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Complex regional pain syndrome (CRPS) type I in stroke patients is usually known to affect the hemiplegic upper limb. We report a case of CRPS presented in an ipsilesional arm of a 72-year-old female patient after an ischemic stroke at the left middle cerebral artery territory. Clinical signs such as painful range of motion and hyperalgesia of her left upper extremity, swollen left hand, and dystonic posture were suggestive of CRPS. A three-phase bone scintigraphy showed increased uptake in all phases in the ipsilesional arm. Diffusion tensor tractography showed significantly decreased fiber numbers of the corticospinal tract and the spinothalamic tract in both unaffected and affected hemispheres. Pain and range of motion of the left arm of the patient improved after oral steroids with a starting dose of 50 mg/day.
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Cerebellar mutism (CM) is a rare neurological condition characterized by lack of speech due to cerebellar lesions. CM is often reported in children. We describe a rare case of CM after spontaneous cerebellar hemorrhage. The patient showed mutism, irritability, decreased spontaneous movements and oropharyngeal apraxia. Diffusion tensor imaging revealed significant volume reduction of medial frontal projection fibers from the corpus callosum. In Tracts Constrained by UnderLying Anatomy (TRACULA) analysis, forceps major and minor and bilateral cingulum-angular bundles were not visualized. Cerebello-frontal pathway reconstructed from the FMRIB Software Library showed continuity of fibers, with decreased number of fibers on qualitative analysis. These results suggest that cerebello-frontal disconnection may be a neuroanatomical mechanism of CM. Damage of brain network between occipital lobe, cingulate and cerebellum caused by hemorrhage may also have role in the mechanism of CM in our case.
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To analyze the clinical characteristics between neurogenic and non-neurogenic cause of vocal cord immobility (VCI).
The researchers retrospectively reviewed clinical data of patients who underwent laryngeal electromyography (LEMG). LEMG was performed in the bilateral cricothyroid and thyroarytenoid muscles. A total of 137 patients were enrolled from 2011 to 2016, and they were assigned to either the neurogenic or non-neurogenic VCI group, according to the LEMG results. The clinical characteristics were compared between the two groups and a subgroup analysis was done in the neurogenic group.
Among the 137 subjects, 94 patients had nerve injury. There were no differences between the neurogenic and non-neurogenic group in terms of demographic data, underlying disease except cancer, and premorbid events. In general characteristics, cancer was significantly higher in the neurogenic group than non-neurogenic group (p=0.001). In the clinical findings, the impaired high pitched ‘e’ sound and aspiration symptoms were significantly higher in neurogenic group (p=0.039 for impaired high pitched ‘e’ sound; p=0.021 for aspiration symptoms), and sore throat was more common in the non-neurogenic group (p=0.014). In the subgroup analysis of neurogenic group, hoarseness was more common in recurrent laryngeal neuropathy group than superior laryngeal neuropathy group (p=0.018).
In patients with suspected vocal cord palsy, impaired high pitched ‘e’ sound and aspiration symptoms were more common in group with neurogenic cause of VCI. Hoarseness was more frequent in subjects with recurrent laryngeal neuropathy. Thorough clinical evaluation and LEMG are important to differentiate underlying cause of VCI.
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To investigate the characteristics of cognitive deficits in patients with post-stroke dysphagia, and to analyze the relationships between cognitive dysfunction and severity of dysphagia in supratentorial stroke.
A total of 55 patients with first-ever supratentorial lesion stroke were enrolled retrospectively, within 3 months of onset. We rated dysphagia from 0 (normal) to 4 (severe) using the dysphagia severity scale (DSS) through clinical examinations and videofluoroscopic swallowing studies (VFSS). The subjects were classified either as non-dysphagic (scale 0) or dysphagic (scale 1 to 4). We compared general characteristics, stroke severity and the functional scores of the two groups. We then performed comprehensive cognitive function tests and investigated the differences in cognitive performance between the two groups, and analyzed the correlation between cognitive test scores, DSS, and parameters of oral and pharyngeal phase.
