Distinct hippocampal subfield atrophy in Parkinson's disease regarding motor subtypes.

INTRODUCTION: Global hippocampal atrophy has been repeatedly reported in patients with Parkinson's disease (PD). However, there is limited literature on the differential involvement of hippocampal subfields among PD motor subtypes. This study aimed to investigate hippocampal subfield alterations in patients with PD based on their predominant symptoms. METHOD: We enrolled 31 PD patients with the tremor-dominant (TD) subtype, 27 PD patients with postural instability and gait disturbance-dominant (PIGD) subtype, and 40 healthy controls (HCs). All participants underwent high-spatial-resolution T1-weighted magnetic resonance imaging. The volume of hippocampal subfields was measured using FreeSurfer software, compared across groups, and correlated with clinical features. RESULTS: We found volumetric reductions in the hippocampal subfield in both patient subtypes compared to HCs, which were more pronounced in the PIGD subtype. The PIGD subtype had accelerated age-related alterations in the hippocampus compared to the TD subtype. Bilateral hippocampal volumes were positively associated with cognitive performance levels, but not with disease severity and duration in patients. CONCLUSIONS: Alterations in the hippocampal subfields of patients with PD differed based on their predominant symptoms. These findings are of relevance for understanding the pathophysiology of the increased risk of cognitive impairment in PIGD.

Dual-task clinical and functional MRI correlates in Parkinson's disease with postural instability and gait disorders.

BACKGROUND: Dual-task is a challenge for Parkinson's disease patients with postural instability and gait disorders (PD-PIGD). OBJECTIVE: This study investigated clinical, cognitive and functional brain correlates of dual-task deficits in PD-PIGD patients using quantitative gait analysis, neuropsychological evaluations and functional MRI (fMRI). METHODS: Twenty-three PD-PIGD patients performed a clinical assessment of gait/balance abilities. Single and dual-task Timed-Up-and-Go tests were monitored using an optoelectronic system to study turning velocity. Patients underwent executive-attentive function evaluation and two fMRI tasks: motor-task (foot anti-phase movements), and dual-task (foot anti-phase movements while counting backwards by threes starting from 100). Twenty-three healthy subjects underwent neuropsychological and fMRI assessments. RESULTS: Dual-task in PD-PIGD patients resulted in worse gait performance, particularly during turning. Performing the dual-task relative to the motor-fMRI task, healthy subjects showed widespread increased recruitment of sensorimotor, cognitive and cerebellar areas and reduced activity of inferior frontal and supramarginal gyri, while PD-PIGD patients showed increased recruitment of inferior frontal gyrus and supplementary motor area and reduced activity of primary motor, supramarginal and caudate areas. Dual-task gait alterations in patients correlated with balance and executive deficits and with altered dual-task fMRI brain activity of frontal areas. CONCLUSIONS: This study suggested the correlation between dual-task gait difficulties, postural instability and executive dysfunction in PD-PIGD patients. FMRI results suggest that an optimized recruitment of motor and cognitive networks is associated with a better dual-task performance in PD-PIGD. Future studies should evaluate the effect of specific gait/balance and dual-task trainings to improve gait parameters and optimize brain functional activity during dual-tasks.

Altered Processing of Complex Visual Stimuli in Patients with Postconcussive Visual Motion Sensitivity.

