Optimization of a motor learning attention-directing strategy based on an individual's motor imagery ability.

Motor learning performance has been shown to be affected by various cognitive factors such as the focus of attention and motor imagery ability. Most previous studies on motor learning have shown that directing the attention of participants externally, such as on the outcome of an assigned body movement, can be more effective than directing their attention internally, such as on body movement itself. However, to the best of our knowledge, no findings have been reported on the effect of the focus of attention selected according to the motor imagery ability of an individual on motor learning performance. We measured individual motor imagery ability assessed by the Movement Imagery Questionnaire and classified the participants into kinesthetic-dominant (n = 12) and visual-dominant (n = 8) groups based on the questionnaire score. Subsequently, the participants performed a motor learning task such as tracing a trajectory using visuomotor rotation. When the participants were required to direct their attention internally, the after-effects of the learning task in the kinesthetic-dominant group were significantly greater than those in the visual-dominant group. Conversely, when the participants were required to direct their attention externally, the after-effects of the visual-dominant group were significantly greater than those of the kinesthetic-dominant group. Furthermore, we found a significant positive correlation between the size of after-effects and the modality-dominance of motor imagery. These results suggest that a suitable attention strategy based on the intrinsic motor imagery ability of an individual can improve performance during motor learning tasks.

Ultrasound-guided central venous catheterization using an optical see-through head-mounted display: A pilot study.

PURPOSE: We examined the feasibility of using a head-mounted display (HMD) to improve the ergonomics of sonographic-guided interventional procedures. METHODS: Five physicians with experience of more than 20 central venous catheterizations participated in this study. Each participant performed five pairs of simulated jugular vein catheterization under sonographic guidance with and without the HMD. The procedure time was determined as well as the number of head movements, needle redirections, posterior wall punctures, and guidewire malpositionings. RESULTS: All participants could perform simulated sonographic-guided catheterization using this HMD without turning their heads. There were no differences in the procedural time, the number of needle redirections, posterior wall punctures, and guidewire malpositionings. CONCLUSIONS: The binocular optical see-through HMD could be adopted for sonographic-guided interventional procedures © 2016 Wiley Periodicals, Inc. J Clin Ultrasound 44:487-491, 2016.

[Rapid 3-Dimensional Models of Cerebral Aneurysm for Emergency Surgical Clipping].

We developed a method for manufacturing solid models of cerebral aneurysms, with a shorter printing time than that involved in conventional methods, using a compact 3D printer with acrylonitrile-butadiene-styrene(ABS)resin. We further investigated the application and utility of this printing system in emergency clipping surgery. A total of 16 patients diagnosed with acute subarachnoid hemorrhage resulting from cerebral aneurysm rupture were enrolled in the present study. Emergency clipping was performed on the day of hospitalization. Digital Imaging and Communication in Medicine(DICOM)data obtained from computed tomography angiography(CTA)scans were edited and converted to stereolithography(STL)file formats, followed by the production of 3D models of the cerebral aneurysm by using the 3D printer. The mean time from hospitalization to the commencement of surgery was 242 min, whereas the mean time required for manufacturing the 3D model was 67 min. The average cost of each 3D model was 194 Japanese Yen. The time required for manufacturing the 3D models shortened to approximately 1 hour with increasing experience of producing 3D models. Favorable impressions for the use of the 3D models in clipping were reported by almost all neurosurgeons included in this study. Although 3D printing is often considered to involve huge costs and long manufacturing time, the method used in the present study requires shorter time and lower costs than conventional methods for manufacturing 3D cerebral aneurysm models, thus making it suitable for use in emergency clipping.

Arcuate Na+,K+-ATPase senses systemic energy states and regulates feeding behavior through glucose-inhibited neurons.

