A case of inferior frontal gyrus infarction manifesting Gerstmann syndrome.

A 48-year-old female suffered from cerebral infarction involving the left inferior frontal gyrus. This was due to ischemic complications of endovascular treatment for subarachnoid hemorrhage. She exhibited severe acalculia, agraphia, finger agnosia, and right-left disorientation (the four features of Gerstmann syndrome), but aphasia was scarcely noticeable. Single-photon emission tomography revealed hypoperfusion in the left inferior frontal area and also in the left parietal area. It is possible that Gerstmann syndrome was caused in the present case by disruption of the association fiber connecting the inferior frontal area with the inferior parietal area.

Evaluation of the Arterial Wall in Vertebrobasilar Artery Dissection Using High-Resolution Magnetic Resonance Vessel Wall Imaging.

BACKGROUND: High-resolution magnetic resonance vessel wall imaging (HRMR-VWI) has been used to explore vascular diseases such as vasculitis and vulnerable plaque of intracranial arteries. Although vessel wall inflammation is suspected as one of the causes of cerebral arterial dissection, there have been few reports regarding the application of HRMR-VWI to arterial dissection. We have therefore evaluated the efficacy of HRMR-VWI in patients with vertebrobasilar artery dissection. METHODS: HRMR-VWI was performed on 5 patients who had been diagnosed with nonhemorrhagic vertebrobasilar artery dissection. RESULT: Four patients exhibited vessel wall enhancement on HRMR-VWI, the range of which corresponded with the dissection sites identified by cerebral angiogram, magnetic resonance imaging, or magnetic resonance angiography. The enhancements observed in all cases were extensive as compared with the findings of conventional angiography. CONCLUSION: HRMR-VWI is thought to elucidate the condition of the affected vessel wall more in detail as compared with conventional methods.

Impairment of bimanual in-phase movement during recovery from frontal lobe tumor surgery: a case report.

The mechanisms underlying bimanual coordination have not yet been fully elucidated. Here, we evaluated the clinical features of bimanual movement impairment in a patient following surgery for a frontal lobe tumor. The patient was an 80-year-old man who had undergone subtotal tumor resection for a tumor in the right superior frontal gyrus. Histological examination of the resected specimen led to the diagnosis of malignant lymphoma of the diffuse large B-cell type, and the patient subsequently received high-dose methotrexate-based chemotherapy. Postoperatively, the patient had difficulty with bimanual movement, and on the 5th postoperative day we found that the impairment could not be attributed to weakness. Temporal changes in the characteristics of manual movements were analyzed. Bimanual diadochokinesis (opening/closing of the hands, pronation/supination of the forearms, and sequential finger movements) was more disturbed than unilateral movements; in-phase movements were more severely impaired than anti-phase movements. Bimanual movement performance was better when cued using an auditory metronome. On the 15th postoperative day, movements improved. The present observations show that in addition to the disturbance of anti-phase bimanual movements, resection of the frontal lobe involving the supplementary motor area (SMA) and premotor cortex (PMC) can cause transient impairment of in-phase bimanual diadochokinesis, which can be more severe than the impairment of anti-phase movements. The effect of auditory cueing on bimanual skills may be useful in the diagnosis of anatomical localization of the superior frontal gyrus and functional localization of the SMA and PMC and in rehabilitation of patients with brain tumors, as in the case of degenerative movement disorders.

Intrathecal baclofen therapy for Lesch-Nyhan disease: illustrative case.

BACKGROUND: Lesch-Nyhan disease (LND) is a very rare metabolic disorder involving the purine salvage pathway. LND manifests hyperuricemia, self-mutilation, cognitive impairment, and movement disorders such as spasticity and dystonia, whose control is difficult pharmaceutically. OBSERVATIONS: Intrathecal baclofen (ITB) therapy was received by a 22-year-old male for generalized dystonia. His paroxysmal abnormal dystonic posturing reduced after surgery, making the task of caregivers easier despite the unchanged assignment on the dystonia scale during a follow-up period of 4 years. LESSONS: ITB may be a safe and feasible option for dystonic symptoms and difficulty with nursing care in patients with LND.

Severe hemodynamic depression after carotid artery stenting: The problem overcome with a transvenous temporary cardiac pacemaker.

