Right putamen and claustrum infarction mimicking normal pressure hydrocephalus.

A woman in her 70s presented with approximately 2 years of sudden-onset gait and cognitive problems. She had been diagnosed with normal pressure hydrocephalus (NPH) and underwent ventriculoperitoneal shunt (VPS) placement 1 year prior. Before VPS placement, brain imaging showed ventriculomegaly and chronic infarction of the right putamen and claustrum. A lumbar drain trial resulted in modest improvement of gait dysfunction. She underwent VPS placement for suspected NPH, but her symptoms remained unchanged. Examination revealed mild cognitive impairment, left-sided and lower body predominant parkinsonism, as well as disproportionately prominent postural instability. Gait analysis showed increased gait variability, reduced velocity and shortened step length bilaterally. Motor and gait abnormalities did not change after administration of levodopa. Her symptoms have remained stable for up to 52 months since symptom onset. We postulate that the infarction affecting the right putamen and claustrum could have led to a higher-level gait disorder mimicking NPH.

Long insular artery damage might be a key sign for predicting functional prognosis of putaminal hemorrhage.

OBJECTIVE: Although the putamen is the most common area of spontaneous intracerebral hemorrhage, previous reports about the effects of surgery are limited. We sometimes experience a poor prognosis in patients in whom there is no damage to the internal capsule, but with injury in the long insular artery (LIA) region. The purpose of this study was to confirm the relationship between LIA damage and patient prognosis following surgery for putaminal hemorrhage. METHODS: We retrospectively collected data of 287 surgical cases who presented with putaminal hemorrhage between January 2004 and March 2022. Among them, we chose patients without initial damage to the posterior limb of the internal capsule, and divided these patients into two groups, those without (Group A) and with (Group B) final damage in the LIA region. We compared positivity rates of final manual muscle test (MMT) scores≥3 and related factors. RESULTS: Sixty-three of the 287 patients were included in this study. Of them, 11 cases in Group A were positive for MMT scores≥3 (68.8%) and 9 cases (19.1%) in Group B had MMT scores≥3 seven days after surgery. Group A thus had a significantly higher rate of MMT scores≥3 than group B (p=0.00). CONCLUSION: In patients without initial damage to the internal capsule, LIA injury might be a key sign for predicting the functional prognosis of putaminal hemorrhage.

[Multiple cerebral infarctions in the deep perforator regions in a case of idiopathic hypereosinophilic syndrome].

A 61-year-old man was admitted to our hospital due to cerebral infarction in the pons and the right putamen. On admission (day 3 from symptom onset), laboratory testing showed a white blood cell count of 13,100/µl with hypereosinophilia of 3,734/µl. As deep vein thrombosis was detected on contrast-enhanced CT, we started anticoagulation therapy. There were no cardio-embolic sources, including right-to-left shunt, but eosinophil infiltration was found in biopsy specimens of the gastric mucosa. These findings allowed us to diagnose multiple perforator infarction due to idiopathic hypereosinophilic syndrome (idiopathic HES). After the administration of oral prednisolone was started on day 10, his hypereosinophilia rapidly improved, and no recurrence of deep perforator infarction occurred other than a symptomatic infarction in the left putamen at day 19. There are a few reports of idiopathic HES with multiple infarctions developing in deep perforator regions. The current case suggests that idiopathic HES could cause multiple cerebral infarction restricted to deep perforator areas.

Reversible Cerebral Angiopathy after Viral Infection in a Pediatric Patient with Genetic Variant of RNF213.

