Efficacy of a hybrid assistive limb in post-stroke hemiplegic patients: a preliminary report

Background

Robotic devices are expected to be widely used in various applications including support for the independent mobility of the elderly with muscle weakness and people with impaired motor function as well as support for nursing care that involves heavy laborious work. We evaluated the effects of a hybrid assistive limb robot suit on the gait of stroke patients undergoing rehabilitation.

Methods

The study group comprised 16 stroke patients with severe hemiplegia. All patients underwent gait training. Four patients required assistance, and 12 needed supervision while walking. The stride length, walking speed and physiological cost index on wearing the hybrid assistive limb suit and a knee-ankle-foot orthosis were compared.

Results

The hybrid assistive limb suit increased the stride length and walking speed in 4 of 16 patients. The patients whose walking speed decreased on wearing the hybrid assistive limb suit either had not received sufficient gait training or had an established gait pattern with a knee-ankle-foot orthosis using a quad cane. The physiological cost index increased after wearing the hybrid assistive limb suit in 12 patients, but removal of the suit led to a decrease in the physiological cost index values to equivalent levels prior to the use of the suit.

Conclusions

Although the hybrid assistive limb suit is not useful for all hemiplegic patients, it may increase the walking speed and affect the walking ability. Further investigation would clarify its indication for the possibility of gait training.

[Aquired stuttering in addition to a recurrence of developmental stuttering caused by brain tumor in the corpus callosum]

We reported a 66-year-old right-handed man, in whom developmental stuttering had almost been cured previously, who suffered a brain tumor. He developed not only left hemiparesis but also speech dysfluency such as acquired stuttering and aphasia. MRI showed a brain tumor in the body of the corpus callosum. The main feature of his stuttering was repetition of syllables. His stuttering was associated without secondary phenomena such as tongue clicking. His stuttering demonstrated no adaptation benefit and no consistency effect. These results suggest that the stuttering in this patient might have characteristics of both developmental and acquired stuttering, which in turn may suggest that after brain tumor, acquired stuttering occurs in addition to a recurrence of developmental stuttering.

Multiple symptoms of higher brain dysfunction caused by Marchiafava-Bignami disease in a patient with dermatomyositis

A 65-year-old woman with dermatomyositis (DM) was admitted because of disorientation, mental dysfunction, and disturbance of consciousness. Prior to admission, she suffered from septic and hypovolemic shock. There was no evidence of active DM on physical examination and laboratory tests. Cerebrospinal fluid examination revealed no signs of meningitis. Because of clinical symptoms and findings on magnetic resonance images, such as the lesion in the splenium of the corpus callosum that was a low-intensity area on T1-weighted images and a high intensity on T2-weighted images; she was diagnosed as Marchiafava-Bignami disease (MBD). She received a combination of vitamin B, vitamin E, vitamin C, and nicotinic acid. Her symptoms improved gradually, and she was discharged at 1.5 months after admission. There has been no report of a case of DM with MBD. This report may provide useful data with regard to the mechanisms of central nervous system (CNS) disorders in patients with DM.

[Case of conduction aphasia due to right hemispheric lesion]

We report the case of conduction aphasia due to injury of the right hemisphere of the brain. The patient was a right-handed male in his fifties with moyamoya disease. T2-weighted MRI showed an extensive high intensity area in the right temporal-parietal-occipital lobes. In the case of language-related symptoms, comprehension was preserved, but phonemic paraphasias were frequent, and kana paragraphias were also observed. Despite the extensive injury of the right hemisphere, these language-related symptoms were consistent with the clinical features of conduction aphasia. Therefore, this patient was diagnosed with atypical crossed aphasia. Improvement in the phonemic paraphasia differed between words and nonsense words, suggesting that the improvement was dependent on the level of meaning of the words.

[Different types of aphasia caused by cerebral hemorrhage in the left frontal lobe: Broca's aphasia and Broca area's aphasia]

We reported two cases of aphasia that exhibited different characteristics of aphasia following cerebral hemorrhage in the left frontal lobe involving the Broca's area. Case 1 is a 74-year-old right-handed woman. She was hospitalized with speech disturbance. Spontanoues speech was fluent and articulation was normal, but she showed verbal paraphasia and speech perseveration. She demonstrated a preserved ability to repeat short sentences and was able to read words aloud. This type of aphasia is called "Broca area's aphasia". MRI and CT showed hematoma involving the left inferior frontal lobe, operculum and insula cortex. Single-photon emission computed tomography (SPECT) showed low perfusion in the frontal lobe without involvement of the postcentral gyrus. Case 2 is a 76-year-old right-handed man. He was also hospitalized with speech disturbance. Spontanoues speech was non-fluent and articulation was poor. He sometimes showed phonemic paraphasia with anarthria, but he demonstrated a preserved ability to repeat short sentences. He was able to read words aloud in a manner comparatively similar to. This type of aphasia is called "Broca's aphasia". MRI and CT showed hematoma involving the left inferior frontal lobe, operculum and precentral cortex. SPECT revealed low perfusion in the frontal lobe extending to the postcentral gyrus. We supposed that the different characteristics of aphasia in those cases were due to extended lesion in the frontal lobe.