Feeding is regulated by perception in the hypothalamus, particularly the first-order arcuate nucleus (ARC) neurons, of the body's energy state. However, the cellular device for converting energy states to the activity of critical neurons in ARC is less defined. We here show that Na(+),K(+)-ATPase (NKA) in ARC senses energy states to regulate feeding. Fasting-induced systemic ghrelin rise and glucose lowering reduced ATP-hydrolyzing activity of NKA and its substrate ATP level, respectively, preferentially in ARC. Lowering glucose concentration (LG), which mimics fasting, decreased intracellular NAD(P)H and increased Na(+) concentration in single ARC neurons that subsequently exhibited [Ca(2+)]i responses to LG, showing that they were glucose-inhibited (GI) neurons. Third ventricular injection of the NKA inhibitor ouabain induced c-Fos expression in agouti-related protein (AgRP) neurons in ARC and evoked neuropeptide Y (NPY)-dependent feeding. When injected focally into ARC, ouabain stimulated feeding and mRNA expressions for NPY and AgRP. Ouabain increased [Ca(2+)]i in single NPY/AgRP neurons with greater amplitude than in proopiomelanocortin neurons in ARC. Conversely, the specific NKA activator SSA412 suppressed fasting-induced feeding and LG-induced [Ca(2+)]i increases in ARC GI neurons. NPY/AgRP neurons highly expressed NKAα3, whose knockdown impaired feeding behavior. These results demonstrate that fasting, via ghrelin rise and LG, suppresses NKA enzyme/pump activity in ARC and thereby promotes the activation of GI neurons and NPY/AgRP-dependent feeding. This study identifies ARC NKA as a hypothalamic sensor and converter of metabolic states to key neuronal activity and feeding behaviour, providing a new target to treat hyperphagic obesity and diabetes.

Early diagnosis of cerebral ischemia in cerebral vasospasm by oxygen-pulse near-infrared optical topography.

PURPOSE: Early diagnosis of vasospasm is a key factor in the choice of treatment after subarachnoid hemorrhage (SAH). However, a noninvasive method of diagnosing delayed ischemic neurological deficit (DIND) has not been established. We therefore propose a new method of diagnosing cerebral ischemia using near-infrared optical topography (OT) with oxygen inhalation. MATERIALS AND METHODS: We used a 44-channel OT system that covers the bilateral front otemporoparietal areas to assess 29 patients who underwent surgery within 72 h of the onset of SAH. The patients inhaled room air followed by oxygen for 2 min, and then peripheral oxygen saturation (SpO2) was continuously monitored at the index fingertip. The patients were assessed by N-isopropyl-p-[¹²³I]iodoamphetamine (IMP)-SPECT and OT on the same day. Ischemic findings were confirmed using principal component analysis with reference to the systemic SpO2value. RESULTS: Seven of 29 patients developed DIND. Evidence of ischemia was identified by OT in all seven of these patients before the onset of DIND. The OT and SPECT findings agreed in 27 (93 %) of the 29 patients. DISCUSSION AND CONCLUSIONS: Our method might detect cerebral ischemia before the onset of DIND and thus be clinically useful for assessing cerebral ischemia with vasospasm.

Microvascular decompression under neuroendoscopic view in hemifacial spasm: rostral-type compression and perforator-type compression.

We report microvascular decompression (MVD) under neuroendoscopic view in hemifacial spasm (HFS) patients with rostral- and perforator-type compression of the root exit zone (REZ) of the facial nerve. Using either a wireless iPad Mini as a monitor on the microscope or a high-resolution monitor, microscopic and endoscopic views enabled MVD for complete cure of HFS with rostral-type compression (the offender compressing the REZ on the opposite rostral side to the operative approach) or perforator-type compression (the offender tethered to the REZ by the perforator). MVD under neuroendoscopic view may offer more accurate MVD and complete resolution of HFS.

Endonasal ultrasonography-assisted neuroendoscopic transsphenoidal surgery.

We report endonasal ultrasonography (US)-assisted neuroendoscopic transsphenoidal surgery (TSS) in seven patients. With sagittal and coronal US images, internal carotid arteries, anterior cerebral arteries, residual tumor, and lateral ventricles were recognized, and the tumors were removed without leakage of cerebrospinal fluid in patients with pituitary adenoma. US images clearly depicted the carotid arteries, anterior cerebral arteries, middle cerebral arteries, chiasmatic cistern, and residual tumor. Endonasal US images can provide real-time animated information and may help neuroendoscopic TSS, whenever needed during TSS.

