของบทความใหละเอยด

และชดเจน

4. เงอนไขในการพมพ

4.1 เรองทสงมาลงพมพตองไมเคยตพมพหรอ

กำาลงรอตพมพในวารสารอนหากเคยนำาเสนอในทประชม

วชาการใดใหระบเปนเชงอรรถ(footnote)ไวในหนาแรก

ของบทความลขสทธในการพมพเผยแพรของบทความท

ไดรบการตพมพเปนของวารสาร

4.2 ขอความหรอขอคดเหนตางๆ เปนของผเขยน

บทความนน ๆ ไมใชความเหนของกองบรรณาธการหรอ

ของวารสารและไมใชความเหนของสมาคมประสาทวทยา

แหงประเทศไทย

4.3 สมาคมฯจะมอบวารสาร5เลมใหกบผเขยน

ทรบผดชอบในการตดตอเปนอภนนทนาการ

4.4 สมาคมฯ จะมอบคาเผยแพรผลงานวจย

นพนธตนฉบบกรณผรบผดชอบบทความหรอผนพนธหลก

เปนแพทยประจำาบานหรอแพทยตอยอดประสาทวทยา

สารบญ

ORIGINAL ARTICLE- NaturalHistory&OutcomesofTreatmentinGuillain-Barre’Syndrome: 1

A1YearRetrospectiveStudyatSunpasitthiprasongHospital

- TheClinicalCharacteristicofNeuropathyinPrediabeticandDiabeticPatients 12

- RapidEyeMovementSleepBehaviorDisorderinParkinson’sDisease 21

INTERESTING CASE- AManwithBurningPainontheLeftLeg 31

บทคดยอ ผลงานวจยแพทยประจำาบาน แพทยตอยอด สาขาประสาทวทยา ประจำาปการศกษา 2561- IntracerebralHemorrhagePostIntravenousThrombolyticTherapy 36

inAcuteIschemicStrokePatientwithLeukoaraiosis

- MyastheniaGravisinThyroidDisorders 37

- TheStudyofCharacteristicsofTremorDuringWalkingandCompare 39

withTremorCharacteristicsDuringtheRestingPositionAmongClassITremorDominant

Parkinson’sDiseasePatientsbyUsing3-AxisGyroscope

- ClinicalFeaturesofParaneoplasticSyndromeRelatedtoAnti-neuronal 41

NuclearAutoantibodyType2(ANNA2):CaseSeriesandReviewofLiterature

- PrevalenceofSupineandNocturnalHypertension,AssociatedFactorsandSleepPosition 42

EffecttoBloodPressureinParkinson’sDiseasePatients

- DetectionofImpairedFingerDexteritybyObjectiveKeyboardTypingTest 43

inParkinson’sDisease:AFeasibilityStudy

- DeepBrainStimulationforAdvancedParkinson’sDisease:RetrospectiveAnalysis 44

andLong-TermOutcomeof55ConsecutivelyOperatedCases

- DiagnosticPerformanceoftheNewFAASStrokeScreeningToolinPatients 45

WhoPresentedtotheEmergencyRoomwithNeurologicalSymptomsinThailand:

AMulti-centerStudy

- TheRetrospectiveStudytoEvaluatedEfficacyBotulinumToxinAInjection, 47

GreaterOccipitalNerveBlockade,OutpatientandInpatientDetoxificationTreatment

inMedicationOveruseHeadacheinHeadacheClinic,NorthernNeuroscienceCentre,

ChiangMaiUniversity

- BehaviorsandTriggerFactorsinEpisodicMigraineversusChronicMigraine 49

inHeadacheClinic,NorthernNeuroscienceCentre,ChiangMaiUniversity:

ACross-sectionalStudy

- EffectofInfluenzaVaccinationonLevelofPhenytoininThaiEpilepticPatientsTreated 50

withPhenytoin

- Pain,PolyneuropathyandDepressioninParkinson’sDisease:Prevalence,Characteristic, 51

andAssociatedFactors

- MRIFindingsinThaiPatientswithOpticNeuritis 52

- EpidemiologyandCharacteristicsofInfectioninPost-cardiacArrestPatientsTreated 53

byTargetedTemperatureManagementinThammasatUniversityHospital

- PhramongkutklaoOdorIdentificationKit:NormativeValuesinHealthyVolunteers 55

- ComparativeEffectivenessandSafetyofDabigatran,Rivaroxaban,andApixaban 56

inNonValvularAtrialFibrillation

- PhramongkutklaoOdorIdentificationKitasaDiagnosticToolforPatientswithParkinson’s 58

andAlzheimer’sDisease

- ValidationofaMobileApplicationforDetectingWearing-offinPatientswithParkinson’s 60

Disease;AProspective,BlindComparisontoaGoldStandardStudy

- SurveysofBehavioralandPsychologicalSymptomsofDementia(BPSD)inDementiaPatients 61

- StudyoftheAssociationbetweenHumanLeukocyteAntigens(HLA) 62

andCarbamazepine-InducedMaculopapularRashinThais

- Long-termVisualOutcomeofOpticNeuritisinNMOandHIVPatients 63

- InfarctPatterninAcuteIschemicStrokePatientswithAtrialFibrillation 64

byDiffusion-WeightedImaging

- EffectsofHandwritingExerciseonFunctionalOutcomeinParkinson’sDiseasePatients: 65

ARandomizedControlledTrial

- IncidenceandAssociatedFactorsofIntracranialHemorrhageafterIntravenous 66

ThrombolysisforAcuteIschemicStrokeinVajiraHospital

- PeripheralNeuropathyinLevodopa-treatedParkinson’sDiseasePatient 67

- APilot,ComparisonStudyoftheTreatmentforanAcuteAttackofNeuromyelitisOptica: 68

IntravenousMethylprednisolone(IVMP)withAdd-onPlasmaExchange(PLEX)

versusIntravenousMethylprednisoloneCombinedwithPlasmaExchange

- TheShort-termEffectofCombinedFacialExercisewithBotulinumToxinInjection 69

inClinicalPracticeinThaiPatientswithHemifacialSpasm:ARandomizedControlledPilot

CrossoverStudy

- AccuracyofSupport-VectorMachinesforDiagnosisofAlzheimer’sDisease 70

UsingVolumeofBrainObtainedbyStructuralMRIatSirirajHospital

- SymptomaticSeizureandEpilepsyafterAnteriorCirculationIschemicStrokeatSirirajHospital, 71

ATertiaryHospitalinThailand

- TheAssociationbetweenPerceptionofCognitiveDeclineandMildCognitiveImpairment 73

inNon-DementedPatientswithParkinson’sDisease

- AReliabilityandValidityStudyofASimpleAssessmentToolforEarlyDetection 74

ofPerioperativeStroke

- PredictingHospitalDischargeOutcomesamongPatientswithCryptococcalMeningitis 75

- PredictorsofClinicalOutcomesamongPatientswithBrainAbscessinThailand 76

- RoleofOpticCoherenceTomographyandVisualEvokePotentialTestinSymptomatic 78

andAsymptomaticOpticNeuritisPatientsinPrasatNeurologicalInstitute

- FactorsCorrelatedwithQualityofLifeinPatientswithAmyotrophicLateralSclerosis 80

atPrasatNeurologicalInstitute,CrossSectionalStudy

- ThePredictiveFactorsandLongTermSeizureOutcomesinPatients 82

withAutoimmuneEncephalitis

- PredictorsofOutcomesinStatusEpilepticus 84

- Self-ResolvedofLateOnsetMesialTemporalLobeEpilepsy;Suspicious 85

ofSero-NegativeImmune-MediatedLimbicEncephalitis

- ThePredictiveRiskFactorsofRelapseinInflammatoryDemyelinatingCNSDisease 87

inAQP4SeronegativeinThaiPatients

Vol.35 • NO.3 • 2019 1

Abstract

Background : Guillain-Barre'syndrome(GBS)

isoneofthemedicalemergencycondition,which

is characterized by acute onset, but treatable

polyneuropathy.Thenaturalhistoryandoutcomes

oftreatmentdataisfewinThailand,andneverbe

studiedinSunpasitthiprasonghospital.Theaimof

this study is to determine natural history and

outcomesoftreatmentofGBSinourhospital.

Material & Method: 26casesofGBSadmitted

during Jan 2012 –Dec2012were searchedby

ICD10inourhospitalelectronicdatabase.Brighton

criteria was applied for the diagnosis of GBS.

Epidemiologicdata, antecedent event, seasonal,

clinicalmanifestationdata,nerveconductionstudy

data,management,ModifiedRankin scaleat the

dayofadmission/dischargeand3-monthsfollowup

were collected.Comparison ofmodifiedRankin

scale at admisson, discharge and at 3-months

followupperiodwasdonetoassessoutcomesof

IVIG treatment. Dataswere analyzed by SPSS

version17.0.

Results: Theratioofmale/femaleinourGBS

patientswas2.25withameanageofonset46.65

±19.46years.OurstudyfoundthatGBShadhigh

prevalence in rainy season (50%).Most of the

patients had no history of antecedent events

(76.9%). Almost patients had generalize limbs

weakness(25patients,96.2%)withvaryingdegree.

Therewere 2 patients (7.7%) developed acute

respiratoryfailure.Byarrangingthemaccordingto

modifiedRankinscale(mRS),80.4%presentedwith

severesymptoms.(mRS4,5).Axonalandmixed

subtype is predominate in our study (52.9%).

16 patients (61.5%) received IVIG and nobody

received plasma exchange. At discharge, 17

Arkhom Arayawichanont, Paitoon Jongviriyavong

Department of Medicine, Sunpasitthiprasong Hospital

Corresponding author:

Arkhom Arayawichanont

Department of Medicine, Sunpasitthiprasong Hospital,

Muang District, Ubonratchathani Province, Thailand, 34000.

Natural History & Outcomes of

Treatment in Guillain-Barre'

Syndrome: A 1 Year Retrospective Study at

Sunpasitthiprasong Hospital

Arkhom ArayawichanontPaitoon Jongviriyavong

วารสารประสาทวทยาแหงประเทศไทย Vol.35 • NO.3 • 20192

Background:

GuillainBarré syndrome (GBS) is an acute

inflammatory polyradiculoneuropathy with an

autoimmuneetiology,whichhadbeendescribed

byGuillainG,BarréJA,andStrohlA.since1916.1

GBS,whichisoneofacurableemergencycondition

inneurology,isthecauseofacuteareflexicparalysis

and also can bemanifested with numbness,

ophthalmoplegia or dysautonomia.2,3,5,6,8 GBS

canbeseenallover theworld.The incidence in

Europeancountry is 1-1.8 case/100,000people/

year,andafrequencyofthediseaseisincreasing

20% in every 10 years after 10 years old.4-6

Themaleandfemaleratioisabout1.78.4Therefore,

therearenoreportof incidenceorprevalence in

Thailand.Data ofGBSabout natural history and

outcomes of treatment is few in Thailand, and

neverbestudiedinourhospital.

patients(65.4%)wereabletowalkwithoutassist

(mRS0-3).AComparisonofmRSofIVIGtreatment

inGBSpatientsduringadmissionandat3-month

followup, andduringdischargeandat 3-month

follow up showed improvementwith statistical

significancebypaired-sample T-test (p=0.0001

andp=0.0001respectively).

Conclusion: AxonalandmixedsubtypeofGBS

ispredominateinourstudy.OurGBSpatientswho

weretreatedwithIVIGhadgoodclinicaloutcomes

withlowmortalityrateandcomplication.

Keyword: Guillain-Barré syndrome,Natural

history,Outcome, Treatment, Sunpasitthiprasong

hospital

Methods:

AretrospectivestudyofGBSpatientsadmitted

in Sunpasitthiprasong hospital,Ubonratchathani

Province,ThailandduringJan2012–Dec2012was

donetodeterminenaturalhistoryandoutcomeof

management.Datawassearched inourhospital

electronic database by using ICD10 codewith

diagnosisofGBS,acuteinflammatorypolyneuropathy,

andMiller-Fischersyndrome.Brightoncriteriawas

applied for the diagnosis ofGBS by reviewing

original chartsof thepatients.9 26cases fullfilled

criterialevel1,2or3ofdiagnosticcertaintyforGBS

describedbySejvarJJ,etal.9Diagnosticcriteria

included:

1. Presenceofbilateral flaccidweaknessof

thelimbs,

2. Decreasedorabsentdeeptendonreflexes

inweaklimbs,

3. Monophasicillnesspattern,

4. Intervalbetweenonsetandnadirofweakness

between12hoursand28daysandsubsequent

clinicalplateau,

5. Absenceofanidentifiedalternativediagnosis

forweakness,and/or

6. Cerebrospinalfluid(CSF)profile:cytoalbu-

minologic dissociation (or just totalCSF

WBC below 50 cells/µl with or without

proteinelevation),and/or

7. Electrophysiologicstudiesconsistentwith

GBS.

All demographic data, antecedent event,

seasonal,clinicalpresentation,laboratoryandnerve

conductionstudydatawererecorded,aswellas

outcome of disease and treatment. Severity of

disease at admission, discharge, and 3-months

followupwererecordedbyusingmodifiedRankin

Vol.35 • NO.3 • 2019 3

scale(mRS).10GradingofmRSincluded:

0=nosymptomsatall,

1=nosignificantdisabilitydespitesymptoms;

abletocarryoutallusualdutiesandactivities,

2= slight disability; unable to carry out all

previousactivities,butabletolookafterownaffairs

withoutassistance,

3= moderatedisabilityrequiringsomehelp,

butabletowalkwithoutassistance,

4= moderateseveredisability;unabletowalk

without assistance and unable to attend to own

bodilyneedswithoutassistance,

5= severedisability;bedridden,incontinent,

andrequiringconstantnursingcareandattention,

and

6= death.

The patients who had severe generalized

weakness or developedacute respiratory failure

weretreatedwithplasmaexchangeorintravenous

immunoglobulin.Comparison ofmodifiedRankin

scale at discharge and at 3-months follow up

period was done to identify outcomes of IVIG

treatment.ThestudywasapprovedbytheResearch

EthicsCommitteeofSunpasitthiprasongHospital.

AllthedatawascollectedandanalyzedbySPSS

version17.

Results:

Twenty-sixpatientswererecruitedinthisstudy,

18(69.2%) patients were male and 8(30.8%)

patientswere female with ameanageof onset

46.65 ± 19.46 years (range16–74). The ratio of

male/femaleis2.25.Demographicandclinicaldata

weresummarizedinTable1.

Table 1: EpidemiologicaldataofGBSpatients

Number of case (N=26) Percentage (%)

Gender

Male

Female

18

8

69.2

30.8

Age (years)

15-30

31-45

46-60

>61

7

5

5

9

26.9

19.2

19.2

34.6

Antecedent events

No

Respiratoryinfection

GIinfection

HIVinfection

Vaccination

20

4

1

1

0

76.9

15.4

3.85

3.85

0

Season

Winter

Summer

Rainy

5

8

13

19.2

30.8

50


Table 2: PresentingsymptomsandhospitalizedoutcomesofGBSpatients

Symptoms Number of case (N=26) Percentage (%)

Limbweakness 25 96.2

Peripheralsensoryloss 21 80.8

Limbweaknessandsensoryloss 21 80.8

Ophthalmoparesis 0 0

Ataxia 1 3.8

Facialdiplegia 4 15.4

Bulbarpalsy 5 19.2

Acuterespiratoryfailure 2 7.7

Headache 1 3.8

Neuropathicpain 3 11.5

Arrhythmia 0 0

Hospital outcomes

Improvement

Noimprovement

Hospitalacquiredinfection

Death

17

9

2

2

65.4

34.6

7.7

7.7

By arranging them according tomodified

Rankinscale(mRS),19.2%ofpatientswereableto

walkwithoutassist(mRS1,2and3).TheOthers

80.8%presentedwithseveresymptoms (mRS4,

5).BrightoncriteriaandmodifiedRankinscaleat

admissionofGBSpatientswaspresentedinTable

3andTable4respectively.

OurstudyfoundthatGBShadhighprevalence

in rainy season, while 50% of patients were

diagnosed.Mostofthepatientshadnohistoryof

antecedentinfectionorvaccination(76.9%).Only

15.4%ofpatientshadhistoryof respiratory tract

infectionbeforetheonsetofGBS.

Almost of thepatients hadgeneralize limbs

weakness(25patients,96.2%),withvaryingdegree

ofseverity.Twopatients(7.7%)developedacute

respiratoryfailurewithin3daysafteradmission.5

patients(19.2%)hadbulbarpalsy,and2patients

(15.4%) presentedwith facial palsy. Presenting

symptomsofGBSandhospitalizedoutcomeare

presentedinTable2.

Vol.35 • NO.3 • 2019 5

Table 3: BrightoncriteriaofGBSpatients

Level of diagnostic certainty of Brighton criteria Number of case (N=26) Percentage (%)

Level1 7 26.9

Level2 13 50

Level3 6 23.1

Table 4: ModifiedRankinScale(mRS)atadmission

ofGBSpatients

mRS Number of case (N=26) Percent (%)

0 0 0

1 2 7.7

2 0 0

3 3 11.5

4 17 65.4

5 4 15.4

Lumbar puncturewas done in 24 patients

(92.3%),and75%ofthemshowalbuminocytologic

dissociationprofile.Nerveconduction studywas

donein17patients(65.4%),and4patients(23.54%

of NCS group) had no evidence of peripheral

neuropathy. Thedata of nerveconduction study

wasshowninTable5.

Table 5: Resultsofnerveconductionstudy(NCS)inGBSpatients

Results Number of case Percentage (%) Percentage (%) among NCS group

Noevidenceofperipheralneuropathy 4 15.4 23.5

Demyelination 4 15.4 23.5

Axonopathy 6 23.1 35.3

Mixed 3 11.5 17.6

Notdone 9 34.6 -

Total 26 100 100

Inmildly affected patients, they received

supportivemanagement.Patientswhohadmoderate

toseveredegreeofdiseasereceivedtreatmentwith

intravenous immunoglobulin (IVIG). 16 patients

(61.5%)receivedIVIGandnobodyreceivedplasma

exchange. 10patients (38.5%) received neither

IVIGnorplasmaexchangeduetomildsymptoms.

Atdischarge,17patients(65.4%)wereabletowalk

withoutassist(mRS0-3),5patients(19.2%)needed

help to walk, and 2 patients (7.7%) were bed

ridden.2patients(7.7%)diedofhospitalacquired

pneumonia.Patientwere followed in themedical

outpatient clinic, the data were collected at 3

monthsafterdischarge.22patientswereable to

walkwithoutassist.Nooneremainedbed-ridden,

2 patients couldwalkwith assist.MRS ofGBS

patients at admission, discharge and 3-months

followupwasshowninTable6.


Table 6: ModifiedRankinscale(mRS)ofGBSpatients

MRS Admission

Number of case, (%)

Discharge

Number of case, (%)

3-months follow up

Number of case, (%)

0 0,(0) 0,(0) 3,(12.5)

1 2,(7.7) 2,(7.7) 14,(58.4)

2 0,(0) 0,(0) 5,(20.8)

3 3,(11.5) 15,(57.7) 0,(0)

4 17,(65.4) 5,(19.2) 2,(8.3)

5 4,(15.4) 2,(7.7) 0,(0)

6(Dead) 0 2,(7.7) 0,(0)

Total 26,(100) 26,(100) 24,(100)

ComparisonofmodifiedRankinScale(mRS)

ofIVIGtreatmentinGBSpatientsduringadmission

andat3-monthfollowup,andduringdischargeand

at 3-month follow up showed improvementwith

statisticalsignificancebypaired-sampleT-test(p=

0.0001andp=0.0001respectively).Insupportive

group,thepatientsalsohadimprovementofmRS,

when compared admissionmRSwith discharge

mRS,admissionmRSwith3-monthsfollowupMRS,

anddischargemRSwith3-monthsfollowupmRS

by paired-sample T-test (p= 0.0005, p= 0.001,

andp=0.0001 respectively). Thecomparisonof

treatments in GBS patients both intravenous

immunoglobulin group and supportive group at

admission and discharge, at admission and

3-monthsfollowup,andatdischargeand3-months

follow up are presented in Table 7, 8, and 9

respectively.

The compareddata of our studywith other

GBSstudiesinAsiaareshowninTable10.

Table 7: ComparisonoftreatmentsinGBSpatientsatadmissionanddischarge

Patients mRS at

admission

mRS at

discharge

Paired differences T score P value

Mean SD 95% CI of

difference

IVIGtreatment

(16patients,61.5%)

3.94±0.929 3.69±1.25 0.25 0.856 -0.25-0.706 1.168 0.261

Non-IVIGtreatment

(10patients,38.5%)

3.60±1.075 3.00±0.943 0.6 0.516 0.231-0.969 3.674 0.005

IVIG:Intravenousimmunoglobulin,mRS:modifiedRankinscale,*bypaired-sampleT-test

Vol.35 • NO.3 • 2019 7

Table 8: ComparisonoftreatmentsinGBSpatientsatadmissionand3-monthsfollowup

Patients mRS at

admission

mRS at

3-months

follow up


Mean SD 95% CI of

difference

IVIGtreatment

(16patients,61.5%)

3.94±0.929 1.88±1.857 2.063 1.806 1.1-3.025 4.568 0.0001

Non-IVIGtreatment

(10patients,38.5%)

3.6±1.075 1.4±1.075 2.2 1.135 1.388-3.012 6.128 0.0001


Table 9: ComparisonoftreatmentsinGBSpatientsatdischargeand3-monthsfollowup

Patients mRS at

discharge

mRS at

3-months

follow up


Mean SD 95% CI of

difference

IVIGtreatment

(16patients,61.5%)

3.69±1.25 1.88±1.857 1.813 1.223 1.161-2.464 5.928 0.0001

Non-IVIGtreatment

(10patients,38.5%)

3.00±0.943 1.4±1.075 1.6 0.843 0.997-2.203 6.0 0.0001


Table 10: ComparisonofourGBSstudyandotherAsiastudies

Clinical series Taiwan

Lyu RK,

et al14

Hong Kong

Hui AC, et al15

Harbin,

China

Cheng Q,

et al16

King

Chulalongkorn

Memorial

Hospital

Areeyapinan P,

et al12

Maharat

Nakhon

Ratchasima

Hospital

Mekvichai P,

et al 26

• Sunpasitthiprasong

Hospital

Arayawichanont A,

Jongviriyavong P.

