| 저자 |
Se Hwi O1*, Jin Gee Park1†, Young Sook Park1, Hyun Jung Chang1, Eunsol Cho1, Jae Sam Seo1, Kyo Hun Ku1, Chang Woo Kim1, Da Hye Kim1 |
Introduction
We report a case of patient with gait disturbance and dysarthria which were resulted from cerebellar dysfunction due to multiple systemic atrophy cerebellar subtype(MSA-C). To diminish symptoms, repetitive transcranial magnetic stimulations(rTMS) were applied to cerebellum.
Case report
The patient was a 63-year-old man with 2-year history of gait and speech dysfunction. He had no other past medical & family history. At his first visit to hospital 2 years ago, he also had constipation, urinary incontinence. To find out the cause, several diagnostic evaluations were performed. On the genetic analysis, there were no abnormal trinucleotide repeats which could account for spinocerebellar ataxia or Huntington’s disease. Magnetic resonance image of the brain showed atrophy of cerebellum with subtle increased signal at both middle cerebellar peduncles in T2 weighted image (Fig.1). He tried to take levodopa but the medication was not helpful. According to the symptoms and findings, diagnosis could be made as probable MSA-C.
When the patient visited rehabilitation department, neurologic examination revealed truncal and limb ataxia, wide-based gait & dysarthria. Deep tendon reflexes were normal and no upper motor neuron signs were observed. Severe ataxia and mild dysmetria were found by heel to shin test and finger to nose test. His symptoms had worsened progressively. Nystagmus were not present and tandem gait was not performed due to falling tendency. Total score of International cooperative ataxia rating scale(ICARS) was 49/100 and Scale for the assessment and rating of ataxia(SARA) was 24/40. Berg Balance Scale(BBS) was 20/56. Dynamic body balance was evaluated by BioRescue(RM INGENIERIE, France). The result showed that he moved to left with more ease than to right 7%, and forward with more ease than back 12%. His total surface area for keeping the stability was 1487 mm2.
Since cerebellar rTMS has been reported to be useful for treating ataxia, we conducted a trial of high-frequency rTMS over the cerebellum. TMS was delivered using MagPro X100(MagVenture, Denmark). The figure-8 coil was placed over inion(international 10-20 systems) and pulses at 100% intensity of the resting motor threshold of dominant hand abductor pollicis brevis muscle were administered at 10 Hz(1s trains, 10s intertrain interval, 1500 pulses/session). Total 10 rTMS sessions were conducted, 5 sessions a week. It was completed without complications. After 10 sessions of rTMS, some sub-scores of ICARS and SARA showed improvements. BBS was increased. Dynamic body balance became more symmetry. Also the patient’s subjective symptoms of ataxia has improved. The improvement is thought to be result of reduction in the inhibitory signals from Purkinje cells and dentate nucleus, enhancing the activation of the motor cortex and vestibular nuclei. The application of high-frequency rTMS over the cerebellum could be safe and useful treatment option in patient with probable MSA-C. |
