วารสารประสาทว�ทยาแหงประเทศไทย ปที่ 34 ฉบับที่ 1 มกราคม - มีนาคม 2561 T h a i J o u r n l f N e g y

วารสารประสาทว�ทยาแหงประเทศไทย Thai Journal of w w w . n e u r o l o g y . o r g Volume 34 No. 1 January - March 2O18

Thai Journal of Neurology ORIGINAL ARTICLE - EEG Patterns and Outcomes among Patients Diagnosed with Heatstroke 1 - Difference Anatomical Pattern of Cortical Thickness between Logopenic Aphasia 8 and Probable Alzheimer’s Disease Patients in Thailand - Driving and in Thailand 15

INTERESTING CASE - Oculomotor Nerve Palsy Caused by Compression of Pituitary Apoplexy 24 - A Middle Aged Man with Abnormal Movement 27

ISSN : 2228 - 9801 บทคัดยองานว�จัย 35 Thai Journal of Neurology

วารสาร ประสาทวิทยา แห่งประเทศไทย ISSN 2 2 2 8 - 9 8 0 1

คณะบรรณาธิการของวารสารประสาทวิทยาแห่งประเทศไทย

บรรณาธิการหลัก นพ.สมศักดิ์ เทียมเก่า สาขาวิชาประสาทวิทยา ภาควิชาอายุรศาสตร์ คณะแพทยศาสตร์ มหาวิทยาลัยขอนแก่น

บรรณธิการร่วม 1. นพ.เมธา อภิวัฒนกุล กลุ่มงานประสาทวิทยา สถาบันประสาทวิทยา 2. นพ.สุรัตน์ ตันประเวช. สาขาวิชาประสาทวิทยา มหาวิทยาลัยเชียงใหม่ 3. นพ.พรชัย สถิรปัญญา สาขาวิชาประสาทวิทยา มหาวิทยาลัยสงขลานครินทร์ 4. นพ.โยธิน ชินวลัญช์ สาขาวิชาประสาทวิทยา โรงพยาบาลพระมงกุฎเกล้า 5. นพ.เจษฎา อุดมมงคล สาขาวิชาประสาทวิทยา โรงพยาบาลพระมงกุฎเกล้า 6. นพ.ชูศักดิ์ ลิโมทัย สาขาวิชาประสาทวิทยา โรงพยาบาลจุฬาลงกรณ์ 7. นพ.ดำ�รงวิทย์ สุขะจินตนากาญจน์ กลุ่มงานประสาทวิทยา โรงพยาบาลราชวิถี 8. พญ.สิริกัลยา พูลผล กลุ่มงานประสาทวิทยา โรงพยาบาลราชวิถี 9. นพ.ก้องเกียรติ กูณฑ์กันทรากร สาขาวิชาประสาทวิทยา มหาวิทยาลัยธรรมศาสตร์ 10. นพ.สมบัติ มุ่งทวีพงษา สาขาวิชาประสาทวิทยา มหาวิทยาลัยธรรมศาสตร์ 11. นพ.นรงฤทธิ์ เกษมทรัพย์ สาขาวิชาประสาทวิทยา มหาวิทยาลัยขอนแก่น 12. พญ.นาราพร ประยูรวิวัฒน์ สาขาวิชาประสาทวิทยา คณะแพทยศาสตร์ ศิริราชพยาบาล 13. พญ.วรพรรณ เสนาณรงค์ สาขาวิชาประสาทวิทยา คณะแพทยศาสตร์ ศิริราชพยาบาล 14. นพ.สุพจน์ ตุลยเดชานนท์ สาขาวิชาประสาทวิทยา คณะแพทยศาสตร์ โรงพยาบาลรามาธิบดี

คณะบรรณาธิการ ประธานวิชาการสมาคมโรคลมชักแห่งประเทศไทย ประธานวิชาการสมาคมหลอดเลือดสมองแห่งประเทศไทย ประธานวิชาการชมรมสมองเส�อมแห่งประเทศไทย ประธานวิชาการชมรมโรคพาร์กินสันแห่งประเทศไทย ประธานวิชาการชมรมศึกษาโรคปวดศีรษะ ประธานวิชาการชมรมประสาทสรีรวิทยา ประธานวิชาการชมรม

สำ�นักงานสมาคมประสาทวิทยาแห่งประเทศไทย เลขที่ 2 อาคารเฉลิมพระบารมี 50 ปี ซอยศูนย์วิจัย ถ.เพชรบุรีตัดใหม่ ห้วยขวาง บางกะปิ กรุงเทพฯ 10320 E-mail : [email protected] www.neurothai.org คณะกรรมการบริหารสมาคมประสาทวิทยาแห่งประเทศไทย สมัยวาระ พ.ศ.2560-2562 1. ศ.พญ.รวิพรรณ วิทูรพณิชย์ ที่ปรึกษา 2. พลตรี.พญ.จิตถนอม สุวรรณเตมีย์ ที่ปรึกษา 3. ศ.นพ.นิพนธ์ พวงวรินทร์ ที่ปรึกษา 4. รศ.พญ.ศิวาพร จันทร์กระจ่าง ที่ปรึกษา 5. ศ.นพ.กัมมันต์ พันธุมจินดา ที่ปรึกษา 6. นายแพทย์สมศักดิ์ ลัพธิกุลธรรม ที่ปรึกษา 7. นายแพทย์สมชาย โตวณะบุตร ที่ปรึกษา 8. รศ.พญ.นาราพร ประยูรวิวัฒน์ ที่ปรึกษา 9. นพ.ไพโรจน์ บุญคงช�น นายกสมาคม 10. ผศ.นพ.สุพจน์ ตุลยาเดชานนท์ อุปนายก คนที่ 1 11. ศ.พญ.นิจศรี ชาญณรงค์ อุปนายก คนที่ 2 12. พญ.ทัศนีย์ ตันติฤทธิศักดิ์ เลขาธิการ 13. ศ.นพ.ก้องเกียรติ กูณฑ์กันทรากร ประธานฝ่ายวิชาการ 14. พันโท พญ.พาสิริ สิทธินามสุวรรณ เหรัญญิก 15. รศ.นพ.สมศักดิ์ เทียมเก่า บรรณาธิการวารสาร ประสาทวิทยา 16. รศ.พญ.กนกวรรณ บุญญพิสิฎฐ์ ประธานฝ่ายฝึกอบรมและสอบ 17. ศ.นพ.รุ่งโรจน์ พิทยศิริ ประธานฝ่ายวิจัย และวิเทศสัมพันธ์ 18. ดร.นพ.จรุงไทย เดชเทวพร รองประธานฝ่ายวิชาการ และฝ่ายกิจกรรมพิเศษ 19. นพ.สุรัตน์ ตันประเวช นายทะเบียน 20. รศ.นพ.สมบัติ มุ่งทวีพงษา รองเลขาธิการ และงานฝ่ายกฏหมาย 21. พันเอก นพ.เจษฎา อุดมมงคล ประชาสัมพันธ์ 22. รศ.พญ.วรพรรณ เสนาณรงค์ ปฏิคม 23. พญ.สัญสณีย์ พงษ์ภักดี รองเลขาธิการ และงานฝ่ายกฏหมาย 24. รศ.นพ.พรชัย สถิรปัญญา ตัวแทนภาคใต้ และผู้ช่วยฝ่ายวิจัย 25. นพ.อาคม อารยาวิชานนท์ ตัวแทนภาคตะวันออกเฉียงเหนือ และผู้ช่วยฝ่ายกิจกรรมพิเศษ 26. นพ.วิฑูรย์ จันทรโรทัย ตัวแทนภาคตะวันออก และผู้ช่วยปฏิคม คณะกรรมการบริหารชมรมโรคพาร์กินสันไทย ภายใต้สมาคมประสาทวิทยาแห่งประเทศไทย สมัยวาระ พ.ศ. 2560-2562 1. พันโท นพ.ปานศิริ ไชยรังสฤษดิ์ ประธานชมรม 2. นพ.อัครวุฒิ วิริยเวชกุล รองประธานชมรม 3. พญ.ณัฎลดา ลิโมทัย เหรัญญิก 4. ผศ.นพ.ประวีณ โล่ห์เลขา ประธานวิชาการ 5. นพ.ไพโรจน์ บุญคงช�น ที่ปรึกษาคณะกรรมการบริหาร 6. นพ.อภิชาติ พิศาลพงศ์ ที่ปรึกษาคณะกรรมการบริหาร 7. ศ.นพ.รุ่งโรจน์ พิทยศิริ ที่ปรึกษาคณะกรรมการบริหาร 8. พญ.จิรดา ศรีเงิน เลขานุการที่ปรึกษาคณะกรรมการบริหาร 9. พญ.อรพร สิทธิ์บูรณะ กรรมการ 10. พญ.ปรียา จาโกต้า กรรมการ 11. พญ.อรอนงค์ จิตรกฤษฎากุล กรรมการ 12. รศ.พญ.สุวรรณา เศรษฐวัชราวนิช กรรมการ 13. นพ.วิฑูรย์ จันทรโรทัย กรรมการ 14. นพ.อาคม อารยาวิชานนท์ กรรมการ 15. นพ.สุรัตน์ ตันประเวช กรรมการ 16. นพ.สิทธิ เพชรรัชตะชาติ กรรมการ 17. นพ.สุรัตน์ สิงห์มณีสกุลชัย กรรมการ 18. นพ.ปรัชญา ศรีวานิชภูมิ กรรมการ 19. พญ.พัทธมน ปัญญาแก้ว กรรมการ 20. ดร.สุรสา โค้งประเสริฐ กรรมการ

คณะกรรมการที่ปรึกษา 1. พลตรีหญิง ศ.คลินิก พญ.จิตถนอม สุวรรณเตมีย์ 2. ศ.พญ.รวิพรรณ วิทูรพณิชย์ 3. ศ.นพ.นิพนธ์ พวงวรินทร์ 4. รศ.พญ.ศิวาพร จันทร์กระจ่าง 5. นพ.สมศักดิ์ ลัพธิกุลธรรม 6. ศ.นพ.กัมมันต์ พันธุมจินดา 7. นพ.สมชาย โตวณะบุตร 8. รศ.พญ.นาราพร ประยูรวิวัฒน์ คณะกรรมการบริหารชมรมศึกษาโรคปวดศีรษะ ภายใต้สมาคมประสาทวิทยาแห่งประเทศไทย สมัยวาระ พ.ศ.2560-2562 1. ศ.นพ.กัมมันต์ พันธุมจินดา ที่ปรึกษา 2. รศ.พญ.ศิวาพร จันทร์กระจ่าง ที่ปรึกษา 3. ศ.นพ.อนันต์ ศรีเกีตรติขจร ประธานชมรม 4. นพ.สุรัตน์ ตันประเวช ประธานฝ่ายวิชาการ 5. นพ.วัฒนชัย โชตินัยวัตรกุล กรรมการ 6. พญ.เพชรรัตน์ ดุสิตานนท์ กรรมการ 7. ผศ.นพ.ธนินทร์ อัศววิเชียรจินดา กรรมการ 8. ผศ.ดร.วีระ สุพรศิลป์ชัย กรรมการ 9. ผศ.ดร.ศุภางค์ มณีศรีเลอกรอง กรรมการ 10. นพ.กีรติกร ว่องไววาณิชย์ เลขานุการ

คณะกรรมการชมรมโรคเส้นประสาทร่วมกล้ามเนื้อ และเวชศาสตร์ไฟฟ้าวินิจฉัย ภายใต้สมาคมประสาทวิทยาแห่งประเทศไทย สมัยวาระ พ.ศ. 2560-2562 1. ศ.นพ.ประเสริฐ บุญเกิด ที่ปรึกษา 2. ศ.พญ.รวิพรรณ วิทูรพณิชย์ ที่ปรึกษา 3. รศ.พญ.ศิวาพร จันทร์กระจ่าง ที่ปรึกษา 4. รศ.พญ.ตุ้มทิพย์ แสงรุจิ ที่ปรึกษา 5. ศ.นพ.ก้องเกียรติ กูณฑ์กันทรากร ประธานชมรม 6. รศ.พญ.กนกวรรณ บุญญพิสิฏฐ์ รองประธาน 7. ดร.นพ.จรุงไทย เดชเทวพร เลขาธิการ และประธานวิชาการ 8. ผศ.นพ.ชัยยศ คงคติธรรม เหรัญญิก 9. นพ.นฤพัชร สวนประเสริฐ ปฏิคม และทะเบียน 10. ศ.ดร.นพ.ธีรธร พูลเกษ กรรมการ 11. ผศ.นพ.ณัฐ พสุธารชาติ กรรมการ 12. พญ.สัญสณีย์ พงษ์ภักดี กรรมการ 13. ผศ.พญ.อรณี แสนมณีชัย กรรมการ 14. นพ.ธเนศ เติมกลิ่นจันทน์ กรรมการ 15. พญ.จันทิมา แทนบุญ กรรมการ

อนุกรรมการพิจารณาให้ความเห็นจริยธรรมทางการแพทย์ สมัยวาระ พ.ศ.2560-2562 1. นายแพทย์สมศักดิ์ ลัพธิกุลธรรม ประธานอนุกรรมการ 2. นายแพทย์กัมมันต์ พันธุมจินดา อนุกรรมการ 3. นายแพทย์สมชาย โตวณะบุตร อนุกรรมการ 4. แพทย์หญิงนาราพร ประยูรวิวัฒน์ อนุกรรมการ 5. นายแพทย์สามารถ นิธินันทน์ อนุกรรมการ 6. นายแพทย์สุพจน์ ตุลยาเดชานนท์ อนุกรรมกา 7. แพทย์หญิงสัญสณีย์ พงษ์ภักดี อนุกรรมการ 8. นายแพทย์สมบัติ มุ่งทวีพงษา อนุกรรมการและเลขานุการ บทบรรณาธิการ

เรียน สมาชิกสมาคมประสาทวิทยาแห่งประเทศไทย สวัสดีสมาชิกสมาคมประสาทวิทยา แห่งประเทศไทยและผู้สนใจทุกท่าน วารสารฉบับนี้เป็นฉบับพิเศษที่ นำ�เสนอบทคัดย่อผลงานวิจัยของแพทย์ประจำ�บ้าน และแพทย์ต่อยอด สาขาประสาทวิทยา จำ�นวน 40 เรื่อง ซึ่งล้วน เป็นผลงานวิจัยที่น่าสนใจทั้งสิ้น ส่วนผลงานวิจัยฉบับสมบูรณ์นั้นจะนำ�เสนอในวารสารเล่มต่อ ๆ ไป นอกจากบทคัดย่อ ที่น่าสนใจแล้ว ยังมี interesting case ที่น่าสนใจ 2 เรื่อง นำ�เสนอผู้ป่วยที่น่าสนใจอย่างยิ่ง กับผลงานวิจัยของแพทย์ ประจำ�บ้าน สาขาประสาทวิทยา ในปีที่ผ่านมาจำ�นวน 3 เรื่อง ล้วนแต่เป็นเรื่องที่น่าสนใจทั้งสิ้น กองบรรณาธิการมีความมุ่งหวังในการพัฒนาวารสารให้มีความน่าสนใจและก่อให้เกิดประโยชน์กับ สมาชิกมากที่สุด ดังนั้นถ้าสมาชิกมีความเห็น ข้อเสนอแนะใด ๆ ส่งมาที่ผมได้ครับที่ email:[email protected]

รศ.นพ. สมศักดิ์ เทียมเก่า บรรณาธิการ คำ�แนะนำ�สำ�หรับผู้นิพนธ์ในการส่งบทความทางวิชาการ เพื่อรับการพิจารณาลงในวารสารประสาทวิทยาแห่งประเทศไทย (Thai Journal of Neurology)

วารสารประสาทวิทยาแห่งประเทศไทย หรือ ความรู้ใหม่ ๆ ที่น่าสนใจที่ผู้อ่านสามารถนำ�ไปประยุกต์ Thai Journal of Neurology เป็นวารสารที่จัดทำ�ขึ้น ได้ โดยอาจมีบทสรุปหรือข้อคิดเห็นของผู้เขียนด้วยก็ได้ เพื่อเผยแพร่ความรู้โรคทางระบบประสาทและความรู้ 1.4 นิพนธ์ต้นฉบับ (Original article) เป็นเรื่อง ทางประสาทวิทยาศาสตร์ในทุกสาขาที่เกี่ยวข้อง เช่น รายงานผลการศึกษาวิจัยทางประสาทวิทยาและประสาท การเรียนรู้ พฤติกรรม สารสนเทศ ความปวด จิตเวชศาสตร์ วิทยาศาสตร์ และสาขาวิชาอื่นที่เกี่ยวข้องของผู้เขียนเอง และอื่นๆ ต่อสมาชิกสมาคมฯ แพทย์สาขาวิชาที่เกี่ยวข้อง ประกอบด้วยบทคัดย่อ บทนำ� วัสดุและวิธีการ ผลการ นักวิทยาศาสตร์ ผู้สนใจด้านประสาทวิทยาศาสตร์ ศึกษา สรุปแบะวิจารณ์ผลการศึกษา และเอกสารอ้างอิง เป็นสื่อกลางระหว่างสมาชิกสมาคมฯ และผู้สนใจ เผยแพร่ 1.5 ย่อวารสาร (Journal reading) เป็นเรื่องย่อ ผลงานทางวิชาการและผลงานวิจัยของสมาชิกสมาคมฯ ของบทความที่น่าสนใจทางประสาทวิทยาและประสาท แพทย์ประจำ�บ้านและแพทย์ต่อยอดด้านประสาทวิทยา วิทยาศาสตร์ และสาขาวิชาอื่นที่เกี่ยวข้อง นักศึกษาสาขาประสาทวิทยาศาสตร์ และเพื่อพัฒนา 1.6 วิทยาการก้าวหน้า (Recent advance) องค์ความรู้ใหม่ ส่งเสริมการศึกษาต่อเนื่อง โดย เป็นบทความสั้น ๆ ที่น่าสนใจแสดงถึงความรู้ ความ กองบรรณาธิการสงวนสิทธิ์ในการตรวจทางแก้ไขต้นฉบับ ก้าวหน้าทางวิชาการด้านประสาทวิทยาและประสาท และพิจารณาตีพิมพ์ตามความเหมาะสม บทความ วิทยาศาสตร์ และสาขาวิชาอื่นที่เกี่ยวข้อง ทุกประเภท จะได้รับการพิจารณาถึงความถูกต้อง 1.7 จดหมายถึงบรรณาธิการ (Letter to the ความน่าเชื่อถือ ความน่าสนใจ ตลอดจนความเหมาะสมของ editor) อาจเป็นข้อคิดเห็นเกี่ยวกับบทความที่ตีพิมพ์ไป เนื้อหาจากผู้ทรงคุณวุฒิจากในหรือนอกกองบรรณาธิการ แล้วในวารสารและกองบรรณาธิการได้พิจารณาเห็นว่าจะ วารสารมีหลักเกณฑ์และคำ�แนะนำ�ทั่วไป ดังต่อไปนี้ เป็นประโยชน์ต่อผู้อ่านท่านอื่น หรืออาจเป็นผลการศึกษา 1. ประเภทของบทความ บทความที่จะได้รับการ การค้นพบความรู้ใหม่ ๆ ที่สั้นและสมบูรณ์ในตัว ตีพิมพ์ในวารสารอาจเป็นบทความประเภทใดประเภทหนึ่ง 1.8 กรณีศึกษาน่าสนใจ (Interesting case) ดังต่อไปนี้ เป็นรายงานผู้ป่วยที่น่าสนใจหรือผู้ป่วยที่มีการวินิจฉัยที่ 1.1 บทบรรณาธิการ (Editorial) เป็นบทความ พบไม่่บ่อยผู้อ่านจะได้เรียนรู้จากตัวอย่างผู้ป่วย สั้น ๆ ที่บรรณาธิการและผู้ทรงคุณวุฒิที่กองบรรณาธิการ 1.9 บทความอื่น ๆ ที่กองบรรณาธิการเห็น เห็นสมควร เขียนแสดงความคิดเห็นในแง่มุมต่าง ๆ สมควรเผยแพร่ เกี่ยวกับบทความในวารสารหรือเรื่องที่บุคคลนั้นเชี่ยวชาญ 1.2 บทความทั่วไป (General article) เป็น 2. การเตรียมต้นฉบับ บทความวิชาการด้านประสาทวิทยาและประสาท 2.1 ให้พิมพ์ต้นฉบับในกระดาษขาวขนาด A4 วิทยาศาสตร์ และสาขาวิชาอื่นที่เกี่ยวข้อง (8.5 x 11 นิ้ว) โดยพิมพ์หน้าเดียวเว้นระยะห่างระหว่าง 1.3 บทความปริทัศน์ (Review article) เป็น บรรทัด 2 ช่วง (double space) เหลือขอบกระดาษแต่ละ บทความที่เขียนจากการรวบรวมความรู้ในเรื่องใดเรื่อง ด้านไม่น้อยกว่า 1 นิ้ว และใส่เลขหน้ากำ�กับไว้ทุกหน้า หนึ่งทางประสาทวิทยาและประสาทวิทยาศาสตร์ และ 2.2 หน้าแรกประกอบด้วย ชื่อเรื่อง ชื่อผู้เขียน สาขาวิชาอื่นที่เกี่ยวข้อง ที่ผู้เขียนได้จากการอ่านและ และสถานที่ทำ�งานภาษาไทยและภาษาอังกฤษ และ วิเคราะห์จากวารสารต่าง ๆ ควรเป็นบทความที่รวบรวม ระบุชื่อผู้เขียนที่รับผิดชอบในการติดต่อ (corresponding author) ไว้ให้ชัดเจน ชื่อเรื่องควรสั้นและได้ใจความตรง 3. การส่งต้นฉบับ ตามเนื้อเรื่อง ส่งต้นฉบับ 1 ชุด ของบทความทุกประเภทในรูปแบบ 2.3 เนื้อเรื่องและการใช้ภาษา เนื้อเรื่องอาจเป็น ไฟล์เอกสารไปที่ อีเมลล์ของ รศ.นพ.สมศักดิ์ เทียมเก่า ภาษาไทยหรือภาษาอังกฤษ ถ้าเป็นภาษาไทยให้ยึดหลัก [email protected] พร้อมระบุรายละเอียดเกี่ยวกับ พจนานุกรมฉบับราชบัณฑิตยสถานและควรใช้ภาษาไทย โปรแกรมที่ใช้ และชื่อไฟล์เอกสารของบทความให้ละเอียด ให้มากที่สุด ยกเว้นคำ�ภาษาอังกฤษที่แปลแล้วได้ใจความ และชัดเจน ไม่ชัดเจน 2.4 รูปภาพและตาราง ให้พิมพ์แยกต่างหาก 4. เงื่อนไขในการพิมพ์ หน้าละ 1 รายการ โดยมีคำ�อธิบายรูปภาพเขียนแยกไว้ต่าง 4.1 เรื่องที่ส่งมาลงพิมพ์ต้องไม่เคยตีพิมพ์หรือ หาก รูปภาพที่ใช้ถ้าเป็นรูปจริงให้ใช้รูปถ่ายขาว-ดำ� ขนาด กำ�ลังรอตีพิมพ์ในวารสารอื่น หากเคยนำ�เสนอในที่ประชุม 3” x 5” ถ้าเป็นภาพเขียนให้เขียนด้วยหมึกดำ�บนกระดาษ วิชาการใดให้ระบุเป็นเชิงอรรถ (foot note) ไว้ในหน้าแรก มันสีขาวหรือเตรียมในรูปแบบ digital file ที่มีความคมชัด ของบทความ ลิขสิทธิ์ในการพิมพ์เผยแพร่ของบทความที่ สูง ได้รับการตีพิมพ์เป็นของวารสาร 2.5 นิพนธ์ต้นฉบับให้เรียงลำ�ดับเนื้อหาดังนี้ 4.2 ข้อความหรือข้อคิดเห็นต่าง ๆ เป็นของผู้เขียน บทคัดย่อภาษาไทยและภาษาอังกฤษพร้อม บทความนั้น ๆ ไม่ใช่ความเห็นของกองบรรณาธิการหรือ คำ�สำ�คัญ (keyword) ไม่เกิน 5 คำ� บทนำ� (introduction) ของวารสาร และไม่ใช่ความเห็นของสมาคมประสาทวิทยา วัสดุและวิธีการ (material and methods) ผลการศึกษา แห่งประเทศไทย (results) สรุปและวิจารณ์ผลการศึกษา (conclusion and 4.3 สมาคมฯจะมอบวารสาร 5 เล่ม ให้กับผู้เขียน discussion) กิตติกรรมประกาศ (acknowledgement) ที่รับผิดชอบในการติดต่อเป็นอภินันทนาการ และเอกสารอ้างอิง (references) 4.4 สมาคมฯ จะมอบค่าเผยแพร่ผลงานวิจัย 2.6 เอกสารอ้างอิงใช้ตามระบบ Vancouver’s นิพนธ์ต้นฉบับกรณีผู้รับผิดชอบบทความหรือผู้นิพนธ์หลัก International Committee of Medical Journal โดยใส่ เป็นแพทย์ประจำ�บ้านหรือแพทย์ต่อยอดประสาทวิทยา หมายเลขเรียงลำ�ดับที่อ้างอิงในเนื้อเรื่อง (superscript) โดยบทความที่มีผู้เขียนจำ�นวน 3 คน หรือน้อยกว่าให้ใส่ ชื่อผู้เขียนทุกคน ถ้ามากกว่า 3 คน ให้ใส่ชื่อเฉพาะ 3 คน แรก ตามด้วยอักษร et al ดังตัวอย่าง

วารสารภาษาอังกฤษ Leelayuwat C, Hollinsworth P, Pummer S, et al. Antibody reactivity profiles following immunisation with diverse peptides of the PERB11 (MIC) family. Clin Exp Immunol 1996;106:568-76.