BACKGROUND: Carotid angioplasty stenting (CAS) may have adverse events including perioperative hemodynamic depression. A transvenous temporary cardiac pacemaker (TTCP) is an option for preventing devastating sequelae due to circulatory failure. An exploration of the predictors of hemodynamic depression following CAS is valuable for selecting candidates for preoperative TTCP implantation before CAS. CASE DESCRIPTION: An 84-year-old man underwent CAS for asymptomatic left carotid severe stenosis. He had no history of bradycardia arrhythmia. A TTCP was implanted in advance in view of the likelihood of perioperative hemodynamic depression. CAS was accomplished successfully, but severe hypotension and vanishing of self-heartbeat occurred about 90 min after the procedure. By activating the pre-implanted TTCP, spontaneous circulation was readily recovered with vasopressor administration. He was discharged with no additional neurological deficits. A literature review using a random effect model found that smoking (odds ratio [OR] 1.68, 95% confidence interval (CI) 1.13-2.52) and severely calcified plaque (OR 3.70, 95% CI 2.15-6.35) were significant predictors of perioperative hemodynamic depression following CAS. CONCLUSION: TTCP can be recommended for a patient receiving CAS to prevent catastrophic consequences, particularly in cases with a history of smoking or severely calcified plaque.

Use of transcranial direct current stimulation in poststroke postural imbalance.

Independent gait following stroke is ultimate goal of rehabilitation. Non-invasive neuromodulation achieving it has never been reported. A 74-year-old woman suffered from subarachnoid haemorrhage, followed by hydrocephalus. Both were treated successfully. Even 1 year after the ictus, ambulation was difficult due to truncal instability with lateropulsion mainly to the left side. Transcranial direct current stimulation (tDCS) was applied to the parietal area (2mA for 20 min/day; anode on left side, cathode on right) for 16 days. The intervention improved her truncal instability and she achieved independent gait. tDCS of the parietal area could be a novel treatment option for gait disturbance due to postural instability following stroke.

Mixed Pial-Dural Arteriovenous Malformation in the Anterior Cranial Fossa Mimicking Dural Arteriovenous Fistula.

Mixed pial-dural arteriovenous malformation (MpdAVM) and dural arteriovenous fistula (dAVF) are rare entities in the anterior cranial fossa (ACF). As dural-pial vascular anastomosis can exist near the cribriform plate, MpdAVM with a small nidus, which cannot be apparently identified, can be logically indistinguishable from dAVF in ACF. A 71-year-old man was referred for evaluation of possible intracranial vascular malformation. Cerebral angiography revealed an arteriovenous shunt in the ACF. The lesion was fed by the bilateral ethmoidal arteries and right orbitofrontal artery, draining through the bilateral cortical veins to the superior sagittal sinus. As a nidus was not detected, dAVF was suspected. Venous interruption was planned with direct surgery. Intraoperatively, an arterial aggregation was observed in the right frontal lobe. The arterial aggregation seemed to be connected to the interrupted drainer in the right ACF. The arterial aggregation was removed and pathologically diagnosed as arteriovenous malformation. Postoperatively, intracerebral hemorrhage was confirmed, and postoperative cerebral angiography confirmed the resolved arteriovenous shunt. The intracranial hemorrhage was possibly due to the timing gap between drainer interruption and removal of the nidus. MpdAVM with a small nidus in the ACF can mimic dAVF. Clinicians must be aware that an unremoved nidus of MpdAVM may postoperatively result in fatal intracranial hemorrhage.

Improved cerebral function in mesial temporal lobe epilepsy after subtemporal amygdalohippocampectomy.

