double-blind controlled study of a new treatment method for postherpetic neuralgia. Pain 1996;65:39 – 44. 3. Bushnell TG, Craig J. Response of chronic neuropathic pain syndromes to ketamine: a role for norketamine? Pain 1995;60:115. 4. Crowley K, Flores JA, Hughes CN, et al. Clinical application of ketamine ointment in the treatment of sympathetically mediated pain. Int J Pharm Compounding 1998;2:122–127. 5. Watson CP, Tyler K, Bickers DR, et al. A randomized vehicle-controlled trial of topical capsaicin in the treatment of postherpetic neuralgia. Clin Ther 1993;15:510 –526. 6. Watson CP, Vernich L, Chipman M, Reed K. Nortriptyline versus amitriptyline in postherpetic neuralgia: a randomized trial. Neurology 1998; 51:1166 –1171. 7. Raja SN, Haythornthwaite JA, Pappagallo M, et al. Opioids versus antidepressants in postherpetic neuralgia: a randomized, placebo-controlled trial. Neurology 2002;59:1015–1021. Traumatic internal carotid artery dissection associated with taekwondo gen activator (tPA). Twelve hours later, he developed right hemiparesis and global aphasia. Brain MRI showed subacute left middle cerebral artery territory infarction and a hemorrhagic crescent in the wall of left internal carotid artery (figure, A through C). The intracranial segment of the left internal carotid artery was absent on MR angiography. Complete blood count and coagulogram were unremarkable. The low-density lipoprotein (LDL) was 150 mg/dL. The final diagnosis was left middle cerebral artery stroke resulting from internal carotid artery dissection. He was treated with warfarin until evaluation 4 months later; he had residual global aphasia but was ambulating with assistance. Follow-up MR angiography showed a patent left internal carotid artery with tapering of flow at its origin (figure, D). Discussion. This athlete suffered a left internal carotid dissection but had no risk factors for it. Despite the elevated LDL, the MR angiography showed no arteriosclerosis. The temporal relationship between the taekwondo class and symptoms of internal carotid dissection suggests that trauma associated with this martial art was the proximate cause of arterial injury. Traumatic dissection of the internal carotid artery has been reported in several sports. In softball, a direct mechanical insult by the ball is the presumed mechanism for carotid dissection in 50% of patients.1 Kickboxing and French boxing, in which punches to the face are allowed, are associated with intracranial arterial dissection.2,3 Luis F. Pary, MD; and Robert L. Rodnitzky, MD Traumatic internal carotid artery dissection has been associated with several sports, but there are no reports of its occurrence in taekwondo. The authors report a patient with such condition occurring during a taekwondo class and review the sport’s biomechanics that could have led to the injury. Case report. A 43-year-old right-handed man experienced sudden onset of right hemisensory loss and Wernicke’s aphasia. Two months before presentation, he obtained a black-belt degree in taekwondo and started training more frequently and aggressively. He never smoked and had no personal or family history of arterial dissection, connective tissue disease, or migraine. Seven days before admission, he noted left hemicrania immediately after a taekwondo class. On the following day, he had transient symptoms of left monocular blindness and right-sided numbness. He was started on aspirin and stopped training because of headaches. He resumed classes on the day of admission and while training experienced left monocular vision loss. This was followed by aphasia, right hemiparesis, and sensory loss. He was transferred to our hospital alert but with fluent aphasia, dense right hemisensory loss, and left miosis. Head CT was unremarkable, and he received intravenous tissue-type plasmino- Figure. Axial fluid-attenuated inversion recovery (A) and diffusionweighted image (B) brain MRI demonstrating ischemic stroke in left middle cerebral artery distribution. A hemorrhagic crescent on axial T1 cervical MRI (C) and the string sign on follow-up neck MR angiography (D) were consistent with left internal carotid artery dissection. 