Nitrogen balance in patients with hemiparetic stroke during the subacute rehabilitation phase.

BACKGROUND: In highly invasive diseases, metabolism commonly changes. Hypercatabolism is frequent in acute stroke, and nitrogen balance tends to be negative. However, there has been no study describing nitrogen balance in subacute and chronic stroke patients. The present study aimed to examine nitrogen balance in the subacute and chronic phases and to identify the factors related to it. METHODS: Nitrogen balance was calculated from the collected urine of 56 patients with subacute stroke [mean (SD) 53.8 (18.4) days post-stroke] who were admitted for rehabilitation for their first-ever ischaemic or nonsurgical haemorrhagic stroke. In the first experiment, their nitrogen balance was measured during the rehabilitation phase, and factors (type, severity of hemiparesis, activities of daily living, dysphagia and malnutrition status) related to it were evaluated. The second experiment was performed to describe the time course of nitrogen balance in 31 consecutive patients, with assessments made at admission and at discharge. RESULTS: Nitrogen balance was positive in all patients in the subacute phase. A significant difference was seen in nitrogen balance between high and low fat-free mass in male patients. In the chronic phase, nitrogen balance was positive in 96% of the patients. There was no significant difference in nitrogen balance between discharge and admission. CONCLUSIONS: In the subacute and chronic phases of stroke, it was confirmed that hypercatabolism had resolved and that intensive rehabilitation is possible in the convalescent period of stroke.

Post-activation depression of the soleus H-reflex in stroke patients.

PURPOSE: We examined post-activation depression in 35 stroke patients and 10 healthy subjects, and investigated whether their clinical symptoms were correlated to post-activation depression. METHODS: Post-activation depression of the soleus H-reflex evoked by electrical stimulation of the common peroneal nerve with supramaximal intensity of motor response on the tibialis anterior muscle. RESULTS: Post-activation depression was decreased on the affected side of the stroke patients. There was a significant difference between the affected and unaffected sides of the patients with post-activation depression, but no difference between the unaffected sides of the patients and healthy subjects. The presence of ankle clonus and the decrease in post-activation depression were correlated. CONCLUSION: Decreased post-activation depression in stroke patients suggests that a mechanism other than postsynaptic inhibition, such as reciprocal Ia inhibition and Ib inhibition, and presynaptic inhibition, may contribute to the exaggerated stretch reflexes, in particular, the manifestation of clonus.

Tonic and kinetic motor units revisited: does motor unit firing behavior differentiate motor units?

OBJECTIVE: We tried to differentiate motor unit into two distinct populations, tonic and kinetic, on the basis of the relationship between the mean inter-spike interval and its variability. METHODS: During voluntary isometric contraction myoelectric activity was recorded with a special quadrifilar electrode from first dorsal interosseous, biceps brachii, soleus, and tibialis anterior muscle. Motor unit action potentials (MUAP) were decomposed into individual MUAP trains, by electromyography (EMG) signal decomposition. The variability in the instantaneous firing rate was assessed at two or more levels of contraction in each muscle. RESULTS: We found each muscle tested had a homogeneous population. There were no tonic and kinetic motor units. But there were differences in the variability in the instantaneous firing rate in the 4 muscles tested. CONCLUSION: Motor unit firing behavior in a muscle may be fitted for its function.

Macro-EMG and motor unit recruitment threshold: differences between the young and the aged.

The relationship between macro-EMG (electromyography) and motor unit recruitment threshold was studied in the first dorsal interosseous (FDI) muscle of normal young and aged subjects. During voluntary isometric contraction, motor unit action potentials (MUAP) were collected by a special quadrifilar electrode and decomposed to each MUAP train (MUAPT) using an EMG signal decomposition technique. Macro-EMG was obtained from the electrode shaft, then triggered and averaged for each MUAPT. A positive linear correlation was observed in both the young and aged subjects. However, the correlation coefficients were significantly lower in the aged individuals than in the young individuals.

Intraventricular cavernous malformation associated with medullary venous malformation.

We reported a case of cavernous malformation (CM) associated with medullary venous malformation in the same area. The CM was located in the trigone of the lateral ventricle in the dominant hemisphere and drained into the longitudinal caudate vein of Schlesinger via deep medullary veins. By a transsylvian transventricular approach, the CM was totally removed with successful preservation of the medullary venous malformation. This approach is available for trigonal lesions, especially in cases with enlarged inferior horn. We stress that CM removal can be conducted with preservation of the adjacent medullary venous malformation.

Laparoscopic splenectomy for an inflammatory pseudotumor of the spleen: operative technique and case report.

The case of a primary inflammatory pseudotumor of the spleen in a 44 year-old female is herein reported. This lesion is extremely rare, with only 33 cases previously reported. The splenic tumor was preoperatively diagnosed as a hemangioma by the combined modalities of ultrasonography, computed tomography and magnetic resonance imaging. A laparoscopic splenectomy was, thus, performed in order to make a final diagnosis. Pathological examination of the mass revealed an inflammatory process. Based on the above findings, a laparoscopic splenectomy is recommended when the tumor is suspected to be benign.