Number 167 20 71 55 68 26

Mean age(year) 37 45 20±17 43±17 44 46.65±19.46

Male

Female

68%

32%

45%

55%

61%

39%

48%

52%

66%

34%

69.2%

30.8%

Season Spring NM Summer Cold,summer NM Rainy

Antecedent events

o Respiratory

infection

o Gastrointestinal

tractinfection

56%

2%

NM

25%

68%

11%

29%

7%

26.5%

4.4%

15.4%

3.8%


Clinical series Taiwan

Lyu RK,

et al14

Hong Kong

Hui AC, et al15

Harbin,

China

Cheng Q,

et al16

King

Chulalongkorn

Memorial

Hospital

Areeyapinan P,

et al12

Maharat

Nakhon

Ratchasima

Hospital

Mekvichai P,

et al 26

• Sunpasitthiprasong

Hospital

Arayawichanont A,

Jongviriyavong P.

Initial

presentation

Limbweakness

Limbnumbness

Bulbarpalsy

Facialpalsy

Backandleg

pain

Headache

Ptosis

Ataxia

Respiratory

failure

41%

38%

10%

0.5%

7%

4%

1.3%

8%

37%

100%

100%

NM

35%

45%

NM

20%

NM

NM

82%

17%

14%

32%

NM

NM

NM

NM

NM

87%

78%

31%

18%

13%

7%

0%

4%

22%

98.%

27.9%

14.7%

NM

NM

NM

NM

NM

26.5%

96.2%

80.8%

19.2%

15.4%

11.5%

3.8%

0%

3.8%

7.7%

Electrophysiologic

test

AIDP

Axonopathy

Mixed

71(100%)

49%

4%

NM

20(100%)

100%

0%

0%

25(35%)

96%

4%

0%

22(40%)

54%

46%

0%

14(20.6%)

14.2%

35.7%

35.7%

17(65.4%)

23.5%

35.3%

17.6%

AIDP:Acuteinflammatorydemyelinatingpolyneuropathy,NM:notmention

Discussion:

GuillainBarréSyndromehasmoreprevalence

inmen than woman in our study. The ratio of

mentowomenwiththesyndromeis2.25,whichis

similartothepreviousmeta-analysisofSejvarJJ,

etal.4[ratio1.78,(95%confidenceinterval,1.36to

2.33)].GBScanbemanifestedineveryyearoflife,

andfrequencyofthediseaseisincreasing20%in

every10yearsafter10yearsold.4Themeanageof

GBSpatientsinourstudy(46.65±19.46yearsold)

ishigherthanotherAsianstudies.12,14-16,26

Although GBS is considered a sporadic

disease,withoutaseasonalfactor11,13,abouthalfof

thecasesinourstudypresentedinrainyseason.

TwothirdsofGBSpatientsareprecededbysymp-

tomsofupperrespiratorytractinfectionordiarrhea.2

However,most of our cases had no history of

antecedentevents.Only15.4%ofourpatientshad

upperrespiratorytractinfectionbeforedeveloped

GBSsymptoms.Alackofawarenessandknowledge

aboutthediseases;suchasrespiratoryorgastro-

intestinalsymptoms,inruralareapatients,maybe

the reasonwhywehad fewpositive antecedent

events(23.1%)inthisstudy.Mostcommonclinical

presentationofourGBSpatientsarelimbsweakness

andnumbness, (96.2%,and80.8% respectively)

Vol.35 • NO.3 • 2019 9

that is not different from previous study,12, 14-16

followedbybulbarpalsyandfacialdiplegia(19.2%,

15.4% respectively). Severe respiratorymuscle

weaknesswasfoundabout30%ofGBScases.27

Therefore,ourreportfoundonly7.7%ofpatients.

Dysautonomic symptoms such as tachycardia,

bradycardia, hypotension, loss of sweating and

bowel,bladderdysfunctionwerenotfoundinour

patients.

Typically, theCSF inGBSpatients usually

showedalbuminocytologicdissociation,whichwas

found75%inourstudy.However,CSFproteinmay

be not elevated in the firstweek, andgradually

elevatedinmorethan90%ofthepatientsattheend

of the second week.18,19 Electrophysiological

testingisoneoftheconfirmatorytestfordiagnosis

of GBS and can be used to differentiateGBS

subtypes e.g. demyelination or axonopathy.

Subtypes of GBS were acute inflammatory

demyelinatingpolyneuropathy(AIDP),acutemotor

axonal neuropathy (AMAN), acutemotor-sensory

axonal neuropathy (AMSAN) andMiller Fisher

syndrome.18,19

Thus23.5%ofGBSpatientshadnormalNCS

results.Normal nerve conduction study can be

found in early stage of disease.As compare to

other Asian studies12,14-16,26, our study did

electrophysiologic testmore thanothers, except

Hongkongwhere 100% electrophysiologic test

couldbedone.Wefoundaxonalneuropathymore

than other studies (35.3%), which is a poor

prognostic factor of the disease.24,25 This is in

concordancewithdata fromMekvichaiP,etal.26

andAreeyapinan P, et al.12 The data of 3 Thai

GBS studies found that electrophysiologic study

had axonal and mixed neuropathy subtype

predominate in GBS patients, especially in

northeastprovincesofThailand.(Table10)

Mild disease can spontaneous recovery

without specific treatment.7,11,13,14 However, in

moderatetoseverecasesshouldbetreatedwith

plasma exchange or IVIG. Although, plasma

exchange(PE)was thefirst lineof treatment that

wasfoundtobeeffectiveinimprovingsymptoms

ofGBSpatients3,17,nooneinourstudyreceivedit.

This is because the intravenous immunoglobulin

(IVIG)isslightlysaferandmucheasiertogivethan

PE.20Moreover, plasmaexchangeneed invasive

procedureandstablemedicalcondition.Thereis

an evidence showing that IVIG administration

within2weeksafteronset,canspeeduprecovery

fromsevereGBSasmuchasPEdoes.20According

tomoderatequalityevidencefromonetrialwith249

participants, IVIGaddedtoPE isnotsignificantly

more effective than either alone.21-23Our study

showed good outcome of recovery after IVIG

treatmentinmoderatetosevereGBSpatientswith

statisticallysignificant.MortalityrateofGBSpatients

in our study is 7.7%,which is in same rangeas

otherstudies(1-18%).6,24

Ourstudyhasalimitationtoassessdisability

ratingscaleandtheBarthelindexofGBSpatients

duetoretrospectivestudydesign.

Conclusion:

Guillain-Barrésyndromehasmoreprevalence

inmenthanwomen.Themajorpresentingsymptoms

are generalize limbsweakness and numbness.

Axonalandmixedneuropathysubtypeispredominate

inThaistudies.Milddegreeofdiseasehasgood

clinicaloutcome.Inmoderatetoseveredegreeof

GBS,treatmentwithIVIGcanimproveandprovide

goodclinicaloutcomewithstatisticallysignificant

at3-monthfollowupperiod.SevereGBSpatients


shouldbetreatedwithintravenousimmunoglobulin

orplasmaexchangeinallofthepatients.

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radiculonévrite avec hyper-albuminose du liquide

céphalo-rachidiensans réactioncellulaire: remarques

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123-33.

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11. VanDoornPA,Ruts L, JacobsBC.Clinical features,

pathogenesis,andtreatmentofGuillain-Barrésyndrome.

LancetNeurol2008;7:939–50.

12. AreeyapinanP,etal.Guillain-BarreSyndrome:AClinical

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AssocThai2010;93:1150-5.

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reviewof106cases.BMCNeurology2013;13:95.

14. Lyu RK, Tang LM, Cheng SY, et al. Guillain-Barre

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NeurolNeurosurgPsychiatry1997;63:494-500.

15. HuiAC,ChowKM,TangAS,etal.Electrophysiological,

clinical and epidemiological study ofGuillain-Barre

SyndromeinHongKongChinese.JClinNeurosci2005;

12:134-6.

16. ChengQ,WangDS,JiangGX,etal.Distinctpatternof

age-specific incidence ofGuillain-Barre syndrome in

Harbin,China.JNeurol2002;249:25-32.

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esisandacuteGuillain-Barrésyndrome.Neurology1985;

35:1096-104.

18. Ropper AH,Wijicks EFM, Truax BT. Guillain-Barre

syndrome.Philadelphia:FADavis;1991.

19. HughesRA,CornblathDR.Guillain-Barre syndrome.

Lancet2005;366:1653-66.

20. HughesRAC, SwanAV, vanDoorn PA. Intravenous

immunoglobulin forGuillain-Barrésyndrome (Review);

TheCochraneCollaboration.PublishedbyJohnWiley&

Sons,Ltd,2012.

21. HauptWF,RosenowF,VanderVenC,etal.Sequential

treatmentofGuillain-Barrésyndromewithextracorporeal

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Apheresis1997;1:55–7.

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225-30.

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Abstract

Background:Diabetesmellitus isassociated

withawidespectrumofneuropathysyndromes.Up

to20%ofpatientswithnewlydiagnoseddiabetes

already have symptoms, are diabetic polyneuro

pathy but the relationship between peripheral

neuropathyandprediabetesremaincontroversial.

Objective: To determine the presence and

typeofpolyneuropathyinprediabeticanddiabetic

patientsandtocomparesensitivityoftheteststo

detect neuropathy in prediabetic and diabetic

patients.

Methods: Retrospectivestudyofpatientswith

diagnosisofprediabetesanddiabetes.

Results: Of76patients,40prediabeticand36

diabeticpatientswithavailablenerveconduction

studywere identified.Most of prediabetic and

diabeticpatients had symmetrical, sensorypoly-

neuropathy, followed by sensorimotor polyneu-

ropathy.Autonomicneuropathywascommonalso.

In addition, no significant difference of clinical

manifestations,monofilamenttest,nerveconduction

study, autonomic test inbothgroups.Amongall

neuropathictests,autonomictestappearedtobe

themostsensitivetestinprediabeticstage.

Conclusion:Prediabeticstagecancontribute

neuropathy, which is similar in diabetes. Auto-

nomic test ismore sensitive than routine taking

history,neurologicalexaminations,nerveconduc-

tionstudyandmonofilamenttesttodetectdiabetic

neuropathyinprediabeticpatients.

Keywords: diabeticpolyneuropathy;diabetic

autonomic neuropathy; prediabetes; diabetes;

peripheralneuropathy

Sawitta Srijinda, Narupat Suanprasert, Patcharapim

Masayaanon, Komsan Mingbun

Department of Neurology, Prasat Neurological Institute,

Bangkok, Thailand


Sawitta Srijinda

Email: [email protected]

312 Rajavithee Road, Bangkok, Thailand 10400

The Clinical Characteristic of

Neuropathy in Prediabetic and Diabetic

Patients

Sawitta SrijindaNarupat Suanprasert

Patcharapim MasayaanonKomsan Mingbun

Vol.35 • NO.3 • 2019 13

Introduction:

Diabetesmellitusisthemostcommoncause

of polyneuropathy. The prevalence of diabetic

neuropathywas risingwith the growing global

burdenofdiabeticmellitus.Fortheperipheralnerve,

diabeteswas associatedwith awide spectrum

ofneuropathysyndromes,rangingfromasympto-

matic,diabeticperipheralneuropathy(DPN),toa

severedisabling includingdiabetic lumbrosacral

radiculoplexus neuropathy anddiabeticbrachial

radiculoplexusneuropathy.1

Diabetic neuropathy projected to affect an

estimated366millionpeopleworldwideby2030.2,3

Nearly 50%ofdiabetespatientdevelopdiabetic

peripheralneuropathy(DPN).DPNusuallydevelops

on long-standing hyperglycemia, consequent

metabolicderangementsandmicrovesselaltera-

tions. It is frequentlyassociatedwithmicrovessel

retinalandkidneydisease.4Durationandseverity

ofhyperglycemiaisdirectlycorrelatedwithdegree

ofdiabeticneuropathyanditscomplication.Diabetic

neuropathy is a major cause of morbidity in

diabeticpatients,andmayaffectupto50%oflong-

standingdiabeticpatients.Themajorityofpatients

have distal symmetrical sensory predominant

polyneuropathy anddiabeticpainful neuropathy.

Diabeticautonomicneuropathyisalsocommonin

diabetic patients, which affect cardiovascular,

gastrointestinal, urogenital, thermoregulatory,

sudomotor, and pupillomotor function. Painless

myocardial infarction, suddendeath, congestive

heart failure are more common with diabetic

dysautonomia.Diabeticneuropathyusuallyaffect

nerve axon causing axonal degenerationwhich

typically affect the longest nerve fibers first (a

length-dependent process). Parasympathetic

nervesincludingvagalnervewereusuallyaffected.

Patients with DANmay initially have a relative

predominanceofsympatheticoutflowthatcontributes

to hypertension. Dysfunction of cardiovascular

autonomicactivity,reflectedbyreducedheartrate

variability,werestronglyassociatedwiththeriskof

cardiac events andoverallmortality. Evenwhen

DAN was subclinical, it still increases risk of

mortality.2

The early diagnosis of diabetic neuropathy

was important. Early diagnosis and recognition

allows for implementation of strategies intended

to prevent development of future complications.

Subclinicaldiabeticneuropathymaybereversed

or significantly improved with appropriate

intervention.2

Upto20%ofpatientswithnewlydiagnosed

diabetes alreadyhad sensory symptoms in their

lowerextremities.Studiesofnerveconductiontests

performedatthetimeofdiabetesmellitusdiagnosis

demonstratethatneuropathywasalreadypresent

inpatientswithoutneuropathicsymptoms.These

were raised the question that diabetic polyneu-

ropathyoccurringbeforeorduringtheprediabetic

stage.Previousstudiesreportedthatthefrequency

ofpainfulsmallfiberpolyneuropathywasincreased

inprediabeticpatient.5Contrastwithotherstudies,

theprevalenceofDPNwere not increased in in

prediabeticpatients.6,7Usually,diagnosisofDPN

needed abnormality in nerve conduction study

so diabetic small fiber neuropathy including

diabetic painful neuropathy and diabetic

autonomicneuropathymayunderestimated.Thus,

therelationshipbetweenperipheralneuropathyand

prediabetesremaincontroversial.


Theprimarygoalofthepresentstudywasto

determinetheclinicalcharacteristics,monofilament

tests,electrophysiologicalfindingsandautonomic

testsinprediabeticanddiabeticpatientsinasingle

center.Thesecondarygoalwastodeterminethe

sensitivity of the tests to detect neuropathy in

prediabeticanddiabeticpatients.

Methods:

PrasatNeurologicalInstitutionalReviewBoard

(IRB) approval, the nerve conduction study

registries were searched for the diagnosis of

prediabetes and diabetes dating between

January1st2015andDecember31st2017.

Thediagnosisofprediabeteswasestablished

by 1) values of FPG ≥ 100 – < 126mg/dL or

2)2-hourOGTTPGof≥140–<200mg/dL.The

diagnosisofdiabeteswasestablishedby1)values

ofFPG≥126or2)2-hourOGTTPGof≥200mg/

dL,or3)anA1c≥6.5%,orwereclassifiedasDM

iftheyhadpreviouslybeendiagnosed.

Once theprediabeticanddiabetic patients

wereidentified,themedicalrecordswerereviewed

to assess demographic,clinicalmanifestation,

durationofprediabeticor diabeticprior to 1st

evaluation,monofilament test,electrodiagnostic

studies and autonomic test including heart rate

variabilitytodeepbreathingandvalsavamanuever.

Diabetic retinopathy was diagnosed by

opthalmologist. For diabetic nephropathy,There

are diagnosis criteria included from KDIGO

2012:1)Urine to albumin-creatinineratio (ACR)

30-300mg/g.2)Glomerularfiltrationrate<60mL/

min/ 1.73m2 3)BP > 130/85mmHg. Two third

criteria were needed for suspected diabetic

nephropathy.

Althoughsuchpatientsdonotfulfillthecriteria,

aclinician’shigh indexofsuspicionmaywarrant

additionaldiagnostictestingorclosefollow-upto

detecttheonset.

Monofilament testing used for detecting

neuropathy via nylon. Testingwas performed

onfourplantarsitesoftheforefoot(greattoe,base

offirst,third,andfifthmetatarsals).Lackofperception

at any sitewasidentifiedtobeabnormalpositive

test.

Nerve conduction study were included

1)Motor study of bilateralmedian, ulnar,tibial

andperonealnerves.2)Sensorystudyofbilateral

median,ulnar,andsuralnerves.3)F-wavestudyof

bilateralmedian,ulnar,tibialandperonealnerves

4)H-reflexesatbilateralsoleusmuscle.

Autonomic testing including heart rate

variabilitytodeepbreathingandvalsavamanuever.

Heartratevariability on deep breathing isthe

physiologicalphenomenonofvariationinthetime

intervalbetweenheartbeatsontakedeepbreathing.

Itismeasuredbythevariationinthebeat-to-beat

interval.ReducedHRVhasbeen shown tobea

predictor of mortality. Thevalsava manuever

consists of forced expiration against a closed

glottisafterafullinspiration.Theresponsesreferto

thechangesinbloodpressureandpulsethatoccur

duringboththestrainphaseofthemaneuverand

the recovery period after the strain is released.

ThevalsalvaratioisderivedfromthemaximalHR

generatedbytheValsalvamaneuverdividedbythe

lowestHRfollowingthemaneuver.

The sensitivity of each tests for detect

neuropathy were evaluated inprediabeticand

diabeticpatientswhohadneuropathicsymptoms

withnormalphysicalexamination.

Vol.35 • NO.3 • 2019 15

Statistical analysis:

DataanalyseswereperformedusingtheSPSS

16.0 Software. Descriptive summaries were

presented as frequencies and percentages for

categoricalvariablesandmedian/meanandranges

comparewith independent t-test/MannWhitney

U-test for continuous variables. Comparisons

betweenprediabeticversusdiabeticpatientswere

performed using Fisher’s exact test or Pearson

chi-square test, as appropriate. All of the tests

weretwosided,andp-value less than0.05were

consideredasstatisticalsignificance.

Results:

Demographic and clinical characteristics

From the nerve conduction study registries

betweenJanuary1st,2015andDecember31st,2017

atPrasatNeurological Institute, 76patientswere

includedtothepresentstudy.Fortywerepredia-

beticpatientsand36werediabeticpatients.Of76

patients in thepresentstudy,52%ofprediabetic

patient and11%ofdiabeticpatientswerenewly

diagnosed.Thedemographicandclinicalcharac-

teristicshavebeenshowninTable1.

Table 1. Thedemographicofprediabetesanddiabetespatients

Prediabetes

( n=40)

Diabetes

(n=36)

P-value

Gender(male,%) 12(30%) 15(41.7%) 0.289

Ageat1stevaluation(years,mean,SD) 61.25(11.7) 59.19(12) 0.452

Durationofabnormalplasmaglucosepriorto1st

evaluation(years;mean,SD)

2.0(2.5) 4.81 (3.5) <0.001

Underlyingdisease

Hypertension(%)

Hyperlipidemia(%)

25(62.5)

29(72.5)

27(75)

32(88.9)

0.242

0.073

Bodymassindex(kg/m2,mean,SD) 27.1(8.7) 26.8(9.0) 0.820

Fastingglucose(mg/dl) 109.5(103.2-117.7) 166(131.2-237.2) <0.001

HbA1c(%) 6(5.8-6.3) 8(6.9-9.5) <0.001

Cholesterol(mg/dl) 223(181-250.7) 215.5(190-261.7) 0.424

Triglyceride(mg/dl) 122.5(78.5-162.25) 145(123.5-223.5) 0.028

LDL(mg/dl) 126(108.2-166.7) 123(110.2-148.5) 0.531

Creatinine(mg/dl) 0.7(0.6-0.8) 0.7(0.6-0.8) 0.576

Diabeticretinopathy(%)

Suspecteddiabeticnephropathy(%)

0(0)

0(0)

9 (27.3)

3(8.3)

0.001

0.102


Therewasnodifferenceintermofage,gender,

bodymass indexandother underlyingdiseases

betweenthestudygroups.Thedurationofabnormal

plasmaglucosepriorstudyindiabeticpatientswere

longerthanprediabeticpatients(2vs4.81years,

p=<0.001). Fastingblood sugar andHbA1c in

prediabetic patients were lower than diabetic

patients(109.5vs166,p<0.001)(6vs8,p<0.001)

Themajorityofprediabeticanddiabeticpatients

had symmetrical, sensorypolyneuropathy, follow

bysensorimotorpolyneuropathy.Mostpatientshad

decreasedsensation,72.2%inprediabeticpatients

and78.8%indiabeticpatients.Painwaspresentin

27.8% of prediabetic and 21.2% of diabetic

patients.40%ofprediabeticpatientand33.3%of

diabeticpatientshadhyporeflexiaorareflexia.The

majorityofpatientshadautonomicsymptomsand

morecommonindiabeticpatients(80%vs97.2%,

p=0.031).Themostcommonautonomicsymptom

waslightheadedness;followbyerectiledysfunction

inmale,persistentconstipation,decreasedsweating

and leaking of urine. Diabetic retinopathy and

suspected of diabetic nephropathy were not

presentinprediabeticpatients.Twentysevenpoint

three percent of diabetic patients had diabetic

retinopathyand8.3%had suspectedofdiabetic

nephropathy.