[Shunt passer clamp: a new device to prevent rotation of CSF-shunt passer].

Cerebrospinal fluid shunting is a surgical treatment alternative for hydrocephalus. In general, ventriculoperitoneal (VP) and lumboperitoneal (LP) shunts have been widely practiced as standard procedures. However, these procedures are difficult because the shunt passer often rotates unintentionally. Therefore, we developed a simple device that prevents shunt passer rotation and termed it a "shunt passer-clamp"(SP-C). This device consists of two parts: the first part is the body with a hole through which the passer goes and a "female" screw perpendicular to the hole. The second part is a "male" screw set to the body. The surgeon can attach the SP-C to the shunt passer without the requirement for remodeling. We employed a SP-C for 14 consecutive shunt surgeries and received favorable feedback from the surgeons. Handling was considered "easy" in all cases. The surgical duration was significantly shorter than that if the SP-C was not employed. We conclude that our specially designed SP-C is relatively effective.

[Pre-surgical simulation of microvascular decompression for hemifacial spasm using 3D-models].

We have been performing pre-surgical simulations using custom-built patient-specific 3D-models. Here we report the advantageous use of 3D-models for simulating microvascular decompression(MVD)for hemifacial spasms. Seven cases of MVD surgery were performed. Two types of 3D-printers were used to fabricate the 3D-models:one using plaster as the modeling material(Z Printer®450, 3D systems, Rock Hill, SC, USA)and the other using acrylonitrile butadiene styrene(ABS)(UP! Plus 3D printer®, Beijing Tiertime Technology, Beijing). We tested three types of models. Type 1 was a plaster model of the brainstem, cerebellum, facial nerve, and the artery compressing the root exit zone of the facial nerve. Part of the cerebellum was digitally trimmed off to observe "the compressing point" from the same angle as that used during actual surgery. Type 2 was a modified Type 1 in which part of the skull was opened digitally to mimic a craniectomy. Type 3 was a combined model in which the cerebellum and the artery of the Type 2 model were replaced by a soft retractable cerebellum and an elastic artery. The cerebellum was made from polyurethane and cast from a plaster prototype. To fabricate elastic arteries, liquid silicone was painted onto the surface of an ABS artery and the inner ABS model was dissolved away using solvent. In all cases, the 3D-models were very useful. Although each type has advantages, the Type-3 model was judged extremely useful for training junior surgeons in microsurgical approaches.

Direct cortical hemodynamic mapping of somatotopy of pig nostril sensation by functional near-infrared cortical imaging (fNCI).

Functional near-infrared spectroscopy (fNIRS) is a neuroimaging technique for the noninvasive monitoring of human brain activation states utilizing the coupling between neural activity and regional cerebral hemodynamics. Illuminators and detectors, together constituting optodes, are placed on the scalp, but due to the presence of head tissues, an inter-optode distance of more than 2.5cm is necessary to detect cortical signals. Although direct cortical monitoring with fNIRS has been pursued, a high-resolution visualization of hemodynamic changes associated with sensory, motor and cognitive neural responses directly from the cortical surface has yet to be realized. To acquire robust information on the hemodynamics of the cortex, devoid of signal complications in transcranial measurement, we devised a functional near-infrared cortical imaging (fNCI) technique. Here we demonstrate the first direct functional measurement of temporal and spatial patterns of cortical hemodynamics using the fNCI technique. For fNCI, inter-optode distance was set at 5mm, and light leakage from illuminators was prevented by a special optode holder made of a light-shielding rubber sheet. fNCI successfully detected the somatotopy of pig nostril sensation, as assessed in comparison with concurrent and sequential somatosensory-evoked potential (SEP) measurements on the same stimulation sites. Accordingly, the fNCI system realized a direct cortical hemodynamic measurement with a spatial resolution comparable to that of SEP mapping on the rostral region of the pig brain. This study provides an important initial step toward realizing functional cortical hemodynamic monitoring during neurosurgery of human brains.

