Reliability and validation of the Japanese version of the coma recovery scale-revised (CRS-R).

PRIMARY OBJECTIVE: This study aimed to verify the reliability and validity of the Japanese version of the Coma Recovery Scale-Revised (CRS-R). METHODS: Subjects included 59 patients with disorders of consciousness (DOC) due to acquired brain injury. To validate test-retest reliability, Evaluator A assessed the CRS-R twice on the same day (A1, A2). To examine inter-rater reliability, Evaluators A (A2) and B (B) assessed the CRS-R without a time interval. To test concurrent validity, Evaluator A (A1) assessed the CRS-R, Japan Coma Scale (JCS), and the Glasgow Coma Scale (GCS) consecutively. To validate diagnostic accuracy, we evaluated the degree of agreement between A1 and A2 and between A2 and B in their diagnosis of DOC by CRS-R. RESULTS: The test-retest (ρ = 0.92) and inter- (ρ = 0.98) reliability of CRS-R were excellent" and Concurrent validity of CRS-R with JCS (ρ = -0.82) and GCS (ρ = 0.92) were high. Results of DOC diagnosis were consistent for 48/59 cases (κ = 0.82) for A1 and A2 and for 54/59 cases (κ = 0.92) for A2 and B. CONLCUSION: The Japanese version of the CRS-R may be as reliable and valid as the original English and other language versions.

Idiopathic normal pressure hydrocephalus possibly affects the occurrence of proximal femoral fracture.

AIMS: The clinical triad of idiopathic normal pressure hydrocephalus (iNPH) includes gait disturbance, dementia, and urinary incontinence. These symptoms are also frequently observed in patients with proximal femoral fracture (PFF). The aim of this study was to investigate the relationship between PFF and iNPH retrospectively. PATIENTS AND METHODS: Of the130 patients over 80-years-old with PFF included in this study, 48 were assigned to the PFF group. Forty-eight patients with peripheral vertigo matched with the PFF group for age and sex were included in the control group. We compared the Evans' index (EI), which is a head computed tomography finding of iNPH, and the percentages of patients with EI>0.3 between the two groups. The PFF group was further divided into two subgroups depending on whether EI was higher or lower than 0.3 (the higher or lower subgroup, respectively). We compared the patient's gait abilities before PFF, causes of PFF, cognitive functions, and occurrence of urinary incontinence between both groups. RESULTS: The mean value of EI in the PFF group was significantly higher than that in the control group (PFF group, 0.301; control group, 0.284; p=0.008). The percentages of patients with EI>0.3 in the PFF and control groups were 62.5% and 35.4%, respectively (p=0.014). In subgroup analyses, the gait ability before injury was worse in the higher subgroup than that in the lower subgroup and was prominent among individuals who could walk only with human assistance (p=0.018). There were no significant differences in other parameters. CONCLUSION: Elderly patients with PFF may have underlying idiopathic normal pressure hydrocephalus. LEVEL OF EVIDENCE: III; case-control comparative study.

In vitro analysis of mechanism of pulsed-laser thrombolysis.

Thrombolytic therapy in the treatment of cardiogenic acute cerebral embolism caused by coagulated blood carries the risk of hemorrhagic complications, and there is a need to develop safer and more reliable treatment methods. Laser thrombolysis therapy, which utilizes the difference in energy absorption between the thrombus and the arterial wall, has shown promise as a new treatment method because it can selectively act only on the thrombus. It has not been applied clinically, however, and one of the main reasons for this is that its underlying mechanism has not been elucidated. We developed a pulse laser thrombolysis system for treating cerebral blood vessels that consists of a diode-pumped solid-state neodymium-yttrium aluminum garnet laser, which has excellent stability and maintainability and is suitable for clinical applications coupled to a small-diameter optical fiber. Moreover, we analyzed the mechanisms that occur during pulsed laser irradiation of transparent glass tubes and gelatin phantoms. We found that bubbles form as a thermal effect in addition to ablation of the pulsed laser irradiation. Furthermore, we detected no shock waves or water jets associated with the bubbles. We analyzed the bubbles' dynamics and growth rate, and their effect on a rabbit blood clot phantom. We concluded that the bubbles generated by the laser irradiation physically cut the thrombus and thereby had a thrombectomy effect. We believe that this study will clarify the mechanism of laser thrombolysis therapy and contribute greatly to the realization of its clinical application.

Unexpectedly Smaller Artifacts of 3.0-T Magnetic Resonance Imaging than 1.5 T: Recommendation of 3.0-T Scanners for Patients with Magnet-Resistant Adjustable Ventriculoperitoneal Shunt Devices.