วารสารที่มีบรรณาธิการ Solberg He. Establishment and use of reference values with an introduction to statistical technique. In: Tietz NW, ed. Fundamentals of Clinical Chemistry. 3rd. ed. Philadelphia: WB Saunders, 1987:202-12. สารบัญ

ORIGINAL ARTICLE - EEG Patterns and Outcomes among Patients Diagnosed with Heatstroke 1 - Difference Anatomical Pattern of Cortical Thickness between Logopenic Aphasia 8 and Probable Alzheimer’s Disease Patients in Thailand - Driving and Epilepsy in Thailand 15

INTERESTING CASE - Oculomotor Nerve Palsy Caused by Compression of Pituitary Apoplexy 24 - A Middle Aged Man with Abnormal Movement 27

บทคัดย่องานวิจัย แพทย์ประจำ�บ้าน แพทย์ต่อยอดสาขาประสาทวิทยา 35 ประจำ�ปีการศึกษา พ.ศ. 2558-2560 - Prevalence of Periodic Limb Movements during Sleep and the Association with Obstructive 36 Sleep Apnea - Sunlight Therapy for Excessive Daytime Sleepiness in Patients with Parkinson’s Disease 37 - 3-Month Outcomes Comparison among Wake-up and Non Wake-up Ischemic 38 in Phramongkutklao Hospital - A Study of Effectiveness of Low Dose versus Standard Dose Intravenous Recombinant 39 Tissue-Type Plasminogen Activator in Acute Ischemic Stroke in Phramongkutklao Hospital - Rates of Survival and Causes of Long-Term Mortality of Patients with 40 in Thailand - Risk Factors that Affect Mortality Rate of Epileptic Patients in Thailand 41 - Cytomegalovirus and Neurological Manifestations: Retrospective Review of 52 Patients 42 in King Chulalongkorn Memorial Hospital - Predictive Factors of Post Ischemic Stroke Cognitive Impairment in King Chulalongkorn 43 Memorial Hospital - Wallerian Degeneration in Acute to Subacute Ischemic Stroke Demonstrate by Diffusion 44 Tensor Imaging - The Frequent of Head Turning Sign in Alzheimer’s Disease Patients Compared to Vascular 45 - Predictive Values and Specificity of the EEG Findings in a Diagnosis of Immune-Mediated 46 - VZV Infection of the : Differences in HIV vs Non-HIV Patients 47 - The Study of Diagnosis and Clinical Patterns in Chiang Mai Headache Clinic 48 using Electronic Headache Record - The Retrospective Study to Evaluate Treatment by Botulinum Toxin A Injection 49 and Greater Occipital Nerve Blockade in Headache Clinic, Northern Neuroscience Centre, Chiang Mai University - Obstetric Outcomes in Women with Epilepsy at Maharaj Nakorn Chiang Mai Hospital: 50 A Retrospective Cohort Study - 0.075% Capsaicin Lotion for the Treatment of Painful Diabetic Neuropathy: A Randomized, 51 Double-Blind, Crossover, Placebo-Controlled Trial - Single vs Serial Nerve Conduction Study in Guillain-Barré Syndrome 52 - in Pregnant Thai Women: Prevalence, Natural History, 53 and Risk Factors - Door to Needle Time and Its Delayed Factors of Intravenous Thrombolytic Treatment 54 in Stroke Fast Track System Rajavithi Hospital - Optimal International Normalized Ratio Level in Thai Non Valvular Atrial Fibrillation Patients 55 Who were Receiving Warfarin in Rajavithi Hospital - The Effect of Sleep Disturbances on Primary Headache in the Rangsit University Medical 56 Students - Incidence and Risk Factors of Perioperative Stroke in Thoracic Endovascular Aortic Repair 57 (TEVAR) and Endovascular Aneurysm Repair (EVAR) in Songklanagarind Hospital - The Predictive Risk Score of Intracerebral Hemorrhage in Acute Ischemic Stroke Patients 58 Receiving Intravenous Recombinant Tissue Plasminogen Activator (IV rt-PA) : A Retrospective Study - The Prevalence and Risk Factors of Migraine in Bangkok Metropolitan Administration (BMA) 59 Officers - Manifestation of Neuromyelitis Optica Spectrum Disorder other than Optic Neuritis 60 and Transverse : Epidemiology and Clinical Characteristics - Quality Assessment of Counselling Process in Patients Receiving IV-tPA and/or Mechanical 61 Thrombectomy - Clinical Predictors for Abnormal EEG Results among the Hospitalized Patients with Altered 62 Mental Status - Differences in Clinical Features between Optic Neuritis in Neuromyelitis Optica Spectrum 63 Disorder and in Multiple Sclerosis - Risk Factors of Myasthenia Gravis Exacerbation in Generalized Myasthenia Gravis Patients 64 - The Differences between Obstructive Sleep Apnoea Patients with and without Headache 65 - The Clinical Characteristic of Neuropathy in Prediabetic and Diabetic Patients 66 in Prasat Neurological Institute - Rapid Eye Movement Sleep Behavior Disorder in Parkinson’s Disease 67 - Effect of Cold Compression before Botulinum Neurotoxin Injection in Hemifacial Spasm 68 - Effects of Aromatherapy on Patients with Mild Cognitive Impairment in Prasat Neurological 69 Institute - The Risk of Intracranial Hemorrhage after Thrombolytic Therapy with Recombinant Tissue 70 Plasminogen Activator in Acute Ischemic Stroke in Prasat Neurological Institute - The Effects of Thai Dance on Balance, Cognition, and Mood in Dementia Patients in 71 Prasat Neurological Institute - Incidence and Predictors of Early Recurrent Stroke in Acute Ischemic Stroke with 72 Atrial Fibrillation - Prognostic Factor of Visual Field Defect in PCA Infarction 73 - Study on -Serum Ratio of Electrolytes in Patients with Carcinomatous 74 , Leukemic and Lymphomatous Meningitis - Role of Plasma D-Dimer Levels for Determination of Acute Ischemic Stroke Subtypes 75 and Stroke Severity Vol.34 • NO.1 • 2018 1

Abstract EEG Patterns and Objectives: To identify EEG patterns, outcomes Outcomes among Patients and outcome predictors among patients diagnosed with heatstroke. Diagnosed with Methods: A cross-sectional study was con- Heatstroke ducted at Division of Neurology, Phramongkutklao Army Hospital. Medical records and EEG of patients diagnosed with heatstroke during January 2013- October 2016 were reviewed. Milder patients not requiring ICU placement and post cardiac arrest patient were excluded. Demographic data, EEG pat- terns, treatments, and outcomes were collected. Good outcome included complete recovery, while poor outcome included death and neurological deficits. Results: Total 15 patients diagnosed with heatstroke were included. Mean age was 22.07 Bandit Sirilert , Thongdaeng Foongyai, years (SD 2.9). All were male, developing heatstroke Chesda Udommongkol, during military training. There were 11 patients Pasiri Sithinamsuwan, Yotin Chinvarun (73.3%) developing at the presentation, and 13 (86.7%) in comatose state. EEG background amplitude was more common to be moderate than low or high amplitude. Epileptiform discharges were identified in only 1 patient. Alpha coma was de- tected in 3 patients (20%). All patients were treated with external cooling. Poor outcome group were 1) Death [3 patients (20%)] and 2) neurological deficit at discharge [6 patients (40%)]. Neurological defi- cits were cognitive impairment 2 patients (33.3%), epilepsy 1 (16.7%), critical illness neuropathy 4 (66.7%), spasticity 1 (16.7%), and dysarthria 2 (33.3%). By univariate analysis, good outcome seemed to be associated with the presence of beta Bandit Sirilert, Thongdaeng Foongyai, Chesda Udommongkol, Pasiri Sithinamsuwan, activity in EEG, 4 patients (66.7%) [versus poor Yotin Chinvarun Department of Neurology, Phramongkutklao Hospital, outcome 2 patients (22.2%)], p-value 0.085. Bangkok, Thailand Conclusion: Mortality in heatstroke was 20% Correspondence author: Bandit Sirilert and neurological deficits were 40%. Seizures from 315 Rajavithee Road, Bangkok, Thailand 10400 Email: [email protected] 2 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

heatstroke represented acute severe neuronal in- neurological complications had been found in 15 jury and were not associated with developing epi- patients and 3 died. It was known that unfavorable lepsy. The presence of beta activity in EEG may prognostic factors in heat stroke are delayed cool- predict good outcome. ing, prolonged comatose (longer than two hours), Keywords : EEG patterns, outcomes, heat elevation of creatine phosphokinase, lactate dehy- stroke drogenase, alkaline phosphatase levels, and hypo- tension.2-6 However, electroencephalography (EEG) Introduction to determine neurological outcomes has never been Heat related illnesses are common nowadays studied in heatstroke before. as it is reported that the world temperature is The previous EEG studies for outcomes predic- increasing gradually and heat wave are reported tion were conducted in post cardiac arrest and annually from different parts of the world. Five of the metabolic . It is found that favorable most deadly heat waves occurred in this century, EEG patterns are associated with good neurological including 10,000 deaths in United States during outcome.7-9 EEG patterns in patient received hyper- 1988, 2,541 deaths in India during 1998, 70,000 thermia were similar to those with metabolic en- deaths during 2003 and 3,418 during 2006 in cephalopathies10, so we expected the result of our Europe, and 56,000 deaths in Russia during 20101. study which was conducted among patients with The 3,963 Thai patients suffered from heat heatstroke would be similar to the previous studies. related disorders during 2010-2013 were We would also like to identify the association be- reported with nine death; however, the data would tween EEG patterns in heatstroke and neurological be underestimated1. outcomes. Heatstroke is a severe form of heat related disorders and medically emergent condition that Methods may be serious and life threatening if it is not Design. This cross-sectional study was con- treated adequately and promptly. This is common ducted at Division of Neurology, Phramongkutklao in very hot and humid weather; therefore, it is Army Hospital, Bangkok, Thailand. Medical records mainly seen in tropical countries. Thailand is and EEG of 15 heatstroke patients were reviewed located in tropical area; therefore, heatstroke during January 2013 to October 2016. becomes an important problem in our country. Patients. Inclusion criteria were 1) core body The most effected population from heat injury temperature more than 40oC 2) central nervous are people who have to do mainly activities in out- system abnormalities such as delirium, seizures or door. Thai recruited soldiers and military students coma 3) clear risk factors i.e. high temperature of are the population at risk. The most prevalence of surrounding environment or history of strenuous this condition in Thailand is around late April – June. physical exercise11. The patients were admitted to There were 35 exertional heatstroke patients in medical ICU and EEG were performed. We ex- Phramongkutklao Army Hospital from January 2013 cludes one post cardiac arrest patient since EEG to October 2016, which all were soldiers. Severe pattern was unreliable. Vol.34 • NO.1 • 2018 3

Demographic data included age, first clinical Classified EEG data were subsequently sub- presentations, timing of EEG recording, antiepilep- divided into unfavorable patterns [delta, coma pat- tic agents and outcomes at discharge and follow terns, epileptiform (spikes, sharp wave, status epi- up at OPD. lepticus) and burst-suppression] and favorable EEG were reviewed by both epilepsy fellow patterns (theta, alpha, beta, sleep EEG). and staffs, blinded to patient’s clinical presentations Outcome. The outcome measure were neuro- and outcomes. EEG results were classified as back- logic outcome at discharge and follow-up period at ground (amplitude and frequency) and transient OPD. Outcomes were dichotomized as “good out- waveforms. Amplitude were classified in 3 catego- come” and “poor outcome”. Good outcome was ries as low amplitude (<20 µV), medium amplitude defined as a complete recovery. Poor outcome was (20-50 µV), high amplitude (>50 µV) and frequency defined as dead or neurological deficit. were classified as delta frequency (<4 Hz), theta Statistical analysis. Descriptive data were frequency (4-8 Hz), alpha frequency (8-13 Hz). shown as mean and standard deviation (SD). Cat- Transient waveforms included spike (duration 20-70 egorical data were shown in number and percent. millisecond), sharp wave (duration 70-200 millisec- All available data were analyzed by univariate ond), burst-suppression [increase in amplitude analyses to identify outcome predictors. Statistical (bursts) with inter-burst intervals of at least 1 second significance was p-value < 0.05. SPSS version 15.0 with low-voltage or absent activity (suppression <10 was used for analysis. µV)] , sleep EEG (slow wave, vertex sharp wave, sleep spindles or K-complexes) and status epilep- ticus. Flowchart of the study

Heatstroke patients were screened (n=35) Inclusion criteria Exclusion criteria - EEG was done - Post cardiac arrest - Admitted in ICU Eligible patients (n=15)

Patient’s data and EEG patterns were reviewed (n=15)

Included in analysis (n=15) 4 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Results patients (73.3%), only 1 patient tuned out to be epilepsy, Table 3. Total of 15 patients were included in this study. EEG background amplitude was more com- Mean age was 22.1 years (range 17-29). All par- mon to be moderate than low amplitude. Epilepti- ticipants were male, 14 newly recruited soldiers and form discharges were identifying in only 1 patient. 1 military student. Demographic data and baseline Alpha coma was detected in 3 patients (20%). The characteristics were described in Table 1. Seizures correlation between EEG patterns and good out- at presentation were found in 11 patients (73.3%). come did not reach the statistical significance. EEG There were 13 comatose (86.7%) and 2 stuporous background or transient wave forms were not an (13.3%) patients. Poor neurological outcome oc- outcome predictor but it was shown that beta back- curred in 9 patients (60%); 6 with neurological defi- ground tended to be associated with good neuro- cits, and 3 death. Good neurological outcome was logical outcome (P=0.085). When we subdivided found in 6 patients (40%). The detail of neurological EEG patterns within 2 groups as favorable and outcomes were shown in Table 2. unfavorable patterns. They did not appear any as- Neurological deficits were identified as 4 neu- sociations between EEG patterns and good or poor ropathy (66.7%), 2 cognitive impairment (33.3%), 2 neurological outcome. Regarding treatment, all dysarthria (33.3%), 1 epilepsy (16.7%) and 1 spas- patient were performed hypothermia and almost all ticity (16.7%). We classified cognitive impairment of them received midazolam [10 patients (66.7%)]. and epilepsy as central nervous system complica- From statistical analysis, we did not find the correla- tions, but we did not find its association with the EEG tion between treatment use and neurological out- patterns. Even though was found in 11 come, Table 4. Table 1. Patient characteristics (overall, good outcome and poor outcome groups) Factors Total Good outcome Poor outcome p-value (n =15) (n = 6) (n = 9) Number (%) Number (%) Number (%) Age (years), mean ± SD 22.07 ± 2.9 23.17±3.5 21.33±2.4 0.251 Gender 15 (100) 6 (100) 9 (100) 1.000 Seizure at presentation 11 (73.3) 5 (83.3) 6 (66.7) 0.462 State of consciousness - - - 0.343 - Comatose 13 (86.7) 6 (100) 7 (77.8) - - Stuporous 2 (13.3) 0 2 (22.2) - Vol.34 • NO.1 • 2018 5

Table 2. Outcome at discharge and follow up period Outcome Number (%) Complete recovery 6 (40) Death 3 (20) Neurological deficit 6 (40) - Cognitive dysfunction 2 (33.3) - Ataxia 0 - Epilepsy 1 (16.7) - Neuropathy 4 (66.7) - Dysarthria 2 (33.3) - Spasticity 1 (16.7)

Table 3. EEG patterns (overall, good outcome and poor outcome groups) Factors Total Good outcome Poor outcome P value (n =15) (n = 6) (n = 9) Number (%) Number (%) Number (%) EEG background - - - 0.455 - Low amplitude 4 (26.7) 2 (33.3) 2 (22.2) - - Medium amplitude 9 (60) 4 (66.7) 5 (55.6) - - High amplitude 2 (13.3) 0 2(22.2) - EEG delta activity 5 (33.3) 1 (16.7) 4 (44.4) 0.294 EEG theta activity 6 (40) 2 (33.3) 4(44.4) 0.545 EEG alpha activity 7 (46.7) 4 (66.7) 3 (33.3) 0.231 EEG beta activity 5 (41.7) 4 (66.7) 2 (22.2) 0.085 EEG sleep activity 4(26.7) 1 (16.7) 3 (33.3) 0.462 Sharp/spike 1 (6.7) 0 1 (11.1) 0.600 Rhythmic activity 0 0 0 1.000 Status epilepticus 0 0 0 1.000 Alpha coma pattern 3 (20) 2 (33.3) 1 (11.1) 0.341 6 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Table 4. Treatment (overall, good outcome and poor outcome groups) Factors Total Good outcome Poor outcome P value (n =15) (n = 6) (n = 9) Number (%) Number (%) Number (%) Diazepam 6 (40) 3 (50) 3 (33.3) 0.455 Midazolam 10 (66.7) 5 (83.3) 5(55.6) 0.294 Phenytoin 2 (13.3.3) 1 (16.7) 1(11.1) 0.657 Levetiracetam 7 (46.7) 4 (66.7) 3 (33.3) 0.231 Propofol 1 (6.7) 1 (16.7) 0 0.400 Hypothermia 15 (100) 6 (100) 9(100) 1.000 Discussion (P=0.085). It is widely recognized that the presence of beta activity would be the favorable prognostic Even though heatstroke commonly occurs in factor among comatose patients since it is often tropical area, it is still difficult to diagnosis because related to the effect of medications (e.g. benzodi- the clinical presentations would be similar to sepsis azepine use). The virtual patients in our study re- syndrome. Contrast to the previous studies, con- ceived midazolam for sedation or seizure treatment, ducted in post-cardiac arrest and metabolic en- and that this may be able to explain the result. cephalopathy patients, which were found that fa- Timing of EEG recording was not analyzed in our vorable EEG patterns were associated with good study because EEG recording in our center was 7-9 outcome , our study was found that association. available only daytime of the weekday. Our Phramongkutklao Army Hospital is the largest For outcomes evaluation, we found poor out- referring military hospital of Thailand and also the comes evaluated by doctor or other healthcare excellent center for heatstroke care, therefore our providers at discharge and after follow-up at OPD study was the largest series of heatstroke in the that there were 9 patients and 3 died. Our study country. The reason why there were only 15 patients was a small cross-sectional, therefore there was no to analyze was because neurological symptoms in clear evaluating protocol for the follow up period most of heatstroke patients were improved over the which would affect our results. There would be more time of cooling and resuscitation. Therefore, few than one epilepsy as there were some number of patients required EEG recording to identify seizures loss follow up, so the long-term data were missing. discharges and comatose pattern. Our study was a small cross-sectional study with EEG pattern did not reach the statistical sig- some limitations because some variables were not nificance in predicting of neurological outcomes. controlled. The further larger prospective trials with Nevertheless, it was found that the presence of longer follow up with clear protocols are required. background with predominant of beta activity was tended to be associated with good outcome Vol.34 • NO.1 • 2018 7

4:101-9. Conclusion 9. Hofmeijer J, Tim MJ. Early EEG contributes to multi- In this study, mortality in heatstroke was 20 % modal outcome prediction of post anoxic coma. Ameri- can Academy of Neurology 2015: 137-43. and neurological deficit were 40%. The presence 10. Dubois M, Sato S. Electroencephalographic changes of beta activity in EEG may predict good outcome. during whole body hyperthermia in humans. Electroen- Seizures from heatstroke represents acute severe cephalography and Clinical Neurophysiology1980; neuronal injury but were not associated with devel- 50:486-95. 11. Bouchama A, Knochel JP. Heat stroke. New England oping epilepsy. Journal of Medicine 2002; 346:1978-88. 12. Sharma HS. Neurobiology of hyperthermia. 1st ed. Oxford Acknowledgements UK; 2007. 13. Ebersole JS, Husain AM, Nordli Jr DR. Current practice We would like to share my deep gratitude to of clinical electroencephalography. 4th ed. Philadephia: our patients, in charge physicians, Division of Neu- Wolters Kluwer Health; 2014. rology Phramongkutklao Army Hospital, neurology 14. Heled Y, Rav-Acha M, Shani Y, Epstein Y, Moran DS. The fellow and staffs for their contributions in this work. “golden hour” for heatstroke treatment. Mil Med 2004; 169:184-6. 15. Upadhyay PK, Sinha RK, Karan BM. Detection and References analysis of the effects of heat stress on EEG. J Bio- 1. Thawillarp S, Thammawijaya P. Situation of heat-related medical Science and Engineering 2010; 3: 405-14. illness in Thailand, and the proposing of heat warning 16. พ.อ.รศ. มฑิรุทธ มุ่งถิ่น, พ.อ. ผศ.ราม รังสินธุ์, น.ส. วรรัชนี system. OSIR 2015; 8 : 15-23. อิ่มใจจิตต์, พ.อ.หญิง ผศ.ปนัดดา หัตถโชติ, พ.อ.รศ.สุธี 2. Hassanein T, Razack A, Gavaler J, Van Thiel DH. Heat- พานิชกุล. การศึกษาเชิงคุณภาพเพื่อหาแนวทางในการป้องกัน stroke: its clinical and pathological presentation, with โรคลมร้อนในทหารกองประจาการ.ํ กรุงเทพมหานคร: สมาคม particular attention to the liver. Am J Gastroenterol แพทย์ทหารแห่งประเทศไทย ในพระบรมราชูปถัมภ์; 2555. 1992;87:1382–9. 3. Armstrong LE, De Luca JP, Hubbard RW. Time course of recovery and heat acclimation ability of prior exer- tional heatstroke patients. Med Sci Sports Exerc 1990;22:36–48. 4. Costrini A. Emergency treatment of exertional heatstroke and comparison of whole body cooling techniques. Med Sci Sports Exerc 1990;22:15–8. 5. Alzeer AH, el-Hazmi MA, Warsy AS, Ansari ZA, Yrkendi MS. Serum enzymes in heat stroke: prognostic implica- tion. Clin Chem 1997;43:1182–7. 6. Nylen ES, Al Arifi A, Becker KL, Snider RH Jr, Alzeer A. Effect of classic heatstroke on procalcitonin. Crit Care Med 1997;25:1362–5. 7. Synek VM. Value of a revised EEG coma scale for prog- nosis after cerebral anoxia and diffuse head injury. Clinical Electroencephalography vol 21, 1990. 8. Demira AB, Boraa I, Kaygilia E, Ocakoglub G. The as- sessment of basic features of electroencephalography in metabolic . J Neurol Res 2014; 8 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Abstract Difference Anatomical Objectives: 1) To demonstrate the classical Pattern of Cortical anatomical pattern of cortical atrophy in Thai pa- tients who was clinically diagnosed as logopenic Thickness between aphasia (LPA) and probable Alzheimer’s disease Logopenic Aphasia and (AD). 2) To reveal non-classical atrophic areas that Probable Alzheimer’s may involve in LPA but not in AD. Material and Methods: We obtained magnetic Disease Patients in resonance images of patients in a cohort consisting Thailand of LPA and probable AD patients to determine dif- ference of cortical atrophy pattern between LPA and probable AD. Firstly, cortical surfaces were recon- structed from each patient’s brain magnetic reso- nance image. Cortical thickness measurement was then processed on these surfaces. At last, thickness comparison between the two groups was performed. Sekh Thanprasertsuk, Results: Our LPA patients had significant atro- Yuttachai Likitjaroen phy at left parieto-temporal junction (p<.01), while probable AD patients had significant regional corti- cal atrophy at bilateral entorhino-hippocampal re- gion (p<.01), comparing to another group. These findings were consistent with the classical ana- tomical pattern of cortical atrophy. Interestingly, we also found significant regional atrophy at left (p=0.0023) and right (p=0.0011) post central gyri, left superior parietal gyrus (p=0.0017), left lingual gyrus (p=0.0071), right precentral gyrus (p=0.0004) and right rostral middle frontal gyrus (p=0.0046) in LPA, comparing to probable AD patients. Conclusion: We demonstrated a different cor- tical atrophy pattern between LPA and probable AD patients. Particularly, our study showed significant Sekh Thanprasertsuk, Yuttachai Likitjaroen Division of Neurology, Department of Medicine, Faculty of foci of cortical atrophy scattering on bilateral pari- Medicine, Chulalongkorn University etal and temporal cortices, and on right frontal Correspondence author Yuttachai Likitjaroen cortex in LPA compared to AD. This may support Division of Neurology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, the idea regarding learning disorder-related sus- Bangkok, Thailand 10330 Email address: [email protected] Vol.34 • NO.1 • 2018 9

ceptibility factor for developing LPA. that is involved in LPA but not in probable AD. Keywords: Alzheimer’s disease, logopenic aphasia, cortical atrophy, cortical thickness, mag- Material and Methods netic resonance imaging Study population Introduction We recruited patients from both psychiatry and neurology clinic at King Chulalongkorn Memorial Alzheimer’s disease (AD) is the most common Hospital (KCMH) who were diagnosed as LPA and cause of neurodegenerative dementia. The brain probable AD according to diagnostic criteria4 be- histological findings include amyloid plaques, neu- tween 2014 and 2016. Those who were right rofibrillary tangles and neuronal loss.1 Typically AD handed and had completed magnetic resonance manifests with an insidious onset of episodic mem- imaging protocol performed were selected. Then ory impairment, which gradually involves other cog- selected patients signed a written informed consent nitive domains. This pattern of typical manifestation for the study. Patients were then excluded if 1) is in accordance with histopathological evidence of visually assessment of white matter lesion exceed- early mesial temporal lobe involvement. However, ed 25% of total white brain matter volume on fluid some patients with underlying AD pathology may attenuation inversion recovery (FLAIR) images, 2) present with variation of clinical syndromes such as they had history of disease contributing to brain logopenic aphasia (LPA), posterior cortical atrophy atrophy other than neurodegenerative disorder (PCA), behavioral variants, etc. LPA is as a subtype which were chronic infectious or inflammatory dis- of primary progressive aphasia (PPA) syndrome,4-5 ease, cancer, chronic liver disease, severe head which is one of the common variants of AD. LPA injury, encephalitis and toxic encephalopathy, 3) manifests with predominant language abnormalities there were large structural abnormalities on brain including word-finding difficulty, anomia, verbal work- MRI preventing an accurate assessment of cortical ing memory impairment and sentence repetition atrophy; or 4) they had brain MRI of insufficient while episodic memory is usually intact.2-4 Histo- quality. Age at onset, brain MRI date, sex, Thai pathological studies of the brain in LPA patients re- Mental State Examination (TMSE) score were re- vealed early involvement of temporo-parietal junction corded. In this study, disease duration was defined of the dominant hemisphere. Several imaging studies as duration from disease onset to brain MRI date. compared the difference of cortical atrophic change Standard protocol approvals and registration pattern between AD and its variants using different This study was performed with approval and techniques including cortical thickness measure- in accordance with the guidelines of the institu- ment6-8 and volumetric study.7,9,10 tional review boards of Faculty of Medicine, Chula- This is the first cortical thickness study of LPA longkorn University. and AD in Thai patients. We aimed to demonstrate Imaging acquisition the classical cortical atrophy pattern in LPA com- Brain imaging for patients with cognitive dis- pared to probable AD in Thai patients. Furthermore, orders were obtained for diagnosis within 2 months we desired to search for non-classical atrophic area after the first visit. The scanner is 3 Tesla brain MRI 10 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

scanner Philips Medical Systems, Best, The NY). Fisher exact test and Mann–Whitney U test Netherlands (MR System Ingenia, software release were applied to dichotomous variable and continu- 5.1). The protocol included high resolution 3 ous variables, respectively. Cortical thickness of the

dimension T1 weighted imaging for structural study two groups were compared by using a vertex-by-

and fluid attenuated inversion recovery (FLAIR) T2 vertex general linear model, performed with the weighted imaging to visualize ischemic lesions. The Qdec application (a statistical engine included in

acquisition for T1weighted image is isometric with Freesurfer). Cortical thickness was modeled as a

