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.

Musician developed left putaminal hemorrhage and lost absolute pitch ability-case report.

Absolute pitch (AP) recognizes and labels the pitch chroma of a given tone without external reference. Its neural mechanism remains unclear. We report a 68-year-old AP musician who developed a left putaminal hemorrhage edematous lesion under the posterior insular cortex. Diffusion tensor tractography with the region of interest, including Heschl's gyrus, was performed. In the left hemisphere, the middle longitudinal fasciculus was absent, especially at the parietal lobe. Her AP ability was lost. As the hematoma was absorbed and the left MdLF was observed on the tractography, her AP ability recovered. Our case suggested that the left middle longitudinal fasciculus, a part of the ventral auditory pathway, plays a role in AP.

Relationships among language ability, the arcuate fasciculus and lesion volume in patients with putaminal hemorrhage: a diffusion tensor imaging study.

Relationships among language ability, arcuate fasciculus and lesion volume were investigated by use of diffusion tensor tractography in patients with putaminal hemorrhage. Thirty-three right-handed patients within six weeks of hemorrhage onset were recruited. Correlation of the aphasia quotient with subset (fluency, comprehension, repetition, naming) scores, diffusion tensor tractography parameters and lesion volume of patients, aphasia quotient (r = 0.446) with subset (naming: r = 0.489) score had moderate positive correlations with fractional anisotropy of the left arcuate fasciculus. The aphasia quotient subset (repetition) score had a strong positive correlation with fractional anisotropy of the left arcuate fasciculus (r = 0.520), whereas, aphasia quotient subset (fluency and comprehension) scores had no significant correlations with fractional anisotropy of the left arcuate fasciculus after Benjamini-Hochberg correction. Aphasia quotient (r = 0.668) with subset (fluency: r = 0.736, comprehension: r = 0.739, repetition: r = 0.649, naming: r = 0.766) scores had strong positive correlations with the tract volume of the left arcuate fasciculus and strong negative correlations with lesion volume (r = -0.521, fluency: r = -0.520, comprehension: r = -0.513, repetition: r = -0.518, naming: r = -0.562). Fractional anisotropy of the left arcuate fasciculus had a moderate negative correlation with lesion volume (r = -0.462), whereas the tract volume of the left arcuate fasciculus had a strong negative correlation with lesion volume (r = -0.700). According to the result of mediation analysis, tract volume of the left arcuate fasciculus fully mediated the effect of lesion volume on the aphasia quotient. Regarding the receiver operating characteristic curve, the lesion volume cut-off value was 29.17 cm3 and the area under the curve (0.74), sensitivity (0.77) and specificity (0.80) were higher than those of fractional anisotropy, tract volume and aphasia quotient cut-off values. It was found that level of language disability was related to lesion volume as well as to injury severity of arcuate fasciculus in the dominant hemisphere of patients with putaminal hemorrhage. In particular, the tract volume of the arcuate fasciculus in the dominant hemisphere fully mediated the effect of lesion volume on language ability. Additionally, a lesion volume of approximately 30 cm3 was helpful in discriminating arcuate fasciculus discontinuation in the dominant hemisphere.

Musician developed right putaminal hemorrhage but conserved absolute pitch ability -Case report.

Absolute pitch (AP) is known as the ability to recognize and label the pitch chroma of a given tone without external reference. The neural mechanism and its asymmetry of AP musicians remain unclear. We herein report a 41-year-old AP musician who developed a right putaminal hemorrhage. On a postoperative day 5, a fluid-attenuated inversion recovery image revealed the rest of the hematoma and edematous lesion at the right white matter between the Heschl's gyrus and other cortices. Diffusion tensor tractography with the region of interest at the Heschl's gyrus was performed. In the left hemisphere, the anterior part of the arcuate fiber and middle longitudinal fasciculus were observed. However, these connections were absent in the right hemisphere, but her AP ability was maintained. Our case suggested that the fibers from the right Heschl's gyrus to the right frontal lobe via the right ventral stream is not associated with AP.

Predicting walking ability in hemiplegic patients with putaminal hemorrhage: an observational study in a rehabilitation hospital.