Relationship between cognitive function and regional cerebral blood flow in different types of dementia

PURPOSE

We assessed relationships between cognitive impairment and regional cerebral blood flow (rCBF) in the different types of dementia.

SUBJECTS AND METHODS

Subjects, who included 27 with Alzheimer's disease (AD), seven with frontotemporal dementia (FTD), six with vascular dementia (VaD), and 12 normal controls, were evaluated using the Mini-mental State (MMS), Kana-hiroi Test, an auditory verbal learning test (AVLT), a word fluency test (WFT) and Raven's Coloured Progressive Matrices (RCPM). The rCBF was measured using a three-dimensional stereotaxic ROI template method (3DSRT).

RESULTS

In all dementia types, left superior frontal hypoperfusion was demonstrated. In AD and VaD significant CBF reduction also was seen in both angular, temporal, occipital, and precentral, both hippocampi, thalami, and pericallosal regions, and the left lenticular nucleus. MMS, Kana-hiroi Test, and AVLT scores correlated with CBF in all regions. WFT scores were correlated highly with CBF in the left side in frontal, temporal, and angular regions and right and left lenticular nuclei, thalami, and pericallosal regions. RCPM scores correlated with CBF in posterior regions.

CONCLUSION

Close coupling was evident between reduced rCBF and cognitive dysfunction in patients with dementia. Use of neuropsychologic tests and rCBF determinations in combination should enhance diagnostic accuracy.

Usefulness of a cube-copying test in outpatients with dementia

OBJECTIVE

To clarify whether a quantitatively scored cube-copying test could rapidly assess dementia patients, predicting thier performance in cognitive tests.

METHODS

Subjects were 171 outpatients with amnesia who were including 92 with Alzheimer's disease (AD); 59 vascular dementia (VD); 17 frontotemporal dementia (FTD); and three lewy body disease (DLB) and 32 normal healthy subjects. Subjects asked to copy a perspective drawing of a cube. Points of connection and plane-orientation errors were scored using Maeshima's method. The Mini-Mental State Examination (MMSE), an auditory verbal learning test (AVLT), a word fluency test and Raven's Coloured Progressive Matrices (RCPM) were administered. Age, clinical disease severity, symptom duration, specific diagnosis and neuropsychological scores were evaluated for relationships with constructional ability.

RESULTS

The cube-copying test showed errors in most dementia patients and 11 of 32 normal subjects. Only three patients each with AD and VD copied correctly, but 11 patients with 17 FTD drew the cube correctly. Numbers of connections completed and plane-orientation errors correlated significantly with MMSE, AVLT, word fluency and RCPM scores.

CONCLUSION

The cube-copying test is useful for routine clinical dementia screening, however the test examines only one aspect of cognitive function. While not an alternative to conventional neuropsychological examinations, quantitatively scored cube copying can provide a rough estimate of cognitive dysfunction in dementia patients.

Stroke rehabilitation in a patient with cerebellar cognitive affective syndrome

OBJECTIVE

It has become evident that the cerebellum plays a role in cognitive function, and Schmahmann et al. have introduced the term "Cerebellar cognitive affective syndrome (CCAS)." In the present paper we report a patient with cerebellar hemorrhage who developed CCAS.

DESIGN

A case study.

METHODS

The patient was a 61-year-old right-handed man who was admitted to our hospital because of sudden headache, dizziness and vomiting. The patient showed ataxia of the trunk and the extremities, but no paralysis and disturbance of sensation. He was disoriented in time and showed recent memory disturbance, disturbance of attention, impairment of executive functions and reduced volition, and due to these symptoms, his daily living was also severely impaired.

RESULTS

With the aim of returning home, the patient received exercise therapy and cognitive rehabilitation, while home modification was performed, and living at home under the supervision of his family became possible. Cognitive function improved, while memory and attention disturbance, impairment of executive function remained.

