Hypothalamic Injury and Clinical Outcomes in Patients with Post-Traumatic Hyponatremia: A Diffusion Tensor Imaging Case-Control Study.

BACKGROUND Diffusion tensor imaging (DTI) is an advanced magnetic resonance imaging (MRI) method used to identify changes in microstructures in the brain's white matter. Severe brain injuries after trauma are associated with disorders of consciousness (DOC) and may result in hyponatremia due to damage to the hypothalamus. This case-control study aimed to use DTI to evaluate the hypothalamus in 36 patients with hyponatremia and DOC due to severe brain injuries. MATERIAL AND METHODS Thirty-six patients with DOC after traumatic brain injury (TBI) and 36 healthy control subjects were enrolled in this study. The diagnosis of DOC was based on the coma recovery scale-revised (CRS-R). The 36 patients were divided into 2 groups: Group A (18 with hyponatremia, serum sodium level <135 mmol/L) and group B (18 without hyponatremia). The DTI scans were conducted using a 6-channel head coil on a 1.5T Philips Gyroscan Intera scanner. Among the DTI data, fractional anisotropy (FA) and the apparent diffusion coefficient (ADC) of the hypothalamus were analyzed. RESULTS Patient group A had a lower FA value (P=0.044) and higher ADC value (P=0.004) of the hypothalamus and showed a longer length of hospital stay (P=0.03), lower CRS-R score at discharge (P=0.01), and less change in CRS-R score (P=0.004) compared to patient group B. The improvements in the CRS-R score revealed a moderate negative correlation (r=-0.467) with the severity of the hyponatremia (P=0.004). CONCLUSIONS Post-traumatic hyponatremia was associated with hypothalamic injury and the presence and severity of hyponatremia were associated with poor clinical outcomes in DOC patients.

Relationship between consciousness and the thalamocortical tract in patients with intracerebral hemorrhage.

In patients with intracerebral hemorrhage (ICH), the relationship between consciousness and the thalamocortical tract (TCT), which links the thalamic intralaminar nuclei (ILN) and the cerebral cortex, was investigated. Forty-one patients with ICH were assigned to 1 of 2 groups according to their preservation of consciousness as determined by their Glasgow coma scale (GCS) score. Patient group A had impaired consciousness (GCS < 15, 21 patients), and patient group B had intact consciousness (GCS = 15, 20 patients). The control group included 20 age- and sex-matched healthy subjects. For all groups, the TCTs from the thalamic ILN of both sides were reconstructed using a probabilistic tractography method based on a multifiber model. In addition, tract volume (TV) values were determined. The TV values for the ipsilateral TCT from the thalamic ILN of the all-patient groups and those for contralateral TCT of the patient group B showed no significant differences between ICH and contra-ICH sides (P > .05). The TV results for the ipsilateral and contralateral TCTs from the thalamic ILN of the ICH and contra-ICH sides were significantly different among the 3 groups (P < .05). Among the patients, there were moderate positive correlations between GCS scores and TV values of the ipsilateral TCT on the ICH and contra-ICH sides (R = 0.477, P < .05; R = 0.426, P < .05). The TV of the ipsilateral TCT from the thalamic ILN on the ICH and contra-ICH sides was significantly correlated with the consciousness level in patients with ICH. Our results could be helpful when developing therapeutic strategies for ICH patients with disorders of consciousness.

Cerebellar Peduncle Injuries in Patients with Mild Traumatic Brain Injury.