Monofilament tests, electrodiagnostic and

autonomic studies

Fortheteststodetectingneuropathy,theresult

werepresentedinTable2.Abnormalmonofilament

testwasfoundin25%ofprediabeticand44%of

diabeticpatients.Twentyfivepercentofthepredia-

beticand38.9%ofdiabeticpatientshadabnormal

nerveconductionstudy.Themostcommonabnor-

malityinnerveconductionstudywassensorimotor

axonalpolyneuropathywithorwithoutcarpaltunnel

syndrome.Abnormalitiesinnerveconductionstudy

weremore frequently found in diabetic than in

prediabeticpatientsbutdoesnotreachstatistical

significance. Also, evidence of carpal tunnel

syndromeby usingnerve conduction studywas

commoninbothstudygroups(68%inprediabetic

and56%indiabeticpatients).

Table 2. Theclinicalcharacteristicsofneuropathyinprediabetesanddiabetespatients

Prediabetes Diabetes P-value

Puresensory(%)

Sensorimotor(%)

27(67.5)

9(22.5)

24(66.7)

9(25.0)

Symmetricalpattern(%) 7(17.5) 8(22.2) 0.606

Hyporeflexiaorareflexia(%) 16(40) 12(33.3) 0.547

Sensorysymptom

Negativesensorysymptoms(%)

Painful(%)

26(72.2)

10(27.8)

26(78.8)

7(21.2)

0.527

Vol.35 • NO.3 • 2019 17

Prediabetes Diabetes P-value

Autonomic symptom (%)

Lightheadedness

Drymouthordryeyes

Paleorbluefeet

Feetarecolderthantherestofbody

Decreasedorabsentsweatinginfeet

Whileresting

Afterexerciseorduringhotweather

Increasedsweatinginhandscomparedtherestofbody

Nausea,vomiting,orbloatingaftereatingasmallmeal

Persistentdiarrhea(>3times/dayloosebowelmovements

Persistentconstipation(<1timein2days)

Leakingofurine

Difficultyobtaininganerectile(men)

32(80)

28(70)

9(22.5)

0(0)

11(27.5)

14(35)

14(35)

7(17.5)

1(2.5)

3(7.5)

0

17(42.5)

8(20)

8(57.1)

35 (97.2)

34 (94.4)

2(5.6)

2(5.6)

6(16.7)

9(25)

9(25)

3(8.3)

3(8.3)

3(8.3)

0

19(52.8)

12(33.3)

12(80)

0.031

0.006

0.036

0.221

0.258

0.343

0.343

0.317

0.340

1.000

-

0.370

0.188

0.245

Abnormality in heart rate response todeep

breathingandvalsalvamaneuveralsopresentedin

bothgroupsandtherewerenodifferentamongthe

studygroups.Numberofpatientswhohadabnor-

malityinheartrateresponsetodeepbreathingwas

higherthanvalsalvamaneuverinbothgroups.

Sensitivity of the tests to detect neuropathy in

patients with normal physical examination

Allpatientshadsensoryormotorsymptoms

whichsuspectedtoneuropathybut45%ofprediabetic

and30.6%ofdiabeticpatientshadnormalphysical

examination.Monofilament test,electrodiagnostic

andautonomicstudieswereperformedtodetected

subclinicalormildneuropathy.

TheresultswereshowedinTable3.Sensitivity

among the tests were not different in diabetic

patientsbutquitedifferentinprediabeticpatients.

In prediabetic patients with normal physical

examination,7.7%hadabnormalmonofilamenttest,

10%hadabnormalnerveconductionstudy,23%

had abnormal valsalvamaneuver and 30.8 had

abnormalheartratevariabilitytodeepbreathing.

Table 3. Monofilament,electrodiagnosticandautonomictestinprediabetesanddiabetespatients

Prediabetes Diabetes P- value

Monofi lament test (abnormal, %) 6/24(25) 4/9(44) 0.400

Nerve conduction study (abnormal, %)

Sensoryaxonalneuropathy(abnormal, %)

Sensorimotoraxonalpolyneuropathy

Demyelinatingpolyneuropathy

4/22(18.2)

0/22(0)

3/22(13.6)

1/22(4.5)

10/23(43.5)

2/23(8.7)

4/23(17.4)

4/23(17.4)

0.067

0.193

Carpal tunnel syndrome by nerve conduction study 19/28(67.9%) 15/27(55.6%) 0.348

Abnormal autonomic test (%)

Valsavamanuever

Heartratevariability

8/22(36.4)

11/22(50)

3/11(27.3)

6/11(54.5)

0.709

0.805


Table 4. Sensitivityoftestsinprediabetesanddiabetespatientwithnormalphysicalexamination

Normal physical examination patients Prediabetes

(n=40)

Diabetes (n=36) P-value

Number 18(45%) 11(30.6%) 0.196

Monofilament 1/13(7.7%) 2/6(33.3%) 0.057

Abnormalnerveconductionstudy 1/10(10%) 3/7(42.9%) 0.020

Abnormalvalsavamanuever 3/13(23%) 3/7(42.9%) 0.714

Abnormalheartratevariability 4/13(30.8%) 3/7(42.9%) 0.019

Discussion:

Inthepresentretrospectivestudyoftotal76

patientsconsistedof40prediabeticpatientsand

36diabeticpatients,weidentifiedseveraldifferent

baselinecharacteristicincludingdurationofabnormal

plasma glucose prior to 1st evaluation, fasting

plasmaglucose,hemoglobinA1c,serumtriglyceride

anddiabetic retinopathy.Not onlydemonstrated

theearlyphaseofdiabeticneuropathy,usingan

array of examinations including neurological

examinations, nerve conduction and autonomic

testing.Also, demonstrated othermicrovascular

complications e.g. diabetic retinopathy and

nephropathy.

Prediabetesisastateofintermediatehyper-

glycemia,associatedwithseveralconsequences.

From the present study, smallmyelinated and

unmyelinatednervefibersthatcarrypain,temperature,

and regulate autonomic functionwere involved

morethanlargedemyelinatednervefibersduring

early stage of neuropathy. Additionally, shown

sensoryaxonsdevelopednervedysfunctionprior

tomotoraxons.Thesestrikingresultsenableusto

detectabnormalitiesinsensoryaxonsatearlystage

ofdiabeticneuropathy.

Thepreviousstudyhadshowntheprediabetes

isassociatedwithdysfunctionofcardiacautonomic

activity,reflectedbyreducedheartratevariability8-10,

decreased parasympatheticmodulation of the

heart10, increased prevalence ofmale erectile

dysfunctioninindividualswithprediabetes11,increase

prevalenceofbothhyperesthesiaandhypoesthesia,

and increasedheatdetection thresholds.12 There

werealso increasingevidence todemonstrate a

higher frequency of idiopathic polyneuropathy,

painful sensory neuropathy13 and small fiber

neuropathyinprediabetes.Bycontrast,theother

studyshownnosignificantincreaseintheprevalence

ofpositiveneuropathicsensoryorpainsymptoms,

norofhyperalgesiaorhypoalgesiaintheprediabetes

group.14The present study showed sensory

symptomswerecommoninprediabeticpatientsbut

45%ofprediabeticpatientshadnormalphysical

examination.Only 18.2%of prediabeticpatients

hadabnormal nerveconduction study, 25%had

abnormalmonofilamenttestbutmoreabnormality

foundinautonomictests.Thesearesuggestingthat

physicalexamination,monofilamenttestandnerve

conduction study are insufficient to detect neu-

ropathyinprediabeticpatients.Underdiagnosisof

diabeticneuropathy inclinicalpracticehasbeen

emphasizedinpreviousstudy.15Amongthetests,

themost sensitive test to detect neuropathy in

prediabetic or patients with normal physical

examinationwere heart rate variability to deep

Vol.35 • NO.3 • 2019 19

breathing,followbyvalsavamanuever.Earlydetec-

tionofdiabeticneuropathyisimportant.Intensive

diabetes therapymarkedly delays or prevents

the development of diabetic polyneuropathy.

The clinical or electrophysiological evidence of

neuropathy was reduced by intensive therapy

patients16. Early treatment with strict glycemic

control were associated with improvement in

vibrationperceptionandeducatedthedevelopment

of autonomic neuropathy17-19. Autonomic tests

mayberequirefordiagnosisofsubclinicaldiabetic

neuropathyincludingdiabeticautonomicneuropathy.

Severalstudieshadshownanassociationof

increasedriskofchronickidneydiseaseandearly

nephropathy with prediabetes.19,20 The causal

natureofthisrelationshipremainsunclearasthis

associationmaybedue increased incidence of

diabetes in this group or the presence of other

factors associatedwithboth hyperglycemia and

nephropathyratherthantheeffectofprediabetes

itself.Fromthepreviousstudy,diabeticretinopathy

was presented in 8 percent of prediabetic

patients.21In thepresent, there isnoevidenceof

diabet ic ret inopathy and nephropathy in

prediabeticgroup.Thisresultwascontrasttothe

previous studies andmaydue to a confounding

factorfromthesmallsamplesizeandmicroalbumin

testwassentinafewcases.

Limitationsof thepresentstudywere1) this

study is retrospective study,many informations

including clinical and investigations are not

available 2) the sample size is small, thesemay

interfere the statistical analysis and 3) normal

healthysubjectswerenotincludedtocomparewith

prediabetesanddiabetespatients.

Conclusion:

Nervedysfunctionalreadyoccurred inearly

phase of diabetes. Themajority of prediabetic

anddiabetic patients had symmetrical, sensory

polyneuropathy,followedbysensorimotorpolyneu-

ropathy.Autonomic neuropathywas common in

bothgroups.Additionally,sensoryaxonaldysfunc-

tion is earlier thanmotor dysfunction. Potentially

importantsensoryaxonalnervescreeningfor the

early stage of diabetic neuropathy. Among all

parameters, autonomic test appeared to be the

mostsensitivetodetectneuropathyinprediabetic

stage but similar to nerve conduction study or

monofilamentindiabeticgroup.Earlierdetectionof

sensoryaxonaldysfunctionwoundpromptearlier

neuroprotectionfordiabeticneuropathy.

Disclosure:

Financialsupport:None

Conflictsofinterest:None

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Vol.35 • NO.3 • 2019 21

Abstract

Objective:TodeterminetheprevalenceofREM

sleep behavior disorder (RBD) in patientswith

Parkinson’s disease and ascertain the clinical

characteristicsandriskfactorsassociatedwithRBD.

Method: WeenrolledsubjectswithParkinson’s

diseasewhovisited inneurologyclinicatPrasart

neurologicalinstitutefrom1stJanuaryto31stDecember,

2017.Subjectsandbedpartnerwereinterviewed

withMayoSleepQuestionnaire toascertainRBD

andobtainedalldemographicdataandnon-motor

symptoms.Thepatientswhowereconfirmedtohave

RBDwerelaterinterviewedregardingthedreamcontent.

Results: Forty-nine patients out of 140 PD

patients(35%)inourcohortweredefinedasRBD.

PatientswithRBDweremalepredominance(53vs

37;p =0.042),longerdiseaseduration(7.4vs5.2;

p=0.003),higherscoresofthemodifiedH&Ystage,

higherscoresoftheUPDRSpartIII(31.0vs18.0;

P<0.001), andhigherdoseof total LEDD (765.0

vs 426.0;P<0.001). Non-motor symptomswere

statisticallysignificanceingroupofPDwithRBD.

Logistic regression analysis showed onlymale

genderandnon-motorquestionnairewereassociated

withthepresenceofRBD.Themostcommondream

phenomenonwasfightingwithhuman.Thereport

ofsleep-relatedinjuriesshowedaninjurytothepatient

was16.3%andaninjurytobedpartnerwas6.1%.

Conclusion : Wefoundthattheprevalenceof

RBD in PDwas 35% alongwithmale gender,

diseasedurationanddiseaseseveritymaybethe

riskfactorsinourstudy.ThedreamcontentofRBD

seemed to be passive or defending the attack

ratherthanattacktotheothers.

Keywords:REMsleepbehaviordisorder,RBD,

Parkinson’sdisease

Huda Tohmangee, Chayut Kasemsuk, Natlada Limotai,

Department of Neurology, Prasart Neurological Institute, Bangkok,

Thailand


Natlada Limotai

Email: [email protected]

312 Rajvithee Road,Bangkok, Thailand 10400

Tel:02-3069899

Rapid Eye Movement Sleep Behavior Disorder

in Parkinson’s Disease

Huda TohmangeeChayut Kasemsuk

Natlada Limotai


Introduction:

Rapideyemovementsleepbehaviordisorder

(RBD)isaparasomniacharacterizedbyintermittent

absenceofnormalskeletalatoniaduringrapideye

movement(REM)sleepleadingtodreamenactment

behaviors.1Theappearanceofcomplexmotoror

vocal activities associatedwithdreammentation

maycausedinjurytopatientsandtheirpartners.2

RBD can be idiopathic or associatedwith

neurodegenerativedisorders especially synucle-

inopathydiseases.3-5Severalstudiesshowedhigh

occurrenceofdevelopingParkinson’sdisease(PD)

afterdiagnosisidiopathicRBD.6,7

Factors associated with RBD in PD were

longer diseaseduration8-10, higherHoehn&Yahr

stage8,9, higher dose of levodopa dosage8,9,11,

psychiatriccomorbidity8,oldage8,10,highertremor

score9, and orthostatic hypotension11. Typical

clinicalcharacteristicofRBDinPD,predominantly

inmotorbehaviorsthanvocalization,weredescribe

aspunching,kicking,andbeatingwhilecommon

ofdreamphenomenologywerebeingattack,chase

byunfamiliarpeopleoranimal,andvividdream.2,8,12-14

Diagnosis of RBD was based on clinical

manifestations by presence of limb or body

movements associated with dreammentation

accompaniedbyat least oneof these following:

harmful sleepbehaviors,actedoutondream,or

sleepdisruption.15Usingofpolysomnogram(PSG),

the gold standard for diagnosis RBD, provide

tremendous sensitivity and specificity for detect

RBD inPDwithprevalence19-50%.16-18However

useofPSGtechniquerequiredconsiderableexpert,

time,andresourcesthatlackofavailabilityinmany

clinical units.Supplementaryassessment toolby

usingRBDquestionnairessuchasTheMayoSleep

Questionnaire (MSQ),RBDScreeningQuestion-

naire (RBDSQ), RBDquestionnaire-HongKong

(RBDQ-HK)alsoprovideaccurateappraisalwith

prevalence34-43%.18-24MSQseemtohasadequate

sensitivity and specificity for diagnosis RBD in

Parkinson’s disease subjects even cognitive

impairment.24,25

Thisstudyaimedto1)determinetheprevalence

of REM sleep behavior disorder (RBD) in PD

patients;and2)ascertaintheclinicalcharacteristics

andriskfactorsassociatedwithRBD.

Method:

All patients with a diagnosis of idiopathic

Parkinson’s disease (PD) based on UKPDSS

criteria, who visited the neurology clinic and

movementdisordersclinicatPrasatNeurological

Instituteduring1stJanuaryto31stDecember,2017

were included into our study. The study was

approvedbyethiccommitteeatPrasatNeurological

Institute.Allsubjectswereinformedandaskedfor

writtensignedconsentbeforebeingenrolledinto

thestudy.

Outcome ascertainment:

MayoSleepQuestionnaire(singlequestionnaire)

was used to ascertainRBD in PDpatients. The

patientsor theirbedpartnersorcaregiverswere

interviewedwiththisquestionnaire.

Risk factors and their measurements:

Demographic data including age, gender,

medical history, disease duration and disease

severityusingthemodifiedHoehnandYahr(H&Y)

stageaswell as theUnifiedParkinson’sdisease

ratingscale,motorpart(UPDRSpartIII)while“on”,

Vol.35 • NO.3 • 2019 23

and the total levodopa equivalent dose (LEDD)

werecollected. Inaddition,non-motorsymptoms

werealsoassessedusingThammasatUniversity

Non-MotorSymptomsQuestionnaire(TU-NMS).26

Characteristics of RBD and associated dream:

Theduration ofRBD, the number of sleep-

relatedinjury,anddreamcontentswereassessed

byinterviewingpatientandbedpartnersorcaregivers.

Statistical analysis:

Baseline characteristics of thepatientswith

andwithoutRBDwerecompared.Forcategorical

data,associationbetweenvariables(factors)and

theoccurrenceofRBDwasassessedbyPearson

Chi-SquareorFisher’sexact test if theexpected

frequencywaslessthan5,morethan20%ofthe

total cells. For continuousdata, either Student’s

t-testorMann-Whitneytestwasused,depending

ondistributionofthedata.Topredicttheoccurrence

ofRBDinPDpatients,univariatelogisticregression

analysis foreachpotential factorwasperformed.

Factorswithpvalue<0.2wereselectedforsubsequent

multivariate analysis.Uponmultivariate analysis,

forwardselectionmodelwasperformedtofindthe

bestmodel,where levelofstatisticalsignificance

wasset to<0.05.Adjustedoddsratio (OR)with

95%CIof thesignificant factorswasreported.All

statistical analyseswere performed usingSPSS

softwareversion16.0.

Results:

Atotalof140PDpatientswereincludedand

interviewed.Thedemographiccharacteristicsofall

PD patientswere shown in Table 1. Forty-nine

patientsoutof140PDpatients(35%)weredefined

probableRBD(pRBD).Thecomparisonbetween

bothgroupsofPDwithRBDandPDwithoutRBD

intermsofthecharacteristicsandclinicalfeatures

wereshown inTable2.PatientswithpRBDwere

malepredominance(53vs37;p =0.042), longer

disease duration (7.4 vs 5.2;p=0.003), higher

scoresofthemodifiedH&Ystage,higherscoresof

theUPDRSpart III (31.0 vs 18.0;P<0.001), and

higherdoseoftotalLEDD(765.0vs426.0;P<0.001).

Thepercentageofnon-motorsymptomsbyTU-NMS

questionnaireswereshown inTable3.Wefound

that total and almost all sub-categories of

non-motorsymptomsincludingsleepandfatigue,

cardiovascularandfall,perceptionandhallucination,

cognitionandconcentrationproblems,gastrointestinal

tract problem and urinary tract problem, were

statisticallysignificanceindifferenceingroupofPD

with RBD. Logistic regression analysis was

performedtoverifythepredictorsassociatedwith

thepresenceofpRBD inPDpatient.Weset the

presenceofpRBDasthedependencevariable,and

sex,diseaseduration,UPDRSpart III,non-motor

symptomsand total LEDDas the independence

variablesareshowninTable4.Theresultsshowed

onlymalegenderandnon-motorquestionnairewere

significantlyassociatedwiththepresenceofRBD

inourPDpatients.Innumberof49patientsofPD

withRBDdemonstratingthesleep-relatedinjuryand

dreamcontentwereshowninTable5.Thecommon

dreamphenomenawereacontentoffightingwith

human(81.6%),followedbyseeingthedeadpeople

(18.4%)andbeingchasedbyperson(16.3%),in

respectively.Additionally,thereportofsleep-relat-

ed injuries showed an injury to the patientwas

16.3%andaninjurytobedpartnerwas6.1%.