CONCLUSION

Cognitive dysfunction in patients with cerebellar damage is assumed to develop from disturbance of the cerebrocerebellar circuit, and that rehabilitation of these patients must include assessment of not only the motor function, but also of detailed assessment of cerebral function.

[Amnestic syndrome caused by cerebral infarction in the right medial temporal lobe--case report]

We report here a case of amnestic syndrome with executive dysfunction and attention deficit caused by cerebral infarction in the right temporal lobe was reported. An 80-year-old, right-handed female with complaints of memory impairment, was admitted to our hospital. She had neither motor paresis nor sensory disturbances. She exhibited disorientation, retrograde amnesia, anterograde amnesia, executive dysfunction and attention deficit. Although her immediate recall and remote memory were almost intact, her recent memory was moderately impaired. Both verbal memory and non-verbal memory were impaired. Brain MRI revealed cerebral infarction in the right temporal lobe involving the parahippocampal gyrus, and SPECT demonstrated low perfusion areas in both the cerebral hemispheres involving basal ganglia and the right thalamus. After a 4-month rehabilitation program, her memory impairment improved considerably. We consider that the reason that contributed to these improvement include the fact that her lesion was unilateral and that her executive dysfunction and attention deficit also improved. This finding suggests that memory is related to attention and executive function.

[Study on aspiration and swallowing exercise in stroke patients]

We investigated factors for aspiration by videofluoroscopy (VF) and swallowing exercises in stroke patients. Subjects were 102 stroke patients aged 34-101 years (mean 72.8+/-13.8 years) including 72 males and 30 females and for whom VF was performed because of suspected swallowing difficulty. They consisted of 64 patients with cerebral infarction, 33 patients with cerebral hemorrhage, and 5 patients with subarachnoid hemorrhage. Aspiration was classified into aspiration with choking and silent aspiration (SA) by the presence of a cough reflex. Eating instructions such as foodstuffs and intake methods and outcome were investigated. On VF, aspiration with foodstuffs was found in 59 of 102 (57.8%) patients and SA was found in 44 of them (44.1%). Some patients ate food on the ward in spite of SA in VF. Such patients were given eating instructions by the judgment of the attending physician, but foodstuffs and intake methods based on the results of VF could be changed in most cases. As for swallowing training, direct training was conducted only in a few patients in the group that presented overt aspiration in this study. On the other hand direct training was possible in the majority of patients if foodstuffs and intake methods were handled appropriately in SA. If these strok patients were approached with attention paid to the forms of foodstuffs and intake method on the basis of detailed evaluation on VF using mimic foodstuffs, eating was possible without aspiration in many cases.

[A comparison study of aspiration with clinical manifestions in stroke patients]

This study was investigated clinical factors for aspiration in stroke patients by videofluoroscopy (VF). Subjects were 102 patients with strokes aged between 34 and 101 years including 72 males and 30 females and for whom VF was performed for swallowing difficulty or suspected swallowing difficulty. They consisted of 64 patients with cerebral infarction, 33 patients with cerebral hemorrhage, and 5 patients with subarachnoid hemorrhage. Before VF, pharyngeal reflex, physical status, and cognitive function were evaluated as bedside clinical assessment. As for swallowing evaluation at bedside, the repetitive saliva swallowing test (RSST) and water swallowing test were performed. Aspiration was classified into aspiration with choking and silent aspiration (SA) by presence of a cough reflex. As results, aspiration with foodstuffs on VF was found in 59 of 102 (57.8%) patients and SA was found in 44 of them (43.1%). In patients with not only pharyngeal reflex but also cervical and maintaining a position stability, and those who were decreased in cognitive function, aspiration should always be supposed and the observation for eating behavior against aspiration should be needed. We divided patients into three groups; no aspiration, SA and aspiration with choking. Significant difference was observed between the groups in Mini-Mental State Examination, Barthel Index, and RSST. Although in the water-swallowing test, swallowing was possible without choking, SA was observed on VF in most cases. Therefore, in cases with serious disability and cognitive dysfunction with advanced age, RSST and water swallowing test should not be overestimated, it is worth conducting VF when aspiration is suspected from neurological assessment.

Life-style activities in systemic lupus erythematosus

OBJECTIVE

We evaluated the life-style activities of outpatients with SLE and factors that reduce their social activities.