BACKGROUND: The cerebellum is connected to the brain stem by three pairs of cerebellar peduncles (CPs)-superior (SCP), middle (MCP), and inferior (ICP)-which carry proprioceptive information to regulate movement and maintain balance and posture. Injury or damage to the CPs caused by tumors, infarcts, or traumatic brain injuries (TBI) results in poor coordination and balance problems. Current data on CP-related injuries and their effect on balance control are sparse and restricted to a few case studies. There have been no studies to date that have investigated CP injuries in a large sample of patients with balance problems following a mild TBI. Hence, we investigated CP-related injuries in patients with balance problems following mild TBI using diffusion tensor tractography (DTT). METHODS: Twenty-one patients with TBI and 21 normal subjects were recruited for this study. Balance was evaluated using the Balance Error Scoring System (BESS). Three DTT-related parameters-fractional anisotropy (FA), apparent diffusion coefficient (ADC), and fiber number (FN) of the CPs-were measured. RESULTS: The FN values of the SCP and ICP in the patient group were significantly lower than those in the control group (p < 0.05). No significant differences in the FA, ADC, and FN values of the MCP were observed between the patient and control groups (p > 0.05). CONCLUSIONS: Using DTT, we demonstrated injuries to the SCP and ICP in mild TBI patients with balance problems. Our results suggest that DTT could be a useful tool for detecting injuries to the CPs that may not be identified on conventional brain magnetic resonance imaging in mild TBI patients.

Relationships of the arcuate fasciculus and nigrostriatal tract with language ability in intracerebral hemorrhage using a diffusion tensor imaging.

We investigated the relationships of the arcuate fasciculus (AF) and the nigrostriatal tract (NST) with the language ability in patients with putaminal hemorrhage (PH) in the dominant hemisphere, using diffusion tensor tractography (DTT). Twenty-seven consecutive right-handed patients with PH and 27 age- and sex-matched normal control subjects were recruited. The aphasia quotient (AQ) score was used to evaluate the language ability at the early stage (within six weeks after onset). The fractional anisotropy (FA) value and tract volume (TV) of the ipsilesional AF and the ipsilesional NST were measured. The FA values and TVs of the ipsilesional AF and the ipsilesional NST of the patient group were lower than those of the control group (p < 0.05). The AQ score showed no significant correlation with the FA values of the ipsilesional AF and the ipsilesional NST (p > 0.05). By contrast, the AQ score showed a strong positive correlation with the TV of the ipsilesional AF (r = 0.868, p < 0.05). In addition, the AQ score revealed a moderate positive correlation with the TV of the ipsilesional NST (r = 0.577, p < 0.05). The states of the ipsilesional AF and the ipsilesional NST were closely related to the language ability at the early stages in patients with PH in the dominant hemisphere. Furthermore, the ipsilesional AF was more closely related to the language ability than the ipsilesional NST.

Prognosis prediction for impaired consciousness recovery in stroke patients using videofluoroscopic swallowing study: A retrospective observational study.

Prognosis prediction of impaired consciousness is clinically important for establishing therapeutic strategies, determining a rehabilitative goal and functional outcome, and estimating rehabilitative therapy duration. In this study, we investigated the prognosis prediction value of videofluoroscopic swallowing study (VFSS) in recovery of impaired consciousness in stroke patients. Fifty-one patients with impaired consciousness who underwent VFSS during the early stage of stroke between 2017 and 2021 were recruited in this retrospective study. VFSS were performed using modified Logemann protocol, and bonorex was used as the liquid contrast medium. The penetration-aspiration scale (PAS) was graded for all patients, and they were classified into 2 groups depending on the presence of aspiration on liquid material: the aspiration-positive group with a PAS score ≥ 6, and the aspiration-negative group with a PAS score < 6. The coma recovery scale-revised (CRS-R) was used to evaluate patients' conscious state at the time of VFSS and 3 months after. Statistical analysis was performed using independent t test and Pearson's correlation. The increase in total CRS-R score from time of VFSS to 3 months later was greater in aspiration-negative group than in aspiration-positive group (P < .05). A moderate negative correlation was observed between liquid PAS score and the increase in total CRS-R score (r = -0.499, P < .05). Among 6 CRS-R subscales, a strong negative correlation was observed between liquid PAS score and the communication score increase (r = -0.563, P < .05), while moderate negative correlations were detected between liquid PAS score and the increases in auditory (r = -0.465, P < .05), motor (r = -0.372, P < .05), oromotor (r = -0.426, P < .05), and arousal (r = -0.368, P < .05) scores. We observed that patients without aspiration on videofluoroscopic swallowing study showed better recovery of impaired consciousness, and the degree of penetration and aspiration had a predictive value for impaired consciousness prognosis in the early stage of stroke.

Correlation between spasticity and corticospinal/corticoreticular tract status in stroke patients after early stage.