Table 1. ClinicalcharacteristicsofpatientswithParkinson’sdisease

NumberofPDpatients 140

Sex(male/female) 90/50(64.3%/35.7%)

Age(years)(mean;SD) 62.2(±8.5)

Diseaseduration(years)(mean;SD) 6.0(±3.9)

ModifiedHoehnandYahrstage(N;%)0-1.52-2.53-5

14(10.0%)64(45.7%)62(44.3%)

UPDRSmotorpart† 22.0(16.0-32.0)

Nonmotorsymptomscore(TUNMS)† 3.0(1.0-8.0)

TotalLEDD(mg/day)¥ 550.0(300.0-827.0)

Underlyingdisease(N;%)

Hypertension 18(12.9%)

Cerebrovasculardisease 2(1.4%)

Diabeticmellitus 4(2.95%)

Hyperlipidemia 9(6.4%)

NumberofPDwithpRBD 49(35%)

¥LEDDindicatelevodopaequivalentdailydose

†Median(IQR)

Table 2. UnivariateanalysisofclinicalfeatureofPDpatientswithandwithoutpRBD

Without pRBD N=91

pRBDN=49

P value

OR 95% CI

Sex• Male• Female

53(58.2%)38(41.8%)

37(75.5%)12(24.5%)

0.042* 2.21.0-4.8

Age(years)(mean;SD)

62.3(±8.9) 61.9(±7.9) 0.824 1.0 0.9-1.0

Diseaseduration(years)(mean;SD) 5.2(±3.3) 7.4(±4.4) 0.003* 1.6 1.0-1.2

Underlyingdisease(N;%)

Hypertension10(11%) 8(16.3%)0.3681.60.6-4.3

Cerebrovasculardisease 2(2.2%) 0.0 0.542 - -

Diabeticmellitus 3(3.3%) 1(2%) 1.000 0.6 0.1-6.0

Hyperlipidemia 4(4.45%) 5(10.2%) 0.277 2.5 0.6-2.7

Vol.35 • NO.3 • 2019 25

Without pRBD N=91

pRBDN=49

P value

OR 95% CI

ModifiedH&Ystage(N;%)

0-1.5 14(15.4%) 0.0 <0.001* - -

2-2.5 53(58.2%) 11(22.4%) 0.1 0.1-0.3

3-5 24(26.4%) 38(77.6%) 1.0 -

UPDRSmotorpart

18.0(15.0-28.0)

31.0(22.5-41.5)

<0.001* 1.1 1.0-1.1

TotalLEDD(mg/day)¥

426.0(275.0-700.0)

765.0(537.0-1049.0)

<0.001* 1.0 1.0-1.0

*Significantlevelwassetat0.05

¥LEDDindicatelevodopaequivalentdailydosedose

†Median(IQR)

Table 3. NonmotorsymptominPDwithandwithoutRBD

Symptom PD without pRBD

N = 91

PD with pRBD

N=49

P value

1.Insomnia 44(48.4%) 42(85.7%) <0.001*

2.Daytimesleepiness 15(16.5%) 28(57.1%) <0.001*

3.Intensevividdreams 4(4.4%) 47(95.9%) <0.001*

4.Actingoutdreams 1(1.1%) 45(91.8%) <0.001*

5.Restlesslegs 20(22.0%) 28(57.1%) <0.001*

6.Fatigue 22(24.2%) 21(42.9%) 0.022

7.Dizziness 12(13.2%) 13(26.5%) 0.049

8.Fall 2(2.2%) 8(16.3%) 0.002*

9.Sad,depressedmood 16(17.6%) 13(26.5%) 0.213

10. Anxiety 17(18.7%) 21(42.9%) 0.002*

11. Lossofinterest 1(1.1%) 4(8.2%) 0.032

12. Diplopia 0 1(2.0%) 0.171

13. Hallucinotion 3(3.3%) 10(20.4%) 0.001*

14. Senseofpresence 0 8(16.3%) <0.001*

15. Delusion 0 3(6.1%) 0.017

16. Remembering 28(30.8%) 26(53.1%) 0.010


Symptom PD without pRBD

N = 91

PD with pRBD

N=49

P value

17. Concentration 19(20.9%) 22(44.9%) 0.003*

18. Multitasking 12(13.2%) 13(26.5%) 0.049

19. Constipation 66(72.5%) 43(87.8%) 0.038

20. Bowelincontinence 3(3.3%) 6(12.2%) 0.039

21. Vomitting,acidreflux 2(2.2%) 5(10.2%) 0.038

22. Dribbling 8(8.8%) 14(28.6%) 0.002*

23. Swallowing 3(3.3%) 10(20.4%) 0.001*

24. Urinaryurgency 32(35.2%) 40(81.6%) <0.001*

25. Nocturia 39(42.9%) 37(75.5%) <0.001*

26. Lossofsexdrive 1(1.1%) 1(2.0%) 0.654

27. Sexdifficulty 0 1(2%) 0.171

28. Pains 13(14.3%) 10(20.4%) 0.351

29. Sweating 8(8.8%) 4(8.2%) 0.899

30. Dryeyes 5(5.5%) 1(2.0%) 0.336

31. Taste/smelling 5(5.5%) 1(2.0%) 0.336

32. Seborrhicdermatitis 1(1.1%) 0 0.461

33. Swellinglegs 3(3.3%) 0 0.199

34. Weightchanges 9(9.9%) 12(24.5%) 0.021

35. Gambling 0 0

36. Hypersexuality 0 0

37. Buying 1(1.1%) 1(2%) 0.654

38. Eating 1(1.1%) 3(6.1%) 0.089

39. Hobbyism/punding 1(1.1%) 0 0.461

40. Medicationoveruse 6(6.6%) 6(12.2%) 0.255

Table 4. MultiplelogisticregressionanalysisofpredictorfactorofPDwithpRBD

Covariate Coeff(b) SE(b) P value OR 95%CI

Sex 1.174 0.531 0.027* 3.235 1.142-9.165

Diseaseduration(years) 0.034 0.061 0.0578 1.034 0.918-1.165

UPDRSmotorpart 0.035 0.020 0.086 1.035 0.995-1.007

Nonmotorsymptomscore(TUNMS) 0.238 0.054 <0.001* 1.269 1.141-1.411

Levodopaequivalentdailydose(LEDD) 0.001 0.001 0.421 1.001 0.999-1.002

*Significantlevelwassetat0.05

Vol.35 • NO.3 • 2019 27

Table 5. DreamcontentofPDwithpRBD

NumberofPDwithRBD 49

DurationofclinicalRBD(years)† 1.0(0.5-3)

NumberofpatientinjuredfromclinicalRBD 8(16.3%)

NumberofpatientsthattheirpartnerinjuredfromclinicalRBD 3(6.1%)

CharacteristicofdreaminPDwithRBD

Chasedbyperson 8(16.3%)

Chasedbyanimal 4(8.2%)

Fightingwithhuman 40(81.6%)

Fightingwithanimal 4(8.2%)

Aggressivebehavior 1(2.0%)

Adventureactivity 1(2.0%)

Bizarredream 2(4.1%)

Seedeadpeople 9(18.4%)

Dreamofthepast 1(2.0%)

†Median(IQR)

Discussion:

Inourstudy,theprevalenceofRBDinpatients

withParkinson’sdisease(PDwithRBD)was35%

(95%CI=27.0-42.9).Thiswasinlinewithprevious

reportsusingquestionnairesorinterview,withthe

prevalence of 34-43%.2,18,21-23,27RBDwasmore

prevalent(19-50%)instudiesusingpolysomnography

(PSG)16,18,27sincethepatientsmaybeunawareof

RBD. In addition, subclinicalRBDorREMsleep

withoutatonia(RWA)couldbeonlydetectedwith

PSG.GivenBoeveet.al.showedthatMayoSleep

Questionnaire can reliably help diagnose RBD

withoutPSG28alongwithunavailabilityofthePSG

inourcenter,weusedtheMayoSleepQuestionnaire

asatooltohelpdiagnoseRBD.Theprevalenceof

RBD in our centermight be low, as opposed to

studiesusingPSG,sincesubclinicalRBDmaybe

under-detected.

Malegender,longerdiseaseduration,higher

scoresonthemodifiedH&YstageandUPDRSpart

III,aswellashigherLEDDwerestatisticallysignificant

associatedwith PDwith RBD. Several studies

showedmalepredominanceinPDwithRBDorin

idiopathicRBD.Leeet.al.9hypothesizedthatsex

hormoneabnormalityandviolencenatureofmale

gendermaybeimportantcontributions.Incontrast,

several studies revealednodifference ingender

betweenPDpatientswith andwithout RBD.2,8,18

A recent study fromNorway27 showed no clear

differenceinthefrequencyofRBDamongmenand

women,buttheirclinicalexpressionsweredifferent,

wheremalereportedmoreflightsandaggressive

behaviors. Longer disease duration and higher

scoresofthemodifiedH&YstageandUPDRSpart

III which both reflected advanced stage of the

diseasewereassociatedwithRBDinPDpatients.

Thiswas in linewith previous studies.8-11Higher


dailydoseoflevodopa(LEDD)inpatientswithPD

withRBDmaybesecondarytotheirrelativemore

advanceddisease.Oneshouldbekeptinmindthat

sincewe did not collect information regarding

othermedications,wecannotentirelyexcludethat

RBDinsomeofourpatientsmaybeprecipitated

by dopaminergic or psychiatricmedications. In

otherway,absenceofRBDinsomepatientsmay

berelatedtobenzodiazepineuse.

Non-motor PD symptoms including restless

leg sensation, hallucination, drooling, difficult

swallowing, and nocturnal/frequency in urination

weresignificantlyassociatedwithPDwithRBD.A

relationship between RBD and non-motor PD

symptomshavebeenpreviouslyreported9RLSand

periodic limbmovements in sleep (PLMS)were

common inPDpatients29, particularly inpatients

with RBD(9). Nocturnal behaviors including

hallucinationsandsleepdisordersarecommonin

advancedPD9;however,thepathogenesisremains

controversial. Pacchetti et. al.30 showed that a

severesleepdisorderwasthemainfactorpredicting

theonsetofhallucinations,andpatientswithRBD

carried2.7timeshigherriskofhallucinationsand

delusions.3061.3%ofthepatientswithhallucinations

were associated with preexistent vivid dream

phenomenon.30“Acontinuumhypothesis”proposed

byMoskovitz and colleagues31suggested that

medication-inducedpsychiatric symptoms inPD

patientsusuallyprogress fromsleepalteration to

frankhallucination.Thisissupportedbyastudyby

Pappert32 which demonstrated that the altered

dreamphenomenaincludingvividdreams,nightmare,

andcasessuggestiveofRBDornightterrorswas

thecore relationshipamongsleep fragmentation

andhallucination.Thisistemptingthatdysregulation

ofREMsleepmaybeoneoftheprimaryfactorin

thepathogenesis ofdopaminergicdrug induced

hallucinations.Incontrast,aprospectivelongitudinal

studybyGoetzetal.33revealedthathallucinations

andsleepdisordersaredifferentintheirpatternsof

progression.Hallucinationsappearedtobechronic

andprogressiveovertime,whereassleepdisorders

fluctuatedwidely among the patients and time

pointswithoutevidenceofprogressioninseverity.

Similar toastudyofPostumaetal.34alsodidnot

support a strong relationshipbetweenRBDand

psychosis in PD once strict criteriameasuring

hallucinationswereapplied.Theresultsshowedno

significant increase in hallucinationbetweenPD

patientswithorwithoutRBD.Thelimitationinour

studywas not excludeddementing subjects by

TMSEorMoCAastheimportantfactorforhallucination.

Uponmultivariate logistic regression, the

results revealed that only male gender and

non-motorsymptomsweresignificantlyassociated

withthepresenceofRBDinourPDpatients.

ThecommondreamcharacteristicsofRBDin

our cohort were fighting with human (81%) as

defined as defending against attack by human,

seeing the deadpeople (18%), and chasedby

person(16%).Theseseemedtobeidenticalfrom

previousstudies14wheremostlyfoundvividdream,

beingchasedbyunfamiliarpeopleanddefending

againstattackbypeople.Inaddition,sleeprelated

injuriestoeitherpatientthemselvesorbedpartners

inourcohortwere16.1%and6.1%,inrespectively.

Patientsreportedakindofinjuriesasfallingfrom

bed,punchingthewall,punchingthebedpartner,

kickingthebedpartner.Limitationsofourstudyin

thispointwerealackofahealthycontrolgroupand

thepossibilityofrecallbiasfrominterview.

Vol.35 • NO.3 • 2019 29

Conclusion:

REMsleepbehaviordisorderhasbeencom-

monly found inpatientswithParkinson’sdisease

andassociatedwith other non-motor symptoms.

Theriskfactorsmightbeinfluencedonthepresence

ofRBDinPDfromourstudydemonstratingmale

gender, disease duration and disease severity.

Thesefindingsareconsistentwithseveralprevious

studies.ThedreamcontentofRBDseemedtobe

passiveordefendingtheattackratherthanattack

totheothers.RBDcancauseapoorqualityoflife

andasleep-relatedinjury;thistemptingthephysi-

cianshoulddetectRBDandnon-motorsymptoms

associatedwithRBDinroutineclinic.Itwouldbe

thebestpreventionforseriousRBDcomplications.

Thereareseverallimitationsinourstudy.Thefurther

well-designedstudyandlargernumberofsubjects

shouldbeperformed.

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31Vol.35 • NO.3 • 2019

A Man with Burning Pain on the Left Leg

ณฐพล เกยรตกงวานชนสญสณย พงษภกด

ณฐพล เกยรตกงวานชน1, สญสณย พงษภกด

2

1แพทยประจาบานอายรศาสตร,

2อาจารยแพทย สาขาประสาทวทยา กองอายรกรรม

โรงพยาบาลภมพลอดลยเดช

ผรบผดชอบบทความ:

อ.พญ.สญสณย พงษภกด

สาขาประสาทวทยา กองอายรกรรม

โรงพยาบาลภมพลอดลยเดช กรงเทพมหานคร

พอครวชาวลาวอาย24ปไมมโรคประจำาตว

Chief complaint :

มอาการปวดแสบรอนบรเวณเทาซาย1ชวโมงกอน

มาโรงพยาบาล

Present illness :

2 สปดาหกอน ผ ปวยเรมมอาการเจบแปลบๆ

บรเวณเอวดานหลงตรงกลางราวไปตามแนวกระดกสน

หลงในแนวดง เจบแปลบครงละไมถง1นาทแตละครง

หางกนไมถง1นาทเมอยดหลงตรงจะมอาการเจบมาก

ขนตองนงงอตว จงไปซอยาคลายเสนมารบประทาน

อาการเจบดขน

1ชวโมงกอนมาโรงพยาบาลมอาการปวดแสบรอน

ทบรเวณเทาซาย และไลขนมาทบรเวณนอง โดยจะม

อาการเปนจดๆครงละไมถง1นาทและปวดไลขนมาถง

ตนขา รวมกบมอาการชาและรสกวาขาออนแรงลงกวา

ปกตขณะนอนสงเกตอาการทหองฉกเฉนมอาการปวด

แสบรอนทบรเวณขาขวาลกษณะเชนเดยวกบทเปน

บรเวณขางซายมากอนหลงจากขนไปทนอนทหอผปวย

มอาการปสสาวะไมออกตองใสสวนปสสาวะไว

ขณะนอนรพ.วนท2เรมมอาการขาสองขางออน

แรง โดยขางขวาออนแรงมากกวาขางซายและอาการ

ออนแรงเปนมากขนเรอยๆอาการเจบแปลบๆบรเวณเอว

ดานขวายงคงมอยเปนพกๆ

มประวตชอบกนอาหารสกๆดบๆเชนลาบดบกอย

เนอชวงทอยประเทศลาวกนเปนประจำาตงแตมาทำางาน

ทไทยกกนบางนานๆครงลาสดประมาณ1เดอนกอน

Physical examination :

Upperlimbs:normaltone,motorpower,and

reflexes,normalsensation

วารสารประสาทวทยาแหงประเทศไทย32 Vol.35 • NO.3 • 2019

Lowerlimbs

Right Left

Hipflexors 1 3

Hipextensors 1 3

Kneeflexors 0 3

Kneeextensors 0 3

Ankledorsiflexors 0 2

Ankleplantarflexors 0 2

Longtoeextensors 0 2

Rightleg-flaccidtone,Leftleg-normaltone

DTR:Rightside0,Leftside1+

Clonusnegative

Decreasepinprick, temperature sensationbelow

L1level

Impairedmorningerection

Loosesphinctertone,absentperianalsensation

การตรวจทางหองปฏบตการ:

CBCแรกรบ:WBC11,660cells/ul,PMN83%,

L12%,Eo2%;Hct44.8%,Platelet248,000/ul

CBC(3daysafteradmission)WBC9,710cells/

ul,PMN55%,L22%,Eo17%;Hct45.6%,Platelet

231,000/ul

AntiHIV:non-reactive

CSFprofile:openpressure130mmH20,WBC

1020cell/mm³,PMN40%,Lymphocyte60%,RBC

2 cell/mm³, protein 154mg/dl , sugar 33mg/dl

(plasmaglucose92mg%)

CSFwrightstain(ภาพท1):Eosinophil>10%

CSF cytology: Presence of predominate

eosinophilswith scattered lymphocytes, plasma

cells,neutrophilsandmacrophages,inflammatory

cell such asmacrophages , plasma cells and

eosinophilsareanabnormalfindingsinCSF.They

mayaccompanymalignancybutarealsoseenina

varietyofnon-specificconditions

ภาพท 1:EosinophilในCSFwrightstain(ปกหนา)

33Vol.35 • NO.3 • 2019

MRIwholespine(ภาพท2):Suggestiveofacute

transversemyelitisinvolvingT5toconusmedullaris.

Diffusemild enhancement of the cauda equina

nerveroots,whichcouldbenonspecificradiculitis

orarachnoiditis.Focalsmall leftsubarticulardisc

protrusion/annulartearatL4-5levelwithoutcentral

spinalcanalstenosisornerverootcompression.

ภาพท 2 :MRIwholespineพบhyperintensesignalinT2-weightedบรเวณตงแตT5ถงconusmedullaris(ปกหนา)

อภปราย

จากประวต ตรวจรางกายและการตรวจทางหอง

ปฏบตการตางๆ เขาไดกบโรคEosinophilic radiculo-

myelitisมากทสดซงสาเหตหลกๆแบงเปนinfectious

กบnon-infectiouscauseโดยinfectiouscauseพบ

มากกวา ทพบบอยทสดเกดจากการตดเชอ parasite

ไดแกAngiostrongyluscantonensis,Baylisascaris

procyonisและGnathostomaspinigerumสวนnon-

infectiouscauseเกดจากhematologicmalignancy

ยาเชนIbuprofen,CiprofloxacinหรอการใสVPshunt

ในผปวยรายนสงสยสาเหตจากการตดเชอparasiteคอ

Angiostrongyluscantonensisซงเปนพยาธตวกลมชนด

หนงหรอเรยกวาพยาธปอดหน กอใหเกดโรคพยาธหอย

โขงเนองจากมประวตชอบรบประทานอาหารสกๆดบๆ

และเปนเชอกอโรคทพบบอยทสดในประเทศแถบเอเชย

ตะวนออกเฉยงใต โดยเฉพาะประเทศไทย ซงอาการ

สามารถมาดวยmeningitisหรอradiculomyelitisกได

อาการของAngiostrongyliasisมกพบในชวง1-4

สปดาหหลงจากไดรบเชอ โดยอาจจะมอาการเลกนอย

เชนไขปวดศรษะเดนบรเวณfrontalและbitemporal

คลนไสอาเจยนปวดเปนลกษณะneuropathicpainได

หรอมอาการรนแรงได เชน การมองเหนผดปกต เสน

ประสาทสมองคท7,8เปนอมพาตคอแขงเปนตนแตถา

หากวาเปนการตดเชอGnathostomaspinigerumหรอ

Gnathostomiasis ซงพบไดเปนอนดบสองรองจาก

Angiostrongyluscantonensisจะพบวามไขปวดศรษะ

คลนไสอาเจยนไดเหมอนกนแตจะมอาการรนแรงกวา

เนองจากตวพยาธสามารถไชไปยงอวยวะตางๆ ได

โดยตรงเชนผวหนงเกดmigratoryswellingหรอlarva

migrans หากไปลกตาเกดเปน uveitis, intraocular

hemorrhage และตาบอดไดในทสด สวนอาการทาง

ระบบประสาทอาจพบไดหลายแบบคอnerverootหรอ

radicularpain,myelitis,encephalitis,meningitis

หรออาจจะพบรวมกนไดเปน radiculomyelitis หรอ

radiculomyeloencephalitis และพบเลอดออกบรเวณ

ตำาแหนงตางๆไดตงแตsubduralhematoma,intrac-

ranialhemorrhageหรอsubarachnoidhemorrhage

การวนจฉยเบองตนทำาไดโดยการเจาะตรวจนำาไขสนหลง


พบมโปรตนสงและพบabsolute eosinophilมากกวา

10cells/mm³หรอมากกวา10%ของจำานวนเมดเลอด

ขาวในนำาไขสนหลงหากตรวจCBCอาจพบมeosino-

philia(>700cells/mm³)รวมดวยไดประมาณ80%โดย

การตรวจเพอยนยนการตดเชอA.Cantonensisทำาได

โดยการตรวจดวยวธELISAหรอimmunoblottingtest

ซงจะตรวจหาภมคมกนทจำาเพาะตอA.Cantonensis

แตมขอจำากดเนองจากการตรวจวธนยงไมแพรหลาย

สามารถตรวจไดบางสถาบนเทานน ซงหากมผปวยท

สงสยโรคนอาจใหการรกษาเบองตนไปกอนและดการ

ตอบสนองจากการวจยพบวาโดยการรกษาโดยการให

prednisolone60mg/dayเปนเวลา2สปดาหสามารถ

ลดอาการปวดศรษะจำานวนครงในการเจาะนำาไขสนหลง

เพอระบายความดนในกะโหลกและการใชยาแกปวดได

สวนการใชยาถายพยาธเชนAlbendazoleพบวาไมได

ทำาใหผลการรกษาตางการใหcorticosteroidอยางเดยว

บรรณานกรม1. ChotmongkolV,SawanyawisuthK.Clinicalmanifesta-

tionsandoutcomeofpatientswithsevereeosinophilic

meningoencephalitispresumablycausedbyAngiostron-

gyluscantonensis.SoutheastAsianJTropMedPublic

Health2002;33:231–4.

2. SawanyawisuthK.Treatmentofangiostrongyliasis.Tran

RSocTropMedHyg2008;102:990-6.

3. SawanyawisuthK,ChotmongkolV.Eosinophilicmenin-

gitis.In:HHGarcia,HBTanowitz,OHDelBrutto,Editors.

Handbook ofClinicalNeurology, Vol. 114 (3rdseries)

NeuroparasitologyandTropicalNeurology.Oxford:El-

sevier;2013.p.207-15.

