Compensatory cortical activation during performance of an attention task by patients with diffuse axonal injury: a functional magnetic resonance imaging study.

OBJECTIVE: To determine how cortical compensation occurs in higher cognitive systems during the recovery phase of diffuse axonal injury (DAI). DESIGN: 12 right-handed patients with a magnetic resonance imaging (MRI) lesion pattern compatible with pure DAI were identified. Pure DAI was defined as finding of traumatic microbleeds on T2*-weighted gradient-echo images in the absence of otherwise traumatic or non-traumatic MRI abnormalities. 12 matched healthy controls were also enrolled. Functional magnetic resonance imaging (fMRI) was used to assess brain activation during a working memory test (Paced Visual Serial Attention Test (PVSAT)). RESULTS: No significant group differences were observed in reaction times for the PVSAT. Although patients with pure DAI committed a few errors during the PVSAT, controls respond correctly to each probe. Controls showed activations in the left frontal gyrus, left parietal gyrus and right inferior parietal gyrus. Patients with pure DAI showed activations in the left inferior frontal gyrus, right inferior frontal gyrus and right middle frontal gyrus. Between-group analysis of the PVSAT task showed significantly greater activation of the right inferior frontal gyrus (BA 45) and right middle frontal gyrus (BA 9) in patient with pure DAI versus controls. CONCLUSIONS: Patients with pure DAI require compensatory activation of the contralateral (right) prefrontal region to carry out activities similar to healthy controls. These findings provide further evidence for the adaptive capacity of neuronal systems and brain plasticity during the recovery stages of DAI.

Headache may be a risk factor for complex regional pain syndrome.

We investigated whether headache and family history of headache are risk factors for complex regional pain syndrome (CRPS) or not. Twenty-three CRPS patients and 69 healthy persons were interviewed whether or not they suffered from headache and had first-degree family history of headache. A headache sufferer was defined as a person who regularly suffered from headache for more than 2 days per month. Headache after an occurrence of CRPS (headache after an injury or operation in case of CRPS after an injury or operation) was excluded and just headache before an occurrence of CRPS was included. If a first-degree family had a regular headache, she or he was regarded as a headache sufferer regardless of the frequency of headache. Of the 23 patients with CRPS, 12 (52.2%) had suffered from headache before an occurrence of CRPS. Of the 69 healthy persons, 18 (26.1%) suffered from headache. Significant differences between patients and healthy persons were found. Of the 23 patients with CRPS, eight (34.8%) had a first-degree family history of headache. Of the 69 healthy persons, ten (14.5%) had a first-degree family history of headache. Significant differences between patients and healthy persons were found in a family history. The results suggest that headache and a first-degree family history of headache are risk factors for CRPS. To determine whether or not headache and first-degree family history of headache are risk factors for CRPS, further prospective studies with larger patient numbers should be carried out.

Successful surgical removal of a large arteriovenous malformation in a patient with hemophilia: case report.

OBJECTIVE AND IMPORTANCE: This is the first reported case of the successful surgical removal of a large arteriovenous malformation (AVM) in a patient with hemophilia A. CLINICAL PRESENTATION: A 19-year-old male patient was admitted to our department with intracranial hemorrhage. He had previously been diagnosed with hemophilia A and a cerebral AVM. Carotid angiography revealed a large AVM in the right temporal and parietal lobes. The neurological and neuroradiological findings, especially those of single photon emission computed tomography, identified an area of devitalization around the lesion, which was thought to reduce the risk of new deficits resulting from surgical manipulation. INTERVENTION: We resected the AVM in conjunction with supplemental infusions of Factor VIII before, during, and after the operation. A slight cerebral hemorrhage on the 7th postoperative day was observed despite control with Factor VIII, but the patient was discharged without any new deficits. CONCLUSION: We evaluated and managed all problems of a patient with multiple complications and achieved a medical cure.

Clinical findings in patients with recurrent intracerebral hemorrhage.