We investigated the correlation between spasticity and the states of the corticospinal tract (CST) and corticoreticular tract (CRT) in stroke patients after early stage. Thirty-eight stroke patients and 26 healthy control subjects were recruited. The modified Ashworth scale (MAS) scale after the early stage (more than 1 month after onset) was used to determine the spasticity state of the stroke patients. Fractional anisotropy (FA), apparent diffusion coefficient (ADC), fiber number (FN), and ipsilesional/contra-lesional ratios for diffusion tensor tractography (DTT) parameters of the CST and CRT after the early stage were measured in both ipsi- and contra-lesional hemispheres. This study was conducted retrospectively. The FA and FN CST-ratios in the patient group were significantly lower than those of the control group (P < .05), except for the ADC CST-ratio (P > .05). Regarding the DTT parameters of the CRT-ratio, the patient group FN value was significantly lower than that of the control group (P < .05), whereas the FA and ADC CRT-ratios did not show significant differences between the patient and control groups (P > .05). MAS scores showed a strong positive correlation with the ADC CRT-ratio (P < .05) and a moderate negative correlation with the FN CRT-ratio (P < .05). We observed that the injury severities of the CST and CRT were related to spasticity severity in chronic stroke patients; moreover, compared to the CST, CRT status was more closely related to spasticity severity.

Relationship between the Consciousness State and the Default Mode Network in Traumatic Brain Injury.

INTRODUCTION: This study investigated the relationship between Coma Recovery Scale-Revised (CRS-R) and the neural networks between the medial prefrontal cortex (mPFC) and precuneus (PCun)/posterior cingulate cortex (PCC) in disorders of consciousness (DOC) patients with a traumatic brain injury (TBI) using diffusion tensor tractography (DTT). MEASURES: Twenty-five consecutive patients with TBI admitted to the rehabilitation department of a university hospital were enrolled in this study. The Coma Recovery Scale-Revised (CRS-R) was used to evaluate the consciousness state. The pathway of the neural networks between the mPFC and the PCun (mPFC-PCun DMN)/PCC (mPFC-PCC DMN) were reconstructed using DTT. Fractional anisotropy (FA) and the tract volume (TV) were obtained to assess the diffusion tensor imaging parameters. RESULTS: The CRS-R score had strong positive correlations with the FA value and TV of the mPFC-PCun DMN (p < 0.05), while it showed a moderate positive correlation with the TV of the mPFC-PCC DMN (p < 0.05). In addition, the FA value of the mPFC-Pcun DMN showed that it could explain the variability in the CRS-R score. CONCLUSIONS: The close correlation was noted between the consciousness state and the mPFC-PCun DMN and mPFC-PCC DMN in DOC patients with TBI. On the other hand, the mPFC-PCun DMN appeared to be more closely correlated with the consciousness state than the mPFC-PCC DMN.

Injury of the Spinothalamic Tract Following Whiplash Injury: A Diffusion Tensor Tractography Study.

OBJECTIVES: Using diffusion tensor tractography (DTT), we demonstrated the spinothalamic tract (STT) injury in patients with central pain following whiplash injury. Our primary hypothesis is that fractional anisotropy (FA) and tract volume (TV) of the STT in injured people differ from non-injured people. Our secondary hypothesis is that the direction of the collision results in a different type of injury. METHODS: Nineteen central pain patients following whiplash injury and 19 normal control subjects were recruited. The STT was reconstructed by the DTT, the FA and TV of the STT were measured. In addition, different characteristics of the STT injury according to the collision direction were investigated. RESULTS: The FA value did not differ significantly between the patient and control groups (p > 0.05). However, the significantly lower value of the TV was observed in patient group than the control group (p < 0.05). The onset of central pain was significantly delayed (13.5 days) in patients who were involved in a frontal collision, compared to patients with rear-end collision (0.6 days) (p < 0.05). In contrast, the Visual Analogue Scale was higher in the patients with rear-end collision (p < 0.05). CONCLUSIONS: We found the STT injury mild traumatic brain injury (TBI) who suffered central pain after whiplash injury, using DTT. In addition, we demonstrated different characteristics of the STT injury according to the collision direction. We believe that injury of the STT would be usefully detected by DTT following whiplash injury.