35Vol.35 • NO.3 • 2019

บทคดยอ

ผลงานวจยแพทยประจำาบาน แพทยตอยอดสาขาประสาทวทยา ประจำาปการศกษา 2561


Intracerebral Hemorrhage Post Intravenous

Thrombolytic Therapy in Acute Ischemic Stroke

Patient with Leukoaraiosis

Prompan Tangsakul, Kannikar Kongbunyakiat,

on behalf of North-eastern Stroke Research Group

DepartmentofMedicine,FacultyofMedicine,

SrinagarindHospital,KhonKaenUniversity,

KhonKaen,Thailand

Background and Purpose:Leukoaraiosis(LA)

associatedwithanincreasedriskofsymptomatic

intracerebralhemorrhage(sICH)inpatientstreated

with intravenous thrombolysis for acute ischemic

stroke. Weaimed to investigate the relationship

betweenLAandintravenousthrombolysisrelated

sICHinThaipopulation.

Methods: In this retrospective observational

study, we evaluated data from acute ischemic

strokepatientswhoreceivedrt-PAwithin4.5hrat

SrinagarindHospital,betweenMay2007toNovember

2016(n=573cases). Baselinenon-contrastCTLA

wasgradeusingAgeRelatedWhiteMatterChanges

(ARWMC)scale.Gradingofhemorrhagictransfor-

mations (HTs) according to the ECASS criteria.

Symptomaticintracerebralhemorrhagewasdefined

ashemorrhageanddecreaseintheNIHSSscore

of4ormorepointsinthefirst72hoursafterthrom-

bolytictreatment.

Results:Fromtheunivariableanalysis,12.18%,

24.24% of the patients with LA gr.I-II, gr.III-IV

developedsymptomaticICHasacomplicationof

thrombolytic treatment, compared to 4.25% of

patientswithnoLA(OR2.86,5.69;95%CI1.27-

6.40,1.99-6.23). OtherfactorsassociatedwithsICH

inunivariateanalyseswereage,previousantiplatelet,

NIHSSbeforethrombolysis,hyperdensearterysign,

ASPECT score, large-artery atherosclerosis and

small-vessel occlusion. From themultivariable

analysis,themodelincludingLA,ASPECTscore,

hyperdense artery sign had the best predictive

abilitieswithsensitivity68.9%(95%CI53.4to81.8),

specificity78.2%(95%CI74.2to81.9)areaunder

thecurveusingROCcurves0.77(0.707-0.846).

Conclusions: LAwas associatedwithmore

than a double risk of sICH after thrombolytic

treatmentforacutestroke.

37Vol.35 • NO.3 • 2019

Myasthenia Gravis in Thyroid Disorders

Sasivimol Virameteekul, Somsak Tiamkao,

on behalf of Neuroscience Research Group

DepartmentofMedicine,FacultyofMedicine,

SrinagarindHospital,KhonKaenUniversity,

KhonKaen,Thailand

Introduction: Patientswithmyastheniagravis

(MG)havean increased frequencyof coexisting

autoimmunediseases.Autoimmunethyroiddiseases

(AITDs)frequentlyaccompanymyastheniagravis

andmayinfluenceitscourse.ThepresenceofMG

inAITDsisrarelyreportedanduntilnowfewpublished

studieshavebeenfoundonMG-AITDsdisease.

Objectives: The frequency ofMG and the

courseofMGinassociationwithdifferentsubgroups

ofthyroiddisorders,includingAITDsandnonauto-

immunethyroiddiseases(non-AITDs)wastheaim

ofthisinvestigation.

Materials and Methods: A total of 872MG

patientsand97251 thyroiddisorderpatientshad

beenrecorded.Ninety-sevenpatientswithcoexistent

thyroiddisordersandMGwereanalyzedinaretro-

spectivesinglecenterstudyfrombothambulatory

andinpatientsettingsduringtheperiodfrom1June

1997to1June2017.Patientswithathyroiddisorder

andMGwereidentifiedbyreferringtotheICD-10-

CMcode.Inthesepatients,theassociationofthy-

roiddisorderwithMGalloccurredwithinthestudy

period.TocharacterizethecourseofMGinpatients

with each thyroid disorder, the severity ofMG

accordingtotheOssermanscore,wasrankedto

evaluate themedical treatment of MG and to

stratifythethymuspathology.

Results: Among97patientswithacoexisting

thyroiddisorderandMG,52patientshadGraves’

disease (GD), 16 patients had Hashimoto’s

thyroiditis(HT),12patientshadtoxicgoiters,and

17patientshadnontoxicgoiters.Thefrequencyof

MGinthyroiddisordersat0.2%ofthyroidpatients,

washighestinHT(0.9%),followedbyGD(0.2%).

Thedifferencebetween numbers ofMG in non-

AITDs(toxicandnontoxicgoiter)andthegeneral

populationwasnotsignificant.Inthesepatients,MG


withGDhadocularsymptomsandamildclinical

coursemoreoftenthanpatientswithnon-AITDsor

HT (p<0.001). Immunosuppressive therapywas

alsolessfrequentlyneededinthepatientswithMG

andGD,indirectlyindicatingamilderMGcourse

(p<0.001).Incontrast,theclinicalmanifestationsof

MG inpatientswithcoexistentHTwere themost

severe. In thisgroup;moreaggressive treatment

wasneededincludingimmunosuppressiveagents,

eithermonotherapy with glucocorticoids or in

combinationwithotherimmunosuppressants,and

interventiontherapies(intravenousimmunoglobulin;

IVIG/plasmaexchange; PLEX) (p<0.001). These

treatment requirementsmay indirectly indicate a

higher risk of aMGcrisis and a less favorable

prognosis.

Conclusion:MGinAITDsismorecommonthan

expected.Itappears,however,tobefoundmuch

lessoftencomparedtoAITDsinMG.MGassociated

withGDhasamildclinicalexpression,withprefer-

entialocularinvolvement,whereasMGwithHTwas

associatedwithmoreseverityandmoreaggressive

treatment. Non-AITDs had no influence on the

featuresofMG.ThepresenceofMGinnon-AITD

patientsshouldbeconsideredarandomassociation.

Furtherresearchisneededtoexpandtheunder-

standingoftheseassociationsparticularlyinhow

HTandGDdifferencesinfluencetheclinicalcourse

ofmyastheniagravis.

39Vol.35 • NO.3 • 2019

The Study of Characteristics of

Tremor During Walking and Compare with

Tremor Characteristics During the Resting

Position Among Class I Tremor Dominant

Parkinson’s Disease Patients by Using 3-Axis

Gyroscope

Nattapot Dadphan

DivisionofNeurology,DepartmentofMedicine,Facultyof

Medicine,ChulalongkornUniversity,Bangkok,Thailand.

Introduction: Tremors inParkinson’sdisease

(PD)canhavevariousmanifestations,withthemost

commontypebeingaclassicalparkinsonianrest

tremor.However, a hand tremor can also occur

unilaterallywhilewalking, but its characteristics

havenotbeendefined.

Objective:Todelineateobjectivecharacteristics

ofwalkingtremorinPDpatientsinrelationtoaclassical

parkinsonianresttremorwithinertialsensors.

Methods: This studywas a cross-sectional

studyinvolving22PDpatientswhoexhibitedaclassical

resttremoraccordingtotheconsensuscriteriaand

aunilateralhandtremorwhilewalking.Thetremor

characteristicswere objectively quantifiedwith

inertialsensors,composingofatri-axialgyroscope

placedonthewrist.Thestandardtestingprotocols

wereapplied(restingandposturalpositions)inall

subjects.Awalkingparadigmwasalso included

when subjects were instructed to walk at their

comfortablespeedfor30seconds.Clinicaldemo-

graphics, rating scales, and tremor parameters

(RMSofangularrate,RMSangle,peakmagnitude,

andfrequency)werecollectedforfurtheranalysis.

Results:Participantshadameanageof68.18

(8.93)years,andameandiseasedurationof6.91

(5.5) years. All subjects presentedwith a rest

tremor.Theanalysisinrestingpositionrevealeda

mean frequency of 4.07 (SD=1.96) on the

predominantaxis,whichwasrelativelyunchanged

inposturalposition,consistentwithaclassicalrest

tremor.Duringwalking,thetremorfrequencyonthe

predominant axis decreased significantlywith a

meanfrequencyof1.67(SD=1.77,p=0.001).The

significantdifferenceswerealsoobservedonother

tremor parameters, includingRMSangular rate,

RMSangle,peakmagnitude,andQvalue(p<0.05,

each).


Conclusions:Basedonourpreliminaryresults,

awalkingtremorinPDhasdifferenttremorcharac-

teristicsfromaclassicalresttremor,suggestingthat

awalkingtremorisprobablynotamanifestationof

aresttremorwhilewalking.Furtherstudiesshould

be conducted to identify a possible underlying

mechanismforawalkingtremorinPD.

41Vol.35 • NO.3 • 2019

Clinical Features of Paraneoplastic Syndrome Related to Anti-neuronal

Nuclear Autoantibody Type 2 (ANNA2):

Case Series and Review of Literature

Peerasit Treesuthacheep



Introduction: Paraneoplasticsyndromerelated

to anti-Riwasdiscoveredandhadbeen studied

since1988.Clinicalcharacteristicswerestillpoorly

known.

Objectives: Todescribeclinicalinformationof

fivepatientswithanti-Riparaneoplasticsyndrome

andreviewtheliterature.

Materials and Methods: Information from

patientswithneurologicalsymptomsandlaboratory

positiveforanti-RiatKingChulalongkornMemorial

Hospital between January 2011 andDecember

2018werecollectedinthestudy.MEDLINEdata-

basewasusedtofindrelevantstudieswithkeyword

“anti-Ri”or“antineuronalnuclearantibodytype2”

or“antineuronalnuclearautoantibodytype2”and

“encephalitis”or“paraneoplastic”.

Results: Datafromfivepatients(threewomen

andtwomen)wasrecorded.Clinicalmanifestations

wererangefromopsoclonus-myoclonussyndrome

(20%), peripheral neuropathy (20%), dorsal root

ganglionopathy (20%) and limbic encephalitis

(40%).Nomalignancywasfoundinourpatients.In

the literature review, clinical information from28

casereportsandserieswithtotal65patientswere

analyzed.Similarclinicalcharacteristicwasnoted.

Although,thereweresomedifferencescomprising

younger age of onset, systemic autoimmune

involvementandnoincidenceofmalignancyinour

patients.Mostcommonmalignanciesfoundinthe

literaturewere carcinoma of breast (42%), lung

(28%),urinarybladder(7%)andovary(7%).

Conclusion: Clinical characteristics of para-

neoplasticsyndromerelatedtoanti-Riwerediverse.

Due to high associationwithmalignancy (92%),

furtherstudyshouldfocusonrelationshipbetween

anti-Risyndromeandsystemicautoimmunedisease

especially inyoungerageofonsetgroupwithout

malignancy.


Prevalence of Supine and Nocturnal Hypertension,

Associated Factors and Sleep Position Effect to

Blood Pressure in Parkinson’s Disease

Patients

Ratanut Hamindra



Introduction: Supine hypertension (SH) and

nocturnalhypertension(NH)arerarelyreportedin

PD. Itcan lead tovariousseriousconsequences

suchascardiovascularandcerebrovascularevents

andincreasingmortalityrates.

Objectives:Thisstudyaimedtodeterminethe

prevalence, associated factors of SH/NHand to

identifyrelationshipsbetweenbloodpressure(BP)

andsleeppositioninPDpatients.

Materials and Methods: This is an analytic

cross-sectional study. SeventyPDpatientswere

enrolledintothisstudytoevaluateforSHandNH

bymeasuringBPduringoneday.SHwasdiag-

nosediftherewerehypertensioninsupineposition.

NHwaslossofthephysiologicalnocturnalBPfall

atnightof≥10%.BPineachsleeppositionswere

alsodone.Paired-testandbinarylogisticregression

analysiswereusedinthisstudy.

Results: Therewere35femaleand35male

PD.Theaverageagewas64.5±10.4years.Most

ofpatientswereinmoderatestage(H&Y=2.3).The

prevalenceofSHindaytimeandinnighttimewere

18.6%and5.7%.NHwas 78.6%.We found the

significantcorrelationbetweenSHinnighttimeand

duration of disease, orthostatic hypotension and

betweenNHandRBD.Inaddition,BPinbothlat-

eralpositionswerestatisticalsignificantlylessthan

insupineandfowlerposition.

Conclusion: Thephysicians should alert to

evaluateforthepresenceofSH/NHinPDpatients

especiallyonewhohave longperiodofdisease,

RBDandorthostatichypotension.Thesleepposi-

tions thatwe should recommend forPDpatients

canbeboth lateralpositions todecrease theSH

andNH.

43Vol.35 • NO.3 • 2019

Detection of Impaired Finger Dexterity by Objective Keyboard

Typing Test in Parkinson’s Disease:

A Feasibility Study

Kotchakorn Duangjino



Introduction:Impairedmotordexterityisatype

ofbradykinesiawhichiscommonlyratedbyfinger

tappingtest.Althoughwidelyusedinclinicalpractice,

finger tappingevaluation is frequentlysubjective,

limitingitsapplicationsinfutureclinicaltrialswhere

objectiveoutcomesareincreasinglyconsidered.

Objectives: To objectively evaluate finger

dexterity inParkinson’sdisease (PD)patientsby

keyboardtypingtest.

Materials and Methods: 50PDpatientsand50

age-matchedcontrolswererecruitedinthisstudy.

Objective evaluation of finger dexterity was

assessed by two in-house wearable sensors,

placedonthedorsumofindexandmiddlefingers.

To determine typing performance, side-by-side

typing(M/Nkeystrokes)andfar-reachtyping(P/Q

keystrokes)wereevaluated.Objective outcomes

include typing frequency (F; keys), velocity (V;

keys/s),keystrokes (K;s), repetitionof typing (R;

keys), typingerror (E;keys)andangularvelocity

(AV;deg/s).

Results:PDpatientshadameanH&Ystage

of1.9 (0.6),withameanUPDRS IIIof23 (10.2).

TypingFandVweresignificantlyhigherincontrols

comparedwithPDinbothtasks(p<0.01respec-

tively). Theduration of eachKwas significantly

longer inPD thancontrolsubjects forboth tasks

(p<0.01).ThenumberofEinPDaffectedhandwas

greaterthancontrolinonlyM/Ntyping(p=0.02).

DurationofKwaspositivelycorrelatedwithdisease

severity(UPDRSIII)inbothtasks.(r=0.33,p=0.02,

r= 0.36, p=0.01). H&Y stage was negatively

correlatedwith V only in the P/Q task (r=-0.31,

p=0.03).

Conclusion: Ourpilotstudydemonstratedthe

feasibilityoffingersensorsonkeyboardtypingin

theobjectiveevaluationofimpairedfingerdexterity

inPD.


Deep Brain Stimulation for Advanced Parkinson’s

Disease: Retrospective Analysis and Long-Term

Outcome of 55 Consecutively Operated

Cases

Jutaporn Junwongkaew



Objective:Todeterminethelong-termefficacy

ofdeepbrainstimulation(DBS)foradvancedPD

patientsinKingChulalongkornMemorialHospital

intermsofmotoricimprovement,andthepostop-

erativechangesintotallevodopaequivalentdosage

(LED)anddailymedicationcosts.

Materials and Methods: Fifty-fivepatientswho

treated with bilateral DBS of the subthalamic

nucleus(STN,n=45)orglobuspalidusinterna(GPi,

n=10)wererecruited.Patient’sdemographicdata

andclinicalcharacteristicoutcomeswereassessed

preoperativelyandpostoperativelyinconsecutive

methodsforonemonth,threemonths,sixmonths,

oneyear,andup to fouryears (48months)after

surgery.

Results:Comparingtopreoperativeperiods,

themeanUPDRSmotorsectionscoreat1,3,6,and

12monthspostoperativelywereslightlylowerthan

thepreoperativeperiodwithnostatisticallysignifi-

cant.Additionally,themeanmotorscoreat24,36,

and48monthspostoperativelywereslightlyhigher

than thepreoperativeperiodwith no statistically

significant.However,theLEDandmedicationcosts

at3,6,12,24,36,and48monthspostoperatively

were significantlydecreased (p<0.05, each). For

comparison between DBS-STN and DBS-GPi

groups,theLEDandmedicationcostsweresignifi-

cantly reduced in the STN-treated group only

(p<0.05,each)withunchangedinmotor(p>0.05).

Conclusions: AsthefirststudyinThailandfor

assessingthelong-termefficacyforuptofouryears

follow-up ofDBS in advancedPDpatients, this

studyexperiencedthesignificantreductioninLED

and daily medication price. Meanwhile, STN

seemedtobeapreferentialsurgicallytargetthan

GPibytheadvantageofmedicationreductionwhile

remainingequallyimprovedofmotorsymptoms.

45Vol.35 • NO.3 • 2019

Diagnostic Performance of the New FAAS Stroke

Screening Tool in Patients Who Presented to the Emergency Room

with Neurological Symptoms in Thailand:

A Multi-center StudyWarongporn Phuenpathom



Background :Acutestrokeisthesecondlead-

ingcauseofdeathworldwideandthefirstleading

causeofdeathinThailand.Rapidscreeningand

interventionarethekeystosuccessfulearlytreat-

ment. In Thailand, the conventional FAST stroke

screeningtoolhasgenerallybeenusedbytriage

nurses topromptlydetectacute ischemicstroke.

However, the FAST score has several limitations

includinglowsensitivityindetectionoftheposte-

riorcirculationstroke.Previousstudiesshowedthat

addingataxia,whichwasthesymptomofcerebel-

lar dysfunction, could increase the sensitivity of

posterior circulation ischemic stroke detection.

Therefore, we studied the performance of new

strokescreening tool, FAASscore,amongacute

ischemicstrokepatients.

Objectives:Toevaluatethediagnosticperfor-

manceofFAASscoreandcomparethediagnostic

performancebetweenFAASandtheconventional

FASTscore.

Study design: Multicenter cross-sectional

study.

Materials and methods: ThenewFAASand

conventional FAST score were used by triage

nursesinpatientswhopresentedwithacuteneuro-

logicalsymptomswithinsevendaysat theemer-

gencydepartmentofKingChulalongkornMemorial

Hospital,NopparatrajathaneeHospital andSurin

Hospital.Finaldiagnosiswasmadebyneurologist

usingclinical andneuroimaging information. The

sensitivity, specificity, positive predictive value,

negativepredictivevalue,positivelikelihoodratio,

negativelikelihoodratioandtheROCcurvewere

calculatedusingSPSSversion22.

Results: Onehundredand fortysixpatients

wereenrolled.Onehundredandtwentysevenpa-

tients (86%) hadacute ischemic stroke and19


patients(14%)hadotherdiagnoses.Wefoundthat

thesensitivityofFAASstrokescreening toolwas

higher than the conventional FAST (96.85% vs

95.28%,p=0.125).ThenewFAASstrokescreening

toolcoulddetecttheposteriorcirculationischemic

stroke better than the conventional FAST score

(10.95%vs8.95).

Conclusions:ThenewFAASstrokescreening

tool is a simple, sensitive and suitable to use in

promptlydetectingacutestrokeincludingposterior

circulationstroke.Furtherstudiesshouldbedone

toconfirmthevalidationofthisscore.

47Vol.35 • NO.3 • 2019

The Retrospective Study to Evaluated Effi cacy

Botulinum Toxin A Injection, Greater

Occipital Nerve Blockade, Outpatient and

Inpatient Detoxifi cation Treatment in

Medication Overuse Headache in Headache

Clinic, Northern Neuroscience Centre,

Chiang Mai University

Wichan Kamphu

DivisionofNeurology,DepartmentofInternalMedicine,

FacultyofMedicine,ChiangMaiUniversity,ChiangMai,

Thailand.

Introduction: Differentmethods have been

usedtodetoxifyandmanagemedicationoveruse

headache (MOH).We reviewed the efficacy of

differentmethodinMOHmanagement.

Objectives:Toevaluate treatmentefficacy in

medication overuse headache using botulinum

toxinA(BONT-A)injection,greateroccipitalnerve

blockade (GONB), Outpatient and inpatient

detoxification.

Materials and Methods: RetrospectiveEHR

reviewofmedicationoveruseheadachepatients

(Age≥18year)duringJanuary1st,2012toDecember

31th,2017.Patientweretreatedinoneofbotulinum

toxinA(BONT-A)injection,greateroccipitalnerve

blockade(GONB),outpatientandinpatientdetoxi-

ficationprotocolinHeadacheclinic,NorthernNeu-

roscienceCentre,ChiangMaiUniversity.Outcome

were evaluated by headache frequency, acute

medicationdayused,visualanalogscale(VAS)and

HIT-6scoreandrecurrenceat3monthand6month.

Results:13patientsweretreatedbyBONT-A

injection, 14patientswere treatedbyGONB,14

patientsand4patientweretreatedbyoutpatient

andinpatientdetoxificationprotocol.Mean of head-

ache dayat3monthsignificantlydecreaseinallof

treatmentprotocol(p<0.05)butnosignificantat6

month.Meanofacutemedicationusedat3month

significantlydecreaseinalloftreatmentprotocol(p

<0.05),butonlyoutpatientprotocolat6month,(p

<0.05).VAS (pain score) at 3month significantly

diminishedinalloftreatmentprotocol(p<0.05).At

6month,BOTN-Aandoutpatientprotocoldimin-

ishedwith statistical significant (p<0.05).HIT-6

scoreat3monthsignificantlydiminishedinBOTN-

Aandoutpatientprotocol(p <0.05)and6month,

OnlyBOTN-Adiminishedwithstatisticalsignificant

(p<0.05).Recurrencerateat3month75%ininpa-


tientprotocol.At6monthinGONB,outpatientand

inpatientprotocolhadrecurrenceraterespectively

to21%(3patients) ,29%(4patients)and100%

(4patients).