SENSE, sagittal T1 weighted 3D turbo field echo (T1S function of group, controlling for sex and age at MRI 3D TFE), repetition time TR/echo time TE=8.1ms/3.7ms, by their inclusion as covariates. Disease duration flip angle 8 degrees, voxel size 1.00x1.00x1.00 mm3 and TMSE score were not included in the model 160 slices without gap. The acquisition for FLAIR im- because they were not different between the 2 age is axial plane TR/TE = 11,000 ms/125 ms, TI = groups. Age at onset was also not included as a 2,800 ms, voxel size = 0.7x1.60x6.0 mm3, 20 slices 6 covariate since it had comparable statistical value mm slice thickness with gap = 1mm to age at MRI. Cortical maps showing statistically Brain image pre-processing significant differences between the groups were The image processing was performed using generated. Statistical significance levels were set freesurfer-i386-apple-darwin 11.4.2-stable 5-20130514 at 0.05 and 0.01 for clinical characteristics analyses which is freely-available (http://surfer.nmr.mgh.har- and cortical thickness analyses, respectively. vard.edu/). The detailed procedure for the measure- ment has been described and validated in previous Results 11-13 literatures. Briefly, pre-processing of all patients Seven LPA and 30 AD patients were recruited. used the automate command recon-all to perform 5 AD subjects were excluded because white matter intensity normalization, skull stripping, brain segmen- lesion exceeded 25% of total white matter volume tation, tessellation of the grey and white matter bound- by visual inspection. An AD patient was excluded ary, topology correction, and cortical surface recon- due to the MRI file defect. Finally, 31 patients were struction and parcellations. Finally, before group eligible for analysis including 7 LPA patients and comparison process, cortical thickness was smoothed 24 probable AD patients. Clinical characteristics with a 10 mm full-width at half maximum surface-based including age at onset, disease duration and TMSE Gaussian kernel to reduce local variation in the meas- score of LPA and probable AD groups was shown urements. All images were also carefully visually in- in Table 1. The whole brain cortical thickness spected for possible error. All preprocessing data analysis was demonstrated the significant different were used for statistical group comparison. between groups in figure 1. The figure shows the Statistical analysis template of inflated cortical surface, which allows Comparison of clinical characteristics between visualization of data across the entire surface in- LPA and probable AD groups was assessed by cluding the cortical parts that were folded inside. appropriate univariate analysis, performed with After controlling for sex and age on the dated per- SPSS 20 statistical software (IBM Corp., Armonk, formed MRI, the region of different cortical average Vol.34 • NO.1 • 2018 11

thickness between the 2 groups were overlaid on average cortical thickness in each significant region. the brain template. Tables 2A and 2B showed group Table 1. Comparison of clinical characteristics between LPA group and probable AD group. Clinical characteristics LPA (n=7) Probable AD (n=24) p-value Sex [female (%)] 29% 83% .005a Age at onset, months [median (P25, P75)] 722.7 (576.8, 761.7) 885.7 (806.0, 970.2) .001b Age at MRI, months [median (P25, P75)] 790.8 (760.4, 903.7) 929.1 (835.8, 1000.0) .026b Disease duration, months [median (P25, P75)] 31.2 (28.6, 57.3) 24.0 (13.5, 50.6) .115b TMSE score [median (P25, P75)] 23 (10, 28) 22 (20, 23) .849b aFisher exact test, bMann–Whitney U test

Table 2A. Regions which demonstrated thinner cortex in probable AD group comparing to LPA group [average cortical thickness, mm (SD)], sorted by degree of statistical significance. Regions LPA Probable AD p-value Left superior temporal gyrus (anterior part) 2.763 (0.277) 2.297 (0.272) .0003 Left entorhinal cortex 3.129 (0.671) 2.292 (0.399) .0007 Right entorhinal cortex 3.217 (0.747) 2.329 (0.422) .0008 Right medial orbitofrontal cortex 2.255 (0.242) 1.802 (0.269) .0026 Right insular cortex 3.496 (0.277) 2.972 (0.506) .0037 Right superior temporal gyrus (anterior part) 3.228 (0.457) 2,568 (0.359) .0054

Table 2B. Regions which demonstrated thinner cortex in LPA group comparing to probable AD group [average cortical thickness, mm (SD)], sorted by degree of statistical significance. Regions LPA Probable AD p-value Left supramarginal gyrus 1.915 (0.214) 2.533 (0.414) .0003 Left superior temporal gyrus (posterior part) 2.074 (0.125) 2.360 (0.202) .0004 Right precentral gyrus 2.280 (0.298) 2.557 (0.270) .0004 Right postcentral gyrus 1.781 (0.186) 2.167 (0.206) .0011 Left superior parietal gyrus 1.568 (0.149) 1.860 (0.244) .0017 Left postcentral gyrus 1.865 (0.232) 2.080 (0.224) .0023 Right rostral middle frontal gyrus 1.843 (0.310) 2.301 (0.314) .0046 Left inferior parietal gyrus 1.927 (0.323) 2.315 (0.392) .0059 Left lingual gyrus 1.518 (0.125) 1.757 (0.189) .0071 12 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Figure 1. Inflated cortical surface demonstrating regional variation of average cortical thickness between LPA group and probable AD group. Sex and disease duration were included as covariates. Dark and light blue rep- resent regions with significantly lower cortical thickness in probable AD comparing to LPA group. Red and yellow represent regions with significantly lower cortical thickness in LPA comparing to probable AD group. (cover page) Discussion tients.6,14,15 Corresponding with histopathology and clinical manifestation, typical AD patients usually Several neuroimaging studies measuring cor- have early and peak cortical atrophy at bilateral tical thickness demonstrated different pattern of hippocampo-entorhinal regions while LPA patients cortical atrophy between typical AD and LPA pa- have early and peak atrophy at the temporoparietal Vol.34 • NO.1 • 2018 13

junction on the dominant side, comparing to normal sonal or family history of learning disability (LD), in- control subjects. The main findings from our study cluding dyslexia, comparing to healthy individuals are that LPA patients had significant atrophy at the or patients with other dementia syndromes.17,18 This area around left temporoparietal junction including led an opinion that at least some cases of PPA could supramarginal gyrus, posterior part of superior reflect the tardive manifestation of a developmental temporal gyrus, and inferior parietal gyrus com- or genetic vulnerability of the language area and its pared to AD group. While probable AD patients had network in the dominant hemisphere, which was ac- significant regional cortical atrophy at anterior part celerated by the degenerative neuropathology.5 Our of bilateral superior temporal gyri, bilateral entorhi- results, significant regional atrophy scattering on nal cortices, and right medial orbitofrontal and in- bilateral parietal and temporal cortex, may indicate sular cortex compared to LPA. These findings are that patients in LPA group have vulnerability of these consistent with previously established data regard- areas which are imperative for sensory input pro- ing anatomical pattern of cortical atrophy in LPA cessing (e.g. tactile sensation, visuospatial skill). As and typical AD.1-6,8-10,14,15 impairment of sensory input domain can be found in Interestingly, we additionally found that our non-verbal LD patient19, our observation may support LPA patients had significant regional cortical atro- the hypothesis regarding LD-related susceptibility phy at other areas in parietal and temporal lobes factor for developing LPA. While significant atrophy regardless of hemisphere, including bilateral post in frontal area may also suggest regional vulnerabil- central gyri, left superior parietal gyrus, and left ity, which may associate with abnormal motor func- lingual gyrus. Moreover, there was significant atro- tion (e.g. grip strength, finger tapping)19 in patients phy of right precentral gyrus and right rostral middle with non-verbal LD in the same way. frontal gyrus in LPA patients comparing to probable Limitations in our study include the absence AD group. Our LPA patients did not have clinical of biomarker confirmation of AD diagnosis. Although symptoms accounted by these gyri. It might be that we designed to compare cortical thickness directly degree of atrophy in these gyri might not severe between LPA and probable AD groups, lacking of enough to produce overt clinical symptoms or relate control group is also one of the limitation which will to the later manifestation of limb apraxia.16 be accounted in the future to improve power of the These findings, however, may support the pro- study. Also, we do not have any information regard- posed hypothesis regarding susceptibility factors of ing personal or family history of learning disability. LPA and PPA. There were studies tried to find expla- nation how PPA patients had a distinct character of Conclusion dominant-sided language area involvement compar- The is the first cortical thickness study in Thai ing to bilateral hemispheric involvement in typical patients with LPA and AD. We demonstrated a clas- dementia syndrome despite common neuropatho- sical different anatomical pattern of cortical atrophy logical substrate, either AD pathology or others. A in both LPA and probable AD patients. Particularly, potentially important finding from these studies was our study showed significant foci of cortical atrophy that PPA patients had a higher frequency of per- scattering on bilateral parietal and temporal cortex, 14 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

and on right frontal cortex. This may support the clinical stages across distinct phenotypes of Alzheimer’s idea regarding LD-related susceptibility factor for disease. Hum Brain Mapp 2015;36:4421-37. 10. Madhavan A, Whitwell JL, Weigand SD, Duffy JR, Strand developing LPA. EA, Machulda MM, et al. FDG PET and MRI in logo- penic primary progressive aphasia versus dementia of Acknowledgement the Alzheimer’s type. PLoS One 2013 ;8:e62471. 11. Dale AM, Fischl B, Sereno MI. Cortical surface-based This study was undertaken at KCMH and Fac- analysis. I. Segmentation and surface reconstruction. ulty of Medicine, Chulalongkorn, University, Thai- Neuroimage 1999 ;9:179-94. land. Subjects were derived from KCMH’s demen- 12. Fischl B, Sereno MI, Dale AM. Cortical surface-based tia clinic. analysis. II: Inflation, flattening, and a surface-based coordinate system. Neuroimage 1999 ;9:195-207. 13. Fischl B, Dale AM. Measuring the thickness of the human References cerebral cortex from magnetic resonance images. Proc 1. Braak H, Braak E. Frequency of stages of Alzheimer- Natl Acad Sci U S A 2000 ;97:11050-5. related lesions in different age categories. Neurobiol 14. Du AT, Schuff N, Kramer JH, Rosen HJ, Gorno-Tempini Aging 1997 ;18:351-7. ML, Rankin K, et al. Different regional patterns of cortical 2. Warren JD, Fletcher PD, Golden HL. The paradox of thinning in Alzheimer’s disease and frontotemporal de- syndromic diversity in Alzheimer disease. Nat Rev Neu- mentia. Brain 2007 ;130:1159-66. rol 2012;8:451-64. 15. Lerch JP, Pruessner JC, Zijdenbos A, Hampel H, Teipel 3. Kramer JH, Miller BL. Alzheimer’s disease and its focal SJ, Evans AC. Focal decline of cortical thickness in variants. Semin Neurol 2000;20:447-54. Alzheimer’s disease identified by computational neuro- 4. Gorno-Tempini ML, Hillis AE, Weintraub S, Kertesz A, anatomy. Cereb Cortex 2005 ;15:995-1001. Mendez M, Cappa SF, et al. Classification of primary 16. Adeli A, Whitwell JL, Duffy JR, Strand EA, Josephs KA. progressive aphasia and its variants. Neurology 2011 Ideomotor apraxia in agrammatic and logopenic variants ;76:1006-14. of primary progressive aphasia. J Neurol 2013 ;260:1594- 5. Mesulam MM, Rogalski EJ, Wieneke C, Hurley RS, 600. Geula C, Bigio EH, et al. Primary progressive aphasia 17. Miller ZA, Mandelli ML, Rankin KP, Henry ML, Babiak and the evolving neurology of the language network. Nat MC, Frazier DT, et al. Handedness and language learn- Rev Neurol 2014 ;10:554-69. ing disability differentially distribute in progressive 6. Ridgway GR, Lehmann M, Barnes J, Rohrer JD, Warren aphasia variants. Brain 2013 ;136:3461-73. JD, Crutch SJ, et al. Early-onset Alzheimer disease 18. Rogalski E, Johnson N, Weintraub S, Mesulam M. In- clinical variants: multivariate analyses of cortical thick- creased frequency of learning disability in patients with ness. Neurology 2012 ;79:80-4. primary progressive aphasia and their first-degree rela- 7. Lehmann M, Crutch SJ, Ridgway GR, Ridha BH, Barnes tives. Arch Neurol 2008 ;65:244-8. J, Warrington EK, et al. Cortical thickness and voxel- 19. Volden J. Nonverbal learning disability. Handb Clin based morphometry in posterior cortical atrophy and Neurol 2013;111:245-9. typical Alzheimer’s disease. Neurobiol Aging 2011;32:1466-76. 8. Lehmann M, Rohrer JD, Clarkson MJ, Ridgway GR, Scahill RI, Modat M, et al. Reduced cortical thickness in the posterior cingulate gyrus is characteristic of both typical and atypical Alzheimer’s disease. J Alzheimers Dis 2010;20:587-98. 9. Ossenkoppele R, Cohn-Sheehy BI, La Joie R, Vogel JW, Möller C, Lehmann M, et al. Atrophy patterns in early Vol.34 • NO.1 • 2018 15

Abstract Driving and Epilepsy in Introduction: Given that the number of Thai Thailand epidemiologic studies focusing on driving in pa- tients with epilepsy (PWE) has been limited. The decision not to drive in the context of epilepsy is complex and influenced by multiple factors includ- ing patient factors and the natural history of epi- lepsy, socioeconomic factors. Objective: The objectives of our study are to identify the driving prevalence and to explore the clinical and sociodemographic factors that associ- ated with driving among PWE. Materials and Methods: This is a descriptive cross-sectional and structured interview study that was conducted at the two-study research sites, the university-based Ramathibodi Hospital and the Wattanakit Chantorntanasut, community-based Lomsak Hospital from October Parinyaporn Maipang, 2014 to December 2014. We collected demograph- Watcharaporn Boonjom, ic data, driving information, and epilepsy-related Prakin Promya, Apisit Boongird data that may associate with driving among PWE. Results: Of 159 patients, the driving preva- lence among PWE was about 37%. Comparing the data between two hospitals, PWE from Lomsak Hospital are more likely to drive. Comparing be- tween driving and not driving groups, male, married status, higher income, and unavailability of other transportations were associated with the decision to continue driving. Conclusion: The majority of PWE continue to drive despite the fact that there is other public transportation available in their living areas. Our Wattanakit Chantorntanasut, Parinyaporn Maipang, study suggests that patient education and increas- Watcharaporn Boonjom, Prakin Promya, Apisit Boongird Division of Neurology, Department of Medicine, ing public awareness of epilepsy might be helpful Faculty of Medicine, Ramathibodi Hospital Mahidol University, Bangkok, Thailand in order to decrease the driving prevalence among Correspondence author epilepsy patients. Apisit Boongird Division of Neurology, Department of Medicine, Faculty of Medicine, Ramathibodi Hospital Mahidol University, Bangkok, Thailand 16 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Introduction: Materials and Methods: Patients with epilepsy (PWE) were limited by A survey of cross-sectional design was con- some activities that could cause risks to injury and ducted at the two-study research sites to analyze death such as swimming and driving1-6. Seizure and compare the patient data between the tertiary- attacks while driving had detrimental effect on indi- care and university-based Ramathibodi Hospital vidual life and diminished quality of life (QOL) and the community-based Lomsak Hospital. among PWE even though they only suffered minor This is the structured interview performing at injuries3,7. During the past decades, seizure-attack the Ramathibodi Hospital and Lomsak community while driving has become an interesting topic and Hospital. All epileptic adult patients (age > 18 years increasing more public concern in Thailand be- old) who had an out-patient department(OPD) visit cause of patient safety, public safety, and impaired at Ramathibodi Hospital and Lomsak Hospital from quality of life among patients with epilepsy (PWE). October, 2014 to December, 2014 were recruited To drive, PWE must meet all normal driving require- in this study. The participants must be fully alert, ments and must have completely seizure freedom able to communicate in Thai, able to answer the for sufficient period of time. To best of our knowl- questionnaires, and willing to participate this re- edge, there are no specific Thai laws prohibiting search. Inform consent was obtained from all pa- PWE from driving. According to the Thailand Depart- tients in this study. We exclude the in-patient depart- ment of Land Transport, patients with uncontrolled ment (IPD) epileptic patients, patients with known epilepsy need to be examined by the physicians in medical conditions that may affect either physical order to have a valid driver license. Thus, there are activity or ability to drive the vehicle, such as his- no definite restrictions on people with epilepsy driv- tory of drug abuse, dementia, and psychosis. ing any vehicles in Thailand. The decision not to During the study phase, the structured interviews drive in the context of epilepsy is probably complex were performed on each epileptic patient by the and influenced by multiple factors including patient research coordinator, including registered nurse factors, the natural history of epilepsy, and socio- (RN) and practical nurse (PN). The interviewers economic factors8. Previous studies have shown that were trained for using and filling on the question- many factors are associated with driving among naires before entering the study period. We col- PWE, such as being employed is one of the main lected the following information on each patient reasons for PWE to continue driving1. including demographic data, driving information, Given that the number of Thai epidemiologic and epilepsy-related data. studies focusing on driving in PWE has been limited. There are only few Thai studies addressing this is- Statistical analysis: 9-12 sue . Thus, we conduct a research to study about Statistical analyses were performed with the driving prevalence of PWE in Thailand and ex- STATA. The data obtained from the population from plore the sociodemographic data and clinical fac- Ramathibodi Hospital and Lomsak Hospitals were tors associated with driving in PWE. combined together. Descriptive statistics such as Vol.34 • NO.1 • 2018 17

frequencies, mean and median were used to de- zure characteristics are as follows; seizure with loss scribe the characteristics of participants in this of consciousness (56%), aura before the onset of study. Univariate comparison between those who seizure (43.4%). Thirty-eight percent of patient had drive and those who do not were made by using the less frequent seizure frequency (more than 1 year) Students t-test and chi-square test. than the others. Most of the patients (62.5%) had We also performed multivariate analysis using seizure occurring yearly. Half of our patients (51.5%) multiple logistic regression of variables associated had their seizure under control with one anti-seizure with driving in all epilepsy patients to reveal asso- medication. The vast majority of our patients knew ciation between variables. P-value of 0.05 or less that seizure is contraindicated for driving (76.7%), was considered significant. and had other public transportation available (91.1%) in their areas. Some of our patients had seizure while Results: driving (12.5%). But, only the minority of them had a From October to December 2014, one hundred seizure-related accident (5.6%). and fifty-nine patients were fulfilled the inclusion cri- Comparing the data between two hospitals, teria and entered in our study. Of 159 patients, there higher education level, higher income, and holding were 109 patients from Ramathibodi Hospital and 50 a valid driver license was more likely observed in patients from Lomsak Hospital. Overall, PWE who Ramathibodi Hospital group. Epilepsy awareness continue to drive were 60/159 (37.7%). Comparing and epilepsy-related driving issues were also more the data between two hospitals, PWE from Lomsak available in Ramathibodi Hospital group (86 vs 56%). hospital are more likely to drive, Lomsak hospital The preference of vehicle being used in each group (26/50, 52 %) vs Ramathibodi Hospital (34/109, 31%). shows statistically significant between two groups. Demographic data, driving, and epilepsy-re- The most common type of vehicle being using among lated information are summarized in Table 1. The PWE in Ramathibodi Hospital group is a car. While, mean age of patients was 37. Most of the patients Lomsak Hospital group is a motorcycle. were male (52%) and single (57.8%). Sixty percent The clinical characteristics of patients who of our patients had less than the college degree. drive and who do not drive are summarized in Table Nearly fifty percent of patients had no income. 2. We performed univariate analysis to compare the Regarding driving information, fifty-five percent clinical characteristics between these two groups. of patients are able to drive. But, a valid driver li- In the group of person who continue driving, male cense could be found in only 60% of PWE with (61.6%) continues driving. Comparing between two ability to drive. The most common reason for con- groups (driving vs not driving), male (61 vs 46%), tinue driving was personal business (54.5%). More married status (48 vs 26%), higher income, and than one-third of the patients (38.6%) continued to availability of other transportation (20 vs 2 %) were drive every day. Nearly ninety percent of the pa- associated with the decision to continue driving. tients drove more than one kilometer per day. Multiple logistic regression of significant variables Most of our patients had their first seizure when identified by univariate analysis had been performed they were less than 60 years old (98.2%). The sei- and shown in Table 3. Monthly income below 9,000 18 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

baht (OR=4.84, P<0.001), monthly income more ated with driving in PWE. Marital status was also than 30,000 baht (OR=4.22, P= 0.05), and unavail- associated with driving with odd ratio of 1.71; but ability of other transportations (OR=12.61, P= 0.002) this was not statistically significant. were independent and simultaneous factors associ- Table 1. Description of patient characteristics. All Rama Lomsak P-value n = 159 n = 109 n = 50 Primary outcome Driving a motor vehicles, n (%) 60(37.7) 34(31.1) 26(52.0) 0.012 a Predictor variables Age, mean(SD), year 37(14) 37(14) 39(14) 0.300 c Sex Male, n (%) 83(52.2) 56(51.4) 27(54.0) 0.758 a Female, n (%) 76(47.8) 53(48.6) 23(46.0) Marital status, n (%) Single 92(57.8) 73(67.0) 31(62.0) 0.541 a Married 67 (44.2) 36(33.0) 19(38.0) Highest education level, n (%) Primary 52(32.7) 20(18.5) 32(64.0) <0.001 a Secondary 46(28.9) 32(29.5) 14(28.0) Bachelor 40(25.1) 36(33.0) 4(8.0) Master 11(6.9) 11(10.0) 0(0) Others 10(6.2) 10(9.0) 0(0) Income per month, n (%) No salary 71(44.6) 45(41.2) 26(52.0) 0.002 a Below 9,000 baht 28(17.6) 12(11.01) 16(32.0) 9,000-15,000 baht 24(15.0) 21(19.27) 3(6.0) 15,000-30,000 baht 23(14.5) 19(17.43) 4(8.0) More than 30,000 baht 13(8.3) 12(11.00) 1(2.0) Driving information Can drive, n (%) 88(55) 59(54.1) 29(58.0) 0.648 a Have license, n (%) 54(61.3) 42(71.1) 12(41.3) 0.007 a Type of vehicles, n (%) Motorcycle 44(50.0) 22(37.3) 23(79.3) <0.001 b Car 41(46.5) 37(62.7) 4(13.8) Others 3(3.5) 0(0) 2(6.9) Reason to drive, n (%) To work or study 36(40.9) 19(32.2) 17(58.6) 0.036 b Personal (ex. shopping) 48(54.5) 36(61.0) 12(41.4) Career involves driving 4(4.5) 4(6.8) 0(0) Vol.34 • NO.1 • 2018 19