The functional changes that occur throughout the human brain after the selective removal of an epileptogenic lesion remain unclear. Subtemporal selective amygdalohippocampectomy (SAH) has been advocated as a minimally invasive surgical procedure for patients with medically intractable mesial temporal lobe epilepsy (MTLE). We evaluated the effects of subtemporal SAH on cerebral glucose metabolism and memory function in 15 patients with medically intractable MTLE with hippocampal sclerosis using [(18)F]-fluorodeoxyglucose PET (FDG-PET) and the Wechsler Memory Scale-Revised. The patients were evaluated before and 1-5 years (mean 2.6 years) after surgery. In patients with MTLE of the language-dominant hemisphere, the basal temporal language area was preserved by this surgical approach. Voxel-wise comparison of FDG-PET images was conducted using SPM5 to identify the brain regions showing postoperative changes in glucose metabolism (height threshold, P = 0.01 corrected for multiple comparisons; extent threshold, 100 voxels). During spatial normalization of the postoperative FDG-PET images, we used cost-function masking to minimize any inappropriate image distortion as a result of the abnormal signal within the surgically resected region. Postoperative glucose metabolism increased in extratemporal areas ipsilateral to the affected side, such as the dorsolateral prefrontal cortex, and the dorsomedial and ventromedial frontal cortices. Glucose metabolism also increased in the bilateral inferior parietal lobules and in the remaining temporal lobe regions remote from the resected mesial temporal region, such as the superior temporal gyrus and the temporal pole. By contrast, postoperative glucose metabolism decreased only in the mesial temporal area adjacent to the resected region. Postoperative verbal memory, delayed recall and attention/concentration scores were significantly better than preoperative scores regardless of the resected side. This study suggests that the selective removal of the epileptogenic region in MTLE using a subtemporal approach improved cerebral glucose metabolism in the areas receiving projections from the affected mesial temporal lobe. Cognitive improvement might result from a combination of good seizure control and minimizing the regions of the brain with postoperative functional impairment.

[A case of acute subdural hematoma from dissection of cortico-dural anastomosis].

A case of acute subdural hematoma caused by rupture of a bridging artery between the dura and the cortical surface is reported. A 49-year-old man complained of headache in the left temporal area after he had lifted up a heavy load. His symptom did not improve in spite of taking analgesics, so he was transferred to our hospital. Brain CT disclosed left acute subdural hematoma. Soon after admission, he became comatose and developed right hemiplegia. The cerebral angiogram displayed a tapering occlusion of a branch of the left middle cerebral artery. Emergent decompressive craniectomy was performed, and the anastomotic artery between the dura mater and the cortical artery was followed until it appeared normal in the cortical sulcus. Proximal occlusion of the artery was carried out. Pathological examination demonstrated the dissection of the anastomotic artery. This is the first reported and pathologically-proven case of acute subdural hematoma caused by dissection of the anastomotic artery between the dura mater and the cortical artery.

Premorbid instrumental activities of daily living predicts discharge home following stroke.

BACKGROUND AND PURPOSE: Stroke survivors who remain dependent require multiple healthcare resources, including rehabilitation and nursing care. The effect of premorbid instrumental ADL (IADL) on the discharge destination, which has not been studied previously in detail, is analyzed. MATERIALS AND METHODS: Between April and September 2015, 40 stroke patients admitted to hospital were enrolled prospectively in the present study. The ADL (Barthel index) and IADL (Frenchay activities index: FAI) scores in their premorbid status were recorded. Baseline demographic data, stroke severity (NIHSS) and type of stroke, and whether they lived with family were also recorded. Simple univariate regression was performed between the two discharge destination groups (Home or Not Home). Significant factors were then included in multivariate logistic regression in order to determine the adjusted odds ratio for the discharge destination. A P value <.05 was taken as significant. RESULTS: 25 patients (64.1%) returned home. According to univariate analysis, NIHSS on admission and premorbid FAI were significantly associated with the discharge destination. Multivariate analysis found that NIHSS (OR, 0.71; 95% CI0.56-0.92; p = .008) and premorbid FAI (OR, 1.17; 95% CI1.03-1.33; p = .01) were independent predictors of the discharge destination. CONCLUSIONS: Severity of stroke upon admission and premorbid IADL are associated with discharge destination following stroke.

Transcranial Direct Current Stimulation Improves Pusher Phenomenon.

An 83-year-old man suffered from cerebral infarction of the right middle cerebral artery territory. In association with severe left hemiparesis and hemispatial neglect on the left side, he showed severe pusher phenomenon (PP), which made rehabilitation difficult. Transcranial direct current stimulation (tDCS) was applied to the parietal area (2 mA × 20 min/day; anode on the right and cathode on the left) for 8 days, which resulted in remarkable improvement of PP and caused prolongation of static sitting time. tDCS of the parietal area could be a novel treatment option of PP following stroke.

Carotid Artery Stenting for Symptomatic Internal Carotid Artery Stenosis Associated with Moyamoya Disease.