Ring finger protein (RNF) 213 is known as a susceptibility gene for moyamoya disease (MMD), which is characterized by bilateral carotid folk stenosis. Cerebral angiopathy after viral infection has been known to present angiographical appearance resembling MMD, however its pathogenesis and genetic background are not well known. We report a case of reversible cerebral angiopathy after viral infection in a pediatric patient with genetic variant of RNF213 mutation. The patient had developed a severe headache after hand, foot, and mouth disease. Magnetic resonance imaging and magnetic resonance angiography (MRA) performed 2-3 weeks after disease onset revealed bilateral carotid folk stenosis and an old cerebral infarction in the left putamen. The patient's headache spontaneously resolved and the follow-up MRA showed a complete spontaneous resolution of the arterial stenosis after 9 months. We were able to determine genetic predisposition to angiopathy by identifying the RNF213 c.14576G>A (rs112735431, p.R4859K) mutation. Based on the present case, we hypothesize that an RNF213 variant might play an important role for the onset of postviral cerebral angiopathy.

Heritability of Cerebral Blood Flow and the Correlation to Schizophrenia Spectrum Disorders: A Pseudo-continuous Arterial Spin Labeling Twin Study.

Whether aberrant cerebral blood flow (CBF) in schizophrenia is affected by genetic influences, and consequently a potential marker for genetic susceptibility, is unknown. Our aims were to determine the heritability of CBF in thalamic, frontal, and striatal areas, and to ascertain if associations with disease were under genetic influence. Monozygotic (MZ) twin pairs concordant (n = 2) or discordant (n = 20) for schizophrenia spectrum disorders (ICD-10 F2x.x), matched on sex and age with dizygotic (DZ; n = 20) and healthy control pairs (MZ: n = 27; DZ: n = 18; total: n = 181 individuals), were recruited via the National Danish Twin Register. CBF in thalamus, frontal lobes, and putamen was measured with pseudo-continuous arterial spin labeling on a 3 T magnetic resonance scanner. Twin statistics were performed with structural equation modeling. CBF in the frontal lobes was heritable (h2 = 0.44, 95% CI [0.22-0.60]) but not correlated to disease. CBF correlated to schizophrenia spectrum disorders in the left thalamus (r = 0.17, [0.03-0.31]; P = 0.02), as well as in the left putamen (r = 0.19, [0.05-0.32]; P = 0.007) and the right putamen (r = 0.18, [0.03-0.32]; P = 0.02). When restricting the sample to schizophrenia (F20.x) only, shared genetic influences between CBF in the left putamen and schizophrenia liability (phenotypic correlation = 0.44, [0.28-0.58], P < 0.001) were found. Our results provide heritability estimates of CBF in the frontal lobes, and we find CBF in thalamus and putamen to be altered in schizophrenia spectrum disorders. Furthermore, shared genetic factors influence schizophrenia liability and striatal perfusion. Specifically, higher perfusion in the left putamen may constitute a marker of genetic susceptibility for schizophrenia.

Hemichorea associated with cavernous angioma and a small errhysis: A case report and literature review.

RATIONALE: Chorea is a movement disorder characterized by randomly appearing involuntary movements of the face, neck, limbs, or trunk. Hemichorea is unilateral, involving one side of the body. Hemichorea is commonly caused by non-ketotic hyperglycemia and/or cerebrovascular injury to the contralateral basal ganglia. PATIENT CONCERNS: Here, we report the case of a patient diagnosed with hemichorea who had diabetes, cavernous angioma, and a small intracranial errhysis. Routine testing showed the patient's blood glucose level was slightly higher than the normal range. INTERVENTIONS: The errhysis was too small to be treated. DIAGNOSES: Brain magnetic resonance imaging showed a cavernous angioma with a small errhysis in the right putamen. OUTCOMES: Hemichorea was completely resolved after 4 months. LESSONS: If diabetes is well controlled and imaging indicates brain lesions suggestive of a recent stroke, a diagnosis of post-stroke hemichorea should be considered.

Regional reduction in cortical blood flow among cognitively impaired adults with relapsing-remitting multiple sclerosis patients.