BACKGROUND: The use of computerized tomography has led to the detection of second intracerebral hemorrhage (ICH) in some patients. There have, however, only been a few clinical studies of second ICH. SUBJECTS AND METHODS: Thirty patients with a second ICH were analyzed according to clinical criteria. These patients comprised 5.9% of all patients admitted to Chugoku Rosai Hospital for ICH between 1984 and 1992. RESULTS: The mean interval between the first and second ICH was 27.7 months (range 1-144). The incidence of second hemorrhage was especially high within the first year after the initial ICH. Twelve patients bled bilaterally into the basal ganglia or thalamus during either the first or second attack. Most of these patients had poor outcomes and prognoses. The nine patients with good prognoses included patients with high activity of daily living (ADL) prior to the second attack, and those with neurologic grade 1 following the second attack. All of these patients were managed with conservative therapy. The 10 patients who underwent surgery had poor prognoses. CONCLUSIONS: The incidence of second ICHs is greater than that of initial ICHs. Many patients who experience a second ICH will have a poor prognosis, possibly worse than expected. Surgical therapy should not be recommended in such patients, since our data suggest that they will not do well even after surgery.

Rehabilitation technique facilitates association cortices in hemiparetic patients: functional MRI study.

We used fMRI to study brain activation with facilitative rehabilitation techniques (passive hand movements and visual feedback) in two patients with subcortical lesions. Two tasks were given in a sequence. The first task (trial 1) was repetitive hand grasping by the paretic hand at a rate of 0.5 Hz with the eyes closed. The second task (trial 2), the facilitative rehabilitation technique, included task 1 plus support by a trainer to move the paretic hand with the eyes open to get visual feedback of the movement. The data were analyzed by a subtractive method. When task 1 was subtracted from task 2, it was found that the bilateral visual cortex, contralateral premotor cortex and posterior parietal cortex were involved with the passive hand movement and visual feedback. These facilitative rehabilitation techniques may integrate networks between sensory information and motor commands, and lead to functional reorganization.

Giant intracranial aneurysm with rapid thrombus formation and intramural hemorrhage--case report.

A 50-year-old female presented with an unusual giant intracranial aneurysm that showed rapid, spontaneous thrombus formation and subsequent intramural hemorrhage. The thrombus appeared as a homogeneous area on magnetic resonance images, in contrast to the usual heterogeneous appearance. Two months after thrombus formation, the aneurysm had grown and developed intramural hemorrhage. The growth of giant intracranial aneurysms is related to neovascularization and recurrent intramural hemorrhage. The rapid formation of an intra-aneurysmal thrombus may stimulate neovascularization, resulting in intramural hemorrhage and aneurysmal growth.

Involvement of fluctuating high blood pressure in the enlargement of spontaneous intracerebral hematoma.

The correlations between changes in blood pressure after admission and hematoma expansion were investigated in 118 patients with spontaneous intracerebral hematoma admitted within 24 hours of onset who underwent serial computed tomography. Multiple logistic regression was performed to assess correlations between hematoma enlargement and clinical characteristics on admission. Hematoma enlargement was predominantly correlated with time of onset (p = 0.01567), and not well correlated with blood pressure at admission (p = 0.07908). Serial changes in blood pressure were investigated in 57 patients admitted within 6 hours of ictus whose blood pressures were monitored every hour from admission. Wilcoxon signed-rank analysis was used to determine the relationships between hematoma enlargement and blood pressure. Patients with hematoma enlargement was significantly correlated with increased blood pressure (p = 0.0004). Increases in blood pressure after admission may be a factor in hematoma enlargement.

Cavernous sinus cavernoma treated with radiation therapy--case report.

A 71-year-old female presented with a syncopal attack. She underwent surgery for what appeared to be a meningioma. However, a small incision in the dura mater caused severe bleeding. Histological examination of the biopsy specimen showed sinus cavernoma with an incomplete pseudocapsule. The dura mater encapsulated the cavernous sinus cavernoma, explaining the severe bleeding from the dural incision. She was treated with Linac irradiation (40 Gy) which resulted in a decrease in tumor size. Radiation therapy is indicated for the treatment of cavernous sinus cavernoma, especially if associated with severe intraoperative bleeding.

