Development and evaluation of a new assistive device for low back load reduction in caregivers: an experimental study.

Low back pain among healthcare professionals is associated with the manual handling of patients. Some bed features for turning and repositioning have been developed; however, the load during patient care remains heavy. We developed a device to reduce low back load in caregivers during patient bedside care and evaluated it objectively and subjectively from a caregiver's perspective using a randomised crossover study. Overall, 28 clinical nurses and care workers were randomly assigned to two interventional groups: administering care with (Device method) and without (Manual method) the device in an experimental room. We measured the caregiver's trunk flexion angle using inertial measurement units and video recording during care and then defined a trunk flexion angle of > 45° as the threshold; the variables were analysed using linear mixed models. Subsequently, participants responded to a survey regarding the usability of the device. Trunk flexion time and percentage of time were 26.5 s (95% confidence interval: 14.1 s, 38.9 s) (p < 0.001) and 23.0% (95% confidence interval: 16.4%, 29.6%) (p < 0.001) lower, respectively, in the Device group than in the Manual group. Furthermore, caregivers evaluated the care they could administer with the device as being better than that associated with manual care.

Motor and sensory cortical processing of neural oscillatory activities revealed by human swallowing using intracranial electrodes.

Swallowing is attributed to the orchestration of motor output and sensory input. We hypothesized that swallowing can illustrate differences between motor and sensory neural processing. Eight epileptic participants fitted with intracranial electrodes over the orofacial cortex were asked to swallow a water bolus. Mouth opening and swallowing were treated as motor tasks, whereas water injection was treated as a sensory task. Phase-amplitude coupling between lower-frequency and high γ (HG) bands (75-150 Hz) was investigated. An α (10-16 Hz)-HG coupling appeared before motor-related HG power increases (burst), and a θ (5-9 Hz)-HG coupling appeared during sensory-related HG bursts. The peaks of motor-related coupling were 0.6-0.7 s earlier than that of HG power. The motor-related HG was modulated at the trough of the α oscillation, and the sensory-related HG amplitude was modulated at the peak of the θ oscillation. These contrasting results can help to elucidate the brain's sensory motor functions.

Swallowing-related neural oscillation: an intracranial EEG study.

OBJECTIVE: Swallowing is a unique movement due to the indispensable orchestration of voluntary and involuntary movements. The transition from voluntary to involuntary swallowing is executed within milliseconds. We hypothesized that the underlying neural mechanism of swallowing would be revealed by high-frequency cortical activities. METHODS: Eight epileptic participants fitted with intracranial electrodes over the orofacial cortex were asked to swallow a water bolus and cortical oscillatory changes, including the high γ band (75-150 Hz) and ß band (13-30 Hz), were investigated at the time of mouth opening, water injection, and swallowing. RESULTS: Increases in high γ power associated with mouth opening were observed in the ventrolateral prefrontal cortex (VLPFC) with water injection in the lateral central sulcus and with swallowing in the region along the Sylvian fissure. Mouth opening induced a decrease in ß power, which continued until the completion of swallowing. The high γ burst of activity was focal and specific to swallowing; however, the ß activities were extensive and not specific to swallowing. In the interim between voluntary and involuntary swallowing, swallowing-related high γ power achieved its peak, and subsequently, the power decreased. INTERPRETATION: We demonstrated three distinct activities related to mouth opening, water injection, and swallowing induced at different timings using high γ activities. The peak of high γ power related to swallowing suggests that during voluntary swallowing phases, the cortex is the main driving force for swallowing as opposed to the brain stem.

A Swallowing Decoder Based on Deep Transfer Learning: AlexNet Classification of the Intracranial Electrocorticogram.