All Rama Lomsak P-value n = 159 n = 109 n = 50 Number of days driven per week, n (%) 1 9(10.2) 7(11.86) 2(6.90) 0.042b 2 14(15.9) 8(13.56) 6(20.69) 3 13(14.7) 12(20.34) 1(3.45) 4 5(5.6) 5(8.47) 0(0) 5 12(13.6) 9(15.25) 3(10.34) 6 1(1.1) 1(1.69) 0(0) 7 34(38.6) 17(28.81) 17(58.62) Length of driving (km/day), n (%) Less than 1 km 11(12.5) 6(10.1) 5(17.2) 0.356 b 1-10 km 39(44.3) 25(42.3) 14(48.3) 10-20 km 24(27.2) 16(27.1) 8(27.6) More than 20 km 14(15.9) 12(20.3) 2(6.90) Age of 1st seizure(year), mean (min-max) 1-15 years old 68(42.8) 49(44.90) 19(38.0) 0.524 b 16-30 years old 53(33.4) 33(30.3) 20(40.0) 31-60 years old 35(22.0) 24(22.0) 11(22.0) More than 60 years old 3(1.8) 3(2.8) 0(0) Type of seizure, n(%) Seizure with loss of conscious 90(56) 53(48.6) 37(74.0) 0.003 a Seizure without loss of conscious 69(43.4) 56(51.4) 13(26.0) Present of aura, n (%) 69(43.4) 49(44.9) 20(40.0) 0.558 a Time of last seizure, n (%) Less than 1 month 46(28.9) 38(34.9) 8(16.0) 0.191 a 1-3 months 18(11.3) 12(11.0) 6(12.0) 3-6 months 22(13.8) 14(12.8) 8(16.0) 6-12 months 13(8.1) 8(7.4) 5(10.0) More than 1 year 20(37.7) 37(33.9) 23(46.0) Seizure frequency Every day 7(4.6) 1(1.7) 6(6.6) 0.191 a Every 2-3 days 7(4.6) 2(3.3) 5(5.4) Every week 5(3.3) 0(0) 5(5.4) Every month 38(25.0) 16(26.7) 22(23.9) Every year 95(62.5) 41(68.3) 54(58.7) Number of AEDs 1 type 82(51.5) 59(54.1) 23(46.0) 0.271 b 2 types 49(30.8) 26(26.6) 20(40.0) 3 types 24(15.0) 17(15.6) 7(14.0) More than 3 types 4(2.5) 4(3.7) 0(0) History of seizure during driving, n (%) 20(12.5) 18(16.5) 2(4.0) 0.027 a History of accident due to seizure, n (%) 9(5.6) 7(6.4) 2(4.00) 0.721 b Know that epilepsy is contraindication for driving, n (%) 122(76.7) 94(86.2) 28(56.0) <0.001 a Other transportation available, n(%) 145(91.1) 96(88.0) 49(98.0) 0.066 b a = Pearson chi-square b = Fisher’s exact test c = t-test 20 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Table 2. Comparing characteristics of patients who drive and who do not drive. Drive Do not drive P-value n = 60 (37.7%) n = 99 (62.3) Age, mean (SD) 39(14) 37(14) 0.323 a Sex Male, n (%) 37(61.6) 46(46.4) 0.063 b Female, n (%) 23(38.4) 53(53.6) Marital status, n (%) Single 31(51.7) 73(73.7) 0.005 b Married 29(48.3) 26(26.3) Highest education level, n (%) Primary 15(25.0) 37(37.4) 0.391 b Secondary 17(28.3) 29(29.2) Bachelor 17(28.3) 23(23.2) Master 6(10.0) 5(5.1) Others 5(8.3) 5(5.1) Income per month, n (%) No salary 17(28.3) 54(54.6) <0.001 b Below 9,000 baht 17(28.3) 11(11.1) 9,000-15,000 baht 6(10.0) 18(18.2) 15,000-30,000 baht 11(18.3) 12(12.1) More than 30,000 baht 9(15.0) 4(4.0) Age of first seizure onset 1-15 years old 49(49.5) 19(31.7) 0.142 a 16-30 years old 29(29.3) 24(40.0) 31-60 years old 19(19.2) 16(26.7) More than 60 years old 2(2.0) 1(1.67) Type of seizure Seizure with loss of consciousness 34(56.6) 56(56.5) 0.990 b Seizure without loss of consciousness 26(43.3) 43(43.4) Seizure with aura 30(50.0) 39(39.3) 0.191 b Seizure without aura 30(50.0) 60(60.6) Time of last seizure, n(%) Within 1 month 16(26.6) 30(30.3) 0.781 b Between 1-3 months 5(8.3) 13(13.1) Between 3-6 months 8(13.3) 14(14.1) Between 6-12 months 5(8.3) 8(8.0) More than 1 year 26(43.3) 34(34.3) Seizure frequency, n(%) Every day 1(1.67) 6(6.52) 0.059 b q 2-3 days 2(3.33) 5(5.43) Every week 0(0) 5(5.43) Every month 16(26.67) 22(23.91) Every year 41(68.33) 54(58.70) Vol.34 • NO.1 • 2018 21

Drive Do not drive P-value n = 60 (37.7%) n = 99 (62.3) Number of AEDs 1 type 36(60.0) 46(46.4) 0.317 b 2 types 14(23.3) 35(35.3) 3 types 8(13.3) 16(16.1) More than 3 types 2(3.3) 2(2.0) Know that seizure is contraindication for driving , n (%) Yes 45(75) 77(77.8) 0.688 b No 15(25.0) 22(22.2) Availability of other transportations, n (%) Yes 48(80.0) 97(98.0) <0.001 b No 12(20.0) 2(2.0) a = Students t-test b = Pearson chi-square

Table 3. Multiple logistic regression of variables associated with driving in all epileptic patients Odd ratio 95% CI(Odd ratio) P-value Income Below 9,000 baht 4.84 1.83-12.82 <0.001 9,000-15,000 baht 0.78 0.23-2.61 0.696 15,000-30,000 baht 2.09 0.71-6.10 0.177 More than 30,000 baht 4.22 1.00-16.89 0.050 Marital status 1.71 0.79-3.70 0.168 Married Unavailability of other transportations 12.61 2.51-63.29 0.002 Discussion: tors, most of PWE in this study had their seizure under control with one AED and had low number of The main objective of our study is to determine seizure frequency (seizure once a year). the driving prevalence among epilepsy patients. Comparing the data between two hospitals, After the structured interview and analysis of the Ramathibodi Hospital group had higher educa- data, we found that the driving prevalence in our tional level and monthly income than Lomsak Hos- population study was relatively high. More than pital group. Additionally, greater number of patients one-third of our patients (37%) continued to drive. in Ramathibodi Hospital group showed better Factors associated with driving among PWE are knowledge regarding prohibition on driving than probably multifactorial and may be individualized patients in Lomsak Hospital group. As the results, in each patient. This assumption was based on our most of PWE from our study have been aware that data indicating that both clinical factors and socio- epilepsy is contraindicated for driving any vehicle economic factors probably played an important role and known that they should not drive. The reason for continue driving in PWE. Regarding clinical fac- behind this issue was presumably explained by the 22 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

fact that Ramathibodi Hospital is in the capital city that married status, inaccessibility and unavailabil- of Thailand which is the center of civilization, educa- ity of public transportation were the factors associ- tion, and business; whereas Lomsak Hospital is not. ated with driving among PWE. Regarding monthly Lomsak Hospital is a 120-bed community hospital income and the decision to continue driving, person and is approximately 43 kilometers away from the who earned monthly income less than 9,000 baht center of Phetchabun. Moreover, Ramathibodi and more than 15,000 baht were more likely to physicians may have more experience in taking continue driving. But, the relationship of salary per care of PWE than Lomsak physicians because they month and the decision to drive was not concordant have to take care larger number of PWE. This pre- and had not been significantly demonstrated in the sumption was based on the data from our study that other salary ranges. This was probably explained the greater number of PWE was observed in Ram- by the small number of participants, short duration athibodi Hospital group. of the study, and the inappropriateness of sampling methods. Primary outcome analysis There were some limitations on our study in- The driving prevalence among PWE in this cluding small number of subjects, short duration of study is 37%. Comparing the data between two study period, and interviewer bias. The use of fixed- hospitals, there was a significant difference between wording questions was considered as one method driving prevalence between PWE from two hospi- of reducing interviewer bias. Some participants did tals; with higher driving prevalence in PWE at Lom- not exactly tell the truth about driving because they sak Hospital than Ramathibodi Hospital (52% vs might be afraid of the punishment by the govern- 31%). ment. Furthermore, the minority of subjects in our study (approximately 17%) were diagnosed with The comparison between primary out- drug-resistant epilepsy13-15. Therefore, we were not comes to other research studies in able to apply the results to all PWE. Thailand Conclusion : Our study had found that PWE living in rural The overall of driving prevalence among our areas had a higher chance of driving than PWE epilepsy patients are 37% which are relatively high. living in the urban areas. Tiamkao et al. reported Most of the epileptic patients in our study have been that the majority of PWE living in the northeast of aware of that epilepsy is contraindicated for driving Thailand (84.5%) continued to drive at least 3 days 10 the vehicle and known that they should not drive. per week . But, the majority of them continue to drive despite Secondary outcome analysis the fact that there is other public transportation available in their areas. Our study suggests that Secondary endpoints were analyzed for pur- patient education and increasing public awareness poses of finding the factors related to driving among of epilepsy might be helpful in order to decrease PWE who drive and who do not drive. We had found the driving prevalence among epilepsy patients. Vol.34 • NO.1 • 2018 23

vehicle accidents. Clin Med (Lond) 2004 ;4:50-3. Acknowledgement 9. Tiamkao S, Sawanyawisuth K, Singhpoo K, Ariyanuchit- I would like to express my sincere thanks to kul S, Ngamroop R. Differences of knowledge, attitudes, and behaviors towards epilepsy between populations in my thesis advisor, Dr. Apisit Boongird, MD for his municipal and nonmunicipal areas. Psychol Res Behav invaluable help and constant encouragement Manag 2013;6:111-6. throughout the course of this research. I would not 10. Saengsuwan J, Laohasiriwong W, Boonyaleepan S, have achieved this far and this thesis would not Sawanyawisuth K, Tiamkao S, Talkul A. Seizure-related vehicular crashes and falls with injuries for people with completed without all the support that I have always epilepsy (PWE) in northeastern Thailand. Epilepsy Behav received from them. 2014;32:49-54. In addition, I am grateful for Parinyaporn 11. Locharernkul C. Epilepsy and the law--a view from Thai- Maipang, Watcharaporn Boonjom, Prakin Promya, land. J Med Assoc Thai 2007 ;90:587-98. 12. Tiamkao S, Sawanyawisuth K, Towanabut S, Visudhipun Dr. Pawin Numthavaj for suggestions and all their P. Seizure attacks while driving: quality of life in persons help. with epilepsy. Can J Neurol Sci 2009 ;36:475-9. Finally, I most gratefully acknowledge my par- 13. Jobst BC. Consensus Over Individualism: Validation of ents for all their support throughout the period of the ILAE Definition for Drug Resistant Epilepsy. Epilepsy Curr 2015 ;15:172-3. this research. 14. Espinosa-Jovel CA, Sobrino-Mejia FE. [Drug resistant epilepsy. Clinical and neurobiological concepts]. Rev References Neurol 2015 ;61:159-66. 1. Bautista RE, Wludyka P. Driving prevalence and factors 15. Lopez Gonzalez FJ, Rodriguez Osorio X, Gil-Nagel Rein associated with driving among patients with epilepsy. A, Carreno Martinez M, Serratosa Fernandez J, Vil- Epilepsy Behav 2006 ;9:625-31. lanueva Haba V, et al. Drug-resistant epilepsy: definition 2. Fisher RS, Parsonage M, Beaussart M, Bladin P, Masland and treatment alternatives. Neurologia 2015;30:439-46. R, Sonnen AE, et al. Epilepsy and driving: an interna- tional perspective. Joint Commission on Drivers’ Licens- ing of the International Bureau for Epilepsy and the In- ternational League Against Epilepsy. Epilepsia 1994 ;35:675-84. 3. Gilliam F, Kuzniecky R, Faught E, Black L, Carpenter G, Schrodt R. Patient-validated content of epilepsy-specific quality-of-life measurement. Epilepsia 1997 ;38:233-6. 4. Krumholz A. Driving issues in epilepsy: past, present, and future. Epilepsy Curr 2009 ;9:31-5. 5. Winston GP, Jaiser SR. Western driving regulations for unprovoked first seizures and epilepsy. Seizure 2012 ;21:371-6. 6. Classen S, Crizzle AM, Winter SM, Silver W, Eisenschenk S. Evidence-based review on epilepsy and driving. Epi- lepsy Behav 2012 ;23:103-12. 7. Berg AT, Engel J, Jr. Restricted driving for people with epilepsy. Neurology 1999 ;52:1306-7. 8. Spencer MB, Carter T, Nicholson AN. Limitations of risk analysis in the determination of medical factors in road 24 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

บทคัดย่อ Oculomotor Nerve Palsy ชายไทยอายุคู่อายุ 69 ปี มาด้วยหนังตาขวาตก 1 วันก่อนมาโรงพยาบาล หลังจากได้รับยาฉีดอีน็อกซ่าพา Caused by Compression รินใต้ผิวหนังเพื่อรักษาโรคหลอดเลือดหัวใจตีบ ตรวจ of Pituitary Apoplexy ร่างกายพบหนังตาตก อัมพาตของกล้ามเนื้อกลอกลูกตา ที่เลี้ยงด้วยเส้นประสาทออคูโลมอเตอร์ รูม่านตาขวา ขยายและไม่ตอบสนองต่อแสง ส่งตรวจภาพทาง รังสีวิทยาสนามแม่เหล็กสมอง (MRI brain) พบก้อนเนื้อที่ ต่อมใต้สมองที่มีเลือดออก (pituitary apoplexy) บทน�ำ ภาวะเส้นประสาทสมองออคูโลมอเตอร์เป็นอัมพาต เป็นภาวะที่พบได้บ่อยทางเวชปฏิบัติ โดยทั่วไปใช้ความ ธัญลักษณ์ อมรพจน์นิมมาน, ผิดปกติของการตอบสนองต่อแสงของรูม่านตา (pupil- อินทิพร เมธาสิทธิ์, lary reflex) เป็นตัวจ�ำแนกว่าสาเหตุของอาการเกิดจาก การกดทับต่อเส้นประสาท ซึ่งเป็นภาวะเร่งด่วนทาง พรชัย สถิรปัญญา ศัลยกรรมประสาทออกจากภาวะทางอายุรกรรม สาเหตุ ของการกดทับส่วนใหญ่เกิดจาก posterior communi- cating artery (PCOM) aneurysm อย่างไรก็ตามยังมี สาเหตุอื่น ๆ อีก รายงานนี้น�ำเสนอผู้ป่วยที่มีอาการ อัมพาตของเส้นประสาทออคูโลมอเตอร์จากการกดทับ ด้วยเนื้องอกต่อมใต้สมองที่มีเลือดออก (pituitary apo- plexy) รายงานผู้ป่วย ชายไทยคู่อายุ 69 ปี มีอาการเจ็บแน่น ๆ ที่กลาง หน้า 10 วันก่อนมาโรงพยาบาล (รพ.) เจ็บหน้าอกร้าวมา แขนซ้าย อาการเป็นมากขึ้นเวลาออกแรง ถ้าพักแล้ว อาการดีขึ้น ไปพบแพทย์ที่โรงพยาบาลทุ่งสง ได้รับการ วินิจฉัยเป็น non-ST elevated myocardial infarction และได้รับการรักษาด้วย enoxaparin 60 mg subcuta- พญ. ธัญลักษณ์ อมรพจน์นิมมาน1, พญ. อินทิพร เมธาสิทธิ์2, รศ.นพ. พรชัย สถิรปัญญา3 neous (sc.) ทุก 12 ชั่วโมง x 5 วัน อาการเจ็บหน้าอก 1แพทย์ประจำ�บ้านต่อยอดสาขาประสาทวิทยา, 2แพทย์ประจำ�บ้านปี 3 สาขาประสาทวิทยา กลับเป็นปกติ จึงจ�ำหน่ายออกจาก รพ. 3สาขาประสาทวิทยา ภาควิชาอายุรศาสตร์ คณะแพทยศาสตร์ 1 วันก่อนมาโรงพยาบาล หลังตื่นนอนตอนเช้า ผู้ มหาวิทยาลัยสงขลานครินทร์ ผู้รับผิดชอบบทความ ป่วยสังเกตว่ามองเห็นภาพซ้อน และหนังตาขวาตกลงมา รศ. นพ. พรชัย สถิรปัญญา สาขาประสาทวิทยา ภาควิชาอายุรศาสตร์ คณะแพทยศาสตร์ จนปิดสนิทภายในวันเดียวกัน และปวดศีรษะระหว่างหัว มหาวิทยาลัยสงขลานครินทร์ Vol.34 • NO.1 • 2018 25

คิ้วทั้งสองข้างเล็กน้อย ลักษณะปวดตื้อ ๆ ไม่ร้าวไปไหน การมองเห็นของตาขวายังปกติ ไม่มีแขนขาอ่อนแรง ไม่มีหน้าเบี้ยว และไม่มีอาการชาบนใบหน้า การตรวจร่างกายตามระบบทั่วไปอยู่ในเกณฑ์ปกติ การตรวจร่างกายทางระบบประสาทพบดังต่อไปนี้ • Cranial nerves - CN I: normal smelling - CN II: VA 20/50 corrected by pin hole both รูปที่ 2 ภาพ MRI brain T2W แสดง: - A heterogeneous sella-suprasella mass; size 18 X 15 mm. There was eyes, pupils: RE 5 mm non-react to light internal hemorrhage with extension and mass effect (NRTL); LE 3 mm RTL, no papilledema on right cavernous sinus. Pituitary macroadenoma with - CN III, IV, VI: ดังรูปที่ 1 hemorrhage (apoplexy) is likely (ปกหน้า) - Other CNs: WNL การตรวจร่างกายทางระบบประสาทอื่น ๆ อยู่ใน Discussion เกณฑ์ปกติ จากกรณีตัวอย่างนี้ผู้ป่วยมาด้วยอัมพาตของเส้น ประสาทออคูโลมอเตอร์โดยล�ำพัง และมีม่านตาไม่ตอบ สนองต่อแสง (isolated oculomotor palsy with pupil- lary involvement) ซึ่งเกิดจากรอยโรคที่เป็นก้อนมากด ทับ pupillary fiber ที่ทอดตัวอยู่ที่ผิวด้านบนของเส้น ประสาทออคูโลมอเตอร์ สาเหตุของ isolated oculomo- tor palsy with pupillary involvement เกิดได้จากหลาย สาเหตุ ตัวอย่างเช่น PCOM aneurysm ที่โตขึ้นมากด ต�ำแหน่งดังกล่าว สาเหตุอื่น ๆ นอกจาก PCOM aneu- rysm ที่พบได้ เช่น uncal herniation ซึ่งในกรณีดังกล่าว รูปที่ 1 รูปแสดงการเคลื่อนไหวของลูกตา (extra-ocular นี้ ผู้ป่วยมักมีพยาธิสภาพที่สมองใหญ่เหนือต่อ tentorial movement) (ปกหน้า) cerebri ท�ำให้เกิดความดันภายในกะโหลกศีรษะสูงหรือ มีพยาธิสภาพอยู่ใกล้ uncus ของ temporal lobe แล้ว ผู้ป่วยได้รับการวินิจฉัยว่าเป็น pituitary apoplexy ดันเนื้อสมองท�ำให้ uncus เลื่อนไหลลงมากดเส้น จากการที่มี internal hemorrhage ได้ส่งตรวจหาระดับ ประสาทออคูโลมอเตอร์ ค่า pituitary hormones ในซีรัมพบว่า ปกติทั้งหมด ผู้ Pituitary apoplexy เป็นอีกหนึ่งสาเหตุของการเกิด ป่วยได้รับการรักษาแบบการประคับประคอง และติดตาม isolated oculomotor nerve palsy with pupillary in- อาการ อาการพบว่า ดีขึ้นตามล�ำดับ ประกอบกับการ volvement ซึ่งพบไม่บ่อย กลไกการเกิดอาการอธิบายได้ ติดตามด้วย MRI Brain ก็พบว่าต�ำแหน่งที่มีเลือดออกมี จาก pituitary gland วางตัวอยู่ใน pituitary fossa เหนือ ขนาดเล็กลง และอาการอัมพาตของเส้นประสาทออคู ต่อ cavernous sinus โดยที่มีเส้นประสาทออคูโลมอเตอร์ โลมอเตอร์กลับคืนสู่ปกติ ทอดผ่านมาตรงต�ำแหน่งมุมบนสุดของ cavernous sinus ผู้ป่วยได้รับการตรวจภาพถ่ายสนามแม่เหล็กของ พอดี เมื่อเกิดภาวะแทรกซ้อนจากภายในก้อน pituitary สมอง (MRI Brain) ผลดังรูปที่ 2 adenoma เช่น ตกเลือดภายในก้อนหรือการขาดเลือด จะส่งผลให้ pituitary adenoma ขยายขนาดแล้วเลื่อน 26 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

มากดเบียดเส้นประสาทออคูโลมอเตอร์ (รูปที่ 3) สรุป Pituitary apoplexy สามารถท�ำให้เกิดการกดทับ ต่อเส้นประสาทสมองที่ทอดตัวผ่านเข้ามาบน cavernous sinus โดยเฉพาะเส้นประสาทออคูโลมอเตอร์ที่อยู่ใน ต�ำแหน่งมุมบนสุดของ cavernous sinus จึงอยู่ใกล้กับ pituitary gland ดังนั้น จึงต้องรวมสาเหตุนี้ไว้ในการ วินิจฉัยแยกโรคส�ำหรับ isolated oculomotor nerve III palsy with pupillary involvement ด้วย นอกจากนี้การ วินิจฉัยแยกออกจาก PCOM aneurysm แตกด้วยภาพ รังสีวินิจฉัยก็มีความส�ำคัญอย่างยิ่งเนื่องจากทั้งสอง สาเหตุมีอาการทางคลินิกคล้ายคลึงกันมาก รูปที่ 3 แสดงความสัมพันธ์ของต�ำแหน่งของ pituitary gland และเส้นประสาทออคูโลมอเตอร์ References 1. Boellis A, di Napoli A, Romano A, Bozzao A. Pituitary Pituitary apoplexy เป็นภาวะที่เกิดจากการที่มีการ apoplexy: an update on clinical and imaging features. ตกเลือด (hemorrhage) หรือการขาดเลือด (infarction) Insights Imaging 2014; 5:753–62. 2. Ranabir S, P Baruah M. Pituitary apoplexy. Indian J En- แทรกซ้อนขึ้นภายใน pituitary adenoma เมื่อมีการขยาย docrinol Metab 2011;15(Suppl3): S188–S96. ขนาดของก้อน adenoma เป็นภาวะที่พบไม่บ่อย 3. Glezer A, D.Bronstein M. Pituitary apoplexy: patho- ประมาณร้อยละ 1.6 ถึง 2.8 ของผู้ป่วยที่มี pituitary physiology, diagnosis and management. Arch Endo- adenoma1 แม้ว่าจะพบน้อย แต่เป็นภาวะที่ท�ำให้ถึงแก่ crinol Metab 2015;59:259-64. ชีวิตได้จากภาวะความดันตำ�่ ที่เกิดจากการพร่องฮอร์โมน จากต่อมใต้สมองหากไม่ได้รับการวินิจฉัยที่ถูกต้อง และ รักษาอย่างทันท่วงที2 โดยทั่วไป pituitary apoplexy มักมาด้วยอาการ ปวดศีรษะฉับพลัน คลื่นไส้ อาเจียน การมองเห็นภาพซ้อน หรือการกลอกตาผิดปกติ ซึม และมีภาวะพร่องฮอร์โมน ของต่อมใต้สมองอย่างรุนแรงได้3 การยืนยันการวินิจฉัย โรคนี้ต้องใช้ภาพทางรังสีวินิจฉัย MRI brain เนื่องจาก มี ความไว และความจ�ำเพาะสูงกว่าเอกซเรย์คอมพิวเตอร์ สมอง (CT brain) ในการวินิจฉัยภาวะนี้3 Vol.34 • NO.1 • 2018 27