Spontaneous occlusion of the frontal arteriovenous malformation and the following progression of the associated aneurysm: a case report.

We report the case of a 59-year-old women with a cerebral arteriovenous malformation (AVM) in the right frontal lobe, which was detected incidentally. Additionally, an aneurysm was found at the feeding artery of the AVM. The patient was treated conservatively. Nine years later, the nidus of the AVM was no longer detectable. The angiography showed the associated aneurysm growing irregularly with a daughter sac. The spontaneous occlusion of an AVM and the following progression of an associated aneurysm are rare. The possible mechanisms leading to the occlusion of the AVM and the progression of the associated aneurysm are discussed.

Pregnancy-associated intracranial hemorrhage: results of a survey of neurosurgical institutes across Japan.

BACKGROUND: Pregnancy-associated hemorrhagic stroke is considered a serious complication. Although coagulopathy, pregnancy-induced hypertension, eclampsia, and other systemic complications have been emphasized, pre-existing cerebrovascular diseases (CVDs) have not been fully analyzed. To clarify the role of these vascular lesions more in detail, the Japan Neurosurgical Society conducted a nationwide survey on all the neurosurgical institutes across Japan. METHODS: This 2-year survey focused on hemorrhagic stroke occurring in pregnancy, delivery, and puerperium. Clinical data based on retrospective chart review were obtained through a questionnaire and analyzed according to the time of onset, underlying CVDs, obstetric systemic complications, therapeutic approaches, and maternal and neonatal prognoses. RESULTS: The survey identified 97 hemorrhagic strokes that were associated with pregnancy. Baseline CVDs responsible for hemorrhage were detected in 54 cases (55.7%), among which 47 lesions (87.0%) had been undiagnosed before stroke onset. The detection rate of baseline CVDs before the 32nd week of gestation was significantly higher than that after the 32nd week (90.0% versus 53.3%, P = .0017). Arteriovenous malformations (AVMs) were the most frequent CVDs causing intracranial hemorrhage, occurring at 1.8 times the frequency of ruptured aneurysms during pregnancy. Poor outcomes, including 10 deaths, were seen in 36.1% of the cases despite aggressive treatment. CONCLUSION: Pregnancy-associated hemorrhagic strokes frequently concealed baseline CVDs, especially when they occurred before the 32nd week of gestation. AVMs were the predominant bleeding source. For appropriate treatment, therefore, close examination for cerebral vascular lesions is essential when a pregnancy-associated hemorrhagic stroke is encountered.

[Analysis of initial treatment only by linac-based stereotactic radiosurgery for a metastatic brain tumor from non-small cell lung cancer].

A patient who receives stereotactic radiosurgery(SRS)alone for treating the brain metastatic lesion has a risk of tumor recurrence in the brain. Thus, some patients undergo prophylactic whole brain radiotherapy(WBRT)in addition to the SRS. However, the usefulness of adding WBRT is still debatable. In our hospitals, we initially treat metastatic brain tumors with SRS alone, and have experienced 2 long-surviving cases. Here, we report our treatment outcomes, including those for these 2 cases, and discuss the treatment plan for non-small cell lung cancer(NSCLC)with brain metastases. Forty-two brain metastatic cases were studied. Median survival(MS), tumor control rate(TCR), and recurrence ratio at distant site(RRDS)in the brain were analyzed. Age, Karnofsky performance status(KPS), and recursive partitioning analysis(RPA)class were analyzed as prognostic factors. We present 2 cases of a 42- and a 56-year-old man, surviving for more than 100 months. MS, TCR, and RRDS at 1 year in our hospitals were 20 months, 89.1%, and 25.6%, respectively. The prognostic factors were good KPS and RPA class and younger age. Our data showed a good MS among some reliable random controlled trials. Our strategy of SRS alone preserves the possibility to treat new lesions with WBRT. Prognosis was mainly defined by the systemic condition of the patient and activity of the primary lesion. Thorough treatment of the primary lesion with addition of SRS for initial treatment of metastatic lesions and scheduled MRI follow-up will provide for longer survival times.