BACKGROUND AND PURPOSE: Vestibular symptoms are common after concussion. Vestibular Ocular Motor Screening identifies vestibular impairment, including postconcussive visual motion sensitivity, though the underlying functional brain alterations are not defined. We hypothesized that alterations in multisensory processing are responsible for postconcussive visual motion sensitivity, are detectable on fMRI, and correlate with symptom severity. MATERIALS AND METHODS: Twelve patients with subacute postconcussive visual motion sensitivity and 10 healthy control subjects underwent vestibular testing and a novel fMRI visual-vestibular paradigm including 30-second "neutral" or "provocative" videos. The presence of symptoms/intensity was rated immediately after each video. fMRI group-level analysis was performed for a "provocative-neutral" condition. Z-statistic images were nonparametrically thresholded using clusters determined by Z > 2.3 and a corrected cluster significance threshold of P = .05. Symptoms assessed on Vestibular Ocular Motor Screening were correlated with fMRI mean parameter estimates using Pearson correlation coefficients. RESULTS: Subjects with postconcussive visual motion sensitivity had significantly more Vestibular Ocular Motor Screening abnormalities and increased symptoms while viewing provocative videos. While robust mean activation in the primary and secondary visual areas, the parietal lobe, parietoinsular vestibular cortex, and cingulate gyrus was seen in both groups, selective increased activation was seen in subjects with postconcussive visual motion sensitivity in the primary vestibular/adjacent cortex and inferior frontal gyrus, which are putative multisensory visual-vestibular processing centers. Moderate-to-strong correlations were found between Vestibular Ocular Motor Screening scores and fMRI activation in the left frontal eye field, left middle temporal visual area, and right posterior hippocampus. CONCLUSIONS: Increased fMRI brain activation in visual-vestibular multisensory processing regions is selectively seen in patients with postconcussive visual motion sensitivity and is correlated with Vestibular Ocular Motor Screening symptom severity, suggesting that increased visual input weighting into the vestibular network may underlie postconcussive visual motion sensitivity.

Postural control strategy after incomplete spinal cord injury: effect of sensory inputs on trunk-leg movement coordination.

BACKGROUND: Postural control is affected after incomplete spinal cord injury (iSCI) due to sensory and motor impairments. Any alteration in the availability of sensory information can challenge postural stability in this population and may lead to a variety of adaptive movement coordination patterns. Hence, identifying the underlying impairments and changes to movement coordination patterns is necessary for effective rehabilitation post-iSCI. This study aims to compare the postural control strategy between iSCI and able-bodied populations by quantifying the trunk-leg movement coordination under conditions that affects sensory information. METHODS: 13 individuals with iSCI and 14 aged-matched able-bodied individuals performed quiet standing on hard and foam surfaces with eyes open and closed. We used mean Magnitude-Squared Coherence between trunk-leg accelerations measured by accelerometers placed over the sacrum and tibia. RESULTS: We observed a similar ankle strategy at lower frequencies (f ≤ 1.0 Hz) between populations. However, we observed a decreased ability post-iSCI in adapting inter-segment coordination changing from ankle strategy to ankle-hip strategy at higher frequencies (f > 1.0 Hz). Moreover, utilizing the ankle-hip strategy at higher frequencies was challenged when somatosensory input was distorted, whereas depriving visual information did not affect balance strategy. CONCLUSION: Trunk-leg movement coordination assessment showed sensitivity, discriminatory ability, and excellent test-retest reliability to identify changes in balance control strategy post-iSCI and due to altered sensory inputs. Trunk-leg movement coordination assessment using wearable sensors can be used for objective outcome evaluation of rehabilitative interventions on postural control post-iSCI.

Prospective assessment of function and cold-intolerance following revascularization for hypothenar hammer syndrome.

Ulnar artery revascularization in hypothenar hammer syndrome has repeatedly been shown to reduce ischaemic symptoms, however with varying graft patency percentages. This study prospectively assesses the effect of revascularization surgery with a vein graft using validated questionnaires in seven patients. The Disabilities of the Arm, Shoulder and Hand (DASH) and the Cold Intolerance Symptom Severity (CISS) questionnaires have been used to compare the preoperative and postoperative functionality and cold intolerance. All patients showed improvement in either functionality, or cold intolerance, or both from disabled to nearly normalized levels and resumed their occupation at final follow-up (mean of 28 months). Strikingly this was also the case in a patient with graft stenosis. Patients with the highest preoperative questionnaire scores showed most postoperative improvement. In conclusion, revascularization surgery seems to improve the symptomatology irrespective of graft patency. Questionnaires can be a valuable contribution to quantify and to follow the symptomatology in hypothenar hammer syndrome.

Movement disorder in a patient with Human Immunodeficiency Virus on an anti-retroviral therapy: A Case Report.