ผู้ป่วยชายไทยคู่ อายุ 49 ปี อาชีพรับจ้าง ภูมิล�ำเนา อ.เมือง จ.นครราชสีมา สิทธิการรักษา ประกันสังคม A Middle Aged Man with อาการส�ำคัญ Abnormal Movement แขนขาซีกซ้ายเคลื่อนไหวมากขึ้น 3 วัน ก่อนมาโรง พยาบาล ประวัติเจ็บป่วยปัจจุบัน 5 วันก่อนมาโรงพยาบาล ผู้ป่วยสังเกตว่ามีอาการ แขนซีกซ้ายมีการเคลื่อนไหวผิดปกติ ไม่ทราบระยะเวลา ของการเกิดอาการได้อย่างชัดเจน การเคลื่อนไหวดัง กล่าวเป็นที่บริเวณข้อมือจนถึงต้นแขน โดยมีลักษณะ แกว่งบิดไปมา บางครั้งจะกระตุกแต่ไม่มีจังหวะสมำ�่ เสมอ เวลาเดินสังเกตว่าเท้าข้างซ้ายมีลักษณะแกว่งไปมาโดยที่ สราวุธ สุขสุผิว1, ผู้ป่วยไม่สามารถควบคุมให้น้อยลงหรือหยุดได้ อาการดัง นิภาพรรณ นรการเทียนสิน2, กล่าวเป็นตลอดในเวลากลางวัน โดยอาการหายไปขณะ สพล มหรรฆสุวรรณ3 หลับ ผู้ป่วยรู้สึกตัวดีตลอดเวลา ไม่มีอาการอ่อนแรง ไม่มี อาการชา ไม่มีอาการปวดศีรษะ ไม่มีตาพร่ามัว 3 วันก่อนมาโรงพยาบาล ผู้ป่วยสังเกตว่าอาการ เคลื่อนไหวผิดปกติของมือและเท้าซีกซ้ายเป็นมากขึ้น จน รบกวนชีวิตประจ�ำวัน จึงมาโรงพยาบาล ประวัติอดีต - เคยตรวจพบว่าระดับนำ�้ ตาลในเลือดในเลือดสูง เมื่อ 3 ปีก่อน แต่ไม่ได้รับการรักษาต่อเนื่อง - ปฏิเสธโรคความดันโลหิตสูง ปฏิเสธแพ้ยา - ปฏิเสธประวัติการได้รับอุบัติเหตุบริเวณศีรษะ - ผู้ป่วยไม่เคยมีอาการแบบนี้มาก่อน ประวัติครอบครัว ผศ.นพ. สราวุธ สุขสุผิว1, พญ. นิภาพรรณ นรการเทียนสิน2, - ไม่มีคนในครอบครัวหรือเครือญาติมีอาการ นายสพล มหรรฆสุวรรณ3 1สาขาวิชาอายุรศาสตร์ (ประสาทวิทยา) สำ�นักวิชาแพทยศาสตร์ เคลื่อนไหวผิดปกติ มหาวิทยาลัยเทคโนโลยีสุรนารี จ.นครราชสีมา 2แผนกรังสีวิทยา โรงพยาบาลมหาวิทยาลัยเทคโนโลยีสุรนารี จ.นครราชสีมา - ปฏิเสธโรคลมชักในครอบครัว 3นักศึกษาแพทย์ชั้นปีที่ 1 ปีการศึกษา 2560 สำ�นักวิชาแพทยศาสตร์ มหาวิทยาลัยเทคโนโลยีสุรนารี จ.นครราชสีมา

ผู้รับผิดชอบบทความ ผู้ช่วยศาสตราจารย์ นายแพทย์สราวุธ สุขสุผิว สำ�นักวิชาแพทยศาสตร์ มหาวิทยาลัยเทคโนโลยีสุรนารี จ.นครราชสีมา Email: [email protected] 28 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

การตรวจร่างกาย Abnormal movement: hyperkinetic, repetitive, con- stantly varying, random with large-ampli- General appearance: A Thai middle aged man, tude involuntary movement of the proximal healthy, well co-operative and distal portion of the left side body O Vital signs: BT 37.1 C, PR 74 bpm, RR 16 bpm, Sensory: intact pin prick sensation and propriocep- BP 122/80 mmHg BW 70.1 kgs, tion 2 Height 162 cm, BMI 26.71 kg/m DTR: 2+ all HEENT: pink conjuctiva, anicteric sclera, normal Cerebellar signs: no abnormality pharynx and tonsils, impalpable lymph Babinski sign: dorsiflexion both sides node Clonus: negative both sides Heart: normal S1S2 , no murmur Cortical signs: no aphasia, no agnosia, no right-left Lungs: trachea was in midline, normal breath sound, disorientation, no memory impairment no adventitious sound Abdomen: normal contour, soft, not tender, no Problem lists hepatosplenomegaly 1. Acute progressive left hemiballism within Extremities: no pitting edema, no skin lesion 3 days Neurological examination: Alert, orientation to time, 2. History of hyperglycemia within 3 year with place and person poor control Cranial nerves: - CN I: normal smell Discussion - CN II: pupils 2 mm reactive to light both eyes, no papilledema ผู้ป่วยชายอายุ 49 ปี มาด้วยอาการแขนขาซีกซ้าย - CN III, IV, VI: full movement of extraocular เคลื่อนไหวในลักษณะมากกว่าปกติ (hyperkinetic muscles movement) แบบเฉียบพลันและเป็นมากขึ้น โดยการ - CN V: normal muscle of mastication, normal เคลื่อนไหวจะเป็นแบบซ�้ำๆ (repetitive) มีแอมปลิจูด facial sensation, normal jaw jerk ใหญ่และไม่มีรูปแบบที่ชัดเจน ต�ำแหน่งที่ involved อยู่ - CN VII: no facial weakness ที่ distal จนถึง proximal part ของแขนขาซีกซ้าย อาการ - CN VIII: normal ทั้งหมดจะเป็นมากช่วงกลางวันโดยที่ไม่สามารถควบคุม - CN IX, X: uvula in midline, equally palatal ได้ (involuntary) แต่จะหายไปในเวลานอนหลับช่วงกลาง movement, positive of gag reflex คืน ระหว่างที่มีอาการไม่มีการเปลี่ยนแปลงของการรับรู้ - CN XI: full strength both sternocleidomas- สติ ไม่มีอาการอ่อนแรง ไม่มีอาการชา ไม่มีอาการปวด toid muscle both sides ศีรษะ ไม่มีตาพร่ามัว ไม่มีการพูดที่ผิดปกติ ไม่มีอาการ - CN XII: tongue in midline, full strength both ทาง systemic อื่นๆ ผลตรวจร่างกายทางระบบประสาท sides ไม่พบความผิดปกติของ long tract signs Motor: no muscle atrophy, no fasciculation, normal อาการของผู้ป่วยทั้งหมดคิดถึงรอยโรคที่ระบบ muscle tone, motor power grade V/V both ประสาทส่วนกลาง (central nervous system) ที่ con- sides tralateral extrapyramidal system ของ subcortical Vol.34 • NO.1 • 2018 29

area ที่บริเวณ เนื่องจากไม่พบลักษณะ ของ cortical signs, long tract signs และ cerebellar signs การวินิจฉัยขั้นต้นคิดถึง abnormal hyperkinetic movement เนื่องจากมีรูปแบบของการเคลื่อนไหวเข้าได้ กับ hemiballism การวินิจฉัยแยกโรคอื่นๆ ได้แก่ simple partial seizure ส่วนสาเหตุที่เป็นไปได้ ได้แก่ vascular (ischemic, hemorrhage or vascular malformation), metabolic disorders, progressive space occupying lesion, infection, inflammation, demyelinating dis- ease of surround structure และ paraneoplastic process เป็นต้น Investigation (day of admission): รูปที่ 1 Hyperdense area in the right lentiform nucleus Complete blood count: Hb 13.6 g/dL, Hct 38.4 %, of basal ganglia without surrounding edema (white WBC 6,000 /uL (PMN 66%, L 25%, Mono arrow). The rest of the brain parenchyma show normal 7%, EO 1%, B 1%), Plt 181,000 /uL, MCV parenchymal attenuation. The and brainstem 83.4 (80-98) fL, MCH 26 (25.6-32.2) pg/cell, appears unremarkable. No shift of midline structures. MCHC 35.4 (32.2-36.5) g/dL, RDW 13.7% (ปกหน้า) (11-14), normochromic RBC morphology Chemistry: BS 749 mg/dL, HbA1C 17.6%, BUN 23 จากผล investigation พบภาวะ severe hypergly- mg/dL, Cr 1.13 mg%, eGFR 75.9, Na 138 cemia โดยไม่พบสารคีโตนในเลือด และพบภาวะไขมัน ในเลือดสูง การตรวจ CT brain (non-contrast) พบความ mmol/L, K 4.7 mmol/L, Cl 95 mmol/L, CO2 ผิดปกติเป็นลักษณะ subtle and homogeneous hyper- 24 mmol/L, Mg 1.8 mg%, PO4 4.4 mg/dL, Ca 9.0 mg/dL density ที่บริเวณ right lentiform nucleus (หมายเหตุ ผู้ Serum and urine ketone: Negative ป่วยไม่ได้รับการตรวจด้วยการฉีด contrast หรือ MRI Liver function test: normal เพิ่มเติม) Lipid profiles: Chol 216 mg%, TG 252 mg%, HDL การวินิจฉัยขั้นสุดท้าย: Left hemiballism due 32 mg%, cLDL 118 mg%, to non-ketotic hyperglycemia Coagulogram: normal study การรักษาติดตามผู้ป่วย EKG: normal sinus rhythm, rate 75/min regular, no ischemic pattern, no chamber enlargement ในผู้ป่วยรายนี้พิจารณาให้การรักษาโดยการใช้ยา CXR: normal cardio-thoracic ratio, normal paren- ลดระดับน�้ำตาลในรูปแบบฉีดและแบบรับประทานโดย chymal of both lungs มีวัตถุประสงค์เพื่อควบคุมระดับน�้ำตาลในเลือดในกลับ CT brain without contrast (day of admission): สู่ภาวะปกติให้เร็วที่สุด นอกจากนั้นยังใช้ยาเพื่อลดอาการ รูปที่ 1 ของการเคลื่อนไหวที่ผิดปกติด้วย haloperidol 3 วันหลังนอนโรงพยาบาล ระดับน�้ำตาลเริ่มเข้าสู่ ปกติ การเคลื่อนไหวแบบ ballism ลดลง ไม่มีภาวะ 30 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

แทรกซ้อนอื่น ๆ สามารถจ�ำหน่ายผู้ป่วยออกจากโรง มีรายงานหลายกรณีศึกษาพบว่ากลุ่มอาการดังกล่าว พยาบาลได้ โดยแนะน�ำความรู้เรื่องการใช้ยาและควบคุม สามารถพบในผู้ป่วยที่มีระดับน�้ำตาลในเลือดสูงที่ไม่พบ อาหารเพื่อหลีกเลี่ยงภาวะน�้ำตาลในเลือดสูง รวมถึงการ สารคีโตนร่วมด้วย (non-ketotic hyperglycemia)1-4 ซึ่ง ควบคุมระดับไขมันในเลือด มักพบในผู้ป่วยเบาหวานที่ขาดการรักษาหรือเพิ่งได้รับ 6 สัปดาห์ต่อมาผู้ป่วยได้รับการตรวจ CT brain การวินิจฉัยว่าเป็นเบาหวานตั้งแต่ครั้งแรก โดยอาการ (non-contrast) ซ�้ำพบว่ามี decreased hyperdense แสดงของ HCHB มักเป็นเป็นแบบเฉียบพลัน (acute area in the right lentiform nucleus of basal ganglia onset) แต่สามารถท�ำให้กลับสู่ภาวะปกติหรือลดการ ดังรูปที่ 2 เคลื่อนไหวที่ผิดปกติดังกล่าวได้หากมีการแก้ไขภาวะ ระดับน�้ำตาลให้กลับสู่ค่าปกติ มีบางรายงานอาจพบ อาการแสดงของ HCHB ได้ถึง 3 เดือน5 ส่วนอุบัติการณ์ ของกลุ่มอาการ HCHB ที่พบใน non-ketotic hypergly- cemia นั้นพบว่าไม่มีความแตกต่างกันในแต่ละช่วงอายุ หรือพันธุกรรมในเครือญาติ อาการและอาการแสดงของ HCHB เป็นการ เคลื่อนไหวชนิดที่มากกว่าปกติ (hyperkinetic move- ment disorder) ซึ่งมักแสดงอาการแบบข้างเดียว (uni- lateral) มี amplitude ใหญ่ ไม่สามารถควบคุมการ เคลื่อนไหวได้ แม้ว่าการเคลื่อนไหวแบบ จะแตก ต่างกับ ballism ตรงที่ส่วนของร่างกายที่เกี่ยวข้อง กล่าว คือ chorea จะเป็นการเคลื่อนไหวของรยางค์ส่วนปลาย (distal part) ขณะที่ ballism จะเป็นการเคลื่อนไหวที่ขึ้น รูปที่ 2 Decreased hyperdense area in the right lentiform nucleus of basal ganglia ไปถึงรยางค์ส่วนต้น (proximal part) ร่วมด้วย ต�ำแหน่งของสมองที่ท�ำให้เกิดพยาธิสภาพมักพบที่ วิจารณ์ บริเวณ corpus striatum, lentiform nucleus ด้านตรง ข้ามกับอาการ ส่วนต�ำแหน่งอื่น ๆ ที่มีรายงาน2 เช่น in- Non-ketotic hyperglycemia and hemiballism ternal capsule, medial part of cerebral peduncle ซึ่ง กลุ่มอาการ hemichorea-hemiballism (HCHB) เป็นส่วนหนึ่งของ striatonigral pathway ส่วนประกอบ เกิดจากความผิดปกติของรอยโรคที่บริเวณ basal gan- ของ basal ganglia แสดงดังรูปที่ 3 และความแตกต่าง glia ซึ่งส่วนใหญ่มีสาเหตุจากหลอดเลือด (vascular) แต่ ทางคลินิกระหว่าง corticospinal และ extrapyramidal syndromes แสดงดังตารางที่ 1 Vol.34 • NO.1 • 2018 31

รูปที่ 3 แสดงส่วนประกอบของ basal ganglia (coronal view) ที่มา Allan HR and Robert HB in Adams and Victor’s Principle of Neurology, 8th edition, McGraw-Hill

ตารางที่ 1 แสดงความแตกต่างทางคลินิกระหว่าง corticospinal และ extrapyramidal syndromes Corticospinal Extrapyramidal Character of the alteration of Clasp-knife effect (spasticity) Plastic, equal throughout passive muscle tone movement (rigidity), or intermittent Distribution of hypertonus Flexors of arms, extensors of Generalized but predominates in legs flexors of limbs and of trunk Involuntary movements Absent Presence of , chorea, atheto- sis, Tendon reflexes Increased Normal or slightly increased Babinski sign Present Absent Paralysis of voluntary movement Present Absent or slight ที่มา Allan HR and Robert HB in Adams and Victor’s Principle of Neurology, 8th edition, McGraw-Hill 32 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

ผลของภาวะ hyperglycemia ที่มีผลต่อระบบ ระดับน�้ำตาลในเลือดสูงซึ่งสามารถรักษาให้หายหรือ ประสาทนอกจากกลุ่มอาการ movement disorders6 ท�ำให้ลดการเคลื่อนไหวที่ผิดปกติได้ ซึ่งการพยากรณ์โรค แล้ว ยังอาจพบอาการ weakness, hypotonia, alteration จากสาเหตุนี้ค่อนข้างดี (good prognosis) และจากการ of conscious, cortical signs, pyramidal tract signs ติดตามการรักษาหลังจากระดับนำ�้ ตาลกลับสู่ภาวะปกติ และ seizure ได้ แม้ว่าการเกิดพยาธิสภาพทางระบบ พบว่าการเปลี่ยนแปลงทาง CT brain จากรอยโรคที่พบ ประสาทจะยังเป็นที่โต้แย้งกันอยู่ก็ตาม7 แต่มีหลาย เป็น hyperdensity ที่บริเวณ lentiform nucleus นั้นลด ทฤษฎีสนับสนุนว่าภาวะ hyperglycemia อาจท�ำให้เกิด ลงร่วมกับอาการ hemiballism ลดลงร่วมด้วยแม้จะ regional cerebrovascular insufficiency จนท�ำให้เกิด ปรากฏอาการอยู่บ้างแต่ก็ไม่รบกวนชีวิตประจ�ำวันของผู้ การลดลงของ cerebral blood flow8 ร่วมกับการมี neu- ป่วยเมื่อเปรียบเทียบกับครั้งแรก ronal dysfunction ที่เกิดตามหลังภาวะ hyperosmolar จากการทบทวนรายงานการศึกษาอื่นๆ พบว่าความ หรือ hyperglycemia การเพิ่มจ�ำนวนของ gemistocytes ผิดปกติจากการตรวจวินิจฉัยทางรังสีวิทยา ด้วย CT (a form of reactive astrocytes) ท�ำให้เกิดการสะสมของ brain จะพบลักษณะ abnormal hyperdensity ที่บริเวณ manganese ตามหลังการขาดเลือด (transient is- contralateral putamen โดยที่ในบางรายอาจพบความ chemia) การเกิด petechial hemorrhage การเกิดภาวะ ผิดปกติตรงส่วน caudate nucleus และ globus palli- hyperviscosity การลดการสังเคราะห์ของสารสื่อ dus ร่วมด้วย โดยไม่พบลักษณะ surrounding edema ประสาทชนิด gamma aminobutyric acid (GABA) และ หรือ mass effect ในบางรายสามารถพบรอยโรคทั้งสอง acetylcholine ที่เกิดจากการเปลี่ยนแปลงทางเมตาโบ ข้างได้ ในการตรวจติดตามด้วย imaging study ภายหลัง ลิก เป็นต้น มีหลายรายงานแสดงการลดลงของ blood การรักษากลุ่มอาการ HCHB จะพบว่าความผิดปกตินั้น flow ท�ำให้เกิดการเสื่อมสภาพของ GABAergic neurons ลดลง แต่ในบางราย imaging study อาจไม่พบความผิด ในบริเวณ putamen แล้วท�ำให้เกิดภาวะ hyperactiva- ปกติตั้งแต่แรกรับ15 การวินิจฉัยแยกโรคจากภาพทางรังสี tion ของ dopaminergic neurons9-11 แต่อย่างไรก็ดีกลไก อาจจะต้องแยกจากภาวะ hemorrhage, asymmetric ที่เกิดพยาธิสภาพจากผลของภาวะ hyperglycemia ส่วน calcification และ contrast extravasation กรณีที่เป็น ใหญ่สนับสนุนว่าท�ำให้เกิด petechial hemorrhage12 ซึ่ง stroke ที่มีประวัติได้รับ intra-arterial reperfusion15 ภาวะ hyperglycemia ไปท�ำลาย blood brain barrier ส�ำหรับความผิดปกติที่พบได้ใน MRI นั้น จะเห็นรอยโรค จนท�ำให้เกิด transient ischemia ใน striatal neurons ที่ putamen โดยที่อาจจะมีรอยโรคที่ caudate nucleus นอกจากนี้ในการทดลองยังพบว่า hyperglycemia ยังไป หรือ globus pallidus ร่วมด้วยหรือไม่ก็ได้ ในภาพ T1W กระตุ้นโปรตีนจ�ำนวนมากที่เกี่ยวข้องกับกระบวนการตาย จะพบรอยโรคเป็นลักษณะ T1 shortening หรือ hyper- ของเซลล์ (apoptosis)13 และพบว่าภาวะ insulin defi- intensity15,16 ส่วนในภาพ T2W ความผิดปกติที่พบนั้น ciency มีบทบาทร่วมที่ท�ำให้เกิด neuronal apoptosis variable โดยมากจะพบเป็น hypointensity แต่ก็ยัง จนท�ำให้เกิด primary diabetic encephalopathy ใน สามารถพบลักษณะ isointensity หรือ hyperintensity ที่สุด14 ได้เช่นกัน16 ในบางรายอาจพบลักษณะ restricted diffu- สาเหตุอื่น ๆ ที่ท�ำให้เกิดพยาธิสภาพ ได้แก่ ความ sion และ loss signal ในภาพ gradient-echo images15 ผิดปกติของหลอดเลือด การติดเชื้อ ความผิดปกติของ ความผิดปกติที่พบนั้นเป็นลักษณะที่ reversible แต่บาง สมดุลเกลือแร่ ผลข้างเคียงของยา เนื้องอกสมอง รวมถึง รายยังสามารถพบรอยโรคได้นานถึง 6 ปีหลังจากพบ โรคความเสื่อมทางระบบประสาทต่าง ๆ (neurodegen- ความผิดปกติ15 การวินิจฉัยแยกโรคนั้นต้องแยกจาก erative disorders) ในผู้ป่วยรายนี้พบว่าอาการแสดงทาง ภาวะอื่น ๆ ที่สามารถพบ hyper T1SI ที่ basal ganglia คลินิกของการเคลื่อนไหวที่พบเกิดจากสาเหตุของการมี เช่น chronic liver disease, manganese deposition, Vol.34 • NO.1 • 2018 33

neurofibromatosis type I, calcifications, hemorrhage, ไม่มีความรู้ในโรคเบาหวานมากพอที่จะแนะน�ำผู้ป่วยได้ tuberous sclerosis15,17 post–cardiac arrest enceph- แต่หลังจากอาจารย์แนะน�ำให้ไปศึกษาเพิ่มเติม ข้าพเจ้า alopathy, hypoglycemic coma, hypothyroidism, mild ได้เกิดความตระหนักถึงความส�ำคัญของการเรียนจาก focal ischemia or chronic changes due to hypoxia, ตัวผู้ป่วยและพบว่าการได้เริ่มเรียนรู้จากตัวผู้ป่วยนั้น Fahr disease หรือ abnormal calcium metabolism, ท�ำให้ข้าพเจ้าเกิดแรงบันดาลใจในการเรียนมากขึ้น โดย Wilson disease และ carbon monoxide poisoning16-18 เฉพาะท�ำให้อยากเรียนรู้ในเรื่องระบบประสาทและอยาก ส�ำหรับ pathogenesis ที่พบในภาพ imaging นั้นยังคง มีโอกาสในการพัฒนาความรู้ของตนเองอย่างต่อเนื่องไป controversy จากหลายทฤษฎี และหลายรายงาน เช่น ตามล�ำดับภายใต้ค�ำแนะน�ำของอาจารย์ focal hemorrhage, calcification, การพบ gliotic tissue ที่มี abundant gemistocytes, endothelial dysfunction เอกสารอ้างอิง และการเพิ่มขึ้นของ oxidative stress ใน ischemic 1. Heo YJ, Jeong HW. Hemichorea-hemiballism associated brain tissue ที่เกิดจากภาวะ hyperglycemia15 with hyperglycemia: a case report. J Korean Soc Radiol (หมายเหตุ ผู้ป่วยรายนี้ไม่ได้รับการตรวจ MRI brain เพิ่ม 2017;76:294-7. 2. Shalini S, Salmah W, Tharakan, et al. Diabetic non-ketot- เติม) ic hyperglycemia and the hemichorea-hemiballism syndrome: a report of four cases. Neurology Asia สรุป 2010;15:89-91. 3. Al Montasir A, Sadik MH. Hemichorea-hemiballism in a การซักประวัติผู้ป่วยที่มาด้วย abnormal move- nonketotic diabetic patient. J Fam Med Prim Care ment ควรสอบถามถึงระยะเวลาที่เกิดอาการ ต�ำแหน่ง 2013;2:296-7. ของร่างกายที่เกิดการเคลื่อนไหว ประวัติโรคประจ�ำตัว 4. Padmanabhan S, Zagami AS, Poynten AM. A case of การได้รับอุบัติเหตุบริเวณศรีษะ ครอบคลุมถึงการรักษา hemichorea-hemiballism due to nonketotic hyperglyce- mia. Diabetic Care 2013;36:e55-56. ที่ได้รับมาก่อน จากนั้นจึงท�ำการตรวจร่างกายทั่วไปและ 5. Hashimoto T, Hanyu N, Yahikozawa H, et al. Persistent ทางระบบประสาทอย่างละเอียดเพื่อที่จะท�ำให้สามารถ hemiballism with striatal hyperintensity in T1-weight MRI วางต�ำแหน่งของรอยโรคได้อย่างถูกต้องและส่งตรวจ in a diabetic patients: a 6 year follow-up study. J neural วินิจฉัยเพิ่มเติมตามข้อบ่งชี้ได้อย่างเหมาะสมต่อไป Sci 1999;165:178-81. 6. Jagota P, Bhidayasiri R, Lang AE. Movement disorders in patients with diabetes mellitus. J Neurol Sci 2012;314:5- ประเด็นที่นักศึกษาแพทย์ได้เรียนรู้จากกรณี 11. ศึกษาร่วมกับอาจารย์ 7. Cherian A, Thomas B, Baheti NN, et al. Concepts and controversies in nonketotic hyperglycemia-induced หลังจากได้รับอนุญาตจากอาจารย์ให้เข้าร่วม henichorea: further evidence from susceptibility-weight- สังเกตการณ์ในการตรวจผู้ป่วยในคลินิกระบบประสาท ed MR imaging. J Magn Reson Imaging 2009;29:699- ข้าพเจ้าได้พบเห็นผู้ป่วยมีอาการแขนขาซีกซ้ายกระตุก 703. 8. Cosentino F, Battista R, Scuteri A. Impact of fasting ผิดปกติที่เกิดจากภาวะแทรกซ้อนของนำ�้ ตาลในเลือดสูง glycemia and regional cerebral perfusion in diabetic ได้มีโอกาสสอบถามประวัติผู้ป่วยเกี่ยวกับอาการที่เกิดขึ้น subjects: a study with technetium-99m-ethyl cysteinate และผลกระทบต่อชีวิตประจ�ำวัน ข้าพเจ้ารู้สึกเกิดความ dimer single photon emission computed tomography. เห็นใจผู้ป่วยในความผิดปกติที่เกิดขึ้น แม้ว่าข้าพเจ้ายัง Stroke 2009;40:306-8. 9. Bizet J, Cooper CJ, Quansah R, et al. Chorea, hypergly- ไม่ได้เรียนเนื้อหาเกี่ยวกับ basic neurosciences ในชั้น cemia, basal ganglia syndrome in an uncontrolled dia- ปีที่ 1 เลยอาจจะยังเชื่อมโยงความรู้ไม่ได้มากนักและยัง betic patient with normal glucose levels on presentation. 34 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Am J Case Rep 2014;15:143-6. 10. Chu K, Kang DW, Kim DE, et al. Diffusion-weighted and gradient echo magnetic resonance findings of hemicho- rea- associated with diabetic hyperglyce- mia: a hyperviscosity syndrome?. Arch Neurol 2002;59:448-52. 11. Nagai C, Kato T, Katagiri T, et al. Hyperintense putamen on T1-weighted MR images in a case of chorea with hyperglycemia. AJNR Am J Neuroradiol 1995;16:1243-6. 12. Chang MH, Chiang HT, Lai PH, et al. Putaminal pete- chial haemorrhage as the cause of chorea: a neuroimag- ing study. J Neurol Neurosurg Psychiatry 1997; 63:300- 3. 13. Sharifi AM, Mousavi SH, Harhadi M, et al. Study of high glucose-induced apoptosis in Pcl2 cells:role of Bax protein. J of Pharmacological Sciences 2007;104:258-62. 14. Li ZG, Zhang W, Sima AA. The role of impaired insulin/ IGF action in primary diabetic encephalopathy. Brain Research 2005;1037:12-24. 15. Bathla G, Policeni B, Agarwal A. Neuroimaging in patients with abnormal blood glucose levels. AJNR Am J Neuro- radiol 2014;35:833-40. 16. Priola AM, Gned D, Veltri A, et al. Case 204: Nonketotic hyperglycemia-induced hemiballism-hemichorea. Radi- ology 2014;271:304-8. 17. Suárez-Vega VM, Sánchez Almaraz C, Bernardo AI, et al. CT and MR unilateral brain features secondary to nonketotic hyperglycemia presenting as hemichorea- hemiballism. Case Rep Radiol 2016;2016:5727138. 18. Lin JJ, Lin GY, Shih C. Presentation of striatal hyperin- tensity on T1-weighted MRI in patients with hemiballism- hemichorea caused by non-ketotic hyperglycemia: re- port of seven new cases and a review of literature. J Neurol 2001;248:750-5.