BACKGROUND: In stroke rehabilitation, the most important concern of the patients and their families is whether the patients can walk independently and whether they need braces after discharge. AIM: This study aims to investigate the relationship between several types of putaminal hemorrhage and walking independence and orthotic therapy in patients with hemiplegia. DESIGN: Observational study. SETTING: Inpatients rehabilitation department, Fujita Health University Nanakuri Memorial Hospital, Japan. POPULATION: Total 264 patients with putaminal hemorrhage admitted to our hospital. METHODS: Neurological and cognitive functions were examined as per the stroke scale of the National Institutes of Health and the Mini-mental state examination, respectively. The hematomas were classified into five types, and the volume was measured using computed tomography (CT). Walking ability was evaluated by Functional Ambulation Category (FAC), and walking independence was defined as FAC ≥4. The relationship between the types of hematomas and walking independence and orthotic therapy in patients with hemiplegia with putaminal hemorrhage was also analyzed. RESULTS: We observed differences within the hematoma types in volume, neurological symptoms, and cognitive function but not in age, sex, and lesion side aspects of these patients - 143 of whom could walk independently (FAC≥4) and 121 non-independently. Walking independently and the need for orthosis were closely related to the type of hematoma. CONCLUSIONS: CT imaging at stroke onset can provide useful information when examining walking independence and indicate necessity for an orthosis at the time of discharge to the rehabilitation ward. CLINICAL REHABILITATION IMPACT: This study might help to better understand the role of neuroimaging in stroke rehabilitation.

Late leukoencephalopathy in patients with methanol intoxication / Leucoencefalopatía tardía posterior a intoxicación por metanol

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[A Case of Putaminal Hemorrhage Caused by Underlying Tectal Glioblastoma].

We report a case of glioblastoma due to putaminal hemorrhage. Notably, the glioblastoma was located at some distance from the hematoma. A 42-year-old right-handed man presented with a sudden-onset headache, motor aphasia, and right hemiplegia. CT showed left putaminal hemorrhage and a mass lesion with a slightly high density in the midbrain away from the hematoma. Conservative treatment was initiated for the patient. Initially, we suspected a benign tumor-like cavernous malformation based on the CT findings. However, MRI showed ring enhancement of the mass lesion on contrast-enhanced MRI and hyperintensity on arterial spin labeling(ASL). A part of the wall of the putaminal hemorrhage also exhibited hyperintensity on ASL. Since we suspected a malignant brainstem tumor and a secondary intracerebral hemorrhage caused by this tumor, we performed a stereotactic brain biopsy. Histological examination revealed that the tumor was a wild-type IDH-1 glioblastoma. In the acute phase, the intracerebral hemorrhage presented as a hyperintensity on T1-weighted imaging. Therefore, it was difficult to distinguish hemorrhagic glioblastoma from an intracerebral hemorrhage. Even if an intracerebral hemorrhage is observed at common sites, it is important to consider the possibility of a malignant brain tumor and complete a prompt examination. In addition, ASL imaging may be useful in detecting hemorrhagic malignant brain tumors.

Influence of hematoma volume and age on cognitive functions and ADL after putaminal hemorrhage.

BACKGROUND AND OBJECTIVE: After cerebral hemorrhage, cognitive functions and activities of daily living (ADL) are affected by various factors, including hematoma volume and patient age. In the present study, we investigated the effect of age and hematoma volume on cognitive functions and on ADL. METHODS: The sample comprised 274 patients (183 men and 91 women; mean age 58.2 ± 12.5 years) with putaminal hemorrhage who were hospitalized in a convalescent rehabilitation ward. Hematoma volume was estimated from computed tomography imaging at stroke onset. Cognitive functions were evaluated using Raven's Colored Progressive Matrices test (RCPM) and the Mini-Mental State Examination (MMSE) at hospital admission, while ADL score was assessed at discharge using the Functional Independence Measure motor subscale (FIM-M). In the present study, we classified the patients into six groups according to whether they were non-elderly or elderly (cutoff age, 60 years) and whether their hematoma was small, medium, or large (cutoff volumes, 20 and 40 mL, respectively). Subsequently, the scores on the RCPM, MMSE, and FIM-M were compared among the groups. RESULTS: In both age groups, patients with a larger hematoma volume had lower RCPM and MMSE scores. Patients <60 years old exhibited different trends in their RCPM and MMSE scores, such that the RCPM score showed a step-wise decrease according to hematoma volume, while a difference in the MMSE score was only observed at the 20 mL boundary. Most of the younger patients (<60 years of age) attained high FIM-M scores at discharge, as long as their hematoma volume was either medium or small (<40 mL). This age group had higher RCPM scores on admission, which may have contributed to their higher FIM-M scores on discharge. CONCLUSIONS: In the present study, we demonstrated that advancing age increases the effect of hematoma volume on RCPM and MMSE scores and identified differences in the effects observed on these two scores. Thus, it may be important to use the RCPM alongside the MMSE for patient assessment.

COVID-19-related acute necrotizing encephalopathy with brain stem involvement in a patient with aplastic anemia.

