Stroke and cardio-ankle vascular stiffness index.

BACKGROUND: We investigated the relationship between stroke and cardio-ankle vascular stiffness index (CAVI), a novel noninvasive measure of vascular stiffness. METHODS: Eighty-five patients with cerebrovascular disease who underwent CAVI were enrolled in the current study. They were 63 men and 22 women with a mean age of 70.0 ± 10.8 years. They were divided into 4 groups according to neurologic abnormalities and magnetic resonance imaging (MRI) findings: 12 with transient ischemic attack (TIA), 26 with white matter ischemic lesions (WMLs), 17 with large artery atherosclerosis, and 30 with small vessel occlusion. Eight hundred fifty-four healthy patients (487 men and 367 women; mean age 65.1 ± 9.4 years) served as controls. The results were stratified by gender and age and statistically analyzed using the Fisher, Bonferroni-Dunn, and Scheffe tests. RESULTS: The average of CAVI was as follows: control males 60 to 69 years of age, 9.05 ± 0.82 (as a representative value); TIA, 9.3 ± 1.5; WML, 10.3 ± 1.3; large artery atherosclerosis, 10.2 ± 1.2; and small vessel occlusion, 10.0 ± 1.6, respectively. The difference in CAVI between each group and age- and gender-matched controls was 0.492 for TIA (no statistical significance); WML, 0.733 (P < .001, and P = .002 Scheffe); large artery atherosclerosis, 0.838 (P < .001, and P = .005 Scheffe); and small vessel occlusion, 1.034 (P < .001), respectively. Linear regression analysis of CAVI and plaque score revealed a significant relationship in patients with ischemic cerebrovascular disease (P < .05). CONCLUSIONS: Compared with healthy control subjects, CAVI is statistically greater in patients with ischemic cerebrovascular diseases, particularly with WML, large artery atherosclerosis, and small vessel occlusion, but not in patients with TIA. CAVI had a clear relationship with carotid ultrasound plaque score. It appears that CAVI is a simple and noninvasive test for indicating atherosclerosis in patients with stroke.

Correlation of right frontal hypoperfusion and urinary dysfunction in iNPH: a SPECT study.

OBJECTIVES: To elucidate the pathophysiology of urinary dysfunction in idiopathic normal-pressure hydrocephalus (iNPH) by single-photon emission computed tomography (SPECT) and statistical brain mapping. METHODS: Urinary symptoms were observed and N-isopropyl-p-[(123)I]-iodoamphetamine (IMP)-SPECT imaging was performed in 97 patients with clinico-radiologically definite iNPH. The patients included 56 men and 41 women; mean age, 74 years. The statistical difference in normalized mean tracer counts was calculated and visualized between patients with urinary dysfunction of severer degrees (>grade 2/4) and milder degrees (

Constipation triggered the malignant syndrome in Parkinson's disease.

A 69-year-old, chronically constipated patient with Parkinson's disease developed fecal impaction and the malignant syndrome simultaneously, even while the patient was taking anti-parkinsonian drugs as prescribed. Administration of intravenous levodopa and oral Dai-kenchu-tou, an herbal medicine with serotonergic 5-HT3 receptor agonistic property successfully ameliorated his clinical symptoms. Constipation may trigger worsening of Parkinson's disease and occurrence of the malignant syndrome by affecting levodopa absorption. Further, improved bowel motility may prevent worsening of Parkinson's disease and occurrence of the malignant syndrome.

Lateral medullary infarction presenting as isolated vertigo and unilateral loss of visual suppression.

Isolated vertigo is rare in lateral medullary infarction. We described early diagnostic challenges in such cases by a neuro-otological approach. We report a 56-year-old man who developed a lateral medullary infarction that presented as isolated vertigo. Before the day 4 from disease onset when diffusion-weighted magnetic resonance imaging (MRI) became positive, this patient showed unilateral loss of visual suppression, a central type of vestibular dysfunction. Since MRI abnormalities may not appear in the early few days from disease onset, unilateral loss of visual suppression might become an important diagnostic option for isolated vertigo due to a lateral medullary infarction. This finding is presumably relevant to the inferior olive lesion.

Pathogenesis of reduced or increased bladder sensation.