Transcutaneous auricular vagus nerve stimulation in disorders of consciousness: A mini-narrative review.

In this mini review, 6 studies that investigated the effects of transcutaneous auricular vagus nerve stimulation (taVNS) in patients with disorders of consciousness (DOC) were reviewed. Generally, the application of taVNS in patients with DOC appears to be effective (positive results in 5 of 6 studies) and safe. Furthermore, 4 studies that evaluated changes in the brain following taVNS reported positive results (2 studies, functional magnetic resonance imaging and 2 studies, electroencephalography). Based on our review of the 6 studies, we believe that research and clinical application of taVNS in DOC are in the initial stages and have the following limitations. First, there is a shortage of studies on this topic, with only 6 studies, 2 of which were case reports. Second, 5 studies were performed without control or sham groups. Third, there was no standardization of treatment schedules and electrical stimulation parameters. Therefore, further studies to overcome the above limitations should be encouraged; further original studies involving a larger number of patients in the control or sham groups are needed. However, studies on the optimal conditions (treatment schedule and electrical stimulation parameters) for taVNS in patients with DOC are necessary. Furthermore, neuroimaging studies should be undertaken to elucidate the neurological mechanisms for the recovery of impaired consciousness in DOC and the lasting effects of taVNS on the brain.

Diffusion Tensor Tractography Studies on Recovery Mechanisms of Aphasia in Stroke Patients: A Narrative Mini-Review.

Aphasia is a common and serious clinical feature of stroke. Various neural tracts are known to be involved in language processing. Diffusion tensor tractography (DTT) appears to be an appropriate imaging technique for the elucidation of the recovery mechanisms of aphasia in the language-related neural tracts in stroke patients. In this article, twelve previous DTT-based studies on the recovery mechanisms of aphasia in stroke were reviewed. We classified the twelve studies into the following three categories according to the recovery mechanisms: recovery via the neural tracts in the dominant hemisphere (eight studies), via transcallosal fibers (two studies), and via the neural tracts in the non-dominant hemisphere (two studies). Although there are various neural tracts for language processing, eight of the ten studies focused only on the role of the arcuate fasciculus (AF) in the recovery process. Consequently, it appears from the studies that only one recovery mechanism of aphasia via the restoration of the integrity of the injured AF in the dominant hemisphere was clearly demonstrated. However, because various neural tracts are involved in language processing, there could be other mechanisms that have not yet been elucidated. Therefore, further original studies involving a larger number of patients with aphasia in stroke should be encouraged forthwith. Further studies involving various lesion locations and severity levels of injuries to the language-related neural tracts are also necessary because the recovery mechanisms of aphasia in stroke could be dependent on these factors.

Relationship between the consciousness level and the structural neural connectivity of the medial prefrontal cortex in hypoxic-ischemic brain injury: a pilot study.

This pilot study investigated the relationship between the consciousness level and the structural neural connectivity of the medial prefrontal cortex (mPFC SNC) in patients with hypoxic-ischemic brain injury (HI-BI), using diffusion tensor tractography (DTT). Twenty-three patients with HI-BI were recruited into the study based on predefined inclusion criteria. Their consciousness levels were evaluated using the Glasgow Coma Scale (GCS) and the Coma Recovery Scale-Revised (CRS-R). Using DTT, the mPFC SNC was reconstructed for each patient. The average of the fractional anisotropy (FA), apparent diffusion coefficient (ADC), and voxel number (VN) for the mPFC SNC in both hemispheres were determined. The GCS score showed moderate positive correlations with the FA value and VN of the mPFC SNC [(FA) r = 0.439; (VN) r = 0.466; P < 0.05], and a strong negative correlation with ADC value ( r = -0.531; P < 0.05). The CRS-R score had a strong positive and negative correlation with the FA and ADC values of the mPFC SNC, respectively, [(FA) r = 0.540; (ADC) r = -0.614; P < 0.05] and a moderate positive correlation with the VN of the mPFC SNC ( r = 0.488; P < 0.05). We found that the severity of the injury to the mPFC SNC was closely related to the consciousness level. Our results suggest that the mPFC SNC appears to be a neural correlate for the control of consciousness in patients with HI-BI. Based on these results, we believe that the mPFC could be a target area for noninvasive neurostimulation therapies for patients with impaired consciousness following HI-BI.