1392 NEUROLOGY 60 April (2 of 2) 2003 In taekwondo, punches to the face are not allowed, but kicks to the head and neck are legal. The sport has been associated with head and neck injuries, and men are at higher risk of sustaining injury than women.4-6 For men, the most common mechanism of injury is receiving a blow from an unblocked attack, and the most common type of injury is contusion of the involved body part.4,5 The most common sites of injury are the head and feet, but the most severe ones usually involve the head and neck.4,6 Although one can postulate that a carotid dissection may be a possible consequence of a neck blow in this sport, no such cases have been reported. Because this aphasic patient could not describe the blows received during his taekwondo match, we cannot exclude neck hyperextension as a possible mechanism of injury. However, previous studies have demonstrated that most cervical injuries in taekwondo result from a blow. We presume that a kick was the cause of the dissection because at the black-belt level, roundhouse kicks can be applied more intensely. This attack, allowed in taekwondo and full-contact karate, produces head accelerations as high as 90 to 120 G and is stronger than punches to the front of the head.7 Because blows with such force reportedly cause jaw fractures,6 we postulate they also can cause arterial dissection. This case suggests that carotid artery dissection can be associated with taekwondo, a relatively new martial art that is now an Olympic sport with increasing popularity in North America. It is important that physicians and taekwondo athletes become aware of this complication so that appropriate treatment can be initiated early and further aggravating trauma avoided. From the Department of Neurology, Roy J. and Lucille A. Carver College of Medicine, University of Iowa, Iowa City. Camptocormia, axial dystonia, and parkinsonism: Phenotypic heterogeneity of a parkin mutation over time, were reported in all. Similar to sporadic PD, pain was an early symptom but did not respond to L-dopa. After informed consent, blood samples were collected from all six patients, a maternal aunt with tremor, and her healthy son (⻬ in the figure). Methods for genomic DNA extraction, genotyping, PCR conditions, and restriction analysis for mutation of exon 2 were previously described.3,4 All exons of the parkin gene were screened for deletions, insertions, or point mutations by direct sequencing of the PCR products, which were sequenced on both strands. R. Inzelberg; N. Hattori; P. Nisipeanu; S. Abo Mouch; S.C. Blumen; R.L. Carasso; and Y. Mizuno Autosomal recessive juvenile parkinsonism (AR-JP) is a youngonset parkinsonism caused by mutations in the parkin gene.1 Exonic deletions or multiplications and truncating and missense mutations have been described.2,3 The phenotype encompasses juvenile-, early-, and late-onset patients.2 We describe a large kindred with different phenotypic expressions of a mutation in the parkin gene. Patient report. The patients belonged to two branches of an Arabic Israeli family (figure). Patients in Branch A have been previously described.4 The consanguinity of the branches was established to the seventh ancestral generation. In Branch A, ages of onset of the four affected brothers were in the 4th decade: 35, 33, 37, and 30 years. Disease duration was 27, 22, 9, and 14 years. In Branch B, the onset of symptoms was earlier by almost a decade: 19 years (man, 17 years, disease duration) and 23 years (woman, 40 years, disease duration). Some clinical features were similar among all patients. Hand tremor was the first symptom, followed by bradykinesia and rigidity. Additional to the rest tremor, all had postural hand tremor. Postural reflexes remained intact. Retropulsion or freezing was reported in only one patient (woman, Branch B). Beyond the background of parkinsonism, patients in Branch B were strikingly different. Their main feature was truncal dystonia. The woman patient developed camptocormia: severe forward bending of the trunk appeared approximately 5 years after onset and gradually progressed to permanent, fixed 90° trunk flexion. The camptocormia did not fluctuate and was L-dopa unresponsive. The other patient in Branch B developed axial dystonia expressed by scoliosis, which worsened