To realize a brain-machine interface to assist swallowing, neural signal decoding is indispensable. Eight participants with temporal-lobe intracranial electrode implants for epilepsy were asked to swallow during electrocorticogram (ECoG) recording. Raw ECoG signals or certain frequency bands of the ECoG power were converted into images whose vertical axis was electrode number and whose horizontal axis was time in milliseconds, which were used as training data. These data were classified with four labels (Rest, Mouth open, Water injection, and Swallowing). Deep transfer learning was carried out using AlexNet, and power in the high-[Formula: see text] band (75-150[Formula: see text]Hz) was the training set. Accuracy reached 74.01%, sensitivity reached 82.51%, and specificity reached 95.38%. However, using the raw ECoG signals, the accuracy obtained was 76.95%, comparable to that of the high-[Formula: see text] power. We demonstrated that a version of AlexNet pre-trained with visually meaningful images can be used for transfer learning of visually meaningless images made up of ECoG signals. Moreover, we could achieve high decoding accuracy using the raw ECoG signals, allowing us to dispense with the conventional extraction of high-[Formula: see text] power. Thus, the images derived from the raw ECoG signals were equivalent to those derived from the high-[Formula: see text] band for transfer deep learning.

Nationwide survey of 780 Japanese patients with amyotrophic lateral sclerosis: their status and expectations from brain-machine interfaces.

BACKGROUND: Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disease that causes eventual death through respiratory failure unless mechanical ventilation is provided. Brain-machine interfaces (BMIs) may provide brain control supports for communication and motor function. We investigated the interests and expectations of patients with ALS concerning BMIs based on a large-scale anonymous questionnaire survey supported by the Japan Amyotrophic Lateral Sclerosis Association. METHODS: We surveyed 1918 patients with ALS regarding their present status, tracheostomy use, interest in BMIs, and their level of expectation for communication (conversation, emergency alarm, internet, and writing letters) and movement support (postural change, controlling the bed, controlling household appliances, robotic arms, and wheel chairs). FINDINGS: Seven hundred and eighty participants responded. Fifty-eight percent of the participants underwent tracheostomy. Approximately, 80% of the patients experienced stress or trouble during communication. For all nine supports, > 60% participants expressed expectations regarding BMIs. More than 98% of participants who underwent tracheostomy expected support with conversation and emergency alarms. Participants who did not undergo tracheostomy exhibited significantly greater expectations than participants with tracheostomy did regarding all five movement supports. Seventy-seven percent of participants were interested in BMIs. Participants aged < 60 years had greater interest in both BMIs. INTERPRETATION: This is the first large-scale survey to reveal the present status of patients with ALS and probe their interests and expectations regarding BMIs. Communication and emergency alarms should be supported by BMIs initially. BMIs should provide wide-ranging and high-performance support that can easily be used by severely disabled elderly patients with ALS.

A Fully Implantable Wireless ECoG 128-Channel Recording Device for Human Brain-Machine Interfaces: W-HERBS.

Brain-machine interfaces (BMIs) are promising devices that can be used as neuroprostheses by severely disabled individuals. Brain surface electroencephalograms (electrocorticograms, ECoGs) can provide input signals that can then be decoded to enable communication with others and to control intelligent prostheses and home electronics. However, conventional systems use wired ECoG recordings. Therefore, the development of wireless systems for clinical ECoG BMIs is a major goal in the field. We developed a fully implantable ECoG signal recording device for human ECoG BMI, i.e., a wireless human ECoG-based real-time BMI system (W-HERBS). In this system, three-dimensional (3D) high-density subdural multiple electrodes are fitted to the brain surface and ECoG measurement units record 128-channel (ch) ECoG signals at a sampling rate of 1 kHz. The units transfer data to the data and power management unit implanted subcutaneously in the abdomen through a subcutaneous stretchable spiral cable. The data and power management unit then communicates with a workstation outside the body and wirelessly receives 400 mW of power from an external wireless transmitter. The workstation records and analyzes the received data in the frequency domain and controls external devices based on analyses. We investigated the performance of the proposed system. We were able to use W-HERBS to detect sine waves with a 4.8-µV amplitude and a 60-200-Hz bandwidth from the ECoG BMIs. W-HERBS is the first fully implantable ECoG-based BMI system with more than 100 ch. It is capable of recording 128-ch subdural ECoG signals with sufficient input-referred noise (3 µVrms) and with an acceptable time delay (250 ms). The system contributes to the clinical application of high-performance BMIs and to experimental brain research.