BACKGROUND: Magnetic resonance imaging (MRI) artifacts of adjustable shunt devices are thought to be similar to metal clip artifacts, in that they are larger with higher field strength scanners. We have published several reports about the artifacts of new MRI-resistant adjustable shunt devices, and we found a case in which a 3.0-T scanner showed smaller artifacts than the 1.5-T scanner. We aimed to clarify whether this claim is true or not. METHODS: Under permission of our institutional Ethical Committee, 2 volunteers underwent imaging studies using 3.0-T and 1.5-T scanners from GE, Siemens, and Philips. Four MRI-resistant adjustable shunt devices-proGAV2.0 (Miethke), Codman Certas Plus (Johnson & Johnson), Polaris (Sophysa), and Strata MR valve (Medtronic)-were fixed on the left temporal scalp. Routine MRI images, including T1-and T2-weighted imaging, fluid-attenuated inversion recovery, diffusion-weighted imaging (DWI), and magnetic resonance angiography (MRA), were obtained. We also compared artifacts between a 3.0-T scanner and a-1.5 T scanner in 4 patients. RESULTS: The 3.0 T-scanners showed smaller artifacts than the 1.5-T scanners on DWI and MRA images for all shunt devices and scanners. In the other sequences, the results depended on the MRI scanner manufacturer; however, the GE 3.0-T scanner showed smaller artifacts in every sequence. This was also true in the 4 clinical cases. CONCLUSIONS: A 3.0-T scanner is recommended over a 1.5-T scanner for patients with MRI-resistant adjustable shunt devices in the diagnosis of acute ischemic condition or when using GE scanners.

Setting pressure can change the size and shape of MRI artifacts caused by adjustable shunt valves: a study of the 4 newest models.

OBJECTIVE: Adjustable shunt valves that have been developed for the management of hydrocephalus all rely on intrinsically magnetic components, and artifacts with these valves on MRI are thus inevitable. The authors have previously reported that the shapes of shunt artifacts differ under different valve pressures with the proGAV 2.0 valve. In the present study the authors compared the size and shape of artifacts at different pressure settings with 4 new-model shunt valves. METHODS: The authors attached 4 new models of MRI-resistant shunt valve to the temporal scalp of a healthy volunteer: the proGAV 2.0; Codman Certas Plus; Polaris; and Strata MR. They set 3 different scales of pressures for each valve, depending on magnet orientation to the body axis. Artifacts were evaluated and compared among all valves on a 3.0-T GE scanner and 2 valves were also evaluated on a Philips scanner and a Siemens scanner. In-plane artifact sizes were evaluated as the maximum distance of the artifact from the expected scalp. RESULTS: The sizes and shapes of artifacts changed depending on valve pressure for all valves on the 3 different MRI scanners. Artifacts were less prominent on spin echo sequences than on gradient echo sequences. For diffusion-weighted imaging and time-of-flight MR angiography, the authors matched image numbers within the same sequence and compared appearances of artifacts. For all valves, the number of images affected by artifacts and the image number showing the largest artifact differed among valve settings. CONCLUSIONS: Artifacts of all adjustable shunt valves showed gross changes corresponding to pressure setting. Not only the maximum distance of artifacts but also the shape changed significantly. The authors suggest that changing pressure settings offers one of the easiest ways to minimize artifacts on MRI.

A multicenter brain perfusion SPECT study evaluating idiopathic normal-pressure hydrocephalus on neurological improvement.

PURPOSE: This study was designed to investigate the specific cerebral blood flow (CBF) pattern in patients with idiopathic normal-pressure hydrocephalus (iNPH) and a predictive value for shunt responsiveness in a multicenter study (Study of Idiopathic Normal-Pressure Hydrocephalus on Neurological Improvement: SINPHONI). METHODS: Eighty-four iNPH patients underwent shunt operations using MRI selection criteria from the SINPHONI and were subjected to CBF single photon emission computed tomography (SPECT). The perfusion patterns on SPECT were classified: anterior-dominant CBF reduction type (A type), posterior-dominant CBF reduction type (P type), and mixed or diffuse CBF reduction type (M type). The predictive value of the CBF pattern for favorable shunt outcome was evaluated. RESULTS: Favorable outcomes were obtained in 76% (64/84) of patients, and shunt responsiveness was achieved in 85% (71/84) of patients. Areas of severely reduced relative CBF were demonstrated around the corpus callosum and in the sylvian fissure area, which included the effects of dilatations of the ventricles and sylvian fissures and relatively increased perfusion in the medial and lateral frontal, parietal, and occipital areas at high convexity. Forty-nine (58%) cases were A type, 25 (30%) cases were M type, and 10 (12%) cases were P type. A, M, and P type cases exhibited 83, 84, and 90% positive predictive values for shunt responsiveness, respectively. Mean modified Rankin scale and Mini-Mental State Examination scores of the A type group were significantly better than those of other groups. CONCLUSION: The iNPH patients showed various patterns of CBF reduction, but there was no significant difference in the predictive value among the three patterns, though CBF reduction patterns may suggest a severe condition of iNPH.