Conclusion:IntreatmentprotocolofBONT-A

injection,GONB,outpatientandinpatientprotocol.

Responseoftreatmentwithin3monthsignificant

improve in group of BOTN-A injection,GONB,

outpatientdetoxificationwithnorecurrencerate.At

6month,significant improve ingroupofBOTN-A

injection,GONB,outpatientdetoxificationwithno

recurrence rate. In inpatient protocol, therewas

trendtobenoresponseat3monthand6month

withhighrecurrencerate.

49Vol.35 • NO.3 • 2019

Behaviors and Trigger Factors in Episodic

Migraine versus Chronic Migraine in Headache

Clinic, Northern Neuroscience Centre,

Chiang Mai University: A Cross-sectional Study

Kullanit Khumchana



Thailand.

Objectives: To evaluate the behaviors and

triggerfactorsinepisodicandchronicmigraine.

Materials and Methods: Cross-sectional

analyticstudiesreviewedallpatients(age≥15year)

whom fulfilled criteria ofmigraine, according to

ICHD-3 criteria in Headache clinic, Northern

NeuroscienceCentre,ChiangMaiUniversityfrom

NovembertoDecember2018.

Results: A total117patientswere included,

which86.3%werewomen,andmeanageofonset

were47.82±12.98years.Themosttriggerfactors

wasstressinabout53%,followedbyweather(hot,

cold, change in theweather) 52.1%, and sleep

(oversleep,lackofsleep,changeintimeofsleep)

45.3%.Thebehaviorofexcessivecaffeine intake

were reported by 7.7%. Behaviors and trigger

factorswere not different betweenepisodic and

chronicmigrainepatients,norinmigrainewithand

withoutaurapatients,butbetweenmildtosevere

degree and very severe of headache byHIT-6

score, anxiety and depression had significant

differencefactorsbetweentwogroups(p0.004).

Conclusion:Althoughchronicmigrainehasa

central sensitization on pathophysiology, with

highlyimpactonqualityoflife,butthetriggerfactors

comparingwithepisodicmigrainewasnotdifferent.

Thetriggerfactorsaremoredependedonseverity

basedonthestudyresult.


Effect of Infl uenza Vaccination on Level of

Phenytoin in Thai Epileptic Patients Treated

with Phenytoin

Natthakarn Manoyana



Thailand.

Objective: To test the effects of influenza

vaccinationonserumconcentrationofphenytoin,

interferongammaandCYP2C9 level in epileptic

patients.

Methods: Wedid this prospective pretest-

posttest study at outpatient unit in theMaharaj

NakornChiangMaiHospitalbetweenOctober2018

andJanuary2019.Weenrolled20adultepileptic

patientswhotreatedwithphenytoinmonotherapy.

Allpatientswerecollectedbloodsamplesonday

0beforetheywerevaccinatedandevaluateLFT,

baselinephenytoinconcentration,interferonγandCYP2C9.Thenserumconcentrationofphenytoin,

interferongammaandCYP2C9weremeasuredon

day3,7and14.Clinicaltoxicityofphenytoinand

adverseeventsofinfluenzavaccineweremonitored.

Results:SignificantdecreaseofCYP2C9level

wasobservedonday3aftervaccination(p=0.032).

A trendwas also seen of increased interferon

gammalevelonthesameday(p=0.198).Therewas

nosignificantdifferenceinmeanserumphenytoin

concentrationsbetweenbaseline and later three

timepoints.Increasedserumphenytoinmorethan

20%wereobservedinoursevenpatients.Surpris-

ingly,peakserumphenytoinlevelsofthesepatients

revealeddifferentpattern.Oneofourcasedevel-

opedmildphenytointoxicityduringstudyperiod.

Conclusions: CytochromeP4502C9 signifi-

cantlydecreasedafterreceivinginfluenzavaccination.

Thisresponsemaybelinkedtoincreaseinterferon

gamma production. Some of our cases had

increase serumphenytoin level on day 14 after

receivingvaccinationthustheclinicalofphenytoin

toxicityneedtobeobservedatleast2weeksafter

gettingvaccinated.

51Vol.35 • NO.3 • 2019

Pain, Polyneuropathy and Depression in

Parkinson’s Disease: Prevalence,

Characteristic, and Associated Factors

Ekkawit Charoenwanit


ThammasatUniversity,Pathumthani,Thailand.

Introduction:Parkinson’sdiseaseisaprogressive

neurodegenerativedisorder thatleadstomotorand

non-motordisturbances.Painandpolyneuropathy

arefrequentlyobservedinPDpatientsandrecognized

asamajorcauseofthediseaseburden.Despiteits

impact and disabling effects, the prevalence,

character, and associated factors are poorly

documented.

Method:Across-sectionalstudyincluded49

non-demented and non-diabetic (NDND) PD

patientswasconductedatThammasatUniversity

hospital. Prevalence and subtype of painwere

identified by interviewing and questionnaire.

Polyneuropathy was defined the patient’s

characteristicsandconfirmedbynerveconduction

studies.Depression,non-motorsymptoms(NMS),

andqualityoflifewereassessedbytheHamilton

DepressionRatingScale(HDRS),NMSQapplication,

andParkinson’sDiseaseQuestionnaire-8(PDQ-8)

respectively.

Result:Painwasobservedin44.9%ofNDND

PDpatients.Ofthose,musculoskeletalpainwasthe

most common type of pain (63.6%) followedby

radicularpain(45.5%),anddystonicpain(18.2%).

PaininPDwasassociatedwithyoungerage,the

presenceofmotorcomplications,dopamineagonist

use,andhighNMSQscore.Moderateseverityof

unidentifiedpain and restless leg symptoms on

NMSQwereassociatedwithhighHDRSandPDQ8

score.Polyneuropathywasidentifiedin17.5%,all

of themareasymptomatics, sensorimotor axonal

subtypewascommon(71.4%).Polyneuropathywas

notassociatedwithlevodopadose.

Conclusion: Pain in PD is common,mostly

musculoskeletalpainandradicularpain,sensory

polyneuropathyisfrequentlyfoundbutmostofthem

are asymptomatic andnot associatedwith levo-

dopa.


MRI Findings in Thai Patients with Optic

Neuritis

Pichcha Satianwongnusa


ThammasatUniversity,Pathumthani,Thailand.

Introduction: Opticneuritis(ON)isoneofthe

presentingsymptomsofinflammatorydemyelinating

centralnervoussystemdiseases.Magneticresonance

imaging(MRI)ofthebrainandlumbarpuncture(LP)

wererecommendedtobedoneinmostpatientsto

evaluatecausesand/orpredicttheriskofmultiple

sclerosis(MS).

Objectives: WeaimedtostudyMRIfindingsin

ThaipatientspresentingwithONandtofindoutthe

incidence of inflammatory demyelinating central

nervoussystemdiseases,particularlyMS,neuromyelitis

optica spectrum disorders (NMOSD) in these

patients.

Materials and Methods: Patients with the

diagnosisofsuspectedopticneuritisandhaving

brainMRIduringJan1,2015toDec31,2017were

included.MRI, cerebrospinal fluid (CSF) findings

andaquaporin-4(AQP4)antibodywerestudied.

Results: 92patientswereincluded.BrainMRI

wasabnormalin36patients(36/92patients;39%),

whichin28patients,theseabnormalMRIfindings

lead to thediagnosis andmanagement. LPwas

performed in20patients.CSFoligoclonalbands

werepositive in 2patients (2/18patients; 11%).

SerumAQP4IgGwaspositivein4patients(4/19

patients;21%).Commoncausesofopticneuropathy

weretumor(17patients)andinfection(11patients).

AfterallinvestigationsduringacuteONattack,MS

andNMOSDwerediagnosedin4and3patients,

respectively.Withameanfollow-upof10months,

nomorepatientswerediagnosedofMSorNMO.

Conclusion: BrainMRI inONpatientswas

abnormalinalmosthalfofthepatientswhichlead

todiagnosisinathirdofthepatients.

53Vol.35 • NO.3 • 2019

Epidemiology and Characteristics of

Infection in Post-cardiac Arrest Patients Treated

by Targeted Temperature Management in

Thammasat University Hospital

Sirinat Puengcharoen


ThammasatUniversity,Pathumthani,Thailand

Introduction:Targettemperaturemanagement

(TTM) after cardiac arrest improves neurologic

outcome. TTM impairs leukocyte function. The

incidence of significant infections is likely to

increaseifhypothermiaismaintainedlongerthan

24hours.

Objectives:Theaimofthisstudyistodescribe

epidemiologyandcharacteristicsofinfectionafter

treatedbytargetedtemperaturemanagement.

Materials and Methods:Retrospectivereview

ofmedicalrecordsofpost-cardiacarrestpatients,

whowereatleast15yearsold,visitedtoThammasat

UniversityHospitalbetween1stOctober2016 to

31stSeptember2018.Everypatienthadtreatedby

TTM. The primary objectivewas to assess the

epidemiologyofbacterialinfectionsintermsofthe

incidenceof new infections, causativeorganism,

andsite.Thesecondaryendpointwastocompare

infectionratesbetweenpostcardiacarrestpatients

with targeted temperaturemanagement and no

targetedtemperaturemanagementandtoassess

risk factors thatmaydeveloping infection inpost

targetedtemperaturemanagementpatients.

Results:The45post-arrestpatientsenrolled

inourstudy,16ofpatientsdidnotreceiveTTM.29

ofpatientsreceivedTTM,17hadaninfectionafter

TTM(58.62%).Themostcommonorganismresponsible

for infectionwasKlebsiellapneumoniae (55.6%),

and themost common infectionwaspneumonia

(48.28%). Theduration ofmechanical ventilation

andlengthofICUstayweresignificantlyprolonged

in patients developing infections. Therewas no

difference inmortality between thegroups. The

logistic regression analyses identified TTM,DM,

durationofmechanicalventilationmorethan7days,

and ICU length of stay longer than 7 days as

independentriskfactorsforinfections.


Conclusion:Ourstudyfoundahighincidence

ofinfectionsafterTTMwhichdidnotaffectoverall

mortality.Themaincauseofinfectionwaspneumonia

causedbyK.pneumoniae.TheTTM,DM,duration

ofmechanicalventilation,and lengthof ICUstay

wereindependentpredictorsoftheinfections.More

prospectiveobservationalandmulticentricstudies

arenecessarytoenrichourunderstandingofthe

variousriskfactorsandtheirassociations.

55Vol.35 • NO.3 • 2019

Phramongkutklao Odor Identifi cation Kit:

Normative Values in Healthy Volunteers

Nasathapot Namphol

DepartmentofNeurology,PhramongkutklaoHospital,

Bangkok,Thailand.

Introduction: Olfactory function isoneof the

main sensory function.Manyneurodegenerative-

diseaseshaveearlyolfactory involvementbefore

themainsymptom.Bydevelopingourstandardized

PhramongkutklaoOdorIdentificationKit,itcanbe

usedtoevaluatepatientcomplaintofolfactoryloss.

Objectives:Theprimaryobjectiveistodesign

anolfactoryidentificationkitrepresentThaipopula-

tionodor.Secondly,wecompare thescoresbe-

tweencontrol,Parkinson’sdisease(PD)andAlzhei-

mer’sdisease(AD)group.

Materials and Methods: Weenrolled30healthy

volunteers including15malesand15 females in

this experimental study to analyze test-retest

methodtofind8odorswithhighestreliabilityfrom

16odorsidentificationtest.From141participants

including52healthycontrols,62PDpatientsand

27ADpatients,weuse8odorsidentificationtestto

findmean olfactory score of normal population

comparedwithPDandADpatients.

Results: Rose(agreement100%),basil(agree-

ment 100%), banana (agreement 100%), apple

(agreement 100%),whiskey (agreement 100%),

orange(agreement96.67%),pineapple(agreement

93.33%), and coffee (agreement 93.33%)were

chosenfortheirhighestreliabilityrespectively.Our

studyfoundthatmeanolfactoryfunctioninnormal

populationdifferineachagegroup(P-value0.002)

andisdecreasedsignificantlyinagegroup60and

older.Wealsofoundthatmeanolfactoryscoreof

patientswithPDandADalsodecreased signifi-

cantly (P-value<0.001) from5.63±1.72 innormal

populationto3.68±2.08and3.26±2.01inPDand

ADpatientsrespectively.

Conclusion: PhramongkutklaoOdorIdentifica-

tionKitcanbeusedinclinicalsettingtoevaluate

olfactory function inpatient suspectingneurode-

generativediseases.


Comparative Effectiveness and Safety

of Dabigatran, Rivaroxaban, and Apixaban in Non

Valvular Atrial Fibrillation

Rattapas Vorachat


Bangkok,Thailand.

Introduction: Atrial fibrillation is a common

conditionthatincreaseriskofischemicstrokemore

than5timesofnormalpopulation.Theanticoagulant

suchaswarfarinwhichhasanefficacytoreduce

the risk of ischemic stroke about 68% requires

regular international normalized ratio testingand

doseadjustment andhas numerous interactions

withotherdrugsandfood.

Thediscoveryofnon-vitaminKantagonistoral

anticoagulants(NOACs)hasmanyofadvantages

abovewarfarinsuchasfewerdrugsandfoodinter-

action, no need tomonitor drug level and have

demonstrated at least equivalent efficacy and

safetyinlargephaseIIIclinicaltrialscomparingto

warfarin.

Inthepresent,patientsandclinicianshavea

newchoicesofdrugs(NOAC)butstillhavealittle

ofevidencetohelpclinicianstoguidetheirdecision

tochoosetheNOAC.Noheadtoheadtrialofthese

NOACexist.Anumberofstudieshaveperformed

indirectcomparisonandtheytendtodemonstrate

similarefficacyandsafetyamongoftheseNOACs.

Objectives:Tocomparetheriskofstrokeandmajor

bleedingbetweendabigatran, rivaroxaban, and

apixaban in patientswith nonvalvular AF using

Phramongkutklaodatabase

Materials and Methods:Aretrospectivecohort

study was conducted using Phramongkutklao

database in PhramongkutklaoHospital.Medical

recordsofpatientswith ischemicstrokeandnon

valvular AF who received NOAC (apixaban,

dabigatran, rivaroxaban) for secondary stroke

preventionduringJanuary2013toDecember2017

were reviewed. Patientswho had othermedical

illnesswhichcouldinterferewithoutcomeassess-

mentsandfollow-upwereexcluded.Demographic

data, CHADVASc and HASBLED score were

collected.

57Vol.35 • NO.3 • 2019

Results:Totalof371patientswereincludedin

thisstudy,172patientswereexcluded,199patients

weretakingeitherapixaban,dabigatranorrivaroxaban.

Nosignificantdifferenceinrecurrentstrokeratewas

foundbetweenNOAC;4of44patients(8.3%)in

theapixabangroup,5of71patients(6.6%)inthe

dabigatrangroupand1of74patients(1.3%)inthe

rivaroxabangroup(P=1.63).Nosignificantdiffer-

enceinmajorbleedingbetweenNOAC(P=0.911),

butinminorbleedingRivaroxabanwassignificant

lowercomparewithanotherNOAC(P=0.048)

Conclusion: In this study, there was no

significantdifference in stroke recurrent rateand

majorbleedingcomplication.comparingbetween

NOACs.Inaddition,rivaroxabanhadshownlower

minorbleedingcomplicationcomparedwithother

NOACinthisstudy.


Phramongkutklao Odor Identifi cation Kit as a

Diagnostic Tool for Patients with Parkinson’s and Alzheimer’s Disease

Kanchanok Paurika


Bangkok,Thailand.

Introduction: Olfactorydysfunctionhasbeen

describedinpreclinicalstagesincertainneurode-

generative diseases. The association has been

describedinAlzheimer’sdisease(AD)andParkin-

son’sdisease(PD)andmaycorrelatewithdisease

progression.However,therearenostandardmeth-

odsinThailandtostudytheolfactorydysfunction

amongthesegroupsofpatients.

Objectives:Theprimaryobjectiveistoverify

the Phramongkutklaoodor identificationkit asan

accurate tool to identify patientswith early and

establishedADandPD.Thesecondaryobjective

istofindcorrelationsbetweendegreeofolfactory

dysfunctionwithpatients’ age,diseaseduration,

stageorseverityofthetwodiseases.

Materials and Methods:Inthiscross-sectional

study,weenrolled62PD,27ADand52controls

fromNeurologyoutpatientclinic,Phramongkutklao

hospital.Phramongkutklaoodoridentificationkitwith

8differentodorsandallfamiliartoThaipopulation

was used to evaluate odor scores. To assess

disease severity, ThaiMental StateExamination,

FunctionalAssessmentStagingTest,TheLawton

InstrumentalActivities ofDaily LivingScale, The

NeuropsychiatricInventoryQuestionnaire-Thaiwere

applied in ADpatients.While PDpatientswere

evaluatedusingmodifiedHoehh&Yahrstagingand

UnifiedParkinson’sDiseaseRatingScalepartIand

II.Kruskal-Wallistestasarank-basednonparametric

testwasperformedtodeterminedifferenceofthe

odoridentificationscoresbetweengroups.

Results: Atotal141volunteerswereincluded

intheanalysis.PDandADpatientshadasignifi-

cantly lower scorescomparedwithcontrols. The

analysisalsorevealedsignificantlylowerscoresin

PDcomparedwithcontrolsbetween51-60yearsof

age.Therewasnocorrelationbetweenthescores

anddiseaseseverityinbothdiseasegroups.

59Vol.35 • NO.3 • 2019

Conclusions: Phramongkutklaoodoridentifica-

tion kit is applicable as a supplementary tool to

diagnosepatientswithPDandAD.


Validation of a Mobile Application for Detecting

Wearing-off in Patients with Parkinson’s Disease;

A Prospective, Blind Comparison to a Gold

Standard Study

Treesuda Lamyai


Bangkok,Thailand.

Background: TreatmentofParkinson’sdisease

ismainlysymptomatictreatmentwithdopaminergic

therapy. Complicationsofdopaminergictreatment

includemotorandnon-motorfluctuationsbecome

themajorproblemsexperiencedbypatients. Thai

Parkinson’sdiseaseandmovementdisorderssociety

developed an application in Thai language for

tablets and smart phones to detectwearing-off

(WO) in Parkinson’s disease patients but never

beforevalidatedasatoolfordiagnosisofWO.

Objectives:Thisstudypurposedtodetermine

1)whethertheapplicationisausefultooltoassist

physicianstodetectWOinclinicalpractice2)the

relationshipbetweentheresultsofapplicationand

factorsconcerningtheclinicalconditionandcourse

ofthedisease3)relativefrequencyofthesymptoms

associatedtoWOasassessedbytheapplication.

Methods:Thisprospective,blindcomparison,

cross-sectionalstudyconductedatPhramongkutklao

hospital. The sensitivity and specificity of the

application to detectWOwere determined by

comparingtheidentificationofWObytheclinical

evaluationperformedbyneurologists.

Results: Atotalof125patientswereincluded

inthisstudy.Accordingtothecriterion,51(40.8%)

and81(64.8%)hadWOdetectedbyclinicaldiag-

nosisandbyapplication,respectively.Theapplica-

tion showed a sensitivity of 100%, specificity of

59.5%,PPVof63%,NPVof100%.PatientswithWO

wereonasignificantlyyoungerthanthosewithout

wearingoffandalsolongerdiseaseduration.

Conclusion: Theresultsofthestudiesindicate

thattheWOdetectingapplicationforThaipatients

has apotentially useful role in everyday clinical

practice,providingbothpatientsandclinicianswith

aconvenientandusefuladjuncttoclinicalpractice.

61Vol.35 • NO.3 • 2019

Surveys of Behavioral and

Psychological Symptoms of Dementia (BPSD) in

Dementia Patients

Winyou Koovimon

NeurologyResident,DepartmentofMedicine,Rajavithi

Hospital,Bangkok,Thailand

Introduction: Behavioral andPsychological

SymptomsofDementia(BPSD)isamajorproblem

indementiapatients.BPSDisnotonly increased

morbidity andmortality of thepatients, but also

impairqualityoflifeinbothpatientsandcaregivers.

ThepatientswithBPSDhavemyriadclinicalmani-

festations,rangingfrompsychiatric,affectiveand

somatic symptoms. This studywas intended to

surveytheincidenceandeffectsofBPSDindemen-

tiapatientsandcaregiversinourhospital.

Objective:Tosurveytheincidenceandeffects

ofBPSD.

Material and Methods: 100dementiapatients

were testedwithTMSEand100caregiverswere

answeredtheNeuropsychiatricInventory-Question-

aire(NPI-Q).

Results: ThethreemostcommonBPSDinmild

dementiagroup(TMSEscore20-24)wereanxiety

(60%),motor disturbance (38.7%) and apathy/

indifference(35.5%).Inmoderatedementiagroup

(TMSE score 13-20) were nighttime behavior

(63.1%),apathy/indifference (60.5%)andanxiety

(57.9%).Caregiversinmilddementiagrouprated

anxiety as themost distress symptom (distress

level 3),while caregivers inmoderate dementia

groupratednighttimebehavior,anxietyandhallu-

cinationas themostdistresssymptoms (distress

level4).