OBJECTIVE: To describe a novel case of coronavirus disease 2019 (COVID-19)-associated acute necrotizing encephalopathy (ANE) in a patient with aplastic anemia where there was early brain stem-predominant involvement. METHODS: Evaluation of cause, clinical symptoms, and treatment response. RESULTS: A 59-year-old woman with a background of transfusion-dependent aplastic anemia presented with seizures and reduced level of consciousness 10 days after the onset of subjective fever, cough, and headache. Nasopharyngeal swab testing for severe acute respiratory syndrome coronavirus (SARS-CoV-2) was positive, and CT during admission demonstrated diffuse swelling of the brain stem. She required intubation and mechanical ventilation for airway protection, given her reduced level of consciousness. The patient's condition deteriorated, and MRI on day 6 demonstrated worsening brain stem swelling with symmetrical hemorrhagic lesions in the brain stem, amygdalae, putamina, and thalamic nuclei. Appearances were consistent with hemorrhagic ANE with early brain stem involvement. The patient showed no response to steroid therapy and died on the eighth day of admission. CONCLUSIONS: COVID-19 may be associated with an acute severe encephalopathy and, in this case, was considered most likely to represent an immune-mediated phenomenon. As the pandemic continues, we anticipate that the spectrum of neurologic presentation will broaden. It will be important to delineate the full clinical range of emergent COVID-19-related neurologic disease.

Relationship between Hematoma Volume and Motor Impairment in Putaminal Hemorrhage.

PURPOSE: Computed tomography (CT) is used for initial assessment of patients with suspected stroke. Motor outcome prediction using the initial CT image is important for clinical rehabilitation. However, there is inconsistency in the results reported by the few publications on hematoma volume and motor outcomes in patients with putaminal hemorrhage. To clarify the direction of hematoma and relationship between the hematoma volume and motor outcomes in patients with putaminal hemorrhage using an initial CT image, we evaluated the volume of direction of hematoma in 170 patients in the subacute phase after putaminal hemorrhage using CT at stroke onset. METHODS: The patients were divided into 5 groups according to the direction of the hematoma. For each group, Spearman's correlation coefficients were calculated to investigate the relationship between hematoma volume and motor outcomes. Motor outcomes were assessed using the motor items of Stroke Impairment Assessment Set, which are impairment indexes for the distal and proximal functions of the upper and lower extremities after stroke. RESULTS: Hematoma volume was significantly correlated with all the motor items in the group whose hematoma extended to the posterior limb of the internal capsule alone (Bonferroni corrected P <.05). On the other hand, significant correlations between hematoma volume and motor outcomes could not be found in almost all the other groups. CONCLUSIONS: Motor outcome after putaminal hemorrhage can be predicted by evaluating the progression of hematoma to the corticospinal tract and its volume using CT images at stroke onset.

Endoscopic Surgery Without Decompressive Craniectomy in Large Putaminal Intracerebral Hemorrhage: Assessment of Efficacy and Safety.

BACKGROUND: Decompressive craniectomy (DC) is performed conventionally for large putaminal intracerebral hemorrhage (ICH). However, DC causes local skull defect and leads to post-surgical cranioplasty. The aim of this study is to investigate the effectiveness and safety of an endoscopic procedure to treat large putaminal ICH without DC. METHODS: This retrospective study included 112 large putaminal ICH patients who underwent hematoma evacuations with either an endoscopic procedure (group A) or with DC (group B) between January 2009 and June 2017. The efficacy was evaluated by mean modified Rankin Scale (mRS) three months after surgery. Safety was evaluated by mortality rate and postoperative complications. Univariate and multivariate logistic regression analyses were performed to determine the risk factors for clinical outcomes. RESULTS: The study included 49 patients in group A and 63 in group B. The mRS scores in both groups were similar after 3 months' follow-up (p = 0.709). There was no difference in the mortality rate between the two groups (p = 0.538). The rate of complications was lower in group A than that in group B (p = 0.024). Smaller preoperative midline shift (p = 0.008) and absent intraventricular extension (p = 0.044) have contributed significantly to better outcomes. CONCLUSION: Endoscopic hematoma evacuation without DC is safe and effective for patients with large putaminal ICH and deserves further investigation, preferably in a randomized controlled setting.

Stimulating neural plasticity with real-time fMRI neurofeedback in Huntington's disease: A proof of concept study.