Vol.34 • NO.1 • 2018 35

บทคัดย่องานวิจัย แพทย์ประจ�ำบ้าน แพทย์ต่อยอดสาขาประสาทวิทยา ประจ�ำปีการศึกษา พ.ศ. 2558-2560 36 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Introduction: Periodic limb movements during sleep (PLMS) and obstructive sleep apnea (OSA) Prevalence of Periodic are the two common sleep disorders. Similarity in Limb Movements During periodicity of PLMS and OSA led us to hypothesize the existence of a common central generator re- Sleep and the Association sponsible for both OSA and PLMS. We aimed to with Obstructive Sleep investigate the association between PLMS and OSA Apnea from polysomnogram and the response from con- tinuous positive airway pressure (CPAP) treatment. Objectives: To identify 1) the prevalence of primary periodic limb movements during sleep, 2) the prevalence of secondary periodic limb move- Captain Juthamas Suwankanoknark ments during sleep and 3) the association between PLMS and OSA, and how much CPAP treatment Neurological Division, Department of Medicine, improves PLMS and other sleep parameters. Phramongkutklao Hospital, Bangkok, Thailand Materials and Methods: In this cross-sectional descriptive study, 88 subjects were enrolled at Phramongkutklao Hospital, Thailand in 2013-2017. Seventy-nine subjects out of 88 patients had both OSA and PLMS. Then, the association of PLMS and OSA were compared before and after continuous positive airway pressure treatment. Results: Prevalence of PLMS and OSA was 89.77% in 5-year polysomnogram collection. Pri- mary and secondary PLMS showed that mean age (63 versus 54.4 years old, p-value 0.011) and sleep efficiency (63 versus 76.1 %, p-value 0.004) were significantly different. No significant correlation was observed for BMI, arousal index and genders. Conclusion: Obstructive sleep apnea is a very common co-morbidity among the patients diag- nosed with periodic limb movement during sleep. The sleep parameters i.e. PLM index, and sleep efficiency after CPAP treatment were dramatically improved in most patients. Vol.34 • NO.1 • 2018 37

Objectives: Sodium oxybate is effective for treating patients with excessive daytime sleepiness Sunlight Therapy for (EDS) which occasionally presents as one of non- Excessive Daytime motor symptoms in Parkinson’s disease (PD). We investigated the effect of sunlight on EDS, which Sleepiness in Patients this intervention is safe and affordable, in modifying with Parkinson’s Disease the circadian rhythm in patients with PD. Materials and Methods: EDS in idiopathic Parkinson’s disease was diagnosed by Epworth sleepiness scale (ESS) of more than 10 points. The Patient Health Questionnaire-9 (PHQ-9) was scored to assess depression at week 0 and then the pa- Potchara Veerarattakul tients were advised to perform the outdoor morning sunlight exposure during 6.30–8.00A.M. (30 minutes daily) for 4 weeks. ESS and PHQ-9 then were re- Neurological Division, Department of Medicine, evaluated at week 4. The differences of ESS and Phramongkutklao Hospital, Bangkok, Thailand PHQ-9 before and after sunlight exposure were our primary and secondary outcomes of this study. Results: Eight patients were completed the study with good compliance. the sunlight therapy significantly reduced average ESS of 4.38 points with 95% confidence interval (CI)[1.59-7.16], p = 0.008 and also reduced PHQ-9 score with average improvement of 2.25 points with 95% CI[0.07–4.43], p = 0.045. There was no side effect reported during the study. Conclusion: Sunlight therapy improves exces- sive daytime sleepiness and depressive symptoms among patients with Parkinson’s disease. 38 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Background: Stroke symptoms noticed upon waking, wake-up ischemic stroke, account for up 3-Month Outcomes to a quarter of all acute ischemic stroke. Patients Comparison among with wake-up ischemic stroke, however, are often excluded from thrombolytic therapy due to stroke Wake-up and Non Wake-up onset time is unknown, and these patients revealed Ischemic Stroke in worse outcomes. Phramongkutklao Objectives: To investigate the 3-month favora- Hospital ble outcomes between wake-up and non wake-up ischemic stroke, as defined by modified Rankin scale 0-2 (mRS 0-2). Materials and Methods: A prospective cohort Porntip Koliyawongsakul study was conducted at Neurological division, Phra- mongkutklao Hospital. All patients of age group 18 years or more presenting with acute ischemic stroke Neurological Division, Department of Medicine, during August 2016 to May 2017 were enrolled. Phramongkutklao Hospital, Bangkok, Thailand Demographic data, clinical presentation, severity, treatment, and outcomes were collected. 3-month favorable outcomes (mRS 0-2) were compared between wake-up and non-wake up ischemic stroke by applying binary logistic regression analysis. Results: A total of 264 patients diagnosed with acute ischemic stroke were included, of which 100 (37.9%) were wake-up ischemic stroke. Wake-up stroke patients were at a significantly lower percent- age to receive thrombolytic therapy (6% vs. 14.6%, p-value=0.044). The 3-month favorable outcomes (mRS 0-2) were similar between wake-up and non wake-up ischemic stroke patients, however, wake- up ischemic stroke patients tend to have less 3-month favorable outcome (60% vs 65.2%, p-value 0.431). Conclusion: In this study, approximately 38% of ischemic were wake-up strokes. The 3-month favorable outcome of wake-up strokes were not significantly different from non-wake up strokes. Vol.34 • NO.1 • 2018 39

Objectives: To compare efficacy between low dose (0.6 mg/kg) and standard dose (0.9 mg/kg) A Study of Effectiveness of intravenous recombinant tissue-type plasmino- of Low Dose versus gen activator (rtPA) in acute ischemic stroke thera- py for a favorable outcome (mRS scores of 0 to 1) Standard Dose Intravenous at 3 months after treatment, and to compare safety Recombinant Tissue-Type outcome between those two doses. Plasminogen Activator in Methods: A retrospective cohort study was Acute Ischemic Stroke in conducted at Phramongkutklao Stroke Center, Phramongkutklao Hospital. Medical records of Phramongkutklao Hospital patients with acute ischemic stroke received intra- venous rtPA during January 2012 to January 2017 were reviewed. Patients who had other medical illness that could interfere with outcome assess- ments and follow-up were excluded. Demographic Ruamhathai Mahavinitchaimontri data, NIHSS score, final stroke subtypes at time of hospital discharge, time from stroke onset to rtPA Neurological Division, Department of Medicine, administration, intracerebral bleeding within 36 Phramongkutklao Hospital, Bangkok, Thailand hours after rtPA (hemorrhagic transformation), dura- tion of hospitalization and outcomes at 3 months after onset of stroke were collected. Results: Total of 116 patients were included in this study, 8 patients were excluded, 75 patients received standard dose rtPA of 0.9 mg/kg and 33 patients received low dose rtPAof 0.6 mg/kg. No significant difference in favorable outcome (mRS = 0-1) was found between two doses of rtPA therapy; 9 of 33 patients (27.3%) in the low-dose group and 35 of 75 patients (46.7%) in the standard-dose group (P = 0.09). No significant difference in intra- cerebral hemorrhage, 7 of 33 patients (21.2%) in Conclusion: In this study, there were no sig- the low-dose group and in 13 of 75 patients (17.6%) nificant differences in favorable outcome at 3 in the standard-dose group (P = 0.66). Moreover, months after onset of stroke, intracerebral bleeding median duration of hospitalization was, 9 days in after rtPA and median duration of hospitalization the low-dose group and 8 days in the standard-dose between reduced dose and standard dose of rtPA group (P = 0.23). treatment in acute ischemic stroke patients. 40 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Introduction: The information related to status epilepticus in Thailand is still limited both in terms Rates of Survival and of mortality causes, comorbidities or complications Causes of Long-Term that are associated with the mortality rates. Materials and Methods: This is a retrospective Mortality of Patients cohort study that collected data of all inpatients with Status Epilepticus in having status epilepticus – ICD-10, coded G41 Thailand (convulsive status epilepticus) – from the elec- tronic databases of the hospitals under the univer- sal health security system of the National Health Security Office (NHSO) from October 1, 2004 to September 30, 2015 (Fiscal years 2005-2015), in- Wuttikon Punprasit cluding the following-up period until November 13, 2016. Division of Neurology, Department of Medicine, Result: There were altogether 24,515 patients Faculty of Medicine, Srinagarind Hospital, Khon having status epilepticus, 9,043 being males Kaen University, Khon Kaen, Thailand (36.89%) with the average age of 35.33 years. The 3 mostly found complications were respiratory fail- ure (19.49%), (14.06%), and pneumonia (13.31%). The long-term mortality rate was at 34.61%. The 3 top causes of mortality were: CNS system (2102 cases, 26.58%), respira- tory system (1447 cases, 18.30%), other complica- tions (975 cases, 12.33%). The rate of mortality within 3 years was from 70.77 (95% CI; 70.18 - CI; 3.84 - 4.61), and 7.29 times (95% CI; 6.69 - 7.90), 71.34), whereas, within 6 years, the mortality rate respectively. The comorbidities and complications was 63.47 (95% CI; 62.80 - 64.13), the rate within affecting the rates of survival included: cancer (ex- 9 years was 58.44 (95% CI; 57.63 - 59.24), and cluding brain tumor) at a risk of 2.54 times (95% CI; within 12 years was 55.21 (95% CI; 54.08 - 56.32). 2.21 - 2.90), brain tumor at a risk of 2.19 times (95% The factors affecting the mortality rate were based CI; 1.80 - 2.66), and shock at a risk of 2.09 times on the referenced age group of 0 years and young- (95% CI; 1.90 - 2.31). er. It was found that the age groups of 11- 20 years, Conclusion: The top 3 causes of mortality were 21 – 30 years, 31-40 years, 41-50 years, 51-60 from CNS system, respiratory system, and others. years, and over 60 years showed the mortality risks The factors contributing to mortality were age at 1.74 times (95% CI; 1.54 - 1.95), 1.93 times (95% ranges, comorbidities, and complications (associ- CI; 1.73 - 2.15), 2.70 times (95% CI; 2.45 - 2.97), ated with the first 3 highest mortality rates: malig- 3.26 times (95% CI; 2.97 - 3.57), 4.21 times (95% nancy, brain tumor, and shock). Vol.34 • NO.1 • 2018 41

Objectives: To study the effect of factors on mortality rate of epileptic patients Risk Factors that Affect Methodology: Retrospective cohort study – on Mortality Rate of the history of all epileptic patients treated at the hospital (ICD-10 – code: G40) from the electronics Epileptic Patients in database of inpatients in the hospitals under the Thailand universal health insurance system of the National Health Security Office (NHSO) from October 1, 2004 until September 30, 2015 (Fiscal Year 2007-2015), with follow-ups until November 13, 2016. Results :From the total number of epileptic patients that passed the criteria, i.e., 171,440 per- Apisit Thongngam sons; 37,441 cases died (21.84%). Mortality causes of 33,479 cases could be pronounced – an inci- dence of 3.99 per 100 patients per year (95% CI Division of Neurology, Department of Medicine, 3.95 to 4.03). The rate of survival in one year was Faculty of Medicine, Srinagarind Hospital, Khon 92.48 (95% CI 92.36 to 92.61). The first cause of Kaen University, Khon Kaen, Thailand mortality was from respiratory diseases (16.58%), while the second was from neurological complica- tions (12.86%) and other causes such as no evi- dence, aging-related diseases (12.11%). The greatest factor leading to death among epileptic patients is cancer (excluding brain tumor), which risks mortality at 3.92 folds (95% CI 3.61 to 4.26). The second greatest cause is brain neoplasm, with mortality risk at 2.15 folds (95% CI 1.93 to 2.40). Underlying diseases that significantly lead to death include chronic kidney disease - with the mortality risk at 1.78 times (95% CI 1.69 to 1.89), stroke - with the mortality risk at 1.52 times (95% CI 1.48 to 1.57), and diabetes mellitus – with the mortality risk at 1.24 times (95% CI 1.20 to 1.29). Conclusion: The factors affecting mortality rate of epileptic patients include those unpreventable and treatable. Thus, the doctors have to treat these risk factors in order to increase the survival rate of patients with epilepsy. 42 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Introduction: Cytomegalovirus (CMV) is a ubiq- uitous virus in in the human population especially Cytomegalovirus immunocompromised host. Clinical manifestations and Neurological of CMV disease of the nervous system accounts for less than 1% of CMV disease, CMV encephalitis Manifestations: result in a mortality rate of approximately 100% Retrospective Review of There was no randomized controlled trial for 52 Patients in King treatment for CMV infection of nervous system dis- Chulalongkorn Memorial ease. Objectives: The main purpose of this study is Hospital to review about epidemiological data, clinical pres- entation, imaging finding, CSF profiles, treatment Panupong Petchoo and outcome in patients who had CMV infection of neurological system at KCMH. Division of Neurology, Department of Medicine, Materials and Methods: This single center, Faculty of Medicine, Chulalongkorn University retrospective, cross-sectional study was conducted and King Chulalongkorn Memorial Hospital, at KCMH. Study population include all adults over Bangkok, Thailand the age of fifteen who had been diagnosed with CMV disease of the nervous system and was admit- ted to KCMH during year 2002-2016. Results: We reviewed 52 cases with CMV disease of the nervous system, 90.4% were found to have HIV infection. Most common neurological manifestations were polyradiculitis. 10 patients (19.2%) received acyclovir and 31 patients (59.6%) received ganciclo- vir. We found no significant correlated in clinical out- come between acyclovir and ganciclovir groups. Pa- tients received acyclovir group were tended to advance aged (P=0.046), immunocompromised status (P=0.04), manifest with prodromic symptoms (P<0.05) and meningoencephalitis (P=0.02). Conclusion: CMV with neurological involve- ment are uncommon and underdiagnosed. Most common syndrome of CMV nervous system infec- tion was polyradiculitis. Acyclovir may be an alterna- tive antiviral drug for patient with less expense, patients who had side effect from ganciclovir. Vol.34 • NO.1 • 2018 43

Objectives: Cognitive impairment is an impor- tant cause of morbidity in post ischemic stroke Predictive Factors of Post patients. Previous studies still had differences in Ischemic Stroke Cognitive predictive factors. Due to the lack of these data in Thailand, we determine to find the predictive factors Impairment in King of post ischemic stroke cognitive impairment in Chulalongkorn Memorial Thailand. Hospital Materials and Methods: We conducted the analytic retrospective cross-sectional study with a total of 100 ischemic stroke patients between 1 Jan 2016 and 30 Oct 2017. The cognitive status was evaluated at 3 months post stroke event using Wongpitak Theppornpitak MoCA and the cut-point for defined cognitive impair- ment was below 22. Demographic data, vascular risk factors, stroke characteristic and radiologic Division of Neurology, Department of Medicine, findings were collected. The logistic regression Faculty of Medicine, Chulalongkorn University analysis was used to find the correlation between and King Chulalongkorn Memorial Hospital, these data and post ischemic stroke cognitive im- Bangkok, Thailand pairments. Results: Age, previous stroke, leukoariarosis at periventricular and deep white matter, and MTA score were shown to have correlation by univariate analysis (P value < 0.05). With multivariate analysis, only age, previous stroke and high grading score of leukoariarosis at periventricular white matter were shown to have correlation with post ischemic stroke cognitive impairment (P value < 0.05). Conclusion: Elderly age, previous stroke and high grading score of leukoariarosis at periventricu- lar white matter were defined to be the predictive factors in our study. 44 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Introduction: Correlation of quantitative meas- urement of Wallerian degeneration (WD) in corti- Wallerian Degeneration cospinal tract (CST) following acute ischemic stroke in Acute to Subacute and its clinical significance have not been well un- derstood. Ischemic Stroke Objective: We evaluated the DTI measure in- Demonstrate by Diffusion dex; fractional anisotropy (FA), mean diffusivity Tensor Imaging (MD), radial diffusivity (RD) and axial diffusivity (AD) by using diffusion tensor imaging (DTI) to assess early WD of the CST and correlation of motor deficits in patients with acute supratentorial ischemic stroke. Materials and Methods: 9 stroke patients with Wasunon Tinroongroj lesion in the supratentorial corticospinal tract were recruited. At 2 time point; admission to 3-day (T1) Division of Neurology, Department of Medicine, and 30-day after stroke onset (T2), We assessed the severity of limb weakness and ataxia by Fugl- Faculty of Medicine, Chulalongkorn University Meyer Assessment (FMA) and performed mag- and King Chulalongkorn Memorial Hospital, Bangkok, Thailand netic resonance imaging (MRI). We used Region of interests (ROI) analysis to detect the changes of diffusion indices in the cerebral peduncles on the affected and unaffected side. Difference was com- pared by paired t-test analysis. The correlation between DTI measure index in the cerebral pedun- cle at T1 and FMA at 30-day was conducted by Spearman correlation method in order to predict the prognosis. Results: We found significant strong correlation between FA at admission to 3-days and total FMA (r = 0.773, p = 0. 015) and upper extremities FMA (r = 0.740, p = 0.023) at 30-days Conclusions: The early change of FA within the cerebral peduncle may potentially predict the clinical outcome. Vol.34 • NO.1 • 2018 45

Objectives: To compare the frequent of Head turning sign (HTS) in Alzheimer’s disease (AD) and The Frequent of (VaD) and determine the asso- Head Turning Sign in ciation between the frequent of HTS and cognitive speed and amount of brain ischemic lesions in Alzheimer’s Disease magnetic resonance imaging (MRI). Patients Compared to Materials and Methods: A cross sectional Vascular Dementia study was conducted period from January 2017 to January 2018 at King Chulalongkorn Memorial Hospital. Included patients who were diagnosed as AD and VaD. All patients had MRI of the brain per- formed for diagnosis. Those were diagnosed as Jutatip Rattanaphan mixed dementia or has the illness, that can cause not be communicated were excluded. Carefully, observed HTS during interview a short cognitive Division of Neurology, Department of Medicine, test. We take the video during interview in order to Faculty of Medicine, Chulalongkorn University review the HTS. Cognitive speed and Amount of and King Chulalongkorn Memorial Hospital, brain ischemic lesion were recorded. Bangkok, Thailand Results: There were 22 patients including 11 AD and 11 VaD. Primary outcome showed the fre- quent of HTS was more significant in AD group than VaD group, p-value < 0.05 (95% CI of the difference 2.12-4.42). Secondary outcomes were shown the frequent of HTS were correlated to cognitive speed, p-value 0.025 but not correlation to amount of brain ischemic lesions, p-value 0.25. Conclusion: In this study, the frequent of HTS in AD more than VaD, significantly and correlated to cognitive speed. Therefore, the frequent of HTS may be one of the distinguish clinical signs of AD. 46 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Purpose: Given paucity of evidence of specific EEG findings to help early diagnose of immune- Predictive Values and mediated encephalitis, this study aimed to ascertain Specificity of the EEG specific EEG findings associated with this condition. Material and Methods: We included all cases Findings in a Diagnosis with immune-mediated encephalitis at King Chula- of Immune-Mediated longkorn Memorial Hospital during 2013 to 2017. Encephalitis Cases were matched with controls by age and level of consciousness on a ratio of 1:2. Controls were patients with other conditions selected from our EEG database. Baseline characteristics which were potential confounders for EEG findings were Chayaporn Denlertchaikul compared. Two epileptologists independently re- viewed EEGs and both were blind from knowing clinical diagnosis of cases and controls. Standard- Division of Neurology, Department of Medicine, ized terminology, definitions, and scoring system of Faculty of Medicine, Chulalongkorn University the EEG findings were employed. Univariate and and King Chulalongkorn Memorial Hospital, subsequent multivariate logistic regression analysis Bangkok, Thailand were performed to find significant specific EEG features. Diagnostic performance of these features were assessed. Results: Twenty cases and 40 controls were included. Among cases, 9 and 11 patients had autoimmune and paraneoplastic encephalitides, respectively. Most baseline characteristics were comparable. Only poorly sustained posterior dominant rhythm (PDR) was significantly associated with immune-mediated encephalitis (p = 0.007). Poorly sustained PDR was even more predictive in anti- NMDA encephalitis. Inter-rater agreement Conclusions: At least, patients with immune- (kappa) was 0.714. We found that none of cases mediated encephalitis should show some EEG had normal EEG nor Grand Total EEG (GTE) score abnormalities particularly poorly sustained PDR. < 4 (negative predictive value (NPV) of 100%). The NPV of GTE < 4 and specificity of good sus- Specificity of the good sustained PDR to exclude tained PDR can be used to differentiate many the diagnosis of anti-NMDA encephalitis was quite conditions from immune-mediated encephalitis. high up to 91.67%. Vol.34 • NO.1 • 2018 47