Prediction of the gait function using the nigrostriatal and corticoreticulospinal tracts of the affected hemisphere in a cerebral infarct: A diffusion tensor imaging study.

Prognosis predictability of the nigrostriatal tract (NST) and corticoreticulospinal tract (CRT) of affected hemisphere at early stage for gait function at chronic stage were investigated using diffusion tensor tractography (DTT) in patients with a cerebral infarction. Thirty consecutive patients with middle cerebral artery (MCA) territory infarction were recruited. Functional ambulation category (FAC) was used to evaluate the gait function at chronic stage. Fractional anisotropy (FA) and tract volume (TV) of ipsilesional NST and ipsilesional CRT were determined to be DTT parameters at early stage. FAC score at chronic stage showed strong positive correlations with TVs of ipsilesional NST and ipsilesional CRT at early stage (ipsilesional NST R = 0.786; ipsilesional CRT R = 0.821; P < .05). According to regression model, FAC score at chronic stage was positively related to TVs of ipsilesional NST and ipsilesional CRT at early stage (Adjusted R2 = 0.700, F = 34.905, P < .05). FAC score at chronic stage was associated more positively with TV of ipsilesional CRT (ß = 0.532) than that of ipsilesional NST (ß = 0.362). Ipsilesional NST and ipsilesional CRT at early stage had prognosis predictability for gait function at chronic stage in patients with an MCA infarction. Moreover, ipsilesional CRT had stronger predictability than ipsilesional NST.

Relationship between hyperhidrosis and hypothalamic injury in patients with mild traumatic brain injury.

Hyperhidrosis is clinical symptom of various diseases and is an important clinical feature of paroxysmal sympathetic hyperactivity (PSH). Traumatic brain injury (TBI) is known to be most common condition associated with PSH, and PSH has been mainly reported in moderate and severe TBI. However, very little has been reported on PSH or hyperhidrosis in mild TBI patients. In this study, we used diffusion tensor imaging (DTI) to investigate the relationship between hyperhidrosis and hypothalamic injury in patients with mild TBI. Seven patients with hyperhidrosis after mild TBI and 21 healthy control subjects were recruited for this study. The Hyperhidrosis Disease Severity Scale was used for evaluation of sweating at the time of DTI scanning. The fractional anisotropy and apparent diffusion coefficient DTI parameters were measured in the hypothalamus. In the patient group, the fractional anisotropy values for both sides of the hypothalamus were significantly lower than those of the control group (P < .05). By contrast, the apparent diffusion coefficient values for both sides of the hypothalamus were significantly higher in the patient group than in the control group (P < .05). In conclusion, we detected hypothalamic injuries in patients who showed hyperhidrosis after mild TBI. Based on the results, it appears that hyperhidrosis in patients with mild TBI is related to hypothalamic injury.

An EEG-based asynchronous MI-BCI system to reduce false positives with a small number of channels for neurorehabilitation: A pilot study.

Many studies have used motor imagery-based brain-computer interface (MI-BCI) systems for stroke rehabilitation to induce brain plasticity. However, they mainly focused on detecting motor imagery but did not consider the effect of false positive (FP) detection. The FP could be a threat to patients with stroke as it can induce wrong-directed brain plasticity that would result in adverse effects. In this study, we proposed a rehabilitative MI-BCI system that focuses on rejecting the FP. To this end, we first identified numerous electroencephalogram (EEG) signals as the causes of the FP, and based on the characteristics of the signals, we designed a novel two-phase classifier using a small number of EEG channels, including the source of the FP. Through experiments with eight healthy participants and nine patients with stroke, our proposed MI-BCI system showed 71.76% selectivity and 13.70% FP rate by using only four EEG channels in the patient group with stroke. Moreover, our system can compensate for day-to-day variations for prolonged session intervals by recalibration. The results suggest that our proposed system, a practical approach for the clinical setting, could improve the therapeutic effect of MI-BCI by reducing the adverse effect of the FP.