[Effect of somatosensory disturbance to outcomes of motor function in thalamic hemorrhage: evaluation with short-latency somatosensory evoked potential (SSEP)].

We investigated the effect of the somatosensory functions to the outcomes of motor functions in 28 patients with thalamic hemorrhage. The disturbance of the pyramidal tracts was assessed by the destruction of the internal capsule found in computed tomography (CT). The disturbance of the somatosensory function was analyzed by the N20 component of short-latency somatosensory evoked potentials (SSEP). The outcomes of motor function was evaluated after 3 months of ictus. Correlations between the outcomes of motor function, disturbance of the pyramidal tract, and disturbance of the somatosensory function were discussed. The result indicated that functional outcomes statistically correlated with neither disturbance of the internal capsule alone nor disturbance of N20 alone. But, there was statistically significant between functional outcomes and the combination of disturbance of the internal capsule with disturbance of N20 (p < 0.05, Wilcoxon signed-rank). There was not statistical difference in hematoma volume or consciousness. The implications of these results suggest that somatosensory function may affect the recovery of motor functions.

[Usefulness of reaction times in high-cortical recognition tasks].

We compared reaction times for high-cortical recognition tasks with kana-searching test in a group of 46 normal individuals aged 21 to 83 who gain a full score in Mini-Mental State. The following tasks of reaction time were used; simple reaction time (SRT), choice reaction time (CRT), memory scanning time (MST), and visual searching time (VST). The results were consistent and demonstrated that mean reaction time of 46 individuals increased in difficult tasks such as MST or VST. All reaction times increased depending on aging, which became longer in difficult tasks. Score of kana-searching test was correlated with MST and VST, but did not correlate with SRT and CRT. These findings suggest that reaction times may be useful for mass-screening of high-cortical functions in different ages as well as the kana-searching test.

Successful treatment of increased intracranial pressure by barbiturate therapy in a patient with severe sinus thrombosis after failure of osmotic therapy. A case report.

A patient with sinus thrombosis and characteristic magnetic resonance imaging (MRI) findings, who was managed successfully by barbiturate therapy is reported. MRI showed massive high intensity lesions on T2-weighted image which indicated venous cerebral infarction and brain oedema. Intravenous infusion of thiopental decreased increased intracranial pressure (ICP). The effectiveness of barbiturate therapy is discussed in terms of the similarity between this case and experimental sinus thrombosis. Barbiturate therapy should be considered in cases of severe sinus thrombosis with elevated ICP.

Cerebral palsy in adults: Independent effects of muscle strength and muscle tone.

OBJECTIVE: To investigate clinical characteristics and their contribution to activities of daily living (ADLs) in adults with cerebral palsy (CP). DESIGN: Descriptions of the clinical features of medical disorders; survey. SETTING: Rehabilitation counseling center in Japan. PATIENTS: A case series of 256 patients (140 men, 116 women; mean age, 31.6yr; range, 17-83yr) admitted to a rehabilitation center from January 1995 to December 1997. MAIN OUTCOME MEASURES: Characteristics investigated included severity of mental retardation, topography of motor deficits, motor power by manual muscle testing, muscle tone rated by using the muscle tone scale, deformity, sensory disturbance, and pain. ADLs were evaluated with the Barthel Index. RESULTS: Patients showed severe impairment in terms of the Ashworth scale for grading spasticity and deformity, and moderate impairment on manual muscle testing. ADLs were influenced significantly by topography of motor deficits, manual muscle test scores, and muscle tone scale assessment (p <.0001). The muscle tone scale findings showed a significant correlation with deformity (p <.0001), but did not correlate with manual muscle testing. ADLs were affected by muscle power and muscle tone independently. CONCLUSION: Adults with CP showed markedly increased muscle tone and moderate muscle weakness. These 2 factors did not correlate with each other, and were independently responsible for worse ADLs.