METHODS

SUBJECTS

SLE group = 60 patients, Control 1 = 30 healthy subjects and Control 2 = 30 patients with other autoimmune diseases. The Frenchay Activity Index (FAI), Zung's self-rating depression scale (SDS), and the Japanese version of the Philadelphia Geriatric Center morale scale-revised (MS) were compared between groups. Relation between FAI and age, disease duration, steroid dose, SDS, and MS were examined in the SLE group, Control 1, and Control 2.

RESULTS

Total scores by FAI was 28.1 +/-8.0 points in Control 1, whereas it was 26.5 +/- 5.8 points in Control 2 and 24.5 +/- 7.7 points in the SLE group. While there was no statistical difference between the SLE group and Control 2, the scores were significantly lower in the SLE group than in Control 1 (P < 0.05). In SLE patients, age, the duration of the disease, and the steroid dose had no correlation, but MS had a positive correlation (P < 0.05) and SDS had a negative correlation (P < 0.05). In Control 2, age, the duration of the disease, the steroid dose, MS and SDS had no correlation whereas there was significant negative relation between FAI and SDS in Control 1 (r= -0.516, P<0.005).

CONCLUSION

The significant relation between life-style activities and subjective well-being, and depression in SLE suggests that detection and treatment of mental status is important in improving the life-style activities of SLE patients.

Neuropsychological deficits associated with a tumour in the posterior corpus callosum: a report of two cases

This study reports two patients with tumours arising from the splenium of the corpus callosum that caused a memory disturbance consistent with retrosplenial amnesia as well as a variety of cognitive deficits including agraphia, acalculia, constructional apraxia and ideomotor and ideational apraxia involving both hands, but not aphasia. Patients showed disorientation to time and place, impaired recent memory and memorizing capacity; immediate and remote memory were preserved. Despite impaired performance intelligence quotients (IQ), verbal IQ was relatively spared. Patients also showed disconnection symptoms including bilateral crossed visuomotor ataxia and alexia to stimuli presented in the right visual field. In both cases, the tumour of the splenium had provoked surrounding oedema extending to the left parietal and occipital lobes.

Acquired stuttering in a patient with Wernicke's aphasia

We report a patient with aphasia caused by cerebral infarction in the left temporal, parietal and occipital lobes that was complicated by acquired stuttering (AS), which is an unusual association. Our findings indicated that Wernicke's area might be involved in the development of AS.

Neuropsychological impairment and decreased regional cerebral blood flow by interferon treatment in patients with chronic hepatitis: a preliminary study

It is well known that interferon (IFN) has various side effects including neuropsychiatric complications such as depression. We examined the relationship between neuropsychological impairment and regional cerebral blood flow (CBF) in chronic hepatitis patients treated with and without IFN-alpha. Eight patients with chronic hepatitis participated in this study. Four patients were treated with IFN-alpha (IFN group) and 4 patients were not treated (control group). The entire IFN group and half of the control group were diagnosed with hepatitis C and the rests of the control group had hepatitis B. Neuropsychological tests were conducted. The Self-Rating Depression Scale and the State-Trait Anxiety Inventory were also completed by the subjects. In addition, cerebral single photon emission computed tomography (SPECT; 3DSRT) was performed in all patients. Neuropsychological tests and SPECT were performed in the IFN group 2 months after starting IFN treatment and in the control group 2 months after starting follow-up. A significant reduction of regional CBF in the IFN group was observed in two cerebral regions (lt-angular and lt-temporal region) (P < 0.05), which have reported associations with memory and language function. In addition, the Auditory-Verbal Learning Test (AVLT), a measure of memory function, showed a decreased tendency in the IFN group. A decrease of regional CBF by IFN treatment was shown, suggesting that a decrease of regional CBF may contribute to the neuropsychological impairment by IFN treatment.

[A case of recurrence of cerebral hemorrhage in a patient with adult moyamoya disease in the recovery period rehabilitation ward]

A 61-year-old woman with a history of repeated cerebral hemorrhage due to moyamoya disease was admitted to our recovery period rehabilitation ward for walking training. She suddenly noticed paresthesia in her left forearm and the palm seven days later. Brain computed tomography on that day and magnetic resonance imaging on the next day after the onset of paresthesia revealed right thalamic hemorrhage. It was suggested that the hematoma localized to a small part of the central portion of the ventroposterior lateral nucleus caused paresthesia limited to the forearm and the palm. In a recovery period rehabilitation ward, we should carefully listen to the complaints of patients who are in advanced age and have a risk like our patient. Then adequate neurological examination should be performed for the pertinent inspection diagnosis, if needed.