Age-related changes of water and fat content in muscles estimated by magnetic resonance (MR) imaging.

The pixel values in fat/water suppression magnetic resonance (MR) images were measured for the thigh muscles of 18 healthy volunteers to investigate age-related changes in muscle water and fat content. Prior to the human studies the reproducibility of the data was confirmed using phantoms. The standard deviations (SDs) of the pixel values for one of the phantoms examined five times were found to be within a relatively narrow range. Both the pixel values in the fat suppression images (PV1) and the pixel values in the water suppression images (PV2) of all muscles tended to be higher in the oldest group. The results indicate that the water and fat content of skeletal muscles is higher in aged persons. Moreover, the PV1 in the non-dominant limbs was found to be increased in the extensor muscles of the knee joints, while the PV2 in the non-dominant limbs did not show a significant difference, except for the rectus femoris.

Objective parameters in magnetic resonance imaging (MRI) for neuromuscular diagnosis: preliminary findings.

T1 relaxation time (T1 time), T2 relaxation time (T2 time), and proton (rho) density in the thigh muscles of 20 normal healthy volunteers and three patients with muscle atrophy in the lower extremity were measured in order to select the useful MRI parameters for neuromuscular diagnosis. Since the standard deviation (SD) of both T1 and T2 times in each muscle was found to be within a relatively small range, these values were expected to be useful MRI parameters for neuromuscular diagnosis. On the contrary, rho density was not a valid parameter for diagnosis, as it was demonstrated to have large SDs in the muscles. The differences of these parameters in the three patients also supported the fact that MRI was useful for discriminating between the various types of muscular abnormalities based on relaxation times. The longer T1 and T2 times in women suggested that the content of water in skeletal muscle was higher in women than in men. Moreover, the T1 time in the dominant limbs was found to be shorter than in the non-dominant limbs for rectus femoris only in both men and women, while there were no differences in T2 time in these muscles.

Rise time or rise rate: which should be a criterion for analysing motor unit action potentials?

We measured the rise time (RT) and rise rate (RR) of motor unit action potentials (MUAPs) when sharp sounds are heard in concentric EMG in the first dorsal interosseus muscle (FDI) and biceps brachii muscle (BIC) of normal subjects. MUAPs from FDI muscle with an RT of less than 500 microseconds were 85%, and those of more than 500 microseconds were 15%. In contrast, MUAPs from BIC muscle with an RT of less than 500 microseconds were 65%, and those of more than 500 microseconds were 35%. Distributions of the RR for FDI and BIC were also determined. MUAPs from FDI muscle with an RR more than 0.3 mV/ms were 98.3%, and those of less than 0.3 mV/ms were 1.7%. In contrast, MUAPs from BIC muscle with an RR of more than 0.3 mV/ms were 93%, and those of less than 0.3 mV/ms were 7%. We conclude it is better to use RR than RT when accepting MUAPs in clinical EMG, because even when sharp sounds are heard, MUAPs do not always have an RT of less than 500 microseconds. The use of RT and the sharpness of MUAPS therefore need to be reconsidered, or RR should be used in clinical EMG by automatic program.

A new method of superficial peroneal nerve conduction studies.

Herein, we report a new method for obtaining sensory nerve conduction velocities (SCVs) in the distal segment of the superficial peroneal nerve (SPN). Twenty lower extremities from 10 normal subjects (mean age: 33.4 years) were evaluated. The recording electrodes were placed on the dorsal surfaces of the ankle and foot. We stimulated the SPNs on the anterior edge of subjects' fibulas, and evoked sensory nerve action potentials (SNAPs) antidromically. SCVs were calculated based upon the distances and the latencies. The mean SCV was 41.3 +/- 4.3 m/s in the distal segment, which was slower than in the proximal segment (51.7 +/- 3.9 m/s). We were able to stimulate only the SPN with certainty. In conclusion, the described technique should be of clinical value in diagnosing peripheral neuropathy.

Quantitative EMG and motor unit recruitment threshold using a concentric needle with quadrifilar electrode.

According to Henneman's size principle, small motor units are recruited before large ones. We used the electromyographic (EMG) signal decomposition technique to determine the quantitative relationships between five motor unit action potential (MUAP) parameters (amplitude, duration, area, thickness, and size index) and the recruitment threshold of the motor units recruited up to 50% of the maximum voluntary contraction in the first dorsal interosseous, biceps brachii, rectus femoris, and tibialis anterior muscles of 5 healthy young men. In each muscle, the amplitude, duration, area, and size index had significant, positive high correlations with the motor unit recruitment thresholds. We conclude that the size principle applies to recordings made with concentric needle EMG electrodes under special recording conditions, and therefore that more importance should be attached to the patient's contraction force during EMG examinations in order to evaluate MUAPs for electrodiagnostic purposes.