Training in Use of Brain-Machine Interface-Controlled Robotic Hand Improves Accuracy Decoding Two Types of Hand Movements.

Objective: Brain-machine interfaces (BMIs) are useful for inducing plastic changes in cortical representation. A BMI first decodes hand movements using cortical signals and then converts the decoded information into movements of a robotic hand. By using the BMI robotic hand, the cortical representation decoded by the BMI is modulated to improve decoding accuracy. We developed a BMI based on real-time magnetoencephalography (MEG) signals to control a robotic hand using decoded hand movements. Subjects were trained to use the BMI robotic hand freely for 10 min to evaluate plastic changes in the cortical representation due to the training. Method: We trained nine young healthy subjects with normal motor function. In open-loop conditions, they were instructed to grasp or open their right hands during MEG recording. Time-averaged MEG signals were then used to train a real decoder to control the robotic arm in real time. Then, subjects were instructed to control the BMI-controlled robotic hand by moving their right hands for 10 min while watching the robot's movement. During this closed-loop session, subjects tried to improve their ability to control the robot. Finally, subjects performed the same offline task to compare cortical activities related to the hand movements. As a control, we used a random decoder trained by the MEG signals with shuffled movement labels. We performed the same experiments with the random decoder as a crossover trial. To evaluate the cortical representation, cortical currents were estimated using a source localization technique. Hand movements were also decoded by a support vector machine using the MEG signals during the offline task. The classification accuracy of the movements was compared among offline tasks. Results: During the BMI training with the real decoder, the subjects succeeded in improving their accuracy in controlling the BMI robotic hand with correct rates of 0.28 ± 0.13 to 0.50 ± 0.11 (p = 0.017, n = 8, paired Student's t-test). Moreover, the classification accuracy of hand movements during the offline task was significantly increased after BMI training with the real decoder from 62.7 ± 6.5 to 70.0 ± 11.1% (p = 0.022, n = 8, t(7) = 2.93, paired Student's t-test), whereas accuracy did not significantly change after BMI training with the random decoder from 63.0 ± 8.8 to 66.4 ± 9.0% (p = 0.225, n = 8, t(7) = 1.33). Conclusion: BMI training is a useful tool to train the cortical activity necessary for BMI control and to induce some plastic changes in the activity.

MEG-BMI to Control Phantom Limb Pain.

A brachial plexus root avulsion (BPRA) causes intractable pain in the insensible affected hands. Such pain is partly due to phantom limb pain, which is neuropathic pain occurring after the amputation of a limb and partial or complete deafferentation. Previous studies suggested that the pain was attributable to maladaptive plasticity of the sensorimotor cortex. However, there is little evidence to demonstrate the causal links between the pain and the cortical representation, and how much cortical factors affect the pain. Here, we applied lesioning of the dorsal root entry zone (DREZotomy) and training with a brain-machine interface (BMI) based on real-time magnetoencephalography signals to reconstruct affected hand movements with a robotic hand. The DREZotomy successfully reduced the shooting pain after BPRA, but a part of the pain remained. The BMI training successfully induced some plastic changes in the sensorimotor representation of the phantom hand movements and helped control the remaining pain. When the patient tried to control the robotic hand by moving their phantom hand through association with the representation of the intact hand, this especially decreased the pain while decreasing the classification accuracy of the phantom hand movements. These results strongly suggested that pain after the BPRA was partly attributable to cortical representation of phantom hand movements and that the BMI training controlled the pain by inducing appropriate cortical reorganization. For the treatment of chronic pain, we need to know how to modulate the cortical representation by novel methods.

Small Hyperintensities in the Area of the Perforating Arteries in Patients with Seizure.