PURPOSE: Detection of cortical abnormalities in relapsing-remitting multiple sclerosis (RRMS) remains elusive. Structural magnetic resonance imaging (MRI) measures of cortical integrity are limited, although functional techniques such as pseudo-continuous arterial spin labeling (pCASL) show promise as a surrogate marker of disease severity. We sought to determine the utility of pCASL to assess cortical cerebral blood flow (CBF) in RRMS patients with (RRMS-I) and without (RRMS-NI) cognitive impairment. METHODS: A total of 19 age-matched healthy controls and 39 RRMS patients were prospectively recruited. Cognition was assessed using the Minimal Assessment of Cognitive Function in Multiple Sclerosis (MACFIMS) battery. Cortical CBF was compared between groups using a mass univariate voxel-based morphometric analysis accounting for demographic and structural variable covariates. RESULTS: Cognitive impairment was present in 51.3% of patients. Significant CBF reduction was present in the RRMS-I compared to other groups in left frontal and right superior frontal cortex. Compared to healthy controls, RRMS-I displayed reduced CBF in the frontal, limbic, parietal and temporal cortex, and putamen/thalamus. RRMS-I demonstrated reduced left superior frontal lobe cortical CBF compared to RRMS-NI. No significant cortical CBF differences were present between healthy controls and RRMS-NI. CONCLUSION: Significant cortical CBF reduction occurs in RRMS-I compared to healthy controls and RRMS-NI in anatomically significant regions after controlling for structural and demographic differences.

Thrombolysis, Complete Recanalization, Diffusion Reversal, and Luxury Perfusion in Hyperacute Stroke.

A 59-year old man was admitted to our stroke care unit 1.8 hours after onset of cardioembolic stroke. Administration of issue-plasminogen activator achieved complete recanalization, and his lesion on diffusion-weighted imaging (DWI) disappeared and single photon emission computed tomography showed luxury perfusion. DWI reversal and luxury perfusion were sometimes observed in hyperacute stroke patients, especially timely reperfusion was achieved. However, the relationships between DWI reversal and luxury perfusion were not well known. Transient DWI reversal may be associated with luxury perfusion in patients treated with t-PA, via early complete recanalization achieved by thrombolysis.

Clinical significance of blood supply to the internal capsule and basal ganglia.

Although the general vascular supply of the basal ganglia and internal capsule is well known, precise data are lacking regarding the variations of the vascular territories in the two regions. Twelve hemispheres were studied following an injection of coloured ink into the main cerebral arteries, namely the anterior cerebral (ACA), middle cerebral (MCA), anterior choroidal (AChA) and posterior cerebral artery (PCA). Serial sections of the injected hemispheres were taken in the axial or coronal plane. In 75% of the hemispheres, ACA perforators were seen to supply the inferomedial part of the head of the caudate nucleus and the anterior limb of the internal capsule, as well as the anterior and inferior portions of the putamen and globus pallidus. The MCA vessels perfused the superolateral part of the head and body of the caudate nucleus, the superior part of the entire internal capsule, most of the putamen and part of the globus pallidus. The AChA perforators perfused the medial segment of the globus pallidus, the inferior part of the posterior limb, the retrolenticular and sublenticular portions of the internal capsule, and occasionally its genu. The same segment of the globus pallidus and the inferior part of the genu of the internal capsule were most likely supplied by the perforators of the internal carotid artery. A predominance of ACA territory was noticed in one specimen (8.33%) and a predominance of MCA territory in two specimens (16.67%). The obtained anatomical data may help radiologic determination of perforators involved in ischemic events, as well as a better understanding of the neurological deficits in the same events.

Characterization of highly proliferative secondary tumor clusters along host blood vessels in malignant glioma.