Physiologic decrease of single thenar motor units in the F-response in stroke patients.

OBJECTIVE: To investigate the left-right difference and the reproducibility by the F-wave motor unit number estimation and to compare the motor unit number between the hemiplegic and unaffected side in stroke patients. SETTING: A referral center and institutional practice providing outpatient care. SUBJECTS: Seven healthy volunteers and 15 consecutive stroke patients. DESIGN: Diagnostic statistical test and correlational study. METHOD: Submaximal stimuli were used to evoke a sample of surface motor unit action potentials (S-MUAPs) in the F-waves that are entirely representative of the relative numbers of detected S-MUAPs of different sizes. The average S-MUAP amplitude was calculated from a selected population of F-wave responses for each abductor pollicis brevis (APB) muscle. The motor unit number was calculated by dividing the maximum M-potential negative peak amplitude by the average S-MUAP negative peak amplitude. RESULT: There was no statistical difference between motor unit numbers on either side and between test and retest in this motor unit number estimation method among normal subjects. The motor unit number on the hemiplegic side was significantly lower than on the unaffected side (p < .05, Mann-Whitney test) among stroke patients. CONCLUSION: The motor unit could decrease in the hemiplegic side after a moderate-to-severe hemiplegic stroke and this decrement might be due to the transsynaptic degeneration secondary to an upper motor neuron lesion.

Relationship between shoulder muscle strength and functional independence measure (FIM) score among C6 tetraplegics.

The degree of disability varies widely among C6 tetraplegic patients in comparison with that at other neurological levels. Shoulder muscle strength is thought to be one factor that affects functional outcome. The aim of this study was to examine the relationship between shoulder muscle strength and the Functional Independence Measure (FIM) motor score among 14 complete C6 tetraplegic patients. The FIM motor score and American Spinal Injury Association (ASIA) motor score of these patients were assessed upon discharge. We evaluated muscle strength of bilateral scapular abduction and upward rotation, shoulder vertical adduction and shoulder extension by manual muscle testing (MMT). The total shoulder strength score was calculated from the summation of those six MMT scores. The relationships among ASIA motor score, total shoulder strength score and FIM motor score were analyzed. The total shoulder strength score was significantly correlated with the FIM motor score and the score of the transfer item in the FIM. In the transfer item of the FIM, the total shoulder strength score showed a statistically significant difference between the Independent and Dependent Group. Shoulder muscle strength appears to be an important factor in the functional abilities of those with C6 complete tetraplegia. Functional variation depends on the strength of shoulder muscles, especially among C6 tetraplegics.

Motor unit firing behavior in slow and fast contractions of the first dorsal interosseous muscle of healthy men.

The motor unit recruitment threshold and firing rate were evaluated during slow and fast contraction of the first dorsal interosseous (FDI) muscle by healthy young men. Using a special quadrifilar electrode myoelectric activity was recorded during voluntary isometric contraction. Motor unit action potentials (MUAPs) were decomposed into individual MUAP trains by the electromyography (EMG) signal decomposition technique. Recruitment thresholds of the motor units decreased with the increase in the speed of contraction, and there was no recruitment reversal despite the increase. In terms of rate coding, the firing rates of the motor units increased as the speed of contraction increased; however, a high threshold motor unit always had a lower firing rate than a low threshold motor unit regardless of the contraction speed. At all contraction speeds, recruitment and rate coding may act through the same mechanism. If excitation of the motoneuron pool occurs rather than excitation of an individual motoneuron, a low threshold motor unit is easier to recruit and fire repetitively than a high threshold one. The motor unit firing behavior during fast contraction basically may be the same as during slow contraction.

Ultrastructural evaluation following catheterization of the fallopian tube with a hysteroscopic catheter.

PURPOSE: Our purpose was to assess the morphology and ultrastructural changes in the tubal epithelium following catheterization of the fallopian tube. METHODS: Fallopian tubes were obtained from 20 women who had undergone hysterectomies. Catheterization was performed in 20 tubes using a catheter developed for hysteroscopic tubal embryo transfer. The catheter has a 3-French diameter, tapering to 2 French (0.66 mm) at the tip portion. The 20 contralateral tubes served as controls and were not catheterized. Ultrastructural changes were examined by scanning electron microscopy and transmission electron microscopy. RESULTS: Scanning electron microscopy showed no transformation or defects of the tubal epithelium surface in catheterized or control tubes. Transmission electron microscopy showed no significant differences in the percentage of abnormal desmosomes and the percentage of basement membrane in ciliated and nonciliated cells between catheterized and noncatheterized tubes. No transformation or defects were observed in catheterized or noncatheterized tubes. CONCLUSIONS: These findings suggest that catheterization of the tube using a hysteroscopic catheter caused no acute damage to the tubal epithelium.