Relation between parametric change of the workload and prefrontal cortex activity during a modified version of the 'rock, paper, scissors' task.

BACKGROUND/AIMS: Modified rock, paper, scissors (RPS) tasks have previously been used in neuroscience to investigate activity of the prefrontal cortex (PFC). In this study, we investigated hemodynamic changes in the PFC using near-infrared spectroscopy (NIRS) during a modified RPS task in which each subject's successful performance rate was equalized; the workload was increased parametrically in order to reveal the resulting pattern of PFC activation. METHODS: The subjects were 20 healthy adults. During RPS, the player uses hand gestures to represent rock, paper, and scissors. Rock beats scissors, paper beats rock, and scissors beats paper. In the modified RPS task, the player is instructed to lose intentionally against the computer hand; the computer goes first and the player follows. The interstimulus interval (ISI) level was adjusted with 11 steps. If the level rose, the ISI decreased and the workload increased parametrically. The maximal level (maxLv: the shortest ISI and the biggest workload) in which a subject could perform the task correctly was determined for every subject during rehearsal of the task prior to the experiment. Lowering the level from the maxLv made the task easier. Hemodynamic changes were measured by NIRS over 4 task levels (maxLv-3, maxLv-2, maxLv-1 and maxLv). RESULTS: The hemodynamic changes in the left lateral PFC and bilateral Brodmann area 6 rose significantly with the increase in workload and presented a linear trend. CONCLUSION: These results suggest that PFC activation may linearly increase with increased workload during a modified RPS task in which successful performance rates of subjects are equalized.

Augmented Reality in Stereotactic Neurosurgery: Current Status and Issues.

Stereotactic neurosurgery is an established technique, but it has several limitations. In frame-based stereotaxy using a stereotactic frame, frame setting errors may decrease the accuracy of the procedure. Frameless stereotaxy using neuronavigation requires surgeons to shift their view from the surgical field to the navigation display and to advance the needle while assuming a physically uncomfortable position. To overcome these limitations, several researchers have applied augmented reality in stereotactic neurosurgery. Augmented reality enables surgeons to visualize the information regarding the target and preplanned trajectory superimposed over the actual surgical field. In frame-based stereotaxy, a researcher applies tablet computer-based augmented reality to check for the setting errors of the stereotactic frame, thereby improving the safety of the procedure. Several researchers have reported performing frameless stereotaxy guided by head-mounted-display-based augmented reality that enables surgeons to advance the needle at a more natural posture. These studies have shown that augmented reality can address the limitations of stereotactic neurosurgery. Conversely, they have also revealed the limited accuracy of current augmented reality systems for small targets, which indicates that further development of augmented reality systems is needed.

Health numeracy in Japan: measures of basic numeracy account for framing bias in a highly numerate population.

BACKGROUND: Health numeracy is an important factor in how well people make decisions based on medical risk information. However, in many countries, including Japan, numeracy studies have been limited. METHODS: To fill this gap, we evaluated health numeracy levels in a sample of Japanese adults by translating two well-known scales that objectively measure basic understanding of math and probability: the 3-item numeracy scale developed by Schwartz and colleagues (the Schwartz scale) and its expanded version, the 11-item numeracy scale developed by Lipkus and colleagues (the Lipkus scale). RESULTS: Participants' performances (n = 300) on the scales were much higher than in original studies conducted in the United States (80% average item-wise correct response rate for Schwartz-J, and 87% for Lipkus-J). This high performance resulted in a ceiling effect on the distributions of both scores, which made it difficult to apply parametric statistical analysis, and limited the interpretation of statistical results. Nevertheless, the data provided some evidence for the reliability and validity of these scales: The reliability of the Japanese versions (Schwartz-J and Lipkus-J) was comparable to the original in terms of their internal consistency (Cronbach's α = 0.53 for Schwartz-J and 0.72 for Lipkus-J). Convergent validity was suggested by positive correlations with an existing Japanese health literacy measure (the Test for Ability to Interpret Medical Information developed by Takahashi and colleagues) that contains some items relevant to numeracy. Furthermore, as shown in the previous studies, health numeracy was still associated with framing bias with individuals whose Lipkus-J performance was below the median being significantly influenced by how probability was framed when they rated surgical risks. A significant association was also found using Schwartz-J, which consisted of only three items. CONCLUSIONS: Despite relatively high levels of health numeracy according to these scales, numeracy measures are still important determinants underlying susceptibility to framing bias. This suggests that it is important in Japan to identify individuals with low numeracy skills so that risk information can be presented in a way that enables them to correctly understand it. Further investigation is required on effective numeracy measures for such an intervention in Japan.