Objectives: To compare clinical characteris- tics, laboratory results, radiologic findings, and VZV Infection of the outcome between HIV infected individuals and Nervous System: non-HIV infected individuals who presented with nervous system manifestations related to VZV at Differences in HIV vs King Chulalongkorn Memorial Hospital, Bangkok, Non-HIV Patients Thailand. Materials and Methods: Retrospective review of medical records of all adults over the age of fif- teen that had been admitted to KCMH during the year 2002-2014 with diagnosis of nervous system manifestations related to VZV infection. Anthipa Busagornruangrat Results: Thirty-seven patients with nervous system manifestations related to VZV infection were identified, twenty cases (54.1%) had HIV infection. Division of Neurology, Department of medicine, CD4 level was 200 or less in thirteen patients (65%). Faculty of Medicine, Chulalongkorn University History of previous episode of zoster rash, reported and King Chulalongkorn Memorial Hospital, in six patients, was present exclusively in HIV-in- Bangkok, Thailand fected individuals. Absence of herpes zoster rash was noted in 35% of all patients, same proportions were observed in both HIV and non-HIV groups. Five CNS presentations were observed: meningitis (27%), encephalitis/ (45.9%), myelitis and/or radiculitis (21.6%), VZV vasculopa- thy (8.1%), and cranial nerve palsy (5.4%). HIV- infected individuals are more likely to present with myelitis and/or radiculitis, while encephalitis/menin- goencephalitis was more prevalent in non-HIV group. There was no difference in outcome be- tween HIV and non-HIV group, but worse outcomes were observed in patients who presented with myelitis and/or radiculitis and encephalitis/menin- goencephalitis. Conclusion: Atypical presentations, as well demonstrated that history of previous episode of as, coinfections with other opportunistic infections, zoster rashes and involvement were may occur in immunocompromised individuals, unique to the HIV-infected individuals. especially HIV-infected individuals. Our study 48 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Introduction: Headache is a symptom that the patient can see a physician often in practice. The The Study of Headache incidence of headache in a period of 1 year in the general population reported at 46%. can Diagnosis and Clinical be divided into three types according to the Interna- tional Classification for Headache Disorders-III ver- Patterns in Chiang Mai sion: primary headache disorders, secondary head- Headache Clinic using ache disorders and cranial neuralgia and facial pain. In many institute, the Headache Clinic is estab- Electronic Headache lished to provide special care for headache patients. In Europe, the awareness of headaches treatment Record through the European Headache Federation (EHF) and Lifting the Burden project has been established and suggested the different levels of setting up a headache clinic that classified into level 1 (Headache primary care), level 2 (Headache clinic) and level 3 Surat Tassanasorn (Academic headache center). The headache clinic at Chiang Mai University was established and organized the headache patients Division of Neurology, Department of Internal registration since 2006. In 2016, we generated the Medicine, Faculty of Medicine, Chiang Mai Electronic He adache Record (EHR), the program for University, Thailand headache registration and follow-up, and used as a tool for collecting the data with accurate and standard data record. Our aim of the study is to evaluate the headache patients profile, impact, treatment using Electronic Headache Record. Objectives: To study the types and clinical char- acteristics of patients suffering from headache treated cases, 25.18%), other type of migraine (17 cases, in Chiang Mai Headache Clinic using Electronic 12.23%) and chronic migraine 16 cases (11.51%). Headache Record (EHR). Mean frequency of headache, severity measured by Materials and Methods: We searched the head- HIT-6 scale and psychiatric problems in chronic mi- ache data registered in Chiang Mai Headache Clinic graine were significantly higher than episodic migraine during January 2017 to January 2018 from Electronic (25.31±4.64 vs 5.40±1.11; P < 0.001, (59.25±8.36 vs Headache Record program. The data of the types and 51.50±7.25; P < 0.05, 62.5% vs 1.63%) respectively. clinical characteristics of those eligible patients were About half of chronic migraine had MOH when com- reviewed and collected via the EHR. The demo- paring with only 3.25% in episodic migraine. MOH graphic data included age, gender, education, head- patients contributed from NSAID 22.2%, Eletriptan ache classification (by ICHD-III Beta criteria), disabil- 22.2%, Ergotamine 22.2% and Eletriptan combined ity, and treatment were analysed. with Ergotamin 33.3%. NSAIDs and Triptan were the Results: One hundred and eighty one headache most commonly used in acute migraine medication. cases were included. Primary headache disorder was Topiramate prescription were significantly higher than the most common (87.29%) following by cranial neu- other preventive drugs. ralgia and facial pain (7.73%) and secondary head- Conclusion: At our specialist headache clinic, ache disorder (2.21%). Migraine was the most com- high percentage of migraine and chronic form of mi- mon in primary headache (76.80%) and female was graine out of proportion than other headache type. predominant. Subtype of migraine is migraine without This could rise awareness of chronic migraine and aura (71 cases, 51.08%); migraine with aura (35 generate the special care model. Vol.34 • NO.1 • 2018 49

Introduction: Migraine is the most common headache disorder, contributing to disability and The Retrospective Study large healthcare costs in the world. In chronic mi- to Evaluate Migraine graine, the quality of life are more significantly lower than episodic migraine. Pharmacologic man- Treatment by Botulinum agement has been used for acute and preventive Toxin A Injection and therapy. In addition, the procedures for migraine Greater Occipital Nerve treatment such as botulinum toxin A (BONT-A) injec- Blockade in Headache tion, greater occipital nerve blockade (GONB) has been used to maximize therapeutic propose. Clinic, Northern Objectives: To evaluated the technique and Neuroscience Centre, efficacy of botulinum toxin A (BONT-A) injection, Chiang Mai University and greater occipital nerve blockade (GONB) in migraine treatment. Impact on Headache Impact Test (HIT-6 score), and visual analog scale (VAS). Tittaya Prasertpan Materials and Methods: Retrospective chart review of migraine patients (Age ≥ 15 year) treated Division of Neurology, Department of Internal with BONT-A injection and GONB in Headache Medicine, Faculty of Medicine, Chiang Mai clinic, Northern Neuroscience Centre, Chiang Mai University, Thailand University. During the inclusion period (January 2010 - December 2017). Results: A total 26 patients were treated by BONT-A injection, and 17 patients were treated by GONB. In BONT-A group, the mean HIT-6 score at one month after procedure was significantly dimin- ished compared to baseline (65.14 7.10 ± vs 58.86 11.23 ±, p = 0.038). The result was also similar at three months compared to baseline (64.56 8.09 ± vs 58.89 9.79 ±, p = 0.034). In GONB group, we found significantly diminished on the mean change of HIT-6 scores from baseline to one month after procedure but no statistical significant (p = 0.059). The mean VAS was significantly diminished (6.83 ± 1.27 vs 2.92 2.50 ±, P < 0.001) at 10 minutes after those patients who received BONT-A injection procedure. showed significantly reduced HIT-6 scores and who Conclusion: Both BONT-A injection and GONB received GONB showed significantly reduced VAS are safe and effective in migraine treatment. Among in acute migraine attack. 50 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Objective: To compare adverse pregnancy outcomes between pregnancies with epilepsy and Obstetric Outcomes in normal pregnancies Women with Epilepsy at Methods: A retrospective cohort study was carried out by accessing the MFM (maternal-fetal Maharaj Nakorn Chiang medicine) database during 1st January 2007-31th Mai Hospital: A December 2016 to identify records of singleton Retrospective Cohort pregnancies with epilepsy and no other underlying Study disease (Study group) and then their medical re- cords were reviewed. The low risk pregnancies were randomly allocated as the Control group. The adverse outcomes were compared between the two Tararak Choovanichvong groups. The primary outcomes included rates of abortion, fetal growth restriction, preterm birth, pregnancy-induced hypertension (PIH), post-par- Division of Neurology, Department of Internal tum hemorrhage (PPH), and Cesarean section. Medicine, Faculty of Medicine, Chiang Mai University, Thailand Results: There were 232 pregnancies, 58 pregnancies with epilepsy and 174 normal controls were compared. The rate of PPH was significantly higher in the study group with a relative risk of 7.5 (95% CI: 1.5-37.6). In subgroup analysis, activity of epilepsy and AED use had no increased risk of any pregnancy complications. Conclusions: Pregnancies with epilepsy, even in cases of multidisciplinary care and no other risk factors, are still significantly associated with higher adverse outcomes. Vol.34 • NO.1 • 2018 51

Introduction: Oral medication has modest ef- ficacy in relieving painful diabetic neuropathy 0.075% Capsaicin Lotion (PDN). Topical medication has been tested with for the Treatment of same success. We tested 0.075% capsaicin lotion, a vanilloid 1 receptor agonist, for treatment of PDN. Painful Diabetic Objectives: To test the efficacy and safety of Neuropathy: A 0.075%capsaicin lotion for painful diabetic neu- Randomized, ropathy Double-Blind, Crossover, Materials and Methods: We conducted a 20- week, double-blinded, crossover, randomized, Placebo-Controlled Trial two-center study trial in subjects with PDN. We randomly assigned patients to receive 0.075% Assawin Chomjit capsaicin or placebo for 8 weeks, with a washout period of 4 weeks between the two treatments. Primary endpoint was measure of change in visual Division of Neurology, Department of Internal analog scale (0-100 mm) of pain severity. Second- Medicine, Thammasat University, Thailand ary outcomes were score change in Neuropathic Pain Scale (NPS), short-form McGill Pain Question- naires (SF-MPQ), proportion of patients who had pain score reductions of 30% and 50% and adverse events. Results: A total of 42 subjects were enrolled, 35 completed at least an 8-week treatment period. Intention-to-treat analysis showed no significant improvement in pain control with capsaicin lotion, compared with placebo for visual analog scale (VAS) score at 34.3 mm vs. 36.3 mm (P = 0.725). No significant difference between groups was found in NPS at 27.23 vs 25.13 mm (P = 0.595), SF-MPQ at 9.07 vs. 9.72 mm (P = 0.775) and proportion of patients who had 30% or 50% pain relief. Per Pro- tocol analysis also similar results in pain for all measured outcomes. Capsaicin lotion was well tolerated. Its major side effect is skin reaction, with- out serious adverse events. Conclusion: In patients with PDN, 0.075% relief, when compared to placebo. However, it is capsaicin lotion does not provide significant pain safe with minor skin reaction. 52 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Introduction: Nerve conduction study (NCS) is the important diagnostic tool in Guillain- Barré syn- Single vs Serial Nerve drome (GBS). Misclassification often occurs in Conduction Study in early course of the disease. Timing and selection of the nerves are crucial. Guillain-Barré Syndrome Objectives: The aim of this study is to describe NCS results and their serial changes in specific nerves and related parameters. Materials and Methods: Retrospective review of medical records of GBS patients, who were at least 15 years old, visited to Thammasat University Hospital and Bangkok Hospital Medical Center in Yuwadee Thongchuam Thailand between 1st January 2009 to 31st October 2017. Every patient had at least one NCS at the time of diagnosis and confirmed by the neuromuscular Division of Neurology, Department of Internal specialist or treating neurologist. Medicine, Thammasat University, Thailand Results: 44 patients were recruited, 23 of these were female. The mean age was 49.2 years old. Most patients are Asian (59.1%). Previous infection mainly were upper respiratory tract and GI infection. Clinical diagnostic subtype were AIDP (63.6%), AMAN (15.9%), MFS (11%) and others (9.1%). Comparing demyelinating criteria sets revealed that Albers’ criteria was the highest (98%) but Cornb- lath’s criteria was the lowest (53%) sensitivity. Ho’s (94%) and Hadden’s (91%) criteria provided similar results. Regarding initial NCS, demyelinating pat- ing pattern was also common (80%) in AIDP. tern was found in 64%, mixed pattern in 14% and Conclusion: AIDP is the most common subtype the rest was equivocal. Second NCS was performed of GBS in our study. Albers’ criteria is the most in 20 patients and the classification was changed sensitive criteria but Cornblath’s criteria is the low- in 2 patients (10%) from demyelinating to axonal est. The serial NCS demonstrates subtype change subtypes. Demyelinating pattern was more preva- in 10% of patients, from demyelinating to axonal lent in lower limbs (tibial and peroneal nerves) which pattern. were most defined by slow conduction velocity (CV) Tibial and peroneal nerves were most fre- and conduction block. While in upper limb, median quently affected. Appropriate selection of the stud- nerve was the most affected, based on CV, distal ied nerves, classification criteria and serial NCS are motor latency and temporal dispersion. Sural spar- important to identify accurate GBS subtypes. Vol.34 • NO.1 • 2018 53

Objectives: Restless legs syndrome (RLS) is a sleep-related neurological disorder that causes sleep Restless Legs Syndrome disturbances and affects the quality of sleep. Preg- in Pregnant Thai Women: nancy-related RLS has been proposed, but the natu- ral history has not been cleared.This study was aimed Prevalence, Natural to estimate the prevalence, natural history, and as- History, and Risk Factors sociated factors of RLS in pregnant Thai women. Materials and Methods: A cross-sectional study included 214 pregnant Thai women who attended Thammasat university hospital delivery unit was performed. The diagnosis of RLS was made accord- ing to the revised criteria of the International RLS Supakorn Panvatvanich Study Group (IRLSSG). General demographic data and antenatal care were reviewed. Epworth sleepi- Division of Neurology, Department of Internal ness scale, Pittsburgh sleep quality index, and rest- Medicine, Thammasat University, Thailand less legs syndrome rating scale were determined. Results: A total of 24 pregnant women (11.2 %) were diagnosed with RLS; 4.2% of those re- ported the symptoms in the first trimester, 25% in the second trimester, and 70.8% in the third trimes- ter. Multivariate analysis revealed that anemia was associated with RLS (p< 0.01). Anemia was a risk of developing RLS during pregnancy (OR, 5.44; 95 % CI, 2.02–14.65). Subjects with RLS significantly had higher ESS score (p< 0.01). All subjects with RLS had severe symptom severity according to the IRLSS, and the symptoms subsided within a week after delivery. There was no immediate labor and newborn complications associated with RLS. Conclusions: Our study confirmed a high prevalence of RLS and its negative impacts on sleep in pregnant Thai women. Anemia was a risk factor of RLS during pregnancy. Furthermore, RLS is commonly found and more pronounced in the second to third trimesters of pregnancy and disap- pear within a few days after delivery. 54 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Introduction: Ischemic stroke is an important public health problem in Thailand. One of standard Door to Needle Time and treatment is giving intravenous thrombolytic drug Its Delayed Factors of under stroke fast track system to ischemic stroke patients who came to hospital within 4.5 hrs. In Intravenous Thrombolytic 2013, American stroke association raised topics Treatment in Stroke Fast about door to needle time and door to CT/labs in- Track System Rajavithi terpretation. Door to needle time < 60 minutes (in Hospital 80% of all cases) and door to CT/labs interpretation <45 mins were recommended in this guideline. This study was established for helping us improving these time parameters in our hospital to be standard Phattarawin Ekkachon as guideline. Objective: Collected data of door to needle times, Door to CT/labs interpretation and study delayed fac- Division of Neurology, Department of Medicine, tors of these parameters in Rajavithi hospital. Rajavithi Hospital Material and Methods: Door to needle time, door to CT/labs interpretation were recorded from ischemic stroke patients who received intravenous thrombolytic drugs since 1/1/2557-30/11/2560 Results: 39 patients were recorded data in 2557-2560; mean door to CT interpretation were 28, 17, 28, 24 minutes (4 years data sequent from 2557 to 2560). Mean doors to labs interpretation (CBC) were 35, 26, 32, 28 minutes. Mean doors to labs interpretation (coaulogram) were 52, 49, 50, 39 minutes. Mean doors to labs interpretation (blood chemistry) were 50, 41, 47, 42 minutes. Mean door to needle times were 113, 90, 87, 74 minutes. Conclusion: None from 2557-2560 mean door to needle times passed recommend goal (<60 minutes). 21% were passed goal setting (80%rec- ommend) in 2560. However, trending was improved. Mean door to needle times were decreased year by year from 2557-2560. Strategies for improving these parameters will create for the highest benefits of our patients. Vol.34 • NO.1 • 2018 55

Introduction:Atrial fibrillation(AF) is the most common arrhythmias can increase risk of embolic Optimal International stroke.Warfarin is use to prevent embolic stroke. Normalized Ratio Level Warfarin affected to coagulation system including prolong Prothrombin Time and International Normal- in Thai Non Valvular ized Ratio(INR). However,complications from war- Atrial Fibrillation farin were bleeding disorders. Thailand non valvular Patients Who were AF recommended at INR level 2.0-3.0. Although INR Receiving Warfarin in level 2.0-3.0,it was found embolic stroke and major hemorrhagic events. Rajavithi Hospital Objective: To report optimal INR level and study factors affected occurrence of these events. Visit Leelaswattanakij Materials and Methods: Retrospective study enrolled non valvular AF patients that received warfarin in Rajavithi hospital between October 1st, Division of Neurology, Department of Medicine, 2012 to April 30th, 2017 and collected INR level at Rajavithi Hospital the time of events.Optimal INR level was defined as lowest incidence of embolic stroke and major hem- orrhagic events and study factors affected occur- rence of these events. Results: 555 non valvular AF patients were enrolled.Mean age was 68.67 ± 13.08 years and 50.8% of patients were female. Hypertension was the most common comorbidities(76%).After study,there were 10 patients of embolic stroke and 20 patients of major hemorrhagic events.INR level lower than 1.58 increased risk of embolic stroke (p = 0.001),while INR level more than 2.58 increased risk of major hemorrhagic events (p < 0.001). Study showed no other factors (such as age,gender,smo king,comorbidities) affected occurrence of these events. Conclusion: INR level 1.58 to 2.58 had lowest incidence of embolic stroke and major hemor- rhagic events, and no other factors affected occur- rence of these events. 56 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Introduction: Sleep disturbances and primary headache disorders share anatomical and physi- The Effect of Sleep ological basis, and sleep problems are associated Disturbances on Primary with primary headache. However, no study has in- vestigated the association of poor sleep quality and Headache in the Rangsit primary headache among medical students in University Medical Thailand. Therefore, a questionnaire-based study Students on headache profiles and sleep conditions in medical students was conducted. Objective: To evaluate the quality of sleep and the relationship between poor sleep quality on pri- mary headache in medical students in Thailand. Khwanjai Komhoong Materials and Methods: A cross-sectional questionnaire-based study was done in 99 medical students from Rajavithi Hospital, Bangkok, Thailand. Division of Neurology, Department of Medicine, The data were obtained through self-completed Rajavithi Hospital questionnaires. The sleep quality was assessed with the Pittsburgh Sleep Quality Index and the diagno- sis of primary headache was based on the Interna- tional Classification of Headache Disorder 3rd edition (beta version). Results: In 99 medical students, 64.6% were female, mean age were 23.06±1.60 years old. 30.5%, 37.9%, and 31.6% of the medical students were in 4th, 5th and 6th year, respectively. 35.1% of them were working on night shifts, 58.6% of them used caffeine and 21.1% did exercise. 54.5% of them had poor sleep quality. Higher year of study and caffeine use were significantly associated with poor sleep quality (p-value 0.043 and 0.028, re- spectively). The association between exercise and primary headache was significant (p-value 0.046). The association between poor sleep quality and primary headache was not statistically significant. Conclusion: From this study, the sleep disturbanc- Exercises were associated with primary headaches. es in medical students were more often in higher However, we did not find the association between year of study and also related to caffeine use. sleep disturbances and primary headache. Vol.34 • NO.1 • 2018 57

Introduction: Stroke has emerged as a compli- cation of thoracic endovascular aortic repair (TE- Incidence and Risk VAR) and endovascular aortic repair (EVAR). Iden- Factors of Perioperative tifying risk factors for TEVAR and EVAR–related stroke is important to minimize the periprocedural Stroke in Thoracic stroke. Endovascular Aortic Objective: To investigate the risk factors of Repair (TEVAR) and perioperative stroke in Thoracic endovascular aor- Endovascular Aneurysm tic repair (TEVAR) and Endovascular aortic repair (EVAR) operations. Repair (EVAR) in Methods: This retrospective study enrolled all Songklanagarind Hospital patients underwent TEVAR and EVAR operations from January 2008 to June 2015. Patients’ demo- graphic data and clinical characteristics during pre-, intra-, and post- operative periods were ana- Jirayoot Chusooth lyzed by descriptive statistics to identify factors associated with perioperative stroke. Independent Division of Neurology, Department of Medicine, risks for were further determined by multivariate Faculty of Medicine, Prince of Songkla University analysis. Results: There were 774 patients included. Perioperative stroke occurred in 17 cases (2.2%). Nine patients (53%) had strokes within 24 hours post operation. The overall in-hospital mortality rate was 29%. Independent risk factors of perioperative stroke were previous stroke or TIA (OR 9.19; 95%CI 1.56-54.19, p = 0.014), abnormal radiological find- ings of aorta (OR 15.05; 95%CI 2.54-89.22, p = 0.003), prolong operation time more than 390 min- utes (OR 13.9; 95%CI 2.67-72.28, p < 0.001), oc- currence of intraoperative hypotension more than 4 times (OR 11.98; 95%CI 2.69-53.31, p = 0.001), average duration of hypotension more than 10 Conclusion: Though stroke complicated with minutes (OR 26.09; 95%CI 5.07-134.14, p < 0.001), TEVAR and EVAR is uncommon, it is associated with blood loss more than 600 mL (OR 13.9; 95%CI a high mortality. The recognition of the perioperative (2.67-72.28), p = 0.002), and post-operative hyper- stroke risks will facilitate early prevention of the risks glycemia (OR 9.6; 95%CI (1.8-51.19), p = 0.008). properly. 58 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Introduction: Acute ischemic stroke (AIS) is the most common neurological disorder causing neu- The Predictive Risk rological disability. Intravenous recombinant tissue- Score of Intracerebral type plasminogen activator (IV rt-PA), an approved treatment of AIS by the FDA, is found to signifi- Hemorrhage in Acute cantly increase the risk of intracerebral hemorrhage Ischemic Stroke Patients (ICH). This retrospective study is aimed to find the Receiving Intravenous predictive score of ICH after IV rt-PA. Recombinant Tissue Methods: Patients with AIS who were adminis- tered IV rt-PA in Songklanagarind Hospital during Plasminogen Activator January, 2010 to June 2017 were eligible. The (IV rt-PA) : predictive risk scores were analyzed by multivari- A Retrospective Study ated logistic regression and generated receiver operating characteristic curve (ROC curve). Results: After univariate analysis, significant predictors of ICH occurrence after IV rt-PA in- Inthiporn Maethasith cluded National Institute of Health Stroke Score (NIHSS) at arrival, systolic blood pressure before Division of Neurology, Department of Medicine, given rt-PA, history of old cerebrovascular disease Faculty of Medicine, Prince of Songkla University (CVA), the history of atrial fibrillation and platelet count (p value <0.05). Four independent factors found including NIHSS at arrival, systolic blood pressure (SBP), history of old CVA and platelet count were used to calculate the predictive risk score. The predictive risk scores were [2x(SBP)] +[9x(NIHSS)] +[174x(old CVA)]. The AUC of a ROC curve of the sum of predictive risk score was 0.71. The cutoff score was >370, the sensitivity and specificity were 0.84 and 0.30, respectively. Conclusion: The predictive risk score of ICH after thrombolysis is an easily practical tool to fa- cilitate clinical decision and consider an intensive monitoring program in high-risk AIS patients after receiving IV rt-PA. Vol.34 • NO.1 • 2018 59

Objectives: Migraine is the seventh leading cause of disability worldwide and affects roughly The Prevalence and Risk 12% of the adults in western countries. Prevalence Factors of Migraine in of migraine in Bangkok especially in the same work- place is unknown. Migraine has many trigger fac- Bangkok Metropolitan tors. Knowing triggers will be helpful in preventing Administration (BMA) migraine attack. Officers Methods: This study was a descriptive cross- sectional study. The data was collected by ques- tionnaires replying from Bangkok Metropolitan Administration (BMA) officers in the same workplace on December 2017. Migraine was diagnosed ac- Pattarawut Ruengwanich cording to the criteria of third edition of the Interna- tional Classification of Headache Disorders. Division of Neurology, Faculty of Medicine Vajira Result: 470 participants replied to question- naires and got neurological examination by a neu- Hospital, Navamindradhiraj University rologist and a neurology resident. 16 volunteers (3.4%) were diagnosed as migraine - 13 females and 3 males. The common symptoms of migraine were unilateral, non-pulsating headache with mod- erate severity and common associating symptoms were nausea or vomiting. The average duration of the migraine was 7.5 hours and frequency was 3 attacks per month. Coffee drinking (6.5% vs 1.5%, P = 0.032) was significantly higher in the migraine group than in the non-migraine headache group. Migrainers with divorce or separation (20.0%) were also significantly higher than single (5.7%) and mar- ried (1.4%) (20.0% vs. 5.7% vs. 1.4%, P = 0.007) compared with non-migraine headache group. Conclusion: The prevalence of migraine in this study was lower than other studies. The only sig- nificant modifiable factor that provoked migraine was coffee drinking.(Funded by Navamindradhiraj University) 60 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Objectives: To investigate the frequency and clinical presentations in neuromyelitis optica spec- Manifestation of trum disorder (NMOSD) with non-optic neuritis Neuromyelitis Optica (non-ON) and non- (non-TM) in Thai patients. Spectrum Disorder other Methods: Retrospective review on medical than Optic Neuritis and records of NMOSD patient attended the MS clinic Transverse Myelitis: during 2004-2017. Epidemiology and Results: Myelitis was the most common pres- entation (82.1%) occurred in 190 cases, followed Clinical Characteristics by optic neuritis (62.6%), brainstem syndrome (38.9%), area postrema syndrome (16.8%), symp- Natthapon Rattanathamsakul tomatic (5.8%) and symp- tomatic cerebral syndrome (4.2%). Of 995 attacks, 12.8% were limited form of non-ON/non-TM attacks. Neurology Division, Department of Medicine, Detailed data gathering on consecutive 126 cases Faculty of Medicine Siriraj Hospital, Mahidol was performed, those with at least 1 manifestation University, Bangkok, Thailand other than optic neuritis (ON) or transverse myelitis (TM) (non-ON/non-TM group, n=56) and those with limited form of ON or TM (ON/TM group, n=70). Both group was similar in age at disease onset, number of attacks, types of treatment, relapsing course, and annualized relapse rate; except that the ON/TM group had more proportion of female sex and more proportion of AQP4 IgG seropositiv- ity than non-ON/non-TM group. Those with first non-ON/non-TM attack had lower EDSS at last visit than those with first ON/TM attack. Myelitis at- tack and absence of anti-thyroperoxidase (anti- TPO) were associated with severe attack, while myelitis, optic neuritis, area postrema syndrome, and disease duration was associated with relapsing Conclusion: Brainstem syndrome was the course. Presence of non-ON/non-TM attack in most common non-ON/non-TM feature. Presence clinical course was associated with less occurrence of non-ON/non-TM presentation was associated of relapse (p < 0.001). with less relapse. Vol.34 • NO.1 • 2018 61