Differences in the thalamocortical tract of the ascending reticular activating system in disorders of consciousness after hypoxic-ischemic brain injury: A pilot study.

This study purposed to investigate differences in the thalamocortical tract of the ascending reticular activating system between vegetative state (VS) and minimally conscious state (MCS) patients with hypoxic-ischemic brain injury (HI-BI). Fourteen patients with disorders of consciousness following HI-BI (VS group: 7 patients, MCS group: 7 patients) and 12 normal subjects were recruited. The 5 parts of reconstructed thalamocortical tract were prefrontal cortex (PFC), premotor cortex, primary motor cortex (M1), primary somatosensory cortex (S1), and posterior parietal cortex (PPC). The fractional anisotropy (FA) value and tract volume (TV) in each part of the thalamocortical tract were estimated. The FA values and TV of all parts of the thalamocortical tract in the VS group and the FA values of all parts and TV of PFC, premotor cortex, and PPC parts in the MCS group were lower than the control group (P < .05). In addition, the FA values of PFC and PPC parts were significantly lower in the VS group than the MCS group (P < .05). The results of our pilot study indicate that PFC and PPC parts of the thalamocortical tract are important areas to assess for differentiation of VS and MCS after HI-BI.

Paroxysmal sympathetic hyperactivity concurrent with hypothalamic injury in a patient with intracerebral hemorrhage: A case report.

BACKGROUND: Paroxysmal sympathetic hyperactivity (PSH) is characterized by exacerbated sympathetic discharge following severe brain injury. Here, we reports a patient diagnosed with PSH after ICH concurrent with hypothalamic injury, as demonstrated by diffusion tensor imaging (DTI). METHODS: A 27-year-old man patient was diagnosed with spontaneous intraventricular hemorrhage and intracerebral hemorrhage in both frontal lobes. Two months after onset, brain magnetic resonance imaging of the brain revealed a leukomalactic lesion in the hypothalamus. Three months after the onset, he presented with intermittent high fever, tachycardia, tachypnea, systolic hypertension, diaphoresis, and aggravated rigidity. Infection was ruled out by a physical examination, laboratory tests, and radiological studies. After administrating morphine and bromocriptine, the clinical manifestations improved dramatically. RESULTS: PSH after intracranial hemorrhage concurrent with the hypothalamic injury. Fractional anisotropy and mean diffusivity values of DTI were obtained in the hypothalamus. No significant difference in fractional anisotropy value was observed between the patient and control group (10 age-matched healthy male subjects) (P > .05). On the other hand, the mean diffusivity value was higher in the patient group than in the control group (P < .05), indicating hypothalamic injury. CONCLUSION: PSH concurrent with hypothalamic injury was observed in a patient with stroke. This study suggests that DTI can be a useful imaging method for evaluating the hypothalamic state of patients presenting with PSH after brain injury.

Effects of atrial fibrillation on motor outcome in patients with cerebral infarction.

BACKGROUND: Atrial fibrillation (AF) has been a leading cause of cerebral infarction, but the association with motor outcome after cerebral infarction remains unreported. In this study, we attempted to identify whether AF affects motor outcomes after cerebral infarction. METHODS: Seventy-six patients with a first-incidence cerebral infarction and who completed 6 months of rehabilitation were recruited to this retrospective study. The patients were divided into two groups based on the presence of AF (AF and non-AF groups). The upper extremity motricity index, lower extremity motricity index (LMI), modified Brunnstrom classification, and functional ambulation category (FAC) were evaluated, and those results were obtained within the first day and after 6 months of onset. Clinical factors that could affect motor outcome after cerebral infarction were also obtained. RESULTS: Compared with the non-AF group, the AF group had an upper extremity motricity index (47.15 ± 20.30 vs 58.66 ± 19.19; P = .032), LMI (53.42 ± 12.27 vs 65.58 ± 13.86; P = .001), and FAC scores (2.39 ± 0.93 vs 3.35 ± 0.93; P < .001) at 6 months after onset. Moreover, the AF group showed a lower FAC score gain than the non-AF group at 6 months after onset (2.33 ± 0.95 vs 3.28 ± 0.94; P < .001). Multivariate linear regression analyses showed that presence of AF had negative correlation with LMI gain (ß = -0.197; P = .010) and FAC gain (ß = -0.254; P = .011). CONCLUSION: We observed that AF had a negative effect on the motor outcome of the affected leg and the recovery of gait function in patients with cerebral infarction.