The aim of the present study was to investigate the extensive invasion of tumor cells into normal brain tissue, a life­threatening feature of malignant gliomas. How invasive tumor cells migrate into normal brain tissue and form a secondary tumor structure remains to be elucidated. In the present study, the morphological and phenotypic changes of glioma cells during invasion in a C6 glioma model were investigated. C6 glioma cells were stereotactically injected into the right putamen region of adult Sprague­Dawley rats. The brain tissue sections were then subjected to hematoxylin and eosin, immunohistochemical or immunofluorescent staining. High magnification views of the tissue sections revealed that C6 cells formed tumor spheroids following implantation and marked invasion was observed shortly after spheroid formation. In the later stages of invasion, certain tumor cells invaded the perivascular space and formed small tumor clusters. These small tumor clusters exhibited certain common features, including tumor cell multilayers surrounding an arteriole, which occurred up to several millimeters away from the primary tumor mass; a high proliferation rate; and similar gene expression profiles to the primary tumor. In conclusion, the present study revealed that invading tumor cells are capable of forming highly proliferative cell clusters along arterioles near the tumor margin, which may be a possible cause of the recurrence of malignant glioma.

Changes in corticostriatal connectivity during reinforcement learning in humans.

Many computational models assume that reinforcement learning relies on changes in synaptic efficacy between cortical regions representing stimuli and striatal regions involved in response selection, but this assumption has thus far lacked empirical support in humans. We recorded hemodynamic signals with fMRI while participants navigated a virtual maze to find hidden rewards. We fitted a reinforcement-learning algorithm to participants' choice behavior and evaluated the neural activity and the changes in functional connectivity related to trial-by-trial learning variables. Activity in the posterior putamen during choice periods increased progressively during learning. Furthermore, the functional connections between the sensorimotor cortex and the posterior putamen strengthened progressively as participants learned the task. These changes in corticostriatal connectivity differentiated participants who learned the task from those who did not. These findings provide a direct link between changes in corticostriatal connectivity and learning, thereby supporting a central assumption common to several computational models of reinforcement learning.

Short-term hypoxia/reoxygenation activates the angiogenic pathway in rat caudate putamen.

In response to hypoxia, tissues have to implement numerous mechanisms to enhance oxygen delivery, including the activation of angiogenesis. This work investigates the angiogenic response of the hypoxic caudate putamen after several recovery times. Adult Wistar rats were submitted to acute hypoxia and analysed after 0 h, 24 h and 5 days of reoxygenation. Expression of hypoxia-inducible factor-1 alfa (HIF-1 alpha) and angiogenesis-related genes including vascular endothelial growth factor (VEGF), adrenomedullin (ADM) and transforming growth factor-beta 1 (TGF- beta 1) was determined by both RT-PCR and ELISA. For vessel labelling, lectin location and expression were analysed using histochemical and image processing techniques (fractal dimension). Expression of Hif-1 alpha, Vegf, Adm and Tgf- beta 1 mRNA rose immediately after hypoxia and this increase persisted in some cases after 5 days post-hypoxia. While VEGF and TGF-beta 1 protein levels increased parallel to mRNA expression, ADM remained unaltered. The quantification of the striatal vessel network showed a significant augmentation at 24 h of reoxygenation. These results reveal that not only short-term hypoxia, but also the subsequent reoxygenation period, up-regulate the angiogenic pathway in the rat caudate putamen as a neuroprotective mechanism to hypoxia that seeks to maintain a proper blood supply to the hypoxic tissue, thereby minimizing the adverse effects of oxygen deprivation.

Striatal allografts in patients with Huntington's disease: impact of diminished astrocytes and vascularization on graft viability.

Neuronal transplantation has been proposed as a potential therapy to replace lost neurons in Huntington's disease. Transplant vascularization and trophic support are important for graft survival. However, very few studies have specifically addressed graft vascularization in patients with neurological disorders. In the present study, we analysed the vasculature of the host putamen and solid grafts of foetal striatal tissue transplanted into patients with Huntington's disease 9 and 12 years previously. Grafts were characterized by a significantly reduced number of large calibre blood vessels in comparison with the host brain. There were also significantly fewer astrocytes and gap junctions, suggesting a lack of functional blood-brain barrier components within the grafted tissue. Additionally, grafts demonstrated a nearly complete absence of pericytes (compared with the striatum) that are considered important for vascular stabilization and angiogenesis. Finally, the host striatum had a marked increase in atrophic astrocytes in comparison with controls and grafts. The extent to which the lower number of large calibre vessels and astrocytes within the transplants contributed to suboptimal graft survival is unknown. The marked increase in atrophic astrocytes in the host brain surrounding the grafts suggests that reduced host trophic support may also contribute to poor graft survival in Huntington's disease. A better understanding of the way in which these components support allografted tissue is critical to the future development of cell-based therapies for the treatment of Huntington's disease.