BACKGROUND/AIM: We previously observed spotty hyperintense lesions in the region of the perforating arteries on peri-ictal diffusion-weighted imaging (DWI); however, no report has formally described these findings. The aim of this study was to investigate focal intensities on peri-ictal DWI, and to evaluate the clinical significance of these lesions. METHODS: We conducted a retrospective review of 677 consecutive patients with seizure who completed peri-ictal DWI within 24 h after seizure onset. Patients were grouped according to the presence or absence of diffusion hyperintense lesions (DHLs) in the region of the perforating arteries. We compared clinical and imaging characteristics between these 2 groups. RESULTS: Among 677 patients, 23 patients (3.4%) had DHLs. Analyses of apparent diffusion coefficient values and fluid attenuated inversion recovery images suggested that DHLs were acute or subacute ischemic lesions that had appeared prior to seizure onset. Patients with DHLs were more likely to be older in age, have atrial fibrillation, and coronary artery disease, and have more severe deep white matter hyperintensity or leukoaraiosis compared to patients without DHLs. CONCLUSION: DHLs detected on peri-ictal DWI may represent incidental acute cerebral microinfarcts in the aging brain, especially in patients with small vessel disease.

Non-invasive quantification of human swallowing using a simple motion tracking system.

The number of patients with dysphagia is rapidly increasing due to the ageing of the population. Therefore, the importance of objectively assessing swallowing function has received increasing attention. Videofluoroscopy and videoendoscopy are the standard clinical examinations for dysphagia, but these techniques are not suitable for daily use because of their invasiveness. Here, we aimed to develop a novel, non-invasive method for measuring swallowing function using a motion tracking system, the Kinect v2 sensor. Five males and five females with normal swallowing function participated in this study. We defined three mouth-related parameters and two larynx-related parameters and recorded data from 2.5 seconds before to 2.5 seconds after swallowing onset. Changes in mouth-related parameters were observed before swallowing and reached peak values at the time of swallowing. In contrast, larynx-related parameters showed little change before swallowing and reached peak values immediately after swallowing. This simple swallow tracking system (SSTS) successfully quantified the swallowing process from the oral phase to the laryngeal phase. This SSTS is non-invasive, wireless, easy to set up, and simultaneously measures the dynamics of swallowing from the mouth to the larynx. We propose the SSTS for use as a novel and non-invasive swallowing assessment tool in the clinic.

Voxel-based lesion mapping of meningioma: a comprehensive lesion location mapping of 260 lesions.

OBJECTIVE In the present study the authors aimed to determine preferred locations of meningiomas by avoiding descriptive analysis and instead using voxel-based lesion mapping and 3D image-rendering techniques. METHODS Magnetic resonance images obtained in 248 treatment-naïve meningioma patients with 260 lesions were retrospectively and consecutively collected. All images were registered to a 1-mm isotropic, high-resolution, T1-weighted brain atlas provided by the Montreal Neurological Institute (the MNI152), and a lesion frequency map was created, followed by 3D volume rendering to visualize the preferred locations of meningiomas in 3D. RESULTS The 3D lesion frequency map clearly showed that skull base structures such as parasellar, sphenoid wing, and petroclival regions were commonly affected by the tumor. The middle one-third of the superior sagittal sinus was most commonly affected in parasagittal tumors. Substantial lesion accumulation was observed around the leptomeninges covering the central sulcus and the sylvian fissure, with very few lesions observed at the frontal, parietal, and occipital convexities. CONCLUSIONS Using an objective visualization method, meningiomas were shown to be located around the middle third of the superior sagittal sinus, the perisylvian convexity, and the skull base. These observations, which are in line with previous descriptive analyses, justify further use of voxel-based lesion mapping techniques to help understand the biological nature of this disease.

The optimal stimulation site for high-frequency repetitive transcranial magnetic stimulation in Parkinson's disease: A double-blind crossover pilot study.