Fugl-Meyer motor assessment, the Berg Balance Scale, and the Korean version of the Modified Barthel Index showed significant differences between the two groups. Cognitive test scores for the dysphagia group were significantly lower than the non-dysphagia group. Significant correlations were shown between dysphagia severity and certain cognitive subtest scores: visual span backward (p=0.039), trail making tests A (p=0.042) and B (p=0.002), and Raven progressive matrices (p=0.002). The presence of dysphagia was also significantly correlated with cognitive subtests, in particular for visual attention and executive attention (odds ratio [OR]=1.009; 95% confidence interval [CI], 1.002–1.016; p=0.017). Parameters of premature loss were also significantly correlated with the same subtests (OR=1.009; 95% CI, 1.002–1.016; p=0.017).
Our results suggest that cognitive function is associated with the presence and severity of post-stroke dysphagia. Above all, visual attention and executive functions may have meaningful influence on the oral phase of swallowing in stroke patients with supratentorial lesions.
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Which brain regions participate in musical processing remains controversial. During singing and listening a familiar song, it is necessary to retrieve information from the long-term memory. However, the precise mechanism involved in musical processing is unclear. Amusia is impaired perception, understanding, or production of music not attributable to disease of the peripheral auditory pathways or motor system. We report a case of a 36-year-old right-handed man who lost the ability to discriminate or reproduce rhythms after a right temporoparietal lobe infarction. We diagnosed him as an amusic patient using the online version of Montreal Battery of Evaluation of Amusia (MBEA). This case report suggests that amusia could appear after right temporoparietal lobe infarction. Further research is needed to elucidate the dynamic musical processing mechanism and its associated neural structures.
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To investigate the impact of vascular factors on the electrophysiologic severity of diabetic neuropathy (DPN).
Total 530 patients with type 2 diabetes were enrolled retrospectively. We rated severity of DPN from 1 (normal) to 4 (severe) based on electrophysiologic findings. We collected the data concerning vascular factors (including brachial-ankle pulse wave velocity [PWV], ankle brachial index, ultrasound of carotid artery, lipid profile from the blood test, and microalbuminuria [MU] within 24 hours urine), and metabolic factors of diabetes (such as glycated hemoglobin [HbA1c]). We analyzed the differences among the four subgroups using χ2 test and ANOVA, and ordinal logistic regression analysis was performed to investigate the relationship between significant variables and severity of DPN.
The severity of DPN was significantly associated with duration of diabetes, HbA1c, existence of diabetic retinopathy and nephropathy, PWV, presence of plaque, low density lipoprotein-cholesterol and MU (p<0.05). Among these variables, HbA1c and presence of plaque were more significantly related with severity of DPN in logistic regression analysis (p<0.001), and presence of plaque showed the highest odds ratio (OR=2.52).
Our results suggest that markers for vascular wall properties, such as PWV and presence of plaque, are significantly associated with the severity of DPN. The presence of plaque was more strongly associated with the severity of DPN than other variables.
Citations
To analyze cognitive functions of post-stroke aphasia patients compared to patients having right hemispheric stroke and left hemispheric lesions without aphasia, and to look for a relationship between cognitive deficits and aphasia severity.
Thirty-six patients with right hemispheric stroke (group 1), 32 with left hemispheric lesion without aphasia (group 2), and 26 left hemispheric stroke patients with aphasia (group 3) completed a set of tests in the computerized neurocognitive function batteries for attention, executive function and intelligence and Korean version of Western Aphasia Battery. Data analyses explored cognitive characteristics among the three groups and the correlation between cognitive deficits and aphasia severity.
Right hemispheric and left hemispheric stroke patients without aphasia showed similar findings except for digit span forward test. Cognitive tests for working memory and sustained attention were significantly impaired in the aphasic patients, but intelligence was shown to be similar in the three groups. Significant correlation between cognitive deficit and aphasia severity was only shown in some attention tests.
Cognitive deficits may be accompanied with post-stroke aphasia and there are possible associations between language and cognitive measures. Therefore, detection and treatment towards coexisting cognitive impairment may be necessary for efficient aphasia treatment.