Evaluating quantitative approaches to dynamic susceptibility contrast MRI among carotid endarterectomy patients.

PURPOSE: To evaluate two dynamic susceptibility contrast (DSC) quantification methods in symptomatic carotid artery disease patients undergoing carotid endarterectomy (CEA) surgery by comparing methods directly and assessing the reliability of each method in the hemisphere contralateral to surgery. MATERIALS AND METHODS: Absolute cerebral blood flow (CBF) and volume (CBV) was calculated in putamen and sensorimotor gray matter of 17 patients using two methods: 1) The Bookend method that scales relative DSC images to CBV values calculated from the ratio of pre- and postcontrast T1-weighted images, and 2) the Tail-scaling method that uses the ratio of area under the tails of the venous and arterial concentration time-courses to scale the DSC images. RESULTS: There was a positive correlation between the methods with significant correlation post-CEA (P < 0.035). Intersession correlation was greater when using the Tail-scaling method contralateral to surgery (P < 0.004). CONCLUSION: We have demonstrated correlation between methods that is significant after surgery and have found that the Tail-scaling method produces better test-retest reliability than our implementation of the Bookend method. Results from this study suggest that DSC has the potential to measure hemodynamic changes after endarterectomy and future work is required to establish clinical value.

Recovery process and prognosis of aphasic patients with left putaminal hemorrhage: relationship between hematoma type and language modalities.

To elucidate the precise recovery process and prognosis of language functions in aphasic patients with left putaminal hemorrhage, we investigated 48 aphasic patients classified into 4 groups according to the location and extent of hematoma. The hematoma extended to the corona radiata in all patients, extracapsular in type I (12 cases), to the anterior limb in type II (10 cases), to the posterior limb in type III (12 cases), and to both limbs in type IV (14 cases). The Standard Language Test for Aphasia was performed at 1 month, 3 months, and 6 months after the attack. The type II, III, and IV patients were divided into 2 groups, with and without ventricular rupture of the hemorrhage. At 3 and 6 months after the attack, the type I, II, and III patients showed significant improvement (P < .05) in all language modalities compared with the type IV patients. Most improvement in language modalities occurred in the first 3 months. The evaluation of patients with ventricular rupture after 6 months revealed poor recovery (P < .05) in oral commands, visual commands, confrontation naming, sentence repetition, narratives, verbal fluency, and writing in type II and III patients. In type IV patients, this evaluation showed poor recovery (P < .05) only in oral and written naming (kanji words). No significant difference in prognostic outcome was observed between the surgical treatment group and the nonsurgical treatment group. The classification of hemorrhage may be useful in predicting the outcome of aphasia with putaminal hemorrhage and in guiding clinicians in providing effective instructions to patients and their relatives.

Simultaneous CBF and BOLD mapping of high frequency acupuncture induced brain activity.