OBJECTIVE: Pathogenesis of reduced or increased bladder sensation is not well known. Hence, we systematically investigated the frequency of reduced or increased bladder sensation in neurologic/mental diseases. METHODS: We analyzed 911 patients who were referred from within our hospital. Data registries included a diagnosis, a lower urinary tract symptom questionnaire, a urodynamic study, and neurological examinations. Reduced bladder sensation is defined as bladder volume at the first sensation >300 ml. Increased bladder sensation is defined as bladder volume at the first sensation <100 ml. These patients were stratified into those with and without DO. RESULTS: Neuropathies are the most common cause of reduced bladder sensation (33.3-43.8% in diabetic neuropathy, etc.). Myelopathies are the second most common cause (17.4-25.0% in multiple sclerosis, etc.). Less common is brain diseases (9.6% in multiple system atrophy, etc.). In contrast, myelopathies are the most common cause of increased bladder sensation without DO (25.0-40.0% in spinal forms of systemic lupus erythematosus, Sjogren's syndrome, etc.). Neuropathies are the second most common (17.3-22.2% in post-pelvic organ surgery, diabetic neuropathy, etc.). Less common is brain/mental diseases (20.0% in psychogenic bladder dysfunction, 8.1% in Parkinson's disease, etc.). CONCLUSION: The present study revealed that neuropathies are the most common cause of reduced bladder sensation in neurologic/mental diseases. Increased bladder sensation without DO occurs mainly in peripheral and central sensory pathway lesions, as well as in basal ganglia lesions and psychogenic bladder dysfunction. Reduced and increased bladder sensation should be a major treatment target for maximizing patients' quality of life.

Progressive supranuclear palsy presenting with urinary retention and sleep apnea.

We report a case of a 62-year-old Japanese-Australian woman with progressive supranuclear palsy (PSP) who presented with prominent urinary retention, neurogenic changes in sphincter electromyography, and obstructive sleep apnea syndrome. Urodynamic study revealed a combination of detrusor overactivity during filling and underactivity during voiding. All these non-motor symptoms in PSP mimicked those of multiple system atrophy.

Bilateral abducens palsy in a case of cytomegalovirus-associated Guillain-Barré syndrome.

Ophthalmoparesis in cytomegalovirus (CMV)-associated Guillain-Barré syndrome (GBS) is rare. We treated a 37-year-old woman with CMV-GBS who presented with an acute onset of generalized weakness and numbness in the extremities, followed by facial diplegia, which led to mechanical ventilation. She had increased IgM and IgG-type antibodies against CMV in the serum and increased IgM-type serum anti-GM2 ganglioside antibody was also noted, whereas anti-GQ1b ganglioside antibody was not found. She then developed the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). After recovery of consciousness due to SIADH, she exhibited bilateral abducens palsy, together with the recurrence of limb weakness and facial diplegia. Her neurological signs gradually recovered after high-dose intravenous administrations of immunoglobulin. CMV infection should be listed in the differential diagnosis of GBS patients who present with ophthalmoparesis.

VGCC antibody-positive paraneoplastic cerebellar degeneration presenting with positioning vertigo.

A 70-year-old woman developed paraneoplastic cerebellar degeneration (PCD) due to P/Q-type and N-type voltage-gated calcium channel antibodies and small cell lung cancer, the main clinical manifestations of which were severe positioning vertigo and vomiting. Loss of the visual suppression of caloric nystagmus, spontaneous downbeat nystagmus, periodic alternating nystagmus, and positioning vertigo in our patient most probably corresponds to the cerebellar flocculus/paraflocculus lesion caused by PCD.

Real-time measurement of oxyhemoglobin concentration changes in the frontal micturition area: an fNIRS study.

OBJECTIVE: To explore brain activity in the frontal micturition area during natural bladder behavior. METHODS: Five control subjects (one man and four women; mean age 61 years [38-70]) and four subjects with detrusor overactivity (all men; mean age 55 years [33-65]) were enrolled in the study. We performed real-time measurements of oxyhemoglobin concentration (oxy-Hb) changes in the frontal micturition area using functional near-infrared spectroscopy (fNIRS) in response to quasi-natural, continuous bladder filling, and voiding in a sitting position. RESULTS: In the control group the following results were obtained: (1) a slight increase of oxy-Hb before first sensation occurred, (2) there was a continuous increase of oxy-Hb during bladder filling to the point just after voiding began, (3) there was a continuous decrease of oxy-Hb after voiding, (4) in subjects who were unable to urinate, oxy-Hb also decreased after attempting to void, and (5) the area activated was the bilateral lateral prefrontal area, particularly Brodmann's areas 8, 10, and 46. In the detrusor overactivity group, (6) an increase of oxy-Hb before first sensation was rare and frontal cortical activation was weak, (7) at the moment detrusor overactivity appeared, fNIRS brain activity in the frontal cortex did not change significantly; and otherwise the results were almost the same as those in the control group. CONCLUSIONS: This study shows that the frontal micturition area is activated during natural bladder filling and voiding using fNIRS.

Good maternal and fetal outcomes of predominantly sensory Guillain-Barré syndrome in pregnancy after intravenous immunoglobulin.