Novel methods that stimulate neuroplasticity are increasingly being studied to treat neurological and psychiatric conditions. We sought to determine whether real-time fMRI neurofeedback training is feasible in Huntington's disease (HD), and assess any factors that contribute to its effectiveness. In this proof-of-concept study, we used this technique to train 10 patients with HD to volitionally regulate the activity of their supplementary motor area (SMA). We collected detailed behavioral and neuroimaging data before and after training to examine changes of brain function and structure, and cognitive and motor performance. We found that patients overall learned to increase activity of the target region during training with variable effects on cognitive and motor behavior. Improved cognitive and motor performance after training predicted increases in pre-SMA grey matter volume, fMRI activity in the left putamen, and increased SMA-left putamen functional connectivity. Although we did not directly target the putamen and corticostriatal connectivity during neurofeedback training, our results suggest that training the SMA can lead to regulation of associated networks with beneficial effects in behavior. We conclude that neurofeedback training can induce plasticity in patients with Huntington's disease despite the presence of neurodegeneration, and the effects of training a single region may engage other regions and circuits implicated in disease pathology.

Auditory agnosia caused by bilateral putamen haemorrhage.

A 55-year-old right-handed man with a history of hypertension suddenly fell and developed right hemiparesis. Neurological examination revealed that he was alert, but did not appropriately respond to verbal questions and commands. Detailed examination revealed that he could correctly respond to written commands. His speech was almost fluent, showing no paraphasia and normal articulation. His written sentences were legible. Pure tone audiometry showed that his auditory acuity was relatively preserved. His brainstem auditory evoked potential components from I to V were recorded bilaterally with normal latency. Cerebral CT demonstrated fresh bleeding in the left putamen and an old haemorrhage on the opposite side. He was treated by antihypertensive therapy and rehabilitation. Although there remained mild sensory deficit on his right extremities and he felt a slight noise during conversation, he had little difficulty with verbal communication when he was transferred to another hospital on day 38.

Frequency and Predicting Factors on Chronic Expanding Intracerebral Hematoma in Spontaneous Intracerebral Hemorrhage.

BACKGROUND: Chronic expanding intracerebral hematoma is a well-known complication of spontaneous intracerebral hemorrhage. However, because chronic expanding intracerebral hematoma is relatively rare, it has not been studied systemically. The purpose of this study was to characterize a patient population with chronic expanding intracerebral hematoma, and to identify the predictive factors for it. METHODS: We retrospectively evaluated 112 patients with spontaneous putaminal hemorrhage who were treated at our institution between January 1, 2010 and December 31, 2015. Data on age, sex, Glasgow Coma Scale score, presence of intraventricular hemorrhage, and intracerebral hemorrhage volume were collected, and their predictive values for chronic expanding intracerebral hematoma were investigated. We also evaluated the predictive value of a characteristic radiological finding at onset called the "layer sign," which was represented as a fluid level adjacent to the clot. RESULTS: Chronic expanding intracerebral hematoma was observed in 4 patients (4.9%) with spontaneous intracerebral hemorrhage. Only the layer sign was significantly related to chronic expanding intracerebral hematoma (P = .003), and was found to be independently associated with chronic expanding intracerebral hematoma in a multivariate analysis (odds ratio, 18.6; 95% confidence interval, 1.19-291.0; P = .037). CONCLUSIONS: The frequency of chronic expanding intracerebral hematoma in those with spontaneous intracerebral hemorrhage was estimated at 4.9%. The layer sign was a useful factor for predicting chronic expanding intracerebral hematoma.

A case of musical anhedonia due to right putaminal hemorrhage: a disconnection syndrome between the auditory cortex and insula.

A 63-year-old, right-handed professional chorus conductor developed right putaminal hemorrhage, and became unable to experience emotion while listening to music. Two years later, neurological examination revealed slight left hemiparesis. Neuromusicological assessments revealed impaired judgment of "musical sense," and the inability to discriminate the sound of chords in pure intervals from those in equal temperament. Brain MRI and tractography identified the old hemorrhagic lesion in the right putamen and impaired fiber connectivity between the right insula and superior temporal lobe. These findings suggest that musical anhedonia might be caused by a disconnection between the insula and auditory cortex.

Recurrence of stroke caused by nocturnal hypoxia-induced blood pressure surge in a young adult male with severe obstructive sleep apnea syndrome.

Obstructive sleep apnea syndrome (OSAS) causes resistant hypertension and a hypopnea-related nocturnal blood pressure (BP) surge. This could lead to an increase of not only the nocturnal BP level but also nocturnal BP variability, both of which increase an individual's cardiovascular risk. We recently developed a trigger sleep BP monitoring method that initiates BP measurement when an individual's oxygen desaturation falls below a variable threshold, and we demonstrated that it can detect a BP surge during apnea episodes. We here report the case of a 36-year-old man with severe OSAS who experienced the recurrence of stroke due to nocturnal hypoxia and a nocturnal BP surge measured by this trigger sleep BP monitoring device. A nocturnal BP surge during sleep in OSAS patients could be a strong trigger of cardiovascular events.