Human Immunodeficiency Virus associated neurocognitive dysfunction can present as a case of movement disorder in a patient with prolonged antiretroviral therapy. Diagnosis was made after ruling out space occupying lesions, nutritional deficiencies and infectious causes through brain imaging and cerebrospinal fluid analysis. With multidisciplinary care and change of antiretroviral therapy to drugs with higher cerebrospinal fluid penetration, symptoms of the patient improved over a span of six months. Delayed neurological damage due to Human Immunodeficiency Virus can present with isolated cerebellar symptoms.

Clinical Study of Thirteen Patients with Spinal Cord Infarction.

BACKGROUND: A concept of sensory tracts in the spinal cord has been established in relation to a dorsolateral pathway which is located in the posterior part of the lateral column and conveys the deep sense. METHODS: The clinical status at onset, neurological symptoms, and magnetic resonance imaging (MRI) findings in 13 patients of spinal cord infarction were studied. RESULTS: The clinical status was acute in 11 patients and subacute in 2 patients. Palsy of the extremities was noted in 11 patients. Segmental sensory disturbance was shown in all patients. One patient showed disturbance of all senses and paraplegia, which indicated transverse myelopathy. In the other 12 patients, 11 patients showed impairment of pain sense although joint position sense was preserved, excluding 1 patient whose sensory disturbance showed dysesthesia alone. In these 11 patients, soft touch and vibration senses were impaired in 7 patients. Abnormality of spinal cord MRI was detected 7 patients. The lesions were located in the cervical cord in 3 patients, cervical to thoracic cord in 1 patient, and thoracic cord in 3 patients. CONCLUSIONS: In the 11 patients in whom pain sense was impaired and joint position sense was preserved, involvement of the anterior spinal cord artery (ASCA) was the mainstay. Impairment of vibration sense was accompanied in 7 patients in patients of ASCA infarction. It was speculated that impairment of vibration sense can occur in patients with ASCA infarction whose ischemia spread to the dorsolateral pathway in the posterior part of the lateral column.

Atypical Functional Connectivity Associated with Autonomous Sensory Meridian Response: An Examination of Five Resting-State Networks.

Autonomous sensory meridian response (ASMR) is a perceptual phenomenon in which specific auditory and/or visual stimuli consistently elicit tingling sensations on the neck, scalp, and shoulders, as well as a positive and relaxed emotional state. The "ASMR triggers" that initiate these responses generally consist of soft sounds (e.g., whispering), repetitive noises (e.g., tapping sounds), or videos of people performing socially intimate acts (e.g., watching someone brush her hair). Despite being a relatively common phenomenon, little is known about the neural substrates of ASMR. In the current research, resting-state functional magnetic resonance imaging (fMRI) was used to examine whether ASMR was associated with atypical patterns of functional connectivity. Seventeen individuals with ASMR and 17 matched control participants underwent an anatomical MRI scan and a resting-state fMRI scan. An independent components analysis was used to identify the default mode, salience, central executive, sensorimotor, and visual networks. An analysis of variance with group (ASMR vs. control) as a between-subjects variable was performed to contrast the functional connectivity of each of these networks. The results demonstrated that ASMR was associated with reduced functional connectivity in the salience and visual networks, and with atypical patterns of connectivity in the default mode, central executive, and sensorimotor networks.

Diffusion tensor tractography in children with sensory processing disorder: Potentials for devising machine learning classifiers.

The "sensory processing disorder" (SPD) refers to brain's inability to organize sensory input for appropriate use. In this study, we determined the diffusion tensor imaging (DTI) microstructural and connectivity correlates of SPD, and apply machine learning algorithms for identification of children with SPD based on DTI/tractography metrics. A total of 44 children with SPD and 41 typically developing children (TDC) were prospectively recruited and scanned. In addition to fractional anisotropy (FA), mean diffusivity (MD), and radial diffusivity (RD), we applied probabilistic tractography to generate edge density (ED) and track density (TD) from DTI maps. For identification of children with SPD, accurate classification rates from a combination of DTI microstructural (FA, MD, AD, and RD), connectivity (TD) and connectomic (ED) metrics with different machine learning algorithms - including naïve Bayes, random forest, support vector machine, and neural networks - were determined. In voxel-wise analysis, children with SPD had lower FA, ED, and TD but higher MD and RD compared to TDC - predominantly in posterior white matter tracts including posterior corona radiata, posterior thalamic radiation, and posterior body and splenium of corpus callosum. In stepwise penalized logistic regression, the only independent variable distinguishing children with SPD from TDC was the average TD in the splenium (p < 0.001). Among different combinations of machine learning algorithms and DTI/connectivity metrics, random forest models using tract-based TD yielded the highest accuracy in classification of SPD - 77.5% accuracy, 73.8% sensitivity, and 81.6% specificity. Our findings demonstrate impaired microstructural and connectivity/connectomic integrity in children with SPD, predominantly in posterior white matter tracts, and with reduced TD of the splenium of corpus callosum as the most distinctive pattern. Applying machine learning algorithms, these connectivity metrics can be used to devise novel imaging biomarkers for neurodevelopmental disorders.