Incidence and characteristics of physical disabilities in patients with postconcussion syndromefollowing mTBI.

This study aimed to examine the incidence and characteristics of physical disabilities in patients with postconcussion syndrome (PCS) after a mild traumatic brain injury (mTBI). Of 203 patients diagnosed with PCS after mTBI, 10 patients with definite physical disabilities (worse than moderate disability on the Glasgow outcome scale [GOS], <4 points and inability to walk independently on the Functional Ambulation Category [FAC], <3 points) were enrolled. Ten of the 203 patients included in the analysis based on prespecified inclusion criteria were further evaluated. Seven patients had moderate disability on the GOS, whereas the remaining 3 showed severe disability. On the Modified Barthel Index, 5 patients were moderately dependent, and 2 patients were severely dependent. By the Motricity Index, 9 patients showed mild quadriparesis, and 1 had mild hemiparesis. All 10 patients could grasp-release their fingers as per the Modified Brunnstrom Classification. By contrast, 7 patients required verbal supervision for independent gait by the FAC, and the remaining 3 patients needed intermittent support from 1 person for independent gait. Approximately 5% of patients with PCS after mTBI had a definite physical disability, and most of these patients showed mild quadriparesis. These results suggest that a definite physical disability can occur in patients with PCS after mTBI.

Role of Diffusion Tensor Imaging in the Diagnosis of Traumatic Axonal Injury in Individual Patients with a Concussion or Mild Traumatic Brain Injury: A Mini-Review.

Present review paper aims to understand role of diffusion tensor imaging (DTI) and diffusion tensor tractography (DTT) in diagnosis of traumatic axonal injury (TAI), induced by head trauma, in individual patients with a concussion or mild traumatic brain injury (mTBI). Precise information on presence and severity of TAI in brain is necessary for determining appropriate therapeutic strategies. Several hundred DTI-based studies have reported TAI in concussion or mTBI. Majority of these DTI-based studies have been performed in a group of patients, whereas case studies that have reported TAI in individual patients with a concussion or mTBI are fewer. Summary of these DTI-based studies for individual patients is as follows: DTI can be used as a non-invasive tool for determining presence and severity of TAI in individual patients with concussion or mTBI. However, for diagnosis of TAI in an individual patient, several conditions are required to be met: no past history of head trauma, presence of possible conditions for TAI occurrence during head trauma, development of new clinical features after head trauma, and DTI observed abnormality of a neural structure that coincides with a newly developed clinical feature. However, further studies for a more precise diagnosis of TAI in individual patients should be encouraged.

Role of Diffusion Tensor Imaging in Diagnosis and Estimation of Shunt Effect for Hydrocephalus in Stroke Patients: A Narrative Review.

Hydrocephalus is a dilatation of the brain ventricular system by the accumulation of cerebrospinal fluid within the ventricle caused by impaired cerebrospinal fluid circulation or clearance. A diagnosis of hydrocephalus at the chronic stage of stroke has been mainly made by clinical features and radiologic findings on brain computed tomography and magnetic resonance imaging. On the other hand, it could not determine the effect of hydrocephalus or shunt effect on the periventricular neural structures. By contrast, these effects on the periventricular neural structures can be estimated using diffusion tensor imaging (DTI). This article reviewed 10 DTI-based studies related to the diagnosis and estimation of the shunt effect for hydrocephalus in stroke patients. These studies suggest that DTI could be a useful diagnostic and estimation tool of the shunt effect for hydrocephalus in stroke patients. In particular, some studies suggested that fractional anisotropy value in the periventricular white matter could be a diagnostic biomarker for hydrocephalus. As a result, the role of DTI in diagnosing and estimating the shunt effect for hydrocephalus in stroke patients appears to be promising. However, the number of studies and patients of all reviewed studies were limited (10 studies including a total of 58 stroke patients with heterogenous brain pathologies).