BACKGROUND: Surgical intervention in a case of internal carotid artery stenosis with moyamoya vessels has not been well described. We present a case with detailed description of the surgical procedure and perioperative management. CASE DESCRIPTION: A 58-year-old man with symptomatic internal carotid artery stenosis had concurrent moyamoya vessels intracranially. He had motor weakness and numbness in the left upper extremity. Magnetic resonance imaging showed an ischemic lesion in the right frontal lobe and right chronic subdural hematoma. On day 18 after surgery for subdural hematoma, carotid artery stenting was performed under proximal balloon protection and distal filter protection. After carotid artery stenting, systolic blood pressure was maintained at <120 mm Hg. Hyperperfusion syndrome or hemorrhagic complication did not occur. The patient was discharged without any neurologic deficits. CONCLUSIONS: In our patient with internal carotid artery stenosis with moyamoya vessels, strict control of blood pressure likely contributed to prevention of hyperperfusion syndrome or hemorrhagic complications.

A local excitation magnetic resonance imaging method for intracranial unruptured aneurysm at the distal internal carotid artery.

It is often difficult to diagnose an intracranial aneurysm at the distal internal carotid artery by conventional magnetic resonance imaging. PURPOSE: We assessed the effectiveness of the local excitation technique, a new application for magnetic resonance imaging, to clarify the geometric structure of aneurysm and adjacent branches at the distal internal carotid artery. STUDY DESIGN: Two independent evaluators diagnosed 10 cases of suspected aneurysms at the distal internal carotid artery by T2-weighted magnetic resonance imaging with application of local excitation, adding it to conventional time-of-flight-magnetic resonance angiography. FINDINGS: We successfully distinguished the aneurysm from infundibular dilatation in five of 10 cases. CONCLUSION: Our results suggested that addition of local excitation to conventional magnetic resonance angiography was effective to diagnose unruptured aneurysm at the distal internal carotid artery, to clarify the configuration of the prominent lesion or whether the location of the adjacent branch orifice on the parent vessel was symmetric or asymmetric.

Spontaneous Resolution of Cerebral Pial Arteriovenous Fistula After Angiography: Report of Two Cases.

BACKGROUND: Cerebral pial arteriovenous fistula (AVF) is a rare disorder, and its natural course is uncertain. The present article reports 2 rare cases of pial AVF that underwent spontaneous cure after diagnostic cerebral angiogram. CASE DESCRIPTIONS: A 73-year-old man presented with generalized seizure and reported severe but intermittent headache in the right temporo-occipital area. Single-photon emission computed tomography (SPECT) showed hyperperfusion in that area. The main finding of a cerebral angiogram was an arteriovenous shunt at the cortical surface of the right temporal area. Soon after this diagnostic angiogram, the symptoms vanished. A further cerebral angiogram showed the disappearance of this pial AVF, and a SPECT study showed resolution of the hyperperfusion of the affected area. A 69-year-old man, with a history of intracerebral hemorrhage on the left parietal area 3 years earlier, presented with speech disturbance and headache on his left side. SPECT showed hyperperfusion in the left temporoparietal area. A cerebral angiogram showed an arteriovenous shunt at the surface of the left parietal area. During the same cerebral angiogram session, the pial AVF disappeared after the third injection of a contrast medium with magnification. Two days after the cerebral angiogram, the patient's headache disappeared and speech disturbance gradually improved. SPECT also showed disappearance of the hyperperfusion. CONCLUSIONS: It is possible that pial AVF is a cause of headache and neurologic symptoms in association with focal hyperperfusion. Diagnostic cerebral angiography should be performed to make a definite diagnosis; after this, pial AVF sometimes disappears.

Alteration of Venous Drainage Route in Idiopathic Normal Pressure Hydrocephalus and Normal Aging.

Idiopathic normal pressure hydrocephalus (iNPH) is a highly prevalent condition in the elderly population; however, the underlying pathophysiology in relation to the aging process remains unclear. To investigate the effect of removal of cerebrospinal fluid by lumbar "tap test" on the cerebral circulation in patients with iNPH, 14 patients with "probable" iNPH were studied using a novel blood tracking technique based on blood oxygenation level-dependent (BOLD) magnetic resonance signal intensity. By tracking the propagation of the low-frequency component of the BOLD signal, extended venous drainage times were observed in the periventricular region of the patients, which was reversed by tap test. Interestingly, the venous drainage time in the periventricular region exhibited an age-related prolongation in the healthy control group. Additional regression analyses involving 81 control subjects revealed a dissociation of deep and superficial venous systems with increasing age, presumably reflecting focal inefficiency in the deep system. Our results not only provide insights into the etiology of iNPH, but also point to a potential non-invasive biomarker for screening iNPH.