Periventricular White Matter Abnormalities on Diffusion Tensor Imaging of Postural Instability Gait Disorder Parkinsonism.

BACKGROUND AND PURPOSE: Postural instability gait disorder is a motor subtype of Parkinson disease associated with predominant gait dysfunction. We investigated the periventricular white matter comprising longitudinal, thalamic, and callosal fibers using diffusion tensor MR Imaging and examined clinical correlates in a cohort of patients with Parkinson disease and postural instability gait disorder and healthy controls. MATERIALS AND METHODS: All subjects underwent the Tinetti Gait and Balance Assessment and brain MR imaging. The DTI indices (fractional anisotropy, mean diffusivity, axial diffusivity, and radial diffusivity) from ROIs dropped over the superior and inferior longitudinal fasciculi, inferior fronto-occipital fasciculus, anterior thalamic radiation, anterior and posterior limbs of the internal capsule, and the genu and body of corpus callosum were evaluated. RESULTS: Our findings showed that the superior longitudinal fasciculus, inferior longitudinal fasciculus, inferior fronto-occipital fasciculus, anterior thalamic radiation, genu of the corpus callosum, and body of the corpus callosum are more affected in postural instability gait disorder than in those with Parkinson disease or healthy controls, with more group differences among the longitudinal fibers. Only the callosal fibers differentiated the postural instability gait disorder and Parkinson disease groups. DTI measures in the superior longitudinal fasciculus, frontostriatal fibers (anterior thalamic radiation, anterior limb of the internal capsule), and genu of the corpus callosum fibers correlated with clinical gait severity. CONCLUSIONS: Findings from this case-control cohort lend further evidence to the role of extranigral pathology and, specifically, the periventricular fibers in the pathophysiology of postural instability gait disorder.

Imaging counterpart of postural instability and vertical ocular dysfunction in patients with PSP: A multimodal MRI study.

INTRODUCTION: We investigated the imaging counterpart of two functional domains (ocular motor dysfunction and postural instability) in progressive supranuclear palsy (PSP) patients classified according to the new clinical diagnostic criteria. METHODS: Forty-eight patients with probable PSP-Richardson's syndrome (PSP-RS), 30 with probable PSP-parkinsonism (PSP-P), 37 with Parkinson's disease (PD), and 38 controls were enrolled. For each functional domain, PSP patients were stratified by two certainty levels: vertical supranuclear gaze palsy (O1) and slowness of vertical saccades (O2) for ocular motor dysfunction; early unprovoked falls and tendency to fall on the pull-test for postural instability. Voxel-based morphometry (VBM), whole-brain fractional anisotropy (FA) and MR planimetric measurements were analysed and compared across patient groups. RESULTS: O1 was present in 64%, and O2 in 36% of all PSP patients. All PSP-RS patients showed early unprovoked falls. TBSS whole-brain analysis revealed that superior cerebellar peduncles (SCPs) were the only structures with significantly lower FA values in PSP-RS compared with PSP-P patients. PSP/O1 patients had lower FA values in midbrain than PSP/O2 patients. By contrast, VBM revealed no differences in grey matter volume between PSP patient groups. MR Planimetric measurements confirmed atrophy of midbrain and SCPs, in line with DTI findings. CONCLUSIONS: Our study demonstrates that SCPs were significantly more damaged in patients with PSP-RS in comparison with PSP-P patients, thus suggesting the role of SCPs in developing postural instability. Midbrain damage was less severe in O2 than in O1 patients, suggesting that the degree of vertical ocular dysfunction reflects the severity of midbrain atrophy.