Striatal D2 receptor availability after shunting in idiopathic normal pressure hydrocephalus.

UNLABELLED: Gait disturbance in idiopathic normal pressure hydrocephalus (iNPH) is reminiscent of parkinsonism. Our recent PET study showed reduction in postsynaptic D(2) receptor binding concomitant with a normality of presynaptic dopamine transporter binding. Here, we investigated the plasticity of D(2) receptor in treating iNPH patients with ventriculoperitoneal (VP) shunting using PET with (11)C-raclopride and discuss the contribution of D(2) receptor to the pathophysiology of iNPH. METHODS: Eight iNPH patients participated in this study. After evaluation of their neuropsychologic abilities, all patients underwent 3-dimensional MRI and quantitative PET measurements twice before and 1 mo after VP shunting. MRI-based morphometric analyses were performed to examine postoperative variations of the ventricles. Estimation of binding potential (BP) for (11)C-raclopride was based on Logan plot analysis. Region-of-interest analysis was used to examine changes in (11)C-raclopride BP in the striatum. A 2-tailed paired t test was used for evaluating changes in PET and MRI parameters between conditions, and correlation analysis was used to investigate clinicopathophysiologic relevance (clinical vs. in vivo findings). RESULTS: Clinical evaluation revealed significant recovery in a 5-m back-and-forth navigation test and an affect test and a mild increase in Mini-Mental State Examination scores after VP shunting. Significant postoperative increases in (11)C-raclopride BP were found in the nucleus accumbens and dorsal putamen, and the increases were significantly associated with emotional (Spearman rank r = 0.66, P < 0.05) and navigational improvement (r = 0.72, P < 0.05), respectively. The (11)C-raclopride BP increase in the striaum as a whole correlated significantly with improvement in general cognitive ability. There was a mild ventricular shrinkage after surgery, albeit there was no correlation of its size with clinical and PET parameters. CONCLUSION: Striatal upregulation of D(2) receptor after VP shunting is associated with amelioration of hypokinetic gait disturbance and anhedonic mentation in iNPH patients, indicating that the effect of VP shunting may reside in noninhibition of functionally suppressed D(2) receptor in the striatum. D(2) receptor responsiveness may indicate a mechanism for iNPH pathophysiology.

In vivo presynaptic and postsynaptic striatal dopamine functions in idiopathic normal pressure hydrocephalus.

Differentiation of impaired gait seen in idiopathic normal pressure hydrocephalus (iNPH) from parkinsonian gait is sometimes a great challenge and important for future medication in the clinical setting. To investigate dopaminergic contribution to its pathophysiology, two aspects of the trans-synaptic dopamine functions in the striatal region in eight iNPH patients naïve to dopaminergic drugs were examined using positron emission tomography with a presynaptic marker [11C]CFT ([11C]2-beta-carbomethoxy-3beta-(4-fluorophenyl) tropane) that binds to dopamine transporter and a postsynaptic marker [11C]raclopride that binds to D2 receptor. Quantitative values of binding potentials (BPs) for [11C]CFT and [11C]raclopride were compared between patients and eight age-matched healthy subjects. The BPs and magnetic resonance imaging-based morphometric measures in iNPH were used for correlation analyses between the magnitude of binding of these in vivo markers and clinical severity of the patients. Analysis of variance showed significant reduction in [11C]raclopride binding in the putamen and nucleus accumbens (P<0.05, corrected for multiple comparison) and unchanged striatal [11C]CFT binding in iNPH. The dorsal putamen [11C]raclopride binding correlated negatively with gait severity (r=0.720, P<0.05), and the nucleus accumbens [11C]raclopride binding correlated positively with emotional recognition score (r=0.727, P<0.05) in the disease group. No significant relationship was observed between BPs and morphometric measures. The current result of the postsynaptic D2 receptor reduction along with preserved presynaptic activity in the nigrostriatal dopaminergic system reflects a pathophysiology of iNPH. Postsynaptic D2 receptor hypoactivity in the dorsal putamen may predict the severity of gait impairment in iNPH.

Giant basal cell carcinoma: improvement in the quality of life after extensive resection.

We describe a rare case of giant basal cell carcinoma which invaded the orbital tissue and the anterior skull base. Though the eyeball in the right orbit was preserved with the tumour at the patient's request, the improvement in the quality of the patient's life was achieved.

[A case of infected subdural hematoma following chronic subdural hematoma irrigation].

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