A phase I study of aromatic L-amino acid decarboxylase gene therapy for Parkinson's disease.

Gene transfer of dopamine-synthesizing enzymes into the striatal neurons has led to behavioral recovery in animal models of Parkinson's disease (PD). We evaluated the safety, tolerability, and potential efficacy of adeno-associated virus (AAV) vector-mediated gene delivery of aromatic L-amino acid decarboxylase (AADC) into the putamen of PD patients. Six PD patients were evaluated at baseline and at 6 months, using multiple measures, including the Unified Parkinson's Disease Rating Scale (UPDRS), motor state diaries, and positron emission tomography (PET) with 6-[(18)F]fluoro-L-m-tyrosine (FMT), a tracer for AADC. The short-duration response to levodopa was measured in three patients. The procedure was well tolerated. Six months after surgery, motor functions in the OFF-medication state improved an average of 46% based on the UPDRS scores, without apparent changes in the short-duration response to levodopa. PET revealed a 56% increase in FMT activity, which persisted up to 96 weeks. Our findings provide class IV evidence regarding the safety and efficacy of AADC gene therapy and warrant further evaluation in a randomized, controlled, phase 2 setting.

Wada test using secobarbital sodium (Ional) to determine language dominance.

The intracarotid sodium amobarbital (Amytal) test, the Wada test, remains an efficient test for evaluation of language and memory function. However, due to a world shortage of amobarbital, it has become necessary to investigate the use of alternatives. We report the efficacy of the Wada test using secobarbital sodium (Ional) in determining language dominance. An accurate determination of language dominance was required in 43 patients preoperatively at our institution. Patients underwent the Wada test using secobarbital sodium, effectiveness and safety were assessed. Patients were monitored for vital signs (blood pressure, respiratory rates, heart rates and saturation of oxygen). Ten patients were further monitored for continuous intra-arterial blood pressure and monitored with scalp electroencephalography (EEG). Language dominance was determined by the Wada test with secobarbital sodium in all patients. Total volume of secobarbital sodium injected was 10-25 mg (mean 16.5 ± 3.2 mg). Changes in vital signs were minimal and any induced neurological deficits completely disappeared within 8 min. On EEG records, induced theta waves immediately appeared on the ipsilateral side of the intra-arterial injection and disappeared within 6 min. One patient described a scintillating scotoma (sensation of shimmering light in his eyes) at the moment of injection; another experienced an epileptic episode during the test and recovered after 6 min. No adverse events were observed in the remaining 41 cases. We propose secobarbital sodium as a safe and reliable alternative to sodium amobarbital used in the Wada test to determine language dominance.

[Relationship between living arrangements and stroke in Sano-Kosei General Hospital].

We retrospectively reviewed the relationship between living arrangements and stroke in Sano-Kosei General Hospital, for the 3-year period from December, 2007 to November, 2010. The proportion of live-alone among stroke patients was 14.9% (131/877). The indirect standardized live-alone ratio (95% confidence interval), compared with Sano city's live-alone ratio as a standard group, was 1.34 (1.13-1.60). Among live-alone patients with stroke, sex ratio showed no significant difference (p=0.46). Comparing live-alones with non-live-alones in stroke patients, the mean age of live-alones was younger for men, but older for women (p<0.001). There was no significant difference between living arrangements and diseases risk factors. However, on the point of the mean number of risk factors, live-alones tended to have more risk factors than non-live-alones (p=0.032). Therefore, living arrangements are considered as an important factor for prevention of stroke.