Guillain-Barré syndrome (GBS)-complicating pregnancy is rare; and it is generally believed that it carries a high maternal risk. We reported a case of good maternal and fetal outcomes of predominantly sensory GBS (generalized pain and numbness, mild deep sensory ataxia, positive serum IgM anti-GalNAcGD1a antibody)-complicating pregnancy after intravenous immunoglobulin treatment.

Isolated facio-lingual hypoalgesia and weakness after a hemorrhagic infarct localized at the contralateral operculum.

Isolated facio-lingual hypoesthesia and weakness is rare. We describe a case of isolated facio-lingual hypoesthesia and weakness after a hemorrhagic infarct localized at the contralateral operculum. A 66-year-old woman developed acute onset of facio-lingual hypoalgesia, hypoesthesia, and weakness, with no such symptoms being observed in other parts of the body. Brain magnetic resonance imaging showed a subacute hemorrhagic infarct in the right frontal operculum, which spread slightly to the right temporo-parietal operculum. (123)IMP-SPECT showed hypoperfusion in the right fronto-temporo-parietal operculum, as detected by MRI, without apparent diaschisis within the brain. Neuroimaging findings for our patient suggested the involvement of the primary somatosensory-motor cortices (S1 and M1) and the secondary somatosensory cortex (S2), which receive trigemino-thalamo-cortical pathways.

Aseptic meningitis as the sole manifestation of Behçet's disease.

We report a 33-year-old woman who had aseptic meningitis alone, without any other systemic manifestations, due to Behçet's disease. Behçet's disease should be listed as a differential diagnosis of acute aseptic meningitis because, in acute aseptic meningitis caused by Behçet's disease, early treatment with corticosteroids could ameliorate this disorder.

Vascular incontinence: incontinence in the elderly due to ischemic white matter changes.

This review article introduces the new concept of vascular incontinence, a disorder of bladder control resulting from cerebral white matter disease (WMD). The concept is based on the original observation in 1999 of a correlation between the severity of leukoareosis or WMD, urinary symptoms, gait disorder and cognitive impairment. Over the last 20 years, the realization that WMD is not a benign incidental finding in the elderly has become generally accepted and several studies have pointed to an association between geriatric syndromes and this type of pathology. The main brunt of WMD is in the frontal regions, a region recognized to be crucial for bladder control. Other disorders should be excluded, both neurological and urological, such as normal-pressure hydrocephalus, progressive supranuclear palsy, etc., and prostatic hyperplasia, physical stress incontinence, nocturnal polyuria, etc. Treatment involves management of small vessel disease risk factors and anticholinergic drugs that do not easily penetrate the blood brain barrier to improve bladder control.

Lower Urinary Tract Function in Spinocerebellar Ataxia 6.

OBJECTIVE: To investigate lower urinary tract function in spinocerebellar ataxia type 6 (SCA6). METHODS: We recruited, without bias, nine SCA6 patients with a mean cytosine-adenine-guanine repeat length of 24.3 (21-26, normal <18). They were four men, five women; mean age 58.6 years; mean disease duration 8.2 years. We performed a urinary symptom questionnaire and a urodynamics. RESULTS: Urinary symptoms were observed in five of nine patients (56%) and urinary frequency in three of nine patients (33%), and none had urinary retention. Urodynamic abnormalities included detrusor overactivity in one (11%) and weak detrusor on voiding in two, but none had postvoid residual urine. Sphincter electromyography revealed, while mild in degree, neurogenic change in five of the eight patients (63%) on whom the test was performed. CONCLUSION: We observed urinary frequency in 33%; detrusor overactivity in only 11%; and neurogenic change in the sphincter electromyography in 63% of our nine SCA6 patients. These findings might be relevant to the cerebellar and spinal cord pathologies of this disease.

Pure akinesia with low myocardial metaiodobenzylguanidine uptake.

The objective of this study was to delineate the clinical features of patients with pure akinesia and a low heart versus mediastinum ratio below 2.0 in the delayed images of myocardial metaiodobenzylguanidine scintigraphy, a marker for the clinical diagnosis of Lewy body diseases. A total of 13 patients was enrolled. The clinical features of the patients were uniformly elderly (mean age, 73.7 years), a male gender preponderance (10 men and 3 women), relatively mild motor disability (mean Hoehn Yahr grade 2.4) without laterality, festinating gait (77%) and loss of postural reflex (69%), which were the most common; also observed were fair levodopa responses (70%), cognitive dysfunction in some (23%), common autonomic dysfunction (urinary urgency and frequency, 85%; constipation, 77%; and postural hypotension, 38%) and common occipital hypoperfusion (62%). These features may facilitate the clinical differential diagnosis of these patients from patients with pure akinesia due to progressive supranuclear palsy.