over years and was L-dopa unresponsive. In contrast, dystonia was a mild feature: only two patients in Branch A experienced foot dystonia. None of the patients had orthostatic hypotension, urinary dysfunction, constipation, sleep benefit, diurnal variation, or any mental impairment. Levodopa response was excellent for all patients, except for the severe dystonic features. Total daily dose remained low (⬍500 mg) for a long period, e.g., 27 years. However, after 3 years of treatment, moderate wearing off (two patients in Branch A and the male patient in Branch B), and dyskinesias, which did not worsen Received September 27, 2002. Accepted in final form December 26, 2002. Address correspondence and reprint requests to Dr. Robert L. Rodnitzky, Department of Neurology, University of Iowa Hospitals and Clinics, 200 Hawkins Drive, Iowa City, IA 52242-1061; e-mail: robert-rodnitzky@uiowa.edu Copyright @ 2003 by AAN Enterprises, Inc. References 1. Schievink WI, Atkinson JL, Bartleson JD, Whisnant JP. Traumatic internal carotid artery dissections caused by blunt softball injuries. Am J Emerg Med 1998;16:179 –182. 2. Echaniz-Laguna A, Fleury MC, Petrow P, Arnould G, Beaujeux R, Warter JM. Internal carotid artery dissection caused by a kick during French boxing. Presse Med 2001;30:683. 3. Malek AM, Halbach VV, Phatouros CC, Meyers PM, Dowd CF, Higashida RT. Endovascular treatment of a ruptured intracranial dissecting vertebral aneurysm in a kickboxer. J Trauma 2000;48:143–145. 4. Zemper ED, Pieter W. Injury rates during the 1998 US Olympic Team Trials for taekwondo. Br J Sports Med 1989;23:161–164. 5. Pieter W, Zemper ED. Incidence of reported cerebral concussion in adult taekwondo athletes. J R Soc Health 1998;118:272–279. 6. Siana JE, Borum P, Kryger H. Injuries in taekwondo. Br J Sports Med 1986;20:165–166. 7. Schwartz ML, Hudson AR, Fernie GR, Hayashi K, Coleclough AA. Biomechanical study of full contact karate contrasted with boxing. J Neurosurg 1986;64:248 –252. Figure. The pedigree. Square symbols ⫽ men, circles ⫽ women, diagonal lines ⫽ deceased persons, ⻬ ⫽ genotyped. The consanguinity of the branches of the family was established to the seventh ancestral generation. Four brothers (black squares) in Branch A (right) and two first-degree cousins (black square and circle) in Branch B (middle) are affected. All patients showed homozygous one adenine deletion at nucleotide position 202. The horizontal shaded symbols represent patients with tremor only who were clinically examined. The patient with an asterisk was genotyped and found to have the same mutation (heterozygous), whereas her healthy son (double asterisk) was wild type. Vertical shaded symbols show patients who had tremor (information per history only). April (2 of 2) 2003 NEUROLOGY 60 1393 Traumatic internal carotid artery dissection associated with taekwondo Luis F. Pary and Robert L. Rodnitzky Neurology 2003;60;1392-1393 DOI 10.1212/01.WNL.0000055924.12065.A0 This information is current as of April 22, 2003 Updated Information & Services including high resolution figures, can be found at: http://www.neurology.org/content/60/8/1392.full.html References This article cites 6 articles, 2 of which you can access for free at: http://www.neurology.org/content/60/8/1392.full.html##ref-list-1 Citations This article has been cited by 1 HighWire-hosted articles: http://www.neurology.org/content/60/8/1392.full.html##otherarticles Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): All Cerebrovascular disease/Stroke http://www.neurology.org//cgi/collection/all_cerebrovascular_disease_ stroke All Trauma http://www.neurology.org//cgi/collection/all_trauma Carotid artery dissection http://www.neurology.org//cgi/collection/carotid_artery_dissection Infarction http://www.neurology.org//cgi/collection/infarction Permissions & Licensing Information about reproducing this article in parts (figures,tables) or in its entirety can be found online at: http://www.neurology.org/misc/about.xhtml#permissions Reprints Information about ordering reprints can be found online: http://www.neurology.org/misc/addir.xhtml#reprintsus Neurology ® is the official journal of the American Academy of Neurology. 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