This study mapped brain activity elicited by high frequency electroacupuncture by simultaneously using blood oxygenation level dependent (BOLD) and cerebral blood flow (CBF) contrasts. Forty subjects participated in the study, in which twenty ones were imaged during electrical acupoint stimulation (EAS) to the left LI4 acupoint at a maximal intensity without pain, and the others were with a minimal-EAS at a just detectible intensity. Both BOLD and CBF data were acquired simultaneously during alternating blocks of rest and stimulation. The results showed that the minimal-EAS mostly induced the activities in somatosensory region, including those in inferior parietal lobule, SII, insula, and thalamus. On the other hand, EAS activated more including also posterior middle cingulate cortex (pMCC), and deactivated superior temporal gyrus. Moreover, deactivation was found in posterior cingulated cortex (PCC), precuneus from BOLD and in culmen of cerebellum, caudate from CBF. The comparison between EAS and minimal-EAS revealed deactivation in the default mode network in both BOLD and CBF signals, activation in thalamus, insula, and caudal anterior cingulate cortex (ACC) in the CBF signal alone, and deactivation in putamen, rostral ACC and parahippocampal gyrus in the BOLD signal alone. This study provides, for the first time, simultaneous CBF and BOLD responses to high frequency EAS at the LI4 acupoint, revealing concordant and complementary insights into the neural effects of EAS, including modulation of subcortical structures and limbic system.

Differential recruitment of the sensorimotor putamen and frontoparietal cortex during motor chunking in humans.

Motor chunking facilitates movement production by combining motor elements into integrated units of behavior. Previous research suggests that chunking involves two processes: concatenation, aimed at the formation of motor-motor associations between elements or sets of elements, and segmentation, aimed at the parsing of multiple contiguous elements into shorter action sets. We used fMRI to measure the trial-wise recruitment of brain regions associated with these chunking processes as healthy subjects performed a cued-sequence production task. A dynamic network analysis identified chunking structure for a set of motor sequences acquired during fMRI and collected over 3 days of training. Activity in the bilateral sensorimotor putamen positively correlated with chunk concatenation, whereas a left-hemisphere frontoparietal network was correlated with chunk segmentation. Across subjects, there was an aggregate increase in chunk strength (concatenation) with training, suggesting that subcortical circuits play a direct role in the creation of fluid transitions across chunks.

Evaluation of CT angiography for visualisation of the lenticulostriate artery: difference between normotensive and hypertensive patients.

OBJECTIVE: High-resolution CT angiography (CTA) is currently available using multidetector row CT (MDCT); however, its use for small artery visualisation has been limited. To evaluate its capability, we investigated CTA visualisation for difference in number of the lenticulostriate artery (LSA) branches between normotensive and hypertensive patients, because hypertension is a major cause of LSA damage. METHODS: This was a retrospective study evaluating cerebrovascular CTA at our hospital conducted from February 2008 to June 2009 under approval of the institutional review board. 117 patients (39 males and 78 females, 19-88 years old) were included. CTA was conducted using a 64 channel MDCT. Total numbers of LSA branches were examined for differences by age with regression analysis and the presence or absence of hypertension and/or aneurysm using two-sample t-tests. A p-value <0.016 was considered statistically significant after correction for multiple comparisons. A multiple variable analysis of three factors was also conducted. RESULTS: The average number of LSA branches was 3.6 [95% confidence interval (CI) 3.0-4.1] and 4.4 (95% CI 4.1-4.7), respectively, for a patient with and without history of hypertension, and the difference was statistically significant (p=0.013). The difference was approximately one branch in the multiple variable analysis. No significant correlation was observed for age and no significant difference was observed for the presence or absence of aneurysms. CONCLUSIONS: Contrast-enhanced CTA can visualise significant differences in the number of LSA branches among patients with and without hypertension. Advances in knowledge Current high-resolution CTA can visualise LSA well, which enables finding a difference in the LSA between normotensive subjects and hypertensive patients.

An acute tiny left putamenal lesion presenting with transient global amnesia.

INTRODUCTION: Transient global amnesia (TGA) is one of the most striking syndromes in clinical neurology. Brain lesions producing TGA have been reported in the hippocampus, amygdala, thalamus, caudate nucleus, and neocortex. CASE REPORT: We report a 63-year-old woman presenting with TGA associated with a localized lesion in the left putamen. CONCLUSIONS: This case suggests a potential role of the putamen in human memory processing.