Citations
To adapt and standardize the Motor-Free Visual Perception Test-3 (MVPT-3) to Koreans and investigate the change in visual-perceptual function using the MVPT-3 in healthy Korean adults.
The Korean version of the MVPT-3 was developed through a cross-cultural adaptation process according to 6 steps, including translation, reconciliation, back translation, cognitive debriefing, feedback, and final reconciliation. A total of 321 healthy Korean volunteers (mean age, 51.05 years) were recruited. We collected participant demographic data, such as sex, age, and years of education, and performed the Korean version of the Mini-Mental State Examination (K-MMSE) and MVPT-3. Internal consistency of the MVPT-3 and the relationships between demographic data, K-MMSE and MVPT-3 scores were analyzed. The results of this study were compared with published data from western countries including the United States and Canada.
Total score on the MVPT-3 was positively correlated with years of education (r=0.715, p<0.001) and K-MMSE score (r=0.718, p<0.001). However, it had a negative correlation with age (r=-0.669, p<0.001). A post-hoc analysis of MVPT-3 scores classified age into 5 groups of ≤49, 50-59, 60-69, 70-79, ≥80 years and years of education into 4 groups of 0, 1-9, 10-12, ≥13 years. No significant differences in MVPT-3 scores were observed according to sex or country.
Visual perception was significantly influenced by age, years of education, and cognitive function. Reference values for the MVPT-3 provided in this study will be useful for evaluating and planning a rehabilitation program of visual perceptual function in patients with brain disorders.
Citations
To investigate the factors which affect the motor evoked potential (MEP) responsiveness and parameters and to find the correlation between the function of the upper extremities and the combined study of MEP with a diffusion tensor tractography (DTT) in patients with stroke.
A retrospective study design was used by analyzing medical records and neuroimaging data of 70 stroke patients who underwent a MEP test between June 2011 and March 2013. MEP parameters which were recorded from the abductor pollicis brevis muscle were the resting motor threshold, latency, amplitude, and their ratios. Functional variables, Brunnstrom stage of hand, upper extremity subscore of Fugl-Meyer assessment, Manual Function Test, and the Korean version of Modified Barthel Index (K-MBI) were collected together with the biographical and neurological data. The DTT parameters were fiber number, fractional anisotropy value and their ratios of affected corticospinal tract. The data were compared between two groups, built up according to the presence (MEP-P) or absence (MEP-N) of MEP on the affected hand.
Functional and DTT variables were significantly different between MEP-P and MEP-N groups (p<0.001). Among the MEP-P group, the amplitude ratio (unaffected/affected) was significantly correlated with the Brunnstrom stage of hand (r=-0.427, p=0.013), K-MBI (r=-0.380, p=0.029) and the time post-onset (r=-0.401, p=0.021). The functional scores were significantly better when both MEP response and DTT were present and decreased if one or both of the two studies were absent.
This study indicates MEP responsiveness and amplitude ratio are significantly associated with the upper extremity function and the activities of daily living performance, and the combined study of MEP and DTT provides useful information.
Citations
Kernohan-Woltman notch phenomenon (KWP) is an ipsilateral motor weakness due to compression of the contralateral cerebral peduncle. We report two cases of KWP following traumatic brain injury. In case 1, ipsilateral hemiplegia was noted after right subdural hemorrhage. Although magnetic resonance imaging showed no abnormal signal changes on cerebral peduncle, diffusion tensor tractography (DTT) revealed interruption of corticospinal tract (CST) at lower level of the midbrain level. In case 2, there was abnormal signal change of the right cerebral peduncle contralateral to the primary lesion and we could not reconstruct right CST. Case 1 showed unsatisfactory motor recovery even after 15 months, and follow-up DTT showed no change. In case 2, follow-up DTT was not performed, but her ipsilateral hemiparesis had almost disappeared during the 15 months. DTT would be useful in detecting ipsilateral hemiparesis due to KWP and the clinical course may differ according to the lesion characteristics.
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