Neuroanatomical correlates of sensory deficits in children with neonatal arterial ischemic stroke.

AIM: Our aim was to characterize the sensory processing outcome following neonatal arterial ischemic stroke (NAIS) and identify neuroanatomical correlates of abnormal sensory processing. METHOD: We evaluated children with NAIS longitudinally at 12 months, 18 months, and/or 30 months in areas of cognitive, motor, and language development. We gathered sensory processing data using the Sensory Profile-2 Caregiver Questionnaire. These data were analyzed against early magnetic resonance imaging using a voxel-based approach. RESULTS: Eighteen children (10 males, 8 females) with NAIS were evaluated longitudinally, of which six exhibited atypical sensory processing. Children with sensory processing deficits had lower overall developmental scores in motor, cognitive, and language domains. Neuroanatomical correlates were identified in the posterior periventricular white matter extending superiorly into the supramarginal gyrus, and inferiorly into the fusiform and inferior temporal gyri. INTERPRETATION: Our results provide new evidence that children with NAIS may experience difficulty processing sensory information, which is most likely associated with injuries in the posterior periventricular white matter, supramarginal gyrus, fusiform gyrus, and posterior thalamic radiation. WHAT THIS PAPER ADDS: Atypical sensory processing is common in children with neonatal arterial ischemic stroke (NAIS). NAIS territories in sensory areas were correlated with atypical sensory processing behaviors. Children with NAIS may benefit from early interventions targeted toward sensory processing. Future research mapping NAIS injuries using early magnetic resonance imaging may predict long-term outcomes.

CORRELACIÓN NEUROANATÓMICA DE LOS DÉFICITS SENSORIALES EN NIÑOS CON INFARTO ISQUÉMICO ARTERIAL NEONATAL: OBJETIVO: Nuestro objetivo fue caracterizar los efectos el procesamiento sensorial posterior a un ictus isquémico arterial neonatal (IIAN) e identificar la relación neuroanatómica del procesamiento sensorial anormal. MÉTODO: Evaluamos longitudinalmente a niños con IIAN a los 12, 18 y/o 30 meses en áreas de desarrollo cognitivo, motor y lingüístico. Recopilamos los datos del procesamiento sensorial usando el Perfil Sensorial. Estos datos fueron analizados contra las imágenes de resonancia magnética temprana utilizando la técnica de voxel-based morphometry. RESULTADOS: Fueron evaluados longitudinalmente 18 niños (10 varones, 8 mujeres) con IIAN, de los cuales seis mostraron un procesamiento sensorial atípico. Los niños con déficit del procesamiento sensorial tuvieron puntuaciones menores del desarrollo general en los dominios motor, cognitivo y lingüístico. La correlación neuroanatómica fue identificada en la sustancia blanca periventricular posterior extendiéndose superiormente hacia el giro supramarginal e inferiormente dentro del giro fusiforme y el giro temporal inferior. INTERPRETACIÓN: Nuestros resultados proporcionan nuevas evidencias que los niños con IIAN pueden experimentar dificultades en el procesamiento de información sensorial, que está probablemente asociado con lesiones en la sustancia blanca periventricular posterior, giro supramarginal, giro fusiforme y la radiación talámica posterior.