Many reports have shown improvements in motor symptoms after repetitive transcranial magnetic stimulation (rTMS). However, the best stimulation area in the brain has not currently been determined. We assessed the effects of high-frequency rTMS (HF-rTMS) on the motor and mood disturbances in Parkinson's disease (PD) patients and attempted to determine whether the primary motor area (M1), the supplementary motor area (SMA), and the dorsolateral prefrontal cortex (DLPFC) were the best treatment targets. In this randomized, double-blind crossover design study, we investigated the efficacy of 3 consecutive days of HF-rTMS over the M1, SMA, and DLPFC and compared these HF-rTMS to sham stimulations. We used motor and non-motor scales to evaluate the parkinsonian symptoms. The changes in the Unified Parkinson's Disease Rating Scale part III (UPDRS-III) scores after the application of HF-rTMS over the M1 and SMA were significantly greater than those after the sham stimulation. However, after the application of HF-rTMS over the DLPFC, the UPDRS-III scores were similar to those after the sham stimulation. No significant improvements were demonstrated in the mood disturbances after the stimulations over any of the targets. In conclusion, the application of HF-rTMS over the M1 and SMA significantly improved the motor symptoms in the PD patients but did not alter the mood disturbances.

X-ray angiography perfusion imaging with an intra-arterial injection: comparative study with 15O-gas/water positron emission tomography.

BACKGROUND: X-ray angiography perfusion (XAP) is a perfusion imaging technique based on conventional DSA. OBJECTIVE: In this study, we aimed to validate parameters derived from XAP by comparing them with 15O-gas/water positron emission tomography (PET), using data from patients with chronic ischemic cerebrovascular disease. METHODS: 18 consecutive patients were included. XAP was performed with intra-arterial infusion of contrast media, and a time-density curve was constructed for each cerebral hemisphere. From the curves, the relative values of mean transit time (rMTT) and wash-in rate (rWiR) were obtained by dividing the values of the right hemisphere by those of the left hemisphere. These were then compared with the relative values of cerebral blood flow (rCBF) and rMTT calculated from the PET data. RESULTS: XAP rWiR correlated strongly with PET rCBF (r=0.86, P<0.0001). rMTT measurements from the two modalities were also strongly correlated (r=0.85, P<0.0001). Bland-Altman analysis revealed a bias of 0.14±0.18 (95% limits of agreement -0.22 to 0.51) for PET rCBF versus XAP rWiR, and 0.016±0.093 (95% limits of agreement -0.17 to 0.20) for rMTT between the two modalities. CONCLUSIONS: The relative values obtained from XAP were validated across a population of patients with chronic ischemic cerebrovascular disease.

Delayed massive epistaxis from traumatic intracranial aneurysm after blunt facial injury.

Cases: Traumatic intracranial aneurysm following blunt head injury is uncommon but can be induced by extension of skull base fracture and causes unexpected hemorrhagic complications. We present two cases of traumatic intracranial aneurysm in the paraclinoid area that was revealed by delayed massive epistaxis. Lack of initial neurological deficits omitted screening for cerebrovascular injury. Outcome: Internal trapping was carried out using endovascular techniques in both cases, with extracranial-intracranial bypass in one case. No recurrent bleeding occurred in either case. Conclusion: To prevent unexpected delayed life-threatening hemorrhagic accidents, careful assessment of skull-base fracture is prerequisite, even in cases of mild facial injury.

Transarterial Sinus Embolization for a Dural Arteriovenous Fistula in a Sinus of the Lesser Sphenoid Wing: A Case Report.

Dural arteriovenous fistula (DAVF) in a sinus of the lesser sphenoid wing (SLSW) is rarely reported. Here, we report a case of an isolated SLSW DAVF treated by coils placed into the sinus through the feeding artery. A 68-year-old man was admitted to our hospital with headache. Magnetic resonance images and an angiogram showed a varix in the right middle cranial fossa. A DAVF, consisting of three main feeders and the isolated SLSW, was diagnosed based on the angiogram findings. Retrograde leptomeningeal venous drainage to the deep middle cerebral vein was observed. Given the remarkable extent of cortical venous ectasia together with the presence of headache and right abducens nerve paralysis, endovascular treatment was initiated. A transvenous approach through the right inferior petrosal sinus was not feasible because of difficulty associated with inserting the microcatheter into the SLSW. Thus, we tried a transarterial approach and were able to advance the microcatheter beyond the fistula into the isolated SLSW, through the artery of the foramen rotundum. The isolated sinus and feeding arteries were embolized with coils. The postoperative angiogram showed the total occlusion of the SLSW DAVF. This case demonstrates the feasibility of transarterial sinus packing for an isolated SLSW DAVF.