Objective: To compare the quality of counsel- ling on acute ischemic (AIS) with the indications for Quality Assessment of IV-tPA and/or endovascular thrombectomy between Counselling Process in current practice (control group) and new developed (intervention group) way in information complete- Patients Receiving ness and patient/surrogates comprehension on the IV-tPA and/or Mechanical treatment options. Thrombectomy Material and Methods: The study was a quasi- experimental study on quality of counselling pro- cess in AIS patients and surrogates who received counselling for administration of IV-tPA and/or en- dovascular thrombectomy in Siriraj stroke fast track, Kosit Tangthamrongthanawat Siriraj hospital during 1st August 2017 to 31 st October 2017. All AIS patients presented to hospi- tal within 8 hours of symptom onset and were Neurology Division, Department of Medicine, evaluated by review of voice recordings during Faculty of Medicine Siriraj Hospital, Mahidol counselling process and questionnaires within 48 University, Bangkok, Thailand hours after admitted. Results: The quality of the counselling process (completeness) was improved significantly after the intervention compared to the control (median score = 12 compared to median score = 8, P< 0.001). The perception of information provided and all of its components were significantly improved after the intervention as well. (score from7.44 ± 1.65 to12.06 ±1.03, p-value < 0.001).The inter-reviewer agree- ment of completeness of counselling process scor- ing was high, with an ICC of 0.72 (95% confidence interval [CI] 0.56-0.83). Conclusion: Our new developed counselling process protocol for AIS can improve quality of counselling process and patient/surrogate percep- tion of treatment including risk, benefit and alterna- tives. 62 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Introduction: Altered consciousness during hospitalization is related to mortality. Some need Clinical Predictors for electroencephalography for evaluation; however, Abnormal EEG Results clinical predictors for abnormal results and clinical benefit of short-term electroencephalography are among the Hospitalized still unknown. Patients with Altered Objectives: To investigate the diagnostic yield Mental Status of short-term electroencephalography and the clinical parameters to predict abnormal electroen- cephalography and epileptiform abnormalities among the hospitalized patients with alteration of consciousness. Wikrom Warunyuwong Materials and Methods: We retrospectively reviewed the data of 301 in-hospital altered con- sciousness patients who had short-term electroen- Neurology Division, Department of Medicine, cephalography performed. Clinical parameters Faculty of Medicine Siriraj Hospital, Mahidol between normal and abnormal electroencephalog- University, Bangkok, Thailand raphy groups were evaluated. All records were then evaluated by two independent epileptologists. Comments in clinical decision making in each cases were recorded and analyzed. Results: The EEG results and clinical informa- tion of total of 301 patients were evaluated. Abnor- mal EEG patterns were seen in 82.1% and epilep- tiform EEG patterns in 27.2% of all patients. Non-wakefulness status and epileptic events wit- nessed by the physicians are the clinical predictors of epileptiform EEG abnormalities. Presence of Conclusion: This study emphasized the value epileptiform EEG pattern led to change in manage- of short-term electroencephalography among the ment in 37 patients (12.3%) or nearly half of all hospitalized patients with alteration of conscious- patients with epileptiform pattern. Presence of ab- ness. Abnormal EEG and epileptiform EEG patterns normal EEG pattern (at discharge OR 14.92; 95% are common in the inpatients with altered con- CI 7.06 - 31.33) and epileptiform EEG pattern (at sciousness. Results of short-term EEG can lead to discharge OR 5.06; 95% CI 2.49-10.34) were cor- change in clinical management. Abnormal EEG is related with non-favorable outcome at the discharge related to poor clinical outcome at discharge and date and at three months after hospital discharge. at three months after discharge. Vol.34 • NO.1 • 2018 63

Objective: To compare clinical presentations, laboratories and imaging findings in ON associated Differences in Clinical with MS and NMOSD. Features between Optic Materials and Method: Retrospective chart review was performed in patients presented with Neuritis in Neuromyelitis ON in 59 NMOSD patients with 72 eyes involvement Optica Spectrum and 163 ON attacks and 20 MS patients with 23 Disorder and in eyes involvement and 36 ON attacks. Multiple Sclerosis Results: ON-NMOSD had recurrent ON more often and tended to be simultaneous bilateral ON involvement at their first ON attack. ON-NMOSD revealed worse visual acuity at first ON attacks and Jindapa Srikajon also with poorer long-term visual outcome than those of ON-MS, with nearly half of ON-NMOSD remained to have LogMAR visual acuity ≥ 1 at their Neurology Division, Department of Medicine, last follow-up (p=0.035). Significant thinner average Faculty of Medicine Siriraj Hospital, Mahidol retinal nerve fiber layer thickness was found in ON- University, Bangkok, Thailand NMOSD group. We found no significant differences in segmentation location of the optic nerve lesions and the length involvement between the two groups. Conclusion: It was difficult to completely dif- ferentiate ON-NMOSD from ON-MS. However ON- NMOSD tended to be simultaneous bilateral ON involvement and poorer long-term visual outcome than those of ON-MS. 64 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Objectives: To evaluate the risk factors for MG exacerbation and the effect of immunosuppressive Risk Factors of Myasthenia dosage and pattern of treatment on MG exacerba- Gravis Exacerbation in tion within the first 3 years from the onset. Materials and Methods: Medical records of Generalized Myasthenia generalized MG patients in Siriraj hospital from 2002 Gravis Patients to 2014 were reviewed. We compared the baseline characteristics and immunosuppressive treatment between the exacerbation and stable group. The precipitating factors of MG deterioration were also evaluated. Results: A total of 192 MG patients were in- Mintra Tangrungruengkit cluded. Fifty-five percent of the patients had exac- erbations in the first three years. We found that the presence of thymoma (P 0.004, OR 24.435, 95%CI Neurology Division, Department of Medicine, 2.755-216.723) and delayed treatment with aza- Faculty of Medicine Siriraj Hospital, Mahidol thioprine of more than 6 months (P < 0.001, OR University, Bangkok, Thailand 8.988, 95%CI 2.729-29.599) were associated with higher risk of MG exacerbation by multivariate lo- gistic regression analysis. The common precipitat- ing factors for MG exacerbation were prednisolone withdrawal (28.6%) and infection (24.1%). The median dose of prednisolone prior the exacerbation due to withdrawal treatment factor was 15 mg/day with the median reduction rate of 1.25 mg/week. Conclusion: Thymoma is the strong predictive factor of MG exacerbation. Early initiation of Aza- thioprine within 6 months was associated with lower risk of MG exacerbation in the first three years. Vol.34 • NO.1 • 2018 65

Objectives: To ascertain the prevalence and contributing factors of headaches in obstructive The Differences between sleep apnoea (OSA) patients. Obstructive Sleep Methods: A questionnaire-based cross-sec- tional study was conducted in 272 newly diagnosed Apnoea Patients with and OSA patients (AHI > 5/hr). Information regarding without Headache headache characteristics, frequency, and severity were assessed. Data on baseline Epworth sleepi- ness scale (ESS) and polysomnographic parame- ters were recorded and compared between head- ache and non-headache group. Results: The prevalence of headache among Sani Tavivatana OSA patients was 37.9% with similar proportion of migrainous type and tension type. Patients with headache were younger and had higher median Neurology Division, Department of Medicine, ESS score. Positive correlation between frequency Faculty of Medicine Siriraj Hospital, Mahidol of headache and ESS score was also noted (Spear- University, Bangkok, Thailand man rho = 0.386, p < 0.001). After adjusting all confounding factors, there was no difference in any polysomnographic parameters between headache and non-headache group. Conclusion: The prevalence of headache in OSA patients was high. Patients in the headache group reported more daytime sleepiness than non- headache group without any difference in other polysomnographic findings. 66 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Background: Diabetes mellitus is associated with a wide spectrum of neuropathy syndromes. Up The Clinical Characteristic to 20% of patients with newly diagnosed diabetes of Neuropathy in already have symptoms, are diabetic polyneuropa- thy but the relationship between peripheral neu- Prediabetic and Diabetic ropathy and prediabetes remain controversial. Patients in Prasat Objective: To determine the presence and type Neurological Institute of polyneuropathy in prediabetic and diabetic pa- tients and to compare sensitivity of the tests to detect neuropathy in prediabetic and diabetic pa- tients. Methods: Retrospective study of patients with Sawitta Srijinda diagnosis of prediabetes and diabetes. Results: Of 76 patients, 40 prediabetic and 36 diabetic patients with available nerve conduction Department of Neurology, Prasat Neurological study were identified. Most of prediabetic and dia- Institute, Bangkok, Thailand betic patients had symmetrical, sensory polyneu- ropathy, followed by sensorimotor polyneuropathy. Autonomic neuropathy was common also. In addi- tion, no significant difference of clinical manifesta- tions, monofilament test, nerve conduction study, autonomic test in both groups. Among all neuro- pathic tests, autonomic test appeared to be the most sensitive test in prediabetic stage. Conclusion: Prediabetic stage can contribute neuropathy, which is similar in diabetes. Auto- nomic test is more sensitive than routine taking history, neurological examinations, nerve conduc- tion study and monofilament test to detect diabetic neuropathy in prediabetic patients. Vol.34 • NO.1 • 2018 67

Objective: To determine the prevalence of REM sleep behavior disorder (RBD) in patients with Rapid Eye Movement Parkinson’s disease and ascertain the clinical char- Sleep Behavior Disorder acteristics and risk factors associated with RBD. Method: We enrolled subjects with Parkinson’s in Parkinson’s Disease disease who visited in neurology clinic at Prasart neurological institute from 1st January to 31stDecem- ber, 2017. Subjects and bed partner were inter- viewed with Mayo Sleep Questionnaire to ascertain RBD and obtained all demographic data and non- motor symptoms. The patients who were confirmed to have RBD were later interviewed regarding the Huda Tohmangee dream content. Results: Forty-nine patients out of 140 PD patients (35%) in our cohort were defined as RBD. Department of Neurology, Prasart Neurological Patients with RBD were male predominance (53 vs Institute, Bangkok, Thailand 37; p =0.042), longer disease duration (7.4 vs 5.2; p=0.003), higher scores of the modified H&Y stage, higher scores of the UPDRS part III (31.0 vs 18.0; P<0.001), and higher dose of total LEDD (765.0 vs 426.0; P<0.001). Non-motor symptoms were statis- tically significance in group of PD with RBD. Logis- tic regression analysis showed only male gender and non-motor questionnaire were associated with the presence of RBD. The most common dream phenomenon was fighting with human. The report of sleep-related injuries showed an injury to the patient was 16.3% and an injury to bed partner was 6.1%. Conclusion : We found that the prevalence of RBD in PD was 35% along with male gender, dis- ease duration and disease severity may be the risk factors in our study. The dream content of RBD seemed to be passive or defending the attack rather than attack to the others. 68 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Objective: To compare effect of cold compres- sion before Botulinum neurotoxin (BoNT) injection Effect of Cold Compression with no cold compression on severity, frequency, before Botulinum duration and complication in hemifacial spasm (HFS). We also investigate its effect on pain and Neurotoxin Injection in bleeding during injection. Quality of life (QoL) before Hemifacial Spasm and after treatment were also evaluated. Methods: A prospective, randomized, case- crossover design was employed. 159 patients who was diagnosed as primary HFS with BoNT treatment in botulinum toxin clinic were randomized during May 2017 to November 2017. We divided into 2 Peamnapatch Dhanachanvisith groups with cold compression and no cold com- pression before BoNT injection then evaluated se- verity, frequency of HSF by using Jankovic Rating Department of Neurology, Prasat Neurological Scale. Complication of treatment, pain, bleeding Institute, Bangkok, Thailand and QoL were also assessed. Results: Cold compression before BoNT injec- tion significantly decreased severity and frequency of HFS (p<0.001). Pain scale in cold compression before BoNT injection was significantly lower than those without cold compression (p<0.001). Satisfac- tion scores and bleeding are significantly different (p<0.001). Quality of life was significantly improved after treatment with BoNT (p<0.001). Cocclusion: Cold compression before BoNT injection can improved the efficacy of treatment by reduce the scale of severity and frequency. This study confirms previous studies that cold compres- sion before BoNT injection had a good outcome in pain scale, satisfaction and bleeding. No significant complications were found. Additionally, BoNT injec- tion can also increase quality of life of hemifacial spasm patients . Vol.34 • NO.1 • 2018 69

Objectives: To assess efficacy of aromathera- py on cognition and BPSD symptoms in patient with Effects of Aromatherapy mild cognitive impairment in Prasat Neurological on Patients with Mild Institute. Methods: This study is prospective study at Cognitive Impairment in Prasat Neurological Institute, 35 patients who diag- Prasat Neurological nosed with mild cognitive impairment between Institute May1, 2017 and September 30, 2017 were included in this study. Intervention consists of inhalation es- sential oil rosemary (Rosmarinus officinalis L.) about 30 minutes before bedtime for 6 weeks. MOCA ,The Hamilton rating scale for anxiety (HAM-A), NPI-Q Thitikul Raetong tests were evaluated before and after aromatherapy intervention. Department of Neurology, Prasat Neurological Results: 35 patients with MCI were enrolled in the study. Baseline MOCA score before intervention Institute, Bangkok, Thailand was 22 that was not different after intervention. In subgroup analysis, domain of delayed recall was improved significantly in statistic ( P value 0.007). NPI-q distress score and HAM-A after intervention had improvement significantly ( both P value 0.001). Median NPI-q severity score was not different be- fore and after intervention. Conclusion: Rosemary aromatherapy seems to be safe and effective for improving cognitive and behavioral problems in people with MCI. 70 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Background: Intravenous thrombolysis is as- sociated with good outcome in acute stroke pa- The Risk of Intracranial tients, however this treatment increases risk of Hemorrhage after bleeding especially intracranial hemorrhage (ICH). Studies of risk factors that were associated with Thrombolytic Therapy increasing the risk of ICH were limited in Asian with Recombinant Tissue population. Plasminogen Activator in Objectives: To assess baseline characteristic Acute Ischemic Stroke in and the risk factors which are associated with ICH after intravenous rt-PA in acute ischemic stroke Prasat Neurological patients in Prasat Neurological Institute, Thailand. Institute Methods: Retrospective studies of 197 pa- tients with acute ischemic stroke who were treated with after intravenous rt-PA between July, 2004 to March, 2017 at Prasat Neurological Institute. We Duangduean Paetsart studied baseline characteristics, risk factors of patients with and without ICH. In the ICH group, we Department of Neurology, Prasat Neurological also analyzed the difference between the sympto- Institute, Bangkok, Thailand matic and asymptomatic ICH groups. Results: 20 patients (10.2%) had ICH. Of those, 10 patients (5.1%) had symptomatic ICH. High SBP, nicardipine used, severe stroke, dense MCA sign and low ASPECTS were significantly associated with ICH. We separately analyzed symptomatic and asymptomatic ICH with no ICH groups, risk factors that associated with symptomatic ICH group were SBP>180 mmHg, dense MCA, and ASPECTS<8 (p<0.005); but severe stroke (NIHSS>15) and AS- PECTS< 8 were associated with asymptomatic ICH. Comparing between the symptomatic and asymp- tomatic groups, we found that higher SBP and the use nicardipine are associated with symptomatic dense MCA sign, ASPECTS<8 and use of antihy- ICH. For the cut point that will affect ICH of SBP pertensive drug. Carefully patients’ selection before was>180 mmHg, NIHSS was >15 and ASPECTS thrombolysis with these risk factors may reduce risk was <8 by using ROC curve model. of ICH. High SBP is at risk of symptomatic ICH. Conclusion: ICH after thrombolytic treatment Tightly control of SBP before and between treatment is associated with SBP>180 mmHg, NIHSS>15, may decrease symptomatic ICH. Vol.34 • NO.1 • 2018 71

Objectives: To assess the effects of Thai dance (Ram Thai) on balance, cognition, and mood in The Effects of Thai dementia patients in Prasat Neurological Institute. Dance on Balance, Methods: This study is prospective pilot study, twenty dementia patients who completed Thai tra- Cognition, and Mood in ditional dance in daycare of Prasat Neurological Dementia Patients in Institute from May 2017 through December 2017 Prasat Neurological had included. Intervention consisted Thai tradi- Institute tional dance for 24 sessions, 30 minutes duration twice a week over 12 weeks. Evaluated by using Berg Balance Scale, TMSE, MOCA, NPI-Q, and Barthel index compared between before and after Pimolpun Visassaragool intervention. Results: From May 2017 through December 2017, total of 20 dementia patients were enrolled. Department of Neurology, Prasat Neurological After 12 weeks sessions, the median score on Berg Institute, Bangkok, Thailand Balance Scale was 50 before the intervention as compared with 53 after the intervention (p-value <0.001). Complementary with the improvement of median MOCA score (before 14.5 and after 16; p- value 0.007) and median NPI-Q score but TMSE, and Barthel index did not differ significantly between before and after intervention (p-value >0.05). Conclusion: This study demonstrated that Thai traditional dance can improve balance, gait func- tion, cognition, and mood in dementia patients, but not for the activities of daily life. This finding sug- gests that Thai folk dance or Ram Thai may have benefits for fall prevention in dementia patients. 72 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Introduction: The patient with ischemic stroke and AF developed recurrence ischemic stroke more Incidence and Predictors than ischemic stroke without AF. Risk stratification of Early Recurrent Stroke could help to drive clinician decisions on antico- agulant treatment. in Acute Ischemic Stroke Objective: To analyze incidence and predictors with Atrial Fibrillation of early recurrent stroke in acute ischemic stroke with atrial fibrillation. Our results can be used to identified the AF patients with high recurrent stroke risks for the proper management. Materials and Methods: In our prospective Ramathibodi stroke registry cohort study with retro- Jutamas Sutatikanont spective analysis, 241 acute ischemic stroke pa- tients with atrial fibrillation were evaluated. The in- cidence of recurrent stroke and systemic emboli at Division of Neurology, Department of Medicine, 7 and 90 days were recorded and predictive factors Faculty of Medicine, Ramathibodi Hospital, of early recurrent stroke were determined. Mahidol University, Bangkok, Thailand Results: Of 51 from 241 patients (21.2%) had recurrent stroke and systemic emboli at 7 days, including ischemic stroke in 12 (5.0%), hemor- rhagic stroke or symptomatic hemorrhagic transfor- mation in 38 (15.8%) and systemic emboli in 1 pa- tients (0.4%). There were 44 patients developed events in 90 days, including TIA (1/183; 0.5%), is- chemic stroke (17/183; 9.3%), hemorrhagic stroke (28/183; 15.3%) and systemic emboli (3/183; 1.6%). The major risk factors for recurrent ischemic stroke in 7 days were mitral stenosis and endovascular treatment. The major risk factors for hemorrhagic stroke in 7 days were DM, medium/large infarction and diastolic blood pressure. Conclusion: There are high incidence of early recurrence stroke in 7 days. Early anticoagulant should be considered in AF patients with mitral stenosis or post endovascular treatment. On the contrary, delay anticoagulant base on current tion and/or DM, high blood pressure seem to be guideline in AF patients with medium to large infarc- reasonable. Vol.34 • NO.1 • 2018 73

Objecive: Patients usually present with visual field defect in PCA territorial infarction. Clinical out- Prognostic Factor of comes following PCA territorial infarction have not Visual Field Defect in been well studied. We aimed to assess prognostic factors in PCA territorial infarction. PCA Infarction Methods: This is a single-center, retrospective study. Inclusion criteria included homonymous visual field defect such as homonymous hemipano- pia and homonymous quadrantanopia, PCA infarc- tion, age 15-80 years old and onset 30 days. A visual field test was carried out using confrontation test at baseline and months. All participants were Supalak Ponguthai divided into 2 groups, according to their visual field improvement ; improvement and no improvement groups. Data comparison between the improvement Division of Neurology, Department of Medicine, and no improvement groups were performed. Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Results: A total of 30 patients were recruited. 11 had VF improvement after onset (36.7%). The days from stroke onset to hospital were shorter in the improvement group but not significantly different(p=0.105). The days from stroke onset to MRI/CT were shorter in the improvement group but not significantly different(p=0.093). The regional extension of infarction were not significantly different between the two groups. In patients who had MRI performed within 30 days following the onset, the median infarct volume of the improvement group was significantly lower than that of the no improve- ment group(p=0.01). Additionally, patients with in- farction of 13.7 cm3 had better visual outcome than those with large infarction. Conclusions: The small volume of infarction was an important good prognostic factor in patients with PCA territorial infarction. 74 วารสารประสาทวิทยาแห่งประเทศไทย Vol.34 • NO.1 • 2018

Background: Regarding leptomeningeal me- tastasis, cancer cells probably damage choroid Study on Cerebrospinal plexus and blood barrier, some change of cellular Fluid-Serum Ratio of membrane and its ion channel. Thus, the condition may interfere regular cellular machinery controlling Electrolytes in Patients electrolyte equilibrium in CSF. The objective of this with Carcinomatous research was to study the different values of elec- Meningitis, Leukemic trolyte level ratio in CSF with the serum, compared and Lymphomatous between patients with leptomeningeal metastasis and without leptomeningeal metastasis condition. Meningitis Methods: This is a single center, case-control study. Patients were divided into two groups:1) with Kittawit Rungjang leptomeningeal metastasis and 2) without leptome- ningeal metastasis. Electrolyte levels including sodium, potassium, and chloride in blood and CSF Division of Neurology, Department of Medicine, were analyzed. Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Results: There were total of 17 patients, includ- ing 8 patients without leptomeningeal metastasis, 9 patients with leptomeningeal metastasis. CSF-to- serum ratio of sodium and CSF-to-serum ratio of chloride were significantly lower in the patients with leptomeningeal metastasis (p-value 0.04, and 0.01 respectively). However, no significant change in CSF-to-serum ratio of potassium was noted in these patients. Conclusions: CSF-to-serum ratio of sodium and chloride in patients with leptomeningeal metastasis were significantly lower than patients without lep- tomeningeal metastasis. This observation reflects that normal complex system controlling CSF elec- trolyte in blood brain barrier appear to be interfered by cancer cells. Furthermore, CSF electrolyte may be a good biomarker for simple in the diagnosis in this condition. Vol.34 • NO.1 • 2018 75

Background: The precise etiological classifica- tion of ischemic stroke is the most important process Role of Plasma D-Dimer due to different treatment strategies. Plasma D-di- Levels for Determination mer assay is commonly used in clinical setting. No data is available in Thailand about plasma D-dimer of Acute Ischemic Stroke in acute ischemic stroke patients. Subtypes and Stroke Methods: This was single center cohort with Severity data extract from prospective registry of consecu- tive acute stroke in Ramathibodi Hospital. The purpose was to demonstrate the differences of plasma D-dimer in relation to stroke etiology. The secondary aim was to analyze the relationship be- Wisan Teeratantikanon tween plasma D-dimer, stroke severity and infarc- tion size. Subgroup analysis of the patients pre- sented with classic lacunar syndromes was Division of Neurology, Department of Medicine, performed. Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand Results: A total of 119 patients were included. Significant stroke etiological differences in plasma D-dimer were found. Median plasma D-dimer were significantly higher in CE (1650 ng/mL) than LAA (662 ng/mL) and SVO (262 ng/mL), p<0.001. The plasma D-dimer in CE were significantly higher than non-CE. Moreover, plasma D-dimer had the positive correlation with infarction size and stroke severity. For subgroup analysis of the classic lacunar syn- drome patients, plasma D-dimer in SVO were sig- nificantly lower than non-SVO. Conclusions: Plasma D-dimer assay is a com- monly available test which can be used to reliably determine stroke subtypes. The plasma D-dimer in CE were significantly higher than the other causes. Classic lacunar syndrome presentation was not always from SVO etiology when the plasma D-dim- er were high. Measurement of the plasma D-dimer might be useful to make decision on extensive in- vestigation on cardioembolic source and to prompt- ly prescribe the anticoagulation as secondary prevention. พิมพ์ที่ : หจก.โรงพิมพ์คลังนานาวิทยา 232/199 ถ.ศรีจันทร์ ต.ในเมือง อ.เมือง จ.ขอนแก่น 40000 Tel. 0-4346-6444, 0-4346-6860, 0-4346-6861 Fax. 0-4346-6863 E-mail : [email protected] 2561 รหัส 02