CORRELATOS NEUROANATÔMICOS DOS DÉFICITS SENSORIAIS EM CRIANÇAS COM ACIDENTE VASCULAR CEREBRAL ISQUÊMICO NEONATAL: OBJETIVOS: Nosso objetivo foi avaliar os resultados de processamento sensorial após acidente vascular cerebral isquêmico neonatal (AVC-IN) e identificar correlatos neuroanatômicos de processamentos sensoriais anormais. MÉTODO: Foram avaliadas crianças com AVC-IN longitudinalmente com 12 meses, 18 meses, e /ou 30 meses nas áreas do desenvolvimento cognitivo, motor e linguagem. Obtivemos os dados do processamento sensorial utilizando o Perfil Sensorial. Os dados foram analisados através de imagens de ressonância magnética precoce utilizando uma abordagem baseada em Voxel. RESULTADOS: Dezoito crianças (10 meninos e 8 meninas) com AVC-IN foram avaliadas longitudinalmente, das quais seis exibiram processamento sensorial atípico. Crianças com déficits de processamento sensorial tiveram menor pontuação total nos domínios de desempenho motor, cognitivo, e de linguagem. Correlatos neuroanatômicos foram identificados na substancia branca periventricular posterior, estendendo-se superiormente até o giro supramarginal e inferiormente até o giro fusiforme, e giro temporal inferior. INTERPRETAÇÃO: Estes resultados proporcionam novas evidencias de que crianças com AVC-I possam apresentar dificuldades de processar informações sensoriais, o que está provavelmente associado com danos ocorridos na substancia branca periventricular posterior, giro supramarginal, giro fusiforme, e projeções talâmicas posteriores.

Balance in multiple sclerosis: relationship to central brain regions.

Dizziness, postural instability, and ataxia are among the most debilitating symptoms of multiple sclerosis (MS), reflecting, in large part, dysfunctional integration of visual, somatosensory, and vestibular sensory cues. However, the role of MS-related supratentorial lesions in producing such symptoms is poorly understood. In this study, motor control test (MCT) and dynamic sensory organization test (SOT) scores of 58 MS patients were compared to those of 72 healthy controls; correlations were determined between the MS scores of 49 patients and lesion volumes within 26 brain regions. Depending upon platform excursion direction and magnitude, MCT latencies, which were longer in MS patients than controls (p < 0.0001), were correlated with lesion volumes in the cortex, medial frontal lobes, temporal lobes, and parietal opercula (r's ranging from 0.20 to 0.39). SOT test scores were also impacted by MS and correlated with lesions in these same brain regions as well as within the superior frontal lobe (r's ranging from - 0.28 to - 0.40). The strongest and most consistent correlations occurred for the most challenging tasks in which incongruent visual and proprioceptive feedback were given. This study demonstrates that supratentorial lesion volumes are associated with quantitative balance measures in MS, in accord with the concept that balance relies upon highly convergent and multimodal neural pathways involving the skin, muscles, joints, eyes, and vestibular system.

Altered functional connectivity differs in stroke survivors with impaired touch sensation following left and right hemisphere lesions.

One in two survivors experience impairment in touch sensation after stroke. The nature of this impairment is likely associated with changes associated with the functional somatosensory network of the brain; however few studies have examined this. In particular, the impact of lesioned hemisphere has not been investigated. We examined resting state functional connectivity in 28 stroke survivors, 14 with left hemisphere and 14 with right hemisphere lesion, and 14 healthy controls. Contra-lesional hands showed significantly decreased touch discrimination. Whole brain functional connectivity (FC) data was extracted from four seed regions, i.e. primary (S1) and secondary (S2) somatosensory cortices in both hemispheres. Whole brain FC maps and Laterality Indices (LI) were calculated for subgroups. Inter-hemispheric FC was greater in healthy controls compared to the combined stroke cohort from the left S1 seed and bilateral S2 seeds. The left lesion subgroup showed decreased FC, relative to controls, from left ipsi-lesional S1 to contra-lesional S1 and to distributed temporal, occipital and parietal regions. In comparison, the right lesion group showed decreased connectivity from contra-lesional left S1 and bilateral S2 to ipsi-lesional parietal operculum (S2), and to occipital and temporal regions. The right lesion group also showed increased intra-hemispheric FC from ipsi-lesional right S1 to inferior parietal regions compared to controls. In comparison to the left lesion group, those with right lesion showed greater intra-hemispheric connectivity from left S1 to left parietal and occipital regions and from right S1 to right angular and parietal regions. Laterality Indices were significantly greater for stroke subgroups relative to matched controls for contra-lesional S1 (left lesion group) and contra-lesional S2 (both groups). We provide evidence of altered functional connectivity within the somatosensory network, across both hemispheres, and to other networks in stroke survivors with impaired touch sensation. Hemisphere of lesion was associated with different patterns of altered functional connectivity within the somatosensory network and with related function was associated with different patterns of altered functional connectivity within the somatosensory network and with related functional networks.