Brachial-Ankle Pulse Wave Velocity as a Predictor of Silent Cerebral Embolism after Carotid Artery Stenting.

BACKGROUND: In neuroendovascular therapy, the effect of arterial stiffness on postprocedural cerebral thromboembolism is unknown. In this observational study, we examined the relationship between cerebral thromboembolism after carotid artery stenting and arterial stiffness. METHODS: From April 2015 to February 2017, we enrolled consecutive patients undergoing scheduled carotid artery stenting in our institution. In all patients, preprocedural brachial-ankle pulse wave velocity was used to assess arterial stiffness, whereas the number of new cerebral ischemic lesions on diffusion-weighted magnetic resonance imaging was assessed after treatment. We also analyzed patient data and details of procedures in patients with carotid artery stenting. RESULTS: Twenty-one patients completed the study. The mean brachial-ankle pulse wave velocity was 1879 cm/s. There was no association of cerebral thromboembolisms with age, unstable plaque, protection device, or type of stent. However, the brachial-ankle pulse wave velocity was an independent predictor of cerebral thromboembolisms (P = .0017). CONCLUSIONS: Brachial-ankle pulse wave velocity is predictive of silent cerebral embolisms on diffusion-weighted magnetic resonance imaging after carotid artery stenting.

Downregulation of EGFR in a metastatic brain lesion of EGFR-mutated non-small cell lung cancer using a tyrosine kinase inhibitor: A case report.

Brain metastasis is a common complication in patients with cancer, with lung cancer being the most frequent origin of brain metastases. Epidermal growth factor receptor (EGFR) tyrosine kinase inhibitors (TKIs) have begun to serve a pivotal role in lung cancer treatment and have been reported to demonstrate anticancer activity against brain metastases by penetrating the blood-brain barrier. The present study reports, to the best of our knowledge, the first case of EGFR-mutated non-small cell lung cancer (NSCLC) brain metastasis that was surgically resected while the lesion was responding to the EGFR-TKI erlotinib. The results of the present study demonstrated that EGFR-mutated NSCLC cells were able to evade the cytotoxic effect of EGFR-TKI by downregulating EGFR expression, without exhibiting the T790M EGFR mutation.

Voxel-Based Lesion Mapping of Cryptogenic Stroke in Patients with Advanced Cancer: A Detailed Magnetic Resonance Imaging Analysis of Distribution Pattern.

BACKGROUND: Ischemic stroke is one form of cancer-associated thrombosis that can greatly worsen a patient's performance status. The present investigation aimed to elucidate the characteristic distribution pattern(s) of cryptogenic stroke lesions using a voxel-based lesion-mapping technique and examine the differences in clinical manifestations between cryptogenic and conventional strokes in patients with advanced cancer. METHODS: Data from 43 patients with advanced cancer who developed acute ischemic stroke were retrospectively collected. Stroke etiology was grouped into either cryptogenic or conventional stroke etiology according to the ASCO stroke score. Clinical data were reviewed, and voxel-based lesion mapping using diffusion-weighted imaging (DWI) was performed to visualize the cross-patient spatial distribution of the lesions. RESULTS: Of the 43 patients, 25 were classified as having cryptogenic stroke etiology and 18 were classified as having conventional stroke etiology. Median survival time of patients from stroke onset was 96 days for cryptogenic stroke etiology and 570 days for conventional stroke etiology (P = .01). D-dimer of patients was significantly higher in cryptogenic stoke etiology than in conventional stroke etiology (P = .006). Voxel-based lesion mapping showed that DWI hyperintense lesions accumulated at cortical and internal watershed areas of the cerebrum and at the vascular border zone of the superior cerebellar and posterior inferior cerebellar arteries at the cerebellum. CONCLUSIONS: Voxel-based lesion mapping for cryptogenic stroke in patients with advanced cancer showed that lesions accumulated at vascular border zones within the brain both at the cerebrum and at the cerebellum, but not at perforating arterial territories.