Bereitschaftspotentials recorded from the lateral part of the superior frontal gyrus in humans.

To demonstrate the Bereitschaftspotentials (BPs) over the high lateral convexity in the superior frontal gyrus, movement-related cortical potentials with respect to the middle finger extension were recorded in seven patients with refractory epilepsy who underwent subdural implantation of platinum electrode grids and/or strips covering the high lateral frontal convexity. In two out of the seven patients, BPs were recorded from the electrodes placed on the superior frontal gyrus in the vicinity of the border between the medial and lateral frontal lobes, which were distinct from those recorded from the primary sensorimotor cortex. The results suggest the possible contribution of either the lateral dorsal non-primary motor area or the SMA to the generation of the BPs.

Low-frequency electric cortical stimulation decreases interictal and ictal activity in human epilepsy.

We previously reported that low-frequency electric cortical stimulation (LFECS) directly applied to the epileptic focus by means of subdural electrodes decreased the number of interictal epileptiform discharges in patients with intractable partial epilepsy. In the present study, LFECS was applied to the epileptic foci directly in four patients with medically intractable partial epilepsy through subdural electrodes and evaluated its effect on the number of interictal epileptiform discharges as well as simple partial seizures. We used alternating electric current of 0.3 ms duration presented at 0.9 Hz frequency for 250 s. LFECS did not induce seizures in any of the four patients. In one patient, the number of interictal epileptiform discharge decreased significantly by LFECS, which is in conformity with our previous report. In addition, LFECS applied to the seizure onset zone decreased the frequency of simple partial seizures in one patient. These results suggest that LFECS has an inhibitory effect not only on the interictal but also the ictal activities in patients with intractable partial epilepsy. Further study is required to determine the inhibitory effect of LFECS more in details.

Combination of Transcranial Direct Current Stimulation and Neuromuscular Electrical Stimulation Improves Gait Ability in a Patient in Chronic Stage of Stroke.

BACKGROUND: Walking ability is important in stroke patients to maintain daily life. Nevertheless, its improvement is limited with conventional physical therapy in chronic stage. We report the case of a chronic stroke patient showing a remarkable improvement in gait function after a new neurorehabilitation protocol using transcranial direct current stimulation (tDCS) and neuromuscular electrical stimulation (NMES). CASE PRESENTATION: A 62-year-old male with left putaminal hemorrhage suffered from severe right hemiparesis. He could move by himself with a wheelchair 1 year after the ictus. Anodal tDCS at the vertex (2 mA, 20 min) with NMES at the anterior tibialis muscle had been applied for 3 weeks. The Timed Up and Go test and 10-meter walk test improved after the intervention, which had been maintained for at least 1 month. CONCLUSION: This single case suggests the possibility that tDCS with NMES could be a new rehabilitation approach to improve the gait ability in chronic stroke patients.

Processing of Japanese morphogram and syllabogram in the left basal temporal area: electrical cortical stimulation studies.

Language functions in the left basal temporal area (LBTA) were investigated using electrical cortical stimulation during functional mapping in six Japanese patients with refractory epilepsy. This study provides the first direct evidence that kana (Japanese syllabogram) is processed in the LBTA. Electrical stimulation of some areas within LBTA induced disturbance in overt reading of kana words only in the first trials, with no errors in the subsequent trials. By contrast, stimulation of the same area caused obvious disturbance in kana non-word reading in all trials. Since a kana word carries both meaning and sound while a kana non-word carries only sounds of a letter string, the contrasting results of partial and complete disturbance imply a possibility that there are two distinct pathways for kana reading: one dealing with both phonological and semantic aspects of the words and the other dealing only with phonological aspect. Kanji words (Japanese morphogram) and objects/pictures were found to be processed in an area different from the area for the kana non-word processing. Furthermore, the present study also identified the common area for processing kanji reading and object/picture naming. There were no errors in matching pictures with kanji words, indicating that concepts of pictures and meanings of kanji words were not interfered by the electrical stimulation of that area. The new insight provides a clue for partial description of processing pathways for language-related visual information in LBTA. Three types of information (morphological, phonological, and semantic) are conveyed together at some stages and are separated into different routes at some other stages.