Cheiro-Oral syndrome caused by thalamus hemorrhage: A case report.

RATIONALE: Cheiro-Oral syndrome (COS) is a pure sensory deficit confined to the perioral area and ipsilateral distal fingers or hand. Owing to relatively minor clinical findings and various presentations in different cases, the insidious and severe illness it implies may be overlooked at acute settings. PATIENT CONCERNS: A 70-year-old man with history of hypertension and type II diabetes mellitus under regular medication control came to our emergency department with chief complaint of sudden onset of right perioral region and right upper limb numbness. General physical and neurological examinations were normal except for subtle hypoesthesia to light touch, and pinprick in the right corner of mouth and right forearm to distal fingers. DIAGNOSES: Routine blood analysis was all in normal range including white blood cell count, hemocrit platelet, renal and liver function, and electrolytes such as sodium and potassium. Noncontrast brain computed tomography showed abnormal high-attenuation collection in the left thalamus. INTERVENTION: Follow-up computed tomography showed absorption of the hemorrhage after strict control of his blood pressure. OUTCOMES: The patient was discharged 7 days later from our hospital with stable condition. LESSONS: We demonstrated type I COS associated with thalamic hemorrhage to highlight the neurological implication of COS. It is crucial for emergency clinicians to recognize the symptoms and promptly order a neuroimaging study to exclude large infarction/hemorrhage, which would deeply affect the disposition and following treatment of the patient.

Peripheral nerves are pathologically small in cerebellar ataxia neuropathy vestibular areflexia syndrome: a controlled ultrasound study.

BACKGROUND AND PURPOSE: Sensory neuronopathy is a cardinal feature of cerebellar ataxia neuropathy vestibular areflexia syndrome (CANVAS). Having observed that two patients with CANVAS had small median and ulnar nerves on ultrasound, we set out to examine this finding systematically in a cohort of patients with CANVAS, and compare them with both healthy controls and a cohort of patients with axonal neuropathy. We have previously reported preliminary findings in seven of these patients with CANVAS and seven healthy controls. METHODS: We compared the ultrasound cross-sectional area of median, ulnar, sural and tibial nerves of 14 patients with CANVAS with 14 healthy controls and 14 age- and gender-matched patients with acquired primarily axonal neuropathy. We also compared the individual nerve cross-sectional areas of patients with CANVAS and neuropathy with the reference values of our laboratory control population. RESULTS: The nerve cross-sectional area of patients with CANVAS was smaller than that of both the healthy controls and the neuropathy controls, with highly significant differences at most sites (P < 0.001). Conversely, the nerve cross-sectional areas in the upper limb were larger in neuropathy controls than healthy controls (P < 0.05). On individual analysis, the ultrasound abnormality was sufficiently characteristic to be detected in all but one patient with CANVAS. DISCUSSION: Small nerves in CANVAS probably reflect nerve thinning from loss of axons due to ganglion cell loss. This is distinct from the ultrasound findings in axonal neuropathy, in which nerve size was either normal or enlarged. Our findings indicate a diagnostic role for ultrasound in CANVAS sensory neuronopathy and in differentiating neuronopathy from neuropathy.

Paradoxical Distraction with Upright Position After Halo Fixation in 2 Patients with Atlanto-Occipital Dislocation.

BACKGROUND: Atlanto-occipital dislocation (AOD) is the most uncommon form of traumatic cervical spine injury. The majority of patients die before reaching higher-level care, and only a small percentage of patients with AOD survive the initial injury after receiving tertiary care. As such, there is a paucity of evidence-based management guidelines for treating this condition. Halo vest fixation has been a proposed method for interim stability while these patients undergo medical optimization for surgical intervention. There have been several reports of worsening AOD after halo placement. Reverse Trendelenburg position after halo fixation has been previously described to aid in the reduction of AOD, as well as concomitant atlantoaxial dislocation by gravitational downward force. CASE DESCRIPTION: In this series we present 2 cases of obese patients (body mass index >30) with AOD treated by halo fixation that had increased distraction after head of bed elevation. CONCLUSION: Our theorized mechanism for this phenomenon is due to the downward pull of subaxial forces secondary to a large body habitus.