Conclusion: The common symptomswere

anxiety,apathy/indifference,motordisturbanceand

nighttimebehavior. The severities of BPSDand

caregiverdistresseswerehigher,dependsonthe

severity of dementia. Knowing the incidence of

commonBPSDsymptomswillalertcaregiverand

physicians taking care of dementia patients, so

earlymanagementtopreventmorbidityandimprove

qualityof life inbothpatientsandcaregiverscan

happen.


Study of the Association between Human

Leukocyte Antigens (HLA) and

Carbamazepine-Induced Maculopapular Rash in

Thais

Jukrapope Jitpimolmard

DivisionofNeurology,DepartmentofMedicine,

RamathibodiHospital,MahidolUniversity,Bangkok,

Thailand.

Introduction: HLA-B*1502 is abiomarker for

Carbamazepine-inducedStevens-Johnsonsyndrome

(SJS) and Toxic EpidermalNecrolysis (TEN) in

Thais. But, an association between HLA and

Carbamazepine-inducedmaculopapular eruption

(CBZ-MPE)hasnotbeenstudyThai.InJapanese

andCaucasian,HLA-A*3101 is associatedwith

CBZ-MPE.Toourknowledge, therehasbeenno

researchfocusingontheassociationbetweenHLA

andCBZ-MPEinThais.

Objectives: TodeterminetheroleofHLAon

thedevelopmentofCBZ-MPE

Materials and Methods: Thiswasaretrospective

case-controlstudy.FromJanuary2014toDecember

2018, enrolled 17 patientswithCBZ-MPE after

commencingcarbamazepineandwassentforHLA

genotypinginRamathibodihospital.

Results: ComparingbetweenCBZ-MPEand

control,thefrequencyofHLA-B*1301ishigherthan

thegeneralThai.ThereisnoHLA-A*3101foundin

CBZ-MPEgroup.HLA-B*1502isnotassociatedwith

CBZ-MPE.

Conclusion:ThisisthefirstreportontheHLA-

AgenotypesintheThaipatientswithCBZ-MPE.We

foundneitherHLA-A*3101norHLA-B*1502alleles

inourCBZ-MPEcases.Thus,CBZ-MPEcanoccur

independently ofHLA-A*3101 andHLA-B*1502.

Basedon theThaiClinicalPracticeGuideline for

Epilepsy,andtheadditionalpromisingresultsfrom

ourstudy,theidentificationofsubjectscarryingthe

HLA-B*1502 is theonly test thatwe recommend

performing inThais for thepreventionofCBZ-in-

ducedSJS/TEN.TheevaluationofotherHLAgeno-

typesisnotnecessaryandmaynotbecosteffective

screeningtoolsforthepreventionofCBZ-MPE.

63Vol.35 • NO.3 • 2019

Long-term Visual Outcome of Optic

Neuritis in NMO and HIV Patients

Napat Napapongsuriya



Thailand.

Objectives: Tocomparedclinicalmanifesta-

tionsandvisualoutcomebetweenHIV-relatedoptic

neuritis(ON)andNMOSDassociatedON.

Materials and Methods: Thiswasaretrospective

observational study, conducted in Faculty of

MedicineRamathibodiHospital,MahidolUniversity

between2009-2014.Therewere27patientswith

opticneuritiswererecruitedinthisstudy,9patients

inHIV-relatedONgroup,and18patientsinNMOSD

associated ON group. The visual acuity was

recorded at diagnosis and 1 year follow up in

LogMARunit. The improvedof visual acuitywas

calculatedbetweentwogroups.

Results: ThemeanVAatthefirstvisitwas1.66

inNMOSDassociatedONand1.17inHIV-related

ON(p=0.05).ThemeanVAatthefollow-upvisitwas

0.92 inNMOSDassociatedONand0.77 inHIV-

relatedON(p=0.72).ThemeanimprovedVAwas

0.78 inNMOSDassociatedONand0.40 inHIV-

relatedON. Therewasno significantly statistical

differenceinthemeanimprovedVAbetweenthe

twogroups(p=0.27)

Conclusion: Therewasnostatisticallysignifi-

cant in improved VA between the two groups.

Theclinicalmanifestationsofbothconditionswere

aggressive.


Infarct Pattern in Acute Ischemic Stroke Patients

with Atrial Fibrillation by Diffusion-Weighted

Imaging

Boriwat Koonarangsee



Thailand.

Objective: Our aimwas to investigate the

characteristicsofcerebral infarctionbydiffusion-

weightedimaging(DWI)inacuteischemicstroke

(AIS)patientswithatrialfibrillation(AF)andcompare

infarctionpatternsinpatientswithparoxysmalAF

andotherAFsubtypes.

Methods: In our prospective stroke registry

cohort studywith retrospective analysis (since1

January 2012 and 31 December 2016), acute

ischemicstrokepatientswithatrialfibrillationwho

performedDWIwere evaluated. TheDWI infarct

patterns were characterized and compared

betweenAFsubtypes.

Results: Of 108 AIS patients with AF and

performedbrainMRIwereanalyzed.Themultiple

embolicscatteringlesionswasfoundin55%and

multipleterritorylesionwasfoundin33%.Thesingle

ischemiclesionfoundinonly35%.However,2in3

ofallAISpatientswithAFhad infarctconfined in

onevascularterritory.TheDWIinfarctpattern2and

4wereassociatedwithparoxysmalAFthanperma-

nentAFsubtypes(OR11.1,P=0.025).

Conclusion: The cerebral infarction in AIS

patientswithAFwasusuallymultiple (more than

oneischemiclesion)togetherwithembolicscatter-

ingpattern.TheparoxysmalAFhadmoreembolic

scatteringormultipleischemiclesionthanperma-

nentAFsubtype.

65Vol.35 • NO.3 • 2019

Effects of Handwriting Exercise on Functional

Outcome in Parkinson’s Disease Patients:

A Randomized Controlled Trial

Nisa Vorasoot



Thailand.

Background:Parkinson’sdisease(PD)patients

frequently experiencemicrographia, difficulty

writingandsigning,causingpoorqualityoflife.This

study aimed to determinewhether handwriting

exercisecouldimprovewritingskillandfinemotor

functioninPD.

Methods: The study was a single center,

single-blinded,randomizedcontrolledtrial,evaluat-

ingtheefficacyofa4-weekhandwritingexercise

usingour newlydevelopedhandwritingpractice

book.Theprimaryendpointwasanimprovement

in speed to complete the handwriting test. The

secondary endpointswere the accuracy of the

writing performance, patient’s subjective rating

scaleandUPDRSpartIIImotorexamination.

Results:46subjectswereenrolled,23were

randomly assigned to the handwriting exercise

group.After 4weeks of exercise, timeusing for

completing thehandwriting testwas significantly

improved in the exercisegroup (143.43± 34.02

seconds vs. 175 ± 48.88 seconds, p = 0.015).

Patient’s subjective rating scale in the exercise

groupwasalsoimproved(2.78±0.42scoresvs.

2.08±0.60scores,p<0.001).Furthermore,UPDRS

partIIIscores,especiallyonhandmotorfunction

were shownmore improvement in the exercise

group (-17.95 ± 14.25%vs. -3.15 ± 9.14%,p<

0.001).

Conclusion:The4-weekhandwritingexercise

usingourhandwritingpracticebookappearstobe

abletopromoteanimprovementonwritingspeed

and finemotor function of hands. The optimum

duration,thefrequencyofhandwritingexercise,and

thecharacteristicof the letters in thehandwriting

practicebookaremeritforfurtherstudiestoimprove

thebenefitfromtheexercise.


Incidence and Associated Factors of Intracranial

Hemorrhage after Intravenous

Thrombolysis for Acute Ischemic Stroke in Vajira

Hospital

Chonvipa Siriyutwattana


Medicine,Vajirahospital,NavamindradhirajUniversity,

Bangkok,Thailand.

Objective: This study aimed to identify the

factorsassociatedwithandtheincidenceofintrac-

ranial hemorrhage after IV rt-PA in patientswith

acuteischemicstrokeinVajirahospital

Methods:Thestudydesignwasretrospective

cohortstudy.Wereviewedthemedicalrecordsof

allpatients treatedwith IVrt-PA inVajirahospital

fromJan,2008-Aug,2018.Wedividepatientsinto

2group;symptomaticintracranialhemorrhage(sICH)

andNo symptomatic intracranial hemorrhage(No

sICH) and compared variable factors between

thesegroups.ThesICHwasdefinedasanyintrac-

ranialhemorrhagethatwasnotseenonaprevious

CTscanand therehadbeensubsequentlybeen

eitherasuspicionofhemorrhageoranydeclinein

neurologicstatus(NINDs’sdefinition)

Results: 102 patientswith acute ischemic

strokeweretreatedwithIVrt-PAinVajirahospital

.Theincidenceofsymptomaticintracranialhemor-

rhagewere7/102(6.86%).Atrialfibrillationwasthe

onlysignificantfactorassociatedwithsICH.(sICH

vsNosICH=57.14%vs15.79%,RR5.83,95%CI

(1.30-26.02),p-value0.021).

Conclusion: The incidence of symptomatic

intracranialhemorrhagewassimilartothedatafrom

NINDs.AtrialfibrilationwasassociatedwithsICH.

Thehistoryofantiplateletusemaybesignificantif

therearelargerpopulation.

67Vol.35 • NO.3 • 2019

Peripheral Neuropathy in Levodopa-treated

Parkinson’s Disease Patient

Duangkamol Singwicha


Medicine,VajiraHospital,NavamindradhirajUniversity,

Bangkok,Thailand

Objective: This study is to find the relevant

between Parkinson’s disease (PD) patients in

variousstagesanddurationofdiseasewhohave

beentreatedwithLevodopaanddevelopedperipheral

neuropathy(PN).

Methods:40patientswithPD(diagnosedby

UKPDSBBcriteria)who have been treatedwith

Levodopawereenrolled,8wereexcludedbyexclu-

sion criteria (diabetes, history of chemotherapy,

antiretroviraltherapy,andvertebraldegeneration)

and32patientswerescreenedforpolyneuropathy

by TorontoClinicalNeuropathy Scoring System

(TCSS),30patientswhoTCSSmorethan5outof

12wereconductedNerveConductionStudy(NCS)

toconfirmthediagnosis.30Patientsweredivided

into2groups,shortexposureLevodopadrug;SELD

(3yearsorless)andlongexposureLevodopadrug;

LELD(morethan3years)thencomparedTCSSand

NCS.

Result: PNwas present in both SELD and

LELD, diagnosed by absent of SNAP in Radial

nervesandSuralnerves13.3%and60.0%respec-

tively,manifested as symmetrical andpredomi-

natelysensoryaxonalneuropathy.

Conclusion:Inourresearchshowedthatthe

patients in this study experienced the clinical of

polyneuropathy from TCSS, but no significance

different in bothgroup.Nerve conduction study

(NCS)showedelectrodiagnosticfindingoflength-

dependentdistallargefibersensoryneuropathy.


A Pilot, Comparison Study of the Treatment for an Acute Attack of Neuromyelitis Optica:

Intravenous Methylprednisolone

(IVMP) with Add-on Plasma Exchange

(PLEX) versus Intravenous

Methylprednisolone Combined with Plasma

Exchange

Thanapon Songthammawat


Medicine,SirirajHospital,MahidolUniversity,Bangkok,

Thailand

Background: Plasmaexchange (PLEX) can

remove circulating pathogenic antibodies and

complements in neuromyelitis optica spectrum

disorders(NMOSD).InasevereattackofNMOSD,

add-onPLEXtreatmentforpatientswhohavenot

responded to intravenousmethylprednisolone

(IVMP)isgenerallypracticed.

Objective: To compare the effectiveness of

IVMPaloneorIVMPaddonPLEXwithacombined

IVMPandPLEXtreatment inpatientswithsevere

NMOSDattacks.

Methods: Aprospective, randomized, con-

trolled,pilotstudyofpatientswithasevereNMOSD

attackwasconducted.OnegroupreceivedIVMP

alone,withsubsequentPLEXbeingperformedonly

if their clinical symptomsdid not respond to the

steroid.ThesecondgroupreceivedIVMPcombined

withplasmaexchange.Acomparisonofthegroups

wascarriedoutusingtheExtendedDisabilityStatus

Scale(EDSS)scoresatbaseline,duringtheattack,

andatfollow-upvisits.

Results: Eleven AQP4-positive, NMOSD,

femalepatientswereincluded.Sixwereinthegroup

administeredIVMPwithaddonPLEXiftherewas

noresponsetothesteroid;theremainderreceived

acombinationofIVMPandPLEXfromthebegin-

ning.Theattackscomprisedmyelitis(57.1%)and

optic neuritis (42.9%). Therewas no significant

differencebetweenthe2groups,asmeasuredby

the EDSS scores 6months after the treatment

(∆EDSS=-1.5intheIVMP-with-subsequent-PLEX

group, vs -2.17 in the combination-IVMP-PLEX

group;P=0.398).

Conclusions: Bothtreatments(IVMPwiththe

possiblesubsequentadministrationofPLEX,and

thecombinedIVMP-PLEXtreatment)providedthe

samelevelofneurologicalimprovement,asmeas-

uredby their EDSS scores, for acute attacks of

NMOSD.

69Vol.35 • NO.3 • 2019

The Short-term Effect of Combined Facial

Exercise with Botulinum Toxin Injection in

Clinical Practice in Thai Patients with Hemifacial

Spasm: A Randomized Controlled Pilot Crossover Study

Pannathat Soontrapa



Thailand

Background: Hemifacial spasm (HFS) is a

troublesomeperipheralmyoclonusinvolvinghalfof

theface.BotulinumtoxinA(BTX-A)isatreatment

ofchoice.Therewerefewdatathatshowed some

benefitoffacialmassageontopoftheBTX-Ainjec-

tioninfacialdystonia.

Objectives: Tocomparetheefficacyofcom-

binedfacialexercisewithBTX-AinjectionwithBTX-

Ainjection-alonemeasuredbytotalHFS-30(tHFS-

30)score.

Materials and Methods: Eight-monthprospec-

tive, randomizedcontrolledcrossover studywas

conducted involved fortyHFSpatients.We rand-

omizedthepatientsintotwogroupseitherwithor

without facial exercise in 1:1 ratio then did the

crossoverattheendofthefourthmonth.Weevalu-

atedshort-termeffectof facialexerciseontopof

theBTX-Ainjectionatonemonthaftertheinterven-

tion.Theprimaryoutcomewasthemeanchangeof

qualityoflife(QoL)measuredbythetHFS-30score

comparedbetweentwogroups,andthesecondary

outcomeswerethemeanchangeinseverityusing

SMCseveritygradingscale,time-to-onsetofaction,

time-to-peak effect, self-reported global clinical

response,andadverseeffects.

Results: Thirty-eightpatients completed the

study. MeanchangeoftHFS-30scorewassignifi-

cantlyimprovedby6pointswhichwerelowerinthe

groupof facial exercise (95%CI=1.4-10.6; p-val-

ue=0.01).Thesub-itemsoftheHFS-30scorewhich

showed significant improvementwere emotional

well-being(p-value=0.002),stigma(p-value=0.03),

andcognition(p-value=0.04).Therewasnostatis-

tically significantdifference in all secondary out-

comesandadverseeffectsbetweentwogroups.

Conclusion: Combined facial exercisewith

BTX-A injectionmayenhance the short-termeffi-

cacy onQoL ofHFSpatientsmeasuredby the

tHFS-30score.


Accuracy of Support-Vector Machines

for Diagnosis of Alzheimer’s Disease

Using Volume of Brain Obtained by Structural MRI at Siriraj Hospital

Anutr Khummongkol



Thailand.

Background: Thedeterminationofbrain vol-

umesusingvisualratingslackssufficientaccuracy

for thediagnosis ofAlzheimer’sdisease (AD).A

support-vectormachine (SVM) is a learningma-

chinethatcanbeusedasaclassifier forvarious

circumstances.

Objective:ToinvestigatetheaccuracyofSVM-

classifications for AD subjects usingMRI brain

volumetryandvariousclinicaldata.

Methods:Thestudywasaretrospectivechart

review.Of201subjectsrecruitedfrom“TheDemen-

tiaandDisabilityProjectinThaiElderly”,18were

excludedbecauseofinadequateMRIdata,and92

wereassignedtoa“traininggroup”toenableSVM

learning.Usingonlybrainvolumetry,asecond“test-

inggroup” of 91unknown subjectswere subse-

quentlyclassifiedby the “trained”SVM.Afterex-

cludingsubjectswithmissingclinicaldata,theSVM

modelaccuracywasthenfurtherevaluatedon55

subjectsusingbothMRIdataandclinicalparam-

eters (Thaimental state examination score, con-

trolledoralwordassociationtests,learningmemo-

ry,clock-drawingtest,andconpraxis).Wereported

the results in terms of accuracy and a receiver

operatingcharacteristiccurveanalysis.

Results:Thehighestaccuracyforbrainvolu-

metry(62.64%)wasfoundwiththehippocampus.

Acombination of clinical parametersprovideda

higheraccuracyrange(83%–90%).Incontrast,a

combinationofclinicalparametersandbrainvolu-

metrydidnotfurtherincreasetheaccuracyofthe

results.

Conclusions:Theclinicalparametersprovided

good accuracy (83%–90%).Our study failed to

demonstrategoodaccuracyusingbrainvolumetry

alone.Thebestresultsrelatingtobrainvolumetry

wereobtainedforthehippocampus(62.64%).

71Vol.35 • NO.3 • 2019

Symptomatic Seizure and Epilepsy after

Anterior Circulation Ischemic Stroke at Siriraj

Hospital, A Tertiary Hospital in Thailand

Pornsawan Mekhasingharak



Thailand

Introduction: Stroke is one of the leading

causesof seizureamongadults.Between3and

30%ofpatientswhohavehadanischemicstroke

developpost-strokeseizure.

Objectives: Weaimed to investigate theas-

sociated factors on thedevelopment of sympto-

maticseizureinanteriorcirculationischemicstroke.

Materials and Methods: We retrospectively

analyzedpatientswithischemicstrokepresented

between January 2012 and June 2017. Patients

werefollowedupforatleast1years.Dataincluding

stroke etiology, size, location, and severitywere

recorded.

Results: Atotalof319patients,124patients

(38.9%)weretreatedwithrecombinanttissueplas-

minogen activator (rt-PA). Twenty-nine patients

(9.1%)hadpost-strokeseizuresduringfollow-up,

comprising4(1.3%)withearly-onsetsymptomatic

seizuresand25(7.8%)withlate-onsetseizures.All

patientswithlate-onsetseizures(100%)fulfilledthe

definition of post-stroke epilepsy, while 25% of

early-onsetseizuresmetthecriteria.Regardlessof

seizureonset,theoccurrenceofpost-strokeseizure

wasassociatedwith increasedage (p=0.002),

NationalInstituteofHealthStrokeScale(NIHSS)at

onsetandNIHSSatdischarge(p<0.001forboth),

non-small-vessel occlusion etiology (p<0.001),

exclusivelycorticallesion(p<0.001),hemorrhagic

transformation(p=0.003),andlesionsizegreater

than10milliliters(p<0.001).Administrationofrt-PA

wasnotassociatedwithpost-strokeseizure (p=

0.49).Mostofpatientswithseizure(25/29;86.2%)

were effectively treatedwith single antiepileptic

drug.

Conclusion: Inthethrombolyticera,seizures

after anterior circulation ischemic stroke are still

associatedwith stroke severity, cortical involve-


ment, size, andhemorrhagic transformation.Ad-

ministrationofrt-PAdidnotreducethechanceof

post-strokeseizures.Alllate-onsetseizuresturned

intopost-strokeepilepsy,whereas25%oftheearly-

onsetgrouphadepilepsy.

73Vol.35 • NO.3 • 2019

The Association between Perception of Cognitive

Decline and Mild Cognitive Impairment in Non-Demented Patients

with Parkinson’s Disease

Rabwas Munjit


MedicineSirirajHospital,MahidolUniversity,Bangkok,

Thailand

Objective: Thisstudyisaimedtoevaluatethe

associationbetweenself-andinformant-perception

ofcognitiveproblem,andobjectivecognitivede-

cline in non-dementedpatientswith Parkinson’s

disease(PD).

Material and Methods: 73non-dementedpa-

tientswithPDwereincludedfromParkinsonclinic

atSirirajHospital.Perceptionofcognitivedecline

wasassessedbyusingtheCognitiveChangeIndex

(CCI),Thai-version.TheMontrealCognitiveAssess-

ment(MoCA)Thai-versionwasusedtoassessthe

objectivecognitivedeclineandtodiagnoseamild

cognitiveimpairment(PD-MCI)accordingtoMove-

mentDisorderSocietyguideline.Associationofthe

diagnosisofPD-MCI,MoCAscoreandCCIscores

obtainedfromsubjects(CCI-S)andtheirinformants

(CCI-I)wereanalyzed.Apathywasdiagnosedby

theproposeddiagnosticcriteriaforapathyinAlz-

heimer’sdiseaseandotherneuropsychiatricdisor-

ders.

Results: Therewere 19cognitively-normalPD

patients(PD-CN)and54patientswithPD-MCI.CCI-

IscorewassignificantlyhigherinthePD-MCIgroup

ascompared toPD-CN(37.7±14.8,29.4±5.7, re-

spectively,p=0.001),butnottheCCI-S(p=0.59).

However,bothCCI-I andCCI-S scoreswerenot

correlatedwithMoCAscore(p=0.82and0.36,re-

spectively).19(35.2%)participantswerediagnosed

ashavingapathy,allofthemwereinthePD-MCI

group.NopatientsinthePD-CNgrouphadapathy.

Conclusion:Onlytheinformantperceptionof

cognitivedecline,asmeasuredbytheCCI-IThai-

version,andthediagnosisofapathyareassociated

withthediagnosisofMCIinThaipatientswithPD.

Integrationofareportofcognitivedeficit fromin-

formantandthediagnosisofapathycouldhelpin

thediagnosisofPD-MCI.


A Reliability and Validity Study of A Simple

Assessment Tool for Early Detection of

Perioperative Stroke

Wananwat Danworapong


MedicineSirirajHospital,MahidolUniversity,Bangkok,

Thailand

Introduction: Strokeisafearedpostoperative

complications. Thediagnosis is usually delayed

resulting in a reducedpossibility for therapeutic

intervention.

Objective:Toassessthereliabilityandvalidity

ofasimpleassessmenttoolforearlydetectionof

perioperativestroke

Materials and Methods:We set up a short

course andworkshop for all service nurses in

neurologicalscreeningmethodfortheassessment

tool for early detection of perioperative stroke

includingobservingeyedeviation or extraocular

musclelimitation,asymmetricallimbweaknessand

consciouschangesin24surgicalwardsinSiriraj

hospital.Theprotocolwasappliedduringroutine

postoperativevitalsignmeasurement toevaluate

newneurologicaldeficits≤14daysafter surgery.

Thepostoperativepatientswereselectedunderthe

permission.Weusedcontent validity, sensitivity,

specificity and analysis tomeasure content and

criterionvalidityrespectively.Wealsotestedinter-

raterreliabilitybyusingKappaandFleiss’sKappa

statistics.

Results:The425postoperativepatientsfrom

June toDecember, 2018were assessedby the

protocol.Thesensitivitywas85.71%andspecific-

itywas98.02%.Positivepredictivevalue(PPV)and

Negativepredictivevalue(NPV)was69.23%and

99.25%respectively.Theaccuracyofthetoolwas

97.41%. The interrater reliabilitywas substantial

agreement.

Conclusion: Thissimpleassessmenttoolhas

goodreproducibilityamongnursesandphysician.

It has good validity in identifying perioperative

stroke and increasing the patients’ therapeutic

opportunity.Itisalsosimplyandtimesavingtool.

75Vol.35 • NO.3 • 2019

Predicting Hospital Discharge Outcomes among Patients with

Cryptococcal Meningitis

Nichanan Ekpitakdamrong


FacultyofMedicinePrinceofSongkhlaUniversity,

Songkhla,Thailand

Objective: To define the hospital discharge

outcomesofallpatientsdiagnosedwithCMand

treatedduring theyears2002-2017 inamedical

teachinghospital

Material and Methods:Aretrospectivemedical

records reviewwas done to define the hospital

dischargeoutcomesofallpatientsdiagnosedwith

CMand treatedduring theyears2002-2017 ina

medical teaching hospital. Poor outcomeswere

definedasno improvementordeath.Descriptive

statisticswasusedtoanalyzegeneraldemograph-

icandclinicalparametersandpresentations.Inde-

pendentpredictorswerefurtherdefinedbymultiple

logisticregressionanalysisfromthebaselineclini-

cal data and thecerebrospinal fluid results, and

showninadjustedoddratiowithstatisticalsignifi-

cance(p<0.05).

Results:SixtytwoCMpatientswereincluded.

Thirtythree(54.84%)ofthemwerefemales.Their

medianagewas37(30,46)yearsold.Thepositive

HIVserologywasfoundin70.97%.Concurrentim-

munosuppressantusewas6.46%.Systemicmalig-

nancywasfoundassociatedin4.84%.Themajority

oftheenrolledpatientspresentedwithfever,head-

acheandnauseaandvomiting.Themedian(IQR)

days of hospital staywas 18 days (12.75, 23).

Elevenpatients hadpoor outcomes on hospital

discharge(8died,3noneurologicalimprovement).

Preexistenceofunderlyingdiseases,positiveserol-

ogy of HIV infection, nausea and vomiting and

cranialnervespalsiesatthepresentationwerethe

independentpredictorsofpooroutcomes.

Conclusion:Theclinicaloutcomesoftreated

CMwerebased significantly on the appropriate

management of thepreexisting systemic comor-

biditiesanditscomplications,aswellasthedisas-

trouslyelevatedintracranialpressureofCM.


Predictors of Clinical Outcomes among Patients

with Brain Abscess in Thailand

Thanyalak Amornpojnimman


FacultyofMedicinePrinceofSongkhlaUniversity,

Songkhla,Thailand

Introduction: Brainabscessisanintraparen-

chymalsuppurativeinfectiousconditionofthebrain

whichpotentiallyresultinginalife-threateningcon-

dition.Withthecontinuousnoveldiscoveriesinthe

medical sciences, themortality ofbrain abscess

hassignificantlydecreased.Studiesonbrainab-

scessarequite limitedandoutdatedinThailand.

Therefore,ourstudyaimstoidentifypredictorsof

mortality among patientswith brain abscess in

Thailand.

Objective: Toidentifytheindependentfactors

predictingdeath outcome in patientswith brain

abscess

Material and Method: Weretrospectivelystud-

iedpatientsdiagnosedwithbrainabscessadmitted

toSongklanagarindHospitalinSongkhla,Thailand

between2002and2017. Demographicdata,neu-

rologicalstatus,clinicalpresentations,predisposing

factors,microbiologicalprofiles,neuroimagingfind-

ings,treatments,andoutcomeswerecollectedfrom

electricalmedical records. Predictors of death

outcomewere analyzedby univariate andmulti-

variatelogisticregressionanalysis.

Results: Eighty-onepatientswereenrolledin

the study. Forty-sevenpatients (58%)weremale

and 34patients (42%)were female. The overall

meanagewas47.68±16.92 years. Thecommon

riskfactorsofbrainabscesswereimmunocompro-

misedstate(38.3%)andtheextensionofapericra-

nialinfection(24.7%).Thecommonclinicalpresen-

tationswereheadache(61.7%),fever(50.6%),and

hemiplegia(34.6%).Elevenpatients(13.6%)were

deadathospitaldischarge.Theindependentfactor

associatedwithdeathoutcomeidentifiedbymulti-

variateanalysiswasconfusion(oddsratio7.67,95%

CI1.95-30.14;p=0.003).

77Vol.35 • NO.3 • 2019

Conclusion: Thecurrentstudyshowsthatin-

creasedimmunocompromisedstateisapredispos-

ingfactorofbrainabscess.Theindependentfactor

associatedwith death outcomewas confusion

whichwascorrelatedwithsepticencephalopathy.


Role of Optic Coherence Tomography

and Visual Evoke Potential Test in

Symptomatic and Asymptomatic Optic

Neuritis Patients in Prasat Neurological Institute

Chalinee Puangpoon

DepartmentofNeurology,PrasatNeurologicalInstitute,

Bangkok,Thailand

Background:Opticneuritisisaninflammation

oftheopticnerve,whichcanbeidiopathicoras-

sociatedwithdemyelinatingdiseasesuchasmul-

tiplesclerosis(MS)orneuromyelitisoptica(NMO).

OpticneuritisinNMOandMSmaybesubclinical

orasymptomaticand isnotdetectedbyconven-

tional clinical assessment.Many studies have

shownthepresenceofsubclinicalchangesinoptic

nervefunctiondetectedbyVisualevokedpotential

(VEP)andopticcoherencetomography(OCT),but

thereisnoagreementwhichismoresensitive.

Objective:TocomparethecapacityofVEPand

singleOCTindetectedopticneuritis,andtoevalu-

atetheeffectivenessofVEPandOCTindetecting

asymptomatic optic neuritis inpatientswho sus-

pectedofNMOandMS.

Methods:Cross-sectional studies, reviewing

thecharts of26patientswhoarediagnosedclini-

callywithopticneuritis,orhistoryofopticneuritis,

ortransversemyelitis,NMO,orMS,withorwithout

visualsymptomsbetweenJanuary1,2015andJuly

31,2018 Thesubjectsareclassifiedintotwogroups:

1) eyeswith visual symptomsor history of optic

neuritis (affectedeyesgroup)and2)eyewithout

visualsymptomsorhistoryofopticneuritis(unaf-

fectedfelloweyesgroup).VEPandOCTaredone

inalltheeyesincludedandthecapacityindetect-

ingabnormalitiesofthosetwotestsiscompared.

Thecorrelationbetweentestabnormalityanddis-

easeseverityarealsostudied.

Results:Twenty-sixpatientsprovided52eyes,

33areaffectedeyesand19areunaffectedfellow

eyes.VEPcandetectmoreopticneuritisthanOCT.

Inaffectedeyes,60.6%haveabnormalVEPP100

latency.AbnormalaverageOCTretinalnervefiber

layer(RNFL)thicknessis39.4%.Inunaffectedfel-

loweyesgroup,31.6%haveabnormalVEPP100

79Vol.35 • NO.3 • 2019

latency, andabnormal averageOCT is found in

15.8%.AverageOCTRNFLthicknessdemonstrat-

edcorrelationwithvisualacuity(VA).RNFListhin-

nestinprofoundvisualloss(rangesofVision<0.05).

SimilartoaverageOCTRNFLthickness,VEP-P100

latencyismoreprolonginprofoundvisualloss.

Conclusion: Thepresent studyconfirms that

VEPisthepreferredtestfordetectingsymptomatic

andasymptomaticopticneuritis.OCTmayprovide

complementaryinformationinselectedcases,and

remainsvaluableinclinicalpractice.


Factors Correlated with Quality of Life in Patients with Amyotrophic Lateral

Sclerosis at Prasat Neurological Institute, Cross Sectional Study

Nutcha Intaragumhaeng


Bangkok,Thailand

Background:Amyotrophic lateralsclerosis is

afatalprogressivemuscleweaknessandincurable

diseasethatcanhavesignificantdebilitatingimpact.

Therearelimitedstudiestoassessthequalityoflife

inALSpatientsinThailand.

Objective:Toassesstheimpactonthequality

oflifeandcaregiverburdeninpatientwithAmyo-

trophiclateralsclerosisinPrasatNeurologicalInsti-

tute,Thailand.

Method: 26ALSpatientswho followupbe-

tweenJune2018toDecember2018atALSclinic,

PrasatNeurological Institutewereenrolled in this

study.Individualqualityoflifewasmeasuredwith

globalqualityoflife(GlobalQoL)usingWorldHealth

organization quality of life brief questionnaire

(WHOQOL-BREF) anddisease severitywas as-

sessedusing the revisedALSFunctionalRating

Scale(ALSFRS-R).Caregiverburdenwasassessed

withZaritBurden Interview (ZBI)within thesame

visit.

Result: Atotalof26patients,16(61.5%)fe-

malewereincludedinthisstudy.Themeanageof

onsetwas57years(±8.8).Themajorityofthepa-

tientswereclassic spinal-onsetALS (14, 53.8%)

anddurationofdiseasewasmorethan2years(9,

34.6%).Maincaregiversweretheirchildren’s(14,

53.8%).ALSFRS-Rwerereportedasmoderateto

severedisability(mean30.73±9.77).Mostpatients

had intermediateGlobalQoL (73.1%). andcare

giverburden(ZBI)wasreportedasnoburdenatall

(52%).Therewereastatisticallysignificant,positive

correlation between ALSFRS-R andWHOQOL-

BREF,rs(24)=0.415,p=0.035andnegativecor-

relationbetweenALSFRS-Randcaregiverburden

score(ZBI),rs(24)=-0.629,p=0.001.Turningin

bed,walking,climbingstairanddyspneainALS-

FRS-RthatwerecorrelationimpactbothGlobalQoL

andcaregiverburdenwithastatisticallysignificant.

81Vol.35 • NO.3 • 2019

Conclusion: Thefunctionalimpairmentmeas-

uredbyALSFRS-Rwascorrelationimpactsonboth

GlobalQoLandcaregiverburden,especiallyturn-

ing inbed,walking, climbing stair anddyspnea.

Focusmanagement in these specificdisabilities

mightbeimportantforimprovedpatientqualityof

lifeanddecreasedcaregiverburden.


The Predictive Factors and Long Term Seizure

Outcomes in Patients with Autoimmune

Encephalitis

Tippakorn Muangngm


Bangkok,Thailand

Background: Autoimmuneencephalitis isan

emergingcauseof diffuseor limbic encephalitis

thatfrequentlypresentswithseizureorstatusepi-

lepticus.Seizureitselfcandecreasequalityoflife

andincreasetheriskofinjuriesandsuddenunex-

pecteddeath.Studiesofriskfactorsandlong-term

seizureoutcomewerelackinginautoimmuneen-

cephalitispatients.

Objective: Toassess seizureoutcomesand

identifythepredictivefactorsassociatedwithsei-

zure outcome in patients with autoimmune en-

cephalitiswhodevelopednewonsetseizure.

Methods: Retrospectivestudiesof44patients

whodiagnosedwithautoimmuneencephalitispre-

sentedwithnewonsetseizure.Allbaselineclinical

featureswererecordedincludingsex,ageofonset,

clinical presentation including seizure type, fre-

quencyofseizure,associatedsymptomandinves-

tigationsuchasMRIbrain,CSFprofiles,andEEG.

Seizureoutcomeat6monthsaftertreatmentwith

immunotherapywereclassifiedas“seizureremis-

sion”, “seizure reduction” and “no change”. The

potentialpredictivefactorsassociatedwithseizure

outcomeweredetermined in thiscohort. Inaddi-

tional,thefinalseizureoutcomeatlastfollowupwas

analyzed.

Results: Forty-four autoimmuneencephalitis

patientswhopresentedwith newonset seizure;

including anti-NMDARantibodies in 23 patients

(52.3%),anti-VGKCin14patients(31.8%;13pa-

tientswithLGI-1andonepatientwithCaspr2),and

anti-GABAbantibodiesinfourpatients(9.1%)and

anti-GAD65inonepatient(2.3%).Theseizureout-

comeatsixmonthsaftertreatmentshown79.5%of

seizureremission,20.5%hadseizurereductionand

noneofthepatientswereinnochangegroup.In

addition,theseizureoutcomeatlastfollowupwas

83Vol.35 • NO.3 • 2019

identified.Therewereonlyfivepatients(11.4%)still

sufferedfromseizurewithmeantimefollow-upwas

38months(IQR14.75-62.75).Therewasnopoten-

tial risk factors associatewith seizure remission

wereidentifiedinourstudy.

Conclusion: Patientswith autoimmune en-

cephalitiswhopresentedwithseizureat thenew

onsetespeciallycellsurfaceassociateantibodyhad

dramaticseizurereductionwithinoneortwomonths

afterimmunotherapy.Theeffectwascontinueover-

time.Therewereonly20.5%sufferedfromseizure

at sixmonths. The rate of seizure remissionand

cessationofanti-epilepticdrugwerestableeven

afterperiodofsixmonths.


Predictors of Outcomes in Status Epilepticus

Rasitaporn Rasitanon


Bangkok,Thailand

Objective:Todeterminethepredictorsofout-

comesandrefractorinessinstatusepilepticus(SE).

Methods: This study was a retrospective

analysisof47adultpatientswhowerediagnosed

ashavingSEbetweenJanuary1999andNovember

2018attheNeurologyDepartmentofPrasatNeu-

rologicalInstitute.Caseswereidentifiedandclinical

dataacquiredthroughqueriesofthecomputerized

electroencephalographic(EEG)reportsystemand

themedicalrecordsystem.Theeffectsofclinical,

demographic, electrophysiologic features of pa-

tientswithSEwereevaluated.WeuseSTESS,mRS

and ADL scores to determine the outcomes.

Results:In SE group; logistic regression

analysisdemonstrated related lesion on imaging

(p=0.020)andusageofvasopressin(p=0.031)were

theindependentpredictorsofpoorshort-termout-

comes,whereasdependentADLstatusafterdis-

chargewastheonlyindependentpredictorofpoor

long-termoutcomesof6monthsand1yearfollow

up(p<0.001,p=0.002).Havingrelatedlesionon

imaging (p=0.043), autoimmune encephalitis

(p=0.031)andusageofvasopressin(p=0.021)were

theindependentpredictorsofrefractorinessinRSE

group.

Conclusion: Related lesion on imaging and

usageofvasopressinweretheindependentpredic-

tors of poor short-term outcomes, in themean-

whiledependentADL status after dischargewas

theonly independentpredictorofpoor long-term

outcomesof6monthsand1yearfollowupinSE

group.InRSEgroup,havingrelatedlesiononimag-

ing,autoimmuneencephalitisandusageofvaso-

pressinweretheindependentpredictorsofrefrac-

toriness.

85Vol.35 • NO.3 • 2019

Self-Resolved of Late Onset Mesial Temporal

Lobe Epilepsy; Suspicious of Sero-Negative Immune-

Mediated Limbic Encephalitis

Ranjana Thananuwatsak


Bangkok,Thailand

Objective:Toreporttheclinicalcharacteristics

of21patientswithisolatedlateonsetmesialtem-

porallobeepilepsywhowerenegativeforantibody-

associatedlimbicencephalitisfromimmunological

studyandself-resolved.

Materials and Methods:Retrospectivestudy

of21patientsfrommedicalrecordsduringSeptem-

ber2014–September2017atPrasatNeurological

Institute,Bangkok, Thailand.Demographicdata,

MRIandEEGfindingsweredescriptivestatistical

analysis.

Results:Therewere21patientsidentifiedwith

meanageatthefirstseizureonsetat46.19years

(range20-73)andmeanfollow-updurationof11.43

months.Themostthreeseizuresemiologieswere

dialeptic,automatismandgeneralizedtonic-clonic

(GTC).Number of antiepileptic drugs in the first

visitwas1to3types.Mostofpatientsusedonly

monotherapy. Themost single AED usedwere

phenytoin,levetiracetamandcarbamazepine.Mean

seizure frequencywas 4.28 times/month (range

0.02-30).Mean time to seizure resolve is 24.1

months(range1-108).Therewasonepatientwhom

hadonlyonceseizure.Atlastfollowup,20patients

hadseizurefree≥6monthsandonlyonepatient

hadseizurereduction.Atthefirstvisit,therewere

19patientshadabnormalMRIstudy includingof

unilateralamygdalaand/orhippocampalswelling

andhypersignal intensity. Therewere 5patients

underwentrepeatingbrainMRI.Allof5patientshad

improveresults.EEGabnormalitieswerefoundin

19patientsand3patientswasdonerepeatingEEG

andonlyonefoundnormal.Therewere14patients

thathadMRIfindingsconcordancewithEEGab-

normalities.

Conclusions:Our finding suggests that late

onsetmesialtemporallobeepilepsywithnegative


paraneoplasticcouldbeself-resolved.Patientsat

youngerage tend tohave seizure freedurations

morethanelderly.Weshouldbeawaretoworkup

invasively, rational use of immunosuppressive

drugs,avoidanceofAEDpolytherapyandcareful

considerationofepilepsysurgery.

87Vol.35 • NO.3 • 2019

The Predictive Risk Factors of Relapse in

Infl ammatory Demyelinating CNS

Disease in AQP4 Seronegative in Thai

Patients

Suthruedee P iyaratanaphipat


Bangkok,Thailand

Objective:Toidentifythepredictiveriskfactors

ofrelapseinAQP4-seronegativeinflammatoryde-

myelinatingCNSdiseaseandtoreporttheclinical

spectrum ofMOG-IgG seropositive patients in

Thailand.

Materials and Methods:Retrospectivecohort

studyin158patientswhosediagnosiswereinflam-

matorydemyelinatingCNSdiseaseandAQP4-se-

ronegativeatthePrasatNeurologicalInstitutefrom

January1,2017,throughOctober31,2018.Fifty-

threepatientsmetinclusioncriteria.Weusedlogis-

ticregressionmodeltoidentifytheassociationof

riskfactors,includedemographicdata,ageaton-

set, clinical symptoms at first attack, severity of

disease,treatmentcourseandcomplications.Se-

rumMOG-IgGantibodywastestedin57patients.

Results: Twelve (23%) patients developed

relapsed.Annualrelapseratewas0.22.Themean

ofdurationoffollowupwasdifferentbetweentwo

groups (p=0.001).Alldemographicdata,clinical

featuresatfirstattackandtreatmentcourse,were

notdifferentbetweentwogroups.SerumMOG-IgG

werepositivein16.2%(7/43).Fivepatients(71.4%)

wasmale.Fivepatients(71.4%)hadopticneuritis

and/ormyelitis.Theotherspresentedwiththefocal

corticalencephalitisandtumefactivedemyelinating

disease.

Conclusion:Therewasnopredictiveriskfactor

forrelapsingAQP4-seronegativeCNSdemyelinat-

ingdiseaseintermofsex,ageatonset,clinicalat

firstattack,severity,disabilityandtreatmentcourse.

MOG-IgGpositivepatientssharedclinicalspectrum

withNMOSDsuchasopticneuritisand/ormyelitis,

areapostremasyndrome.Wealsodemonstrated

tworareformsofpresentationinMOG-IgGspec-

trumdiseasewhichwerefocalcorticalencephalitis

andtumefactivedemyelination.

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