[Clinical usefulness of the frontal assessment battery (FAB) for elderly in memory clinic]

To investigate the usefulness of the frontal assessment battery (FAB) as a brief assessment for diagnosis in patients with dementia, we examined cognitive function using the FAB, Mini-mental state examination (MMSE), Kana-hiroi test, and Raven's colored progressive matrices (RCPM). Subjects were 82 senile patients having amnesia as a complaint including 28 Alzheimer's disease (AD), 14 frontotemporal dementia (FTD), 17 vascular dementia (VD), 13 mild cognitive impairment (MCI), and 10 healthy persons. We discussed the difference of scores in different types of dementia. In the FAB, the scores of healthy persons and MCI were much higher compared with the scores of all types of dementia. There were high correlation between FAB and MMSE, Kana-hiroi test, and RCPM. Although some subjects showed normal score in MMSE and/or RCPM, they showed low score in FAB. Based on this, FAB is efficient for the differential diagnosis of dementia as brief screening tool.

[A case of amnesia caused by a falx meningioma in the right frontal region]

A 60-year-old right-handed man suffered frontal lobe dysfunction caused by a falx meningioma. He appeared to have amnesia and left hemiparesis. It is note-worthy that he had a lesion of the right frontal region but exhibited both verbal and non-verbal memory impairment, although his intelligence, remote memory and digit span were normal. Computed tomography and magnetic resonance imaging revealed a falx meningioma in the right frontal lobe including the right cingulate gyrus and corpus callosum. Single photon emission CT revealed a wide area of low perfusion surrounding the right frontal lobe including the cingulate gyrus. After surgery, left hemiparesis and amnesia disappeared. SPECT after surgery showed an area of low perfusion limited to the right frontal region. We concluded that the amnesia in this case might be caused by the interruption of hippocampal input into the cingulate gyrus.

[Jargonagraphia in a left-handed aphasia due to a left hemisphere lesion]

We report a case who developed jargonagraphia, severe aphasia and unilateral spatial neglect due to cerebral infarction in the left hemisphere. The patient was a 57 year-old left-handed woman. She suddenly developed hemiplegia on the right side and aphasia, and was admitted to our hospital. Neuropsychological examination showed non-fluent spontaneous speech. Repetition, reading and auditory comprehension were impaired. Writing was severely impaired and she showed paragraphia without meaning (jargonagraphia). Right unilateral spatial neglect and buccofacial apraxia were noted, but neither ideomotor nor ideational apraxia was observed. The mechanisms of jargonagraphia remain unknown. The localization of language function in this patient is not a mirror image of same function in dextral aphasia. Her condition was considered that free-running on motor engrams of characters stored in the right hemisphere caused jargonagraphia.

Mobility and muscle strength contralateral to hemiplegia from stroke: benefit from self-training with family support

OBJECTIVE

To determine whether patient exercise with the support of family members maximizes mobility and improves muscle strength in the nonparetic lower limb after stroke.

DESIGN

Comparison of improvement at 2 wk between conventional exercise sessions and a program also including the participation of family members. Subjects were 60 patients rendered nonambulatory by severe hemiparesis from their first stroke. Of these, 42 had family members participating in their therapy. Lower limb strength was measured on the nonparetic side using an isokinetic machine. Mobility status was assessed using the Rivermead Mobility Index. Patients were evaluated at the first inpatient gym session and again at 1 and 2 wk.

RESULTS

At the first evaluation, lower limb strength and the Rivermead Mobility Index score did not differ between the two groups. Reevaluations were conducted at 1 and 2 wk after the first evaluation. Patients' strength and mobility improved more when family members participated.

CONCLUSION

Family participation is an important contributor to stroke rehabilitation.

Agraphia with abnormal writing stroke sequences due to cerebral infarction

A 65-year-old, right-handed man presented with speech and gait disturbances. He was alert and cooperative, showing mild right hemiparesis and sensory disturbance. Spontaneous speech was fluent; object naming, word fluency and reading were fully preserved. Sentence repetition and verbal comprehension were mildly impaired. Writing was slow, hesitant and difficult for both spontaneous writing and dictation. Copying was better, although he had some difficulty in copying letters and also complex figures. Sequences of strokes in forming written characters were abnormal; strokes were formed by piecing together several fragments. Computed tomography and magnetic resonance imaging showed a subcortical infarct in the left frontoparietal region. Characteristics of agraphia resembled 'apractic agraphia' and agraphia may have resulted largely from loss or unavailability of the memory of motor patterns necessary for writing letters.

[A case of amnesia caused by a subcortical hematoma in the left retrosplenial region]

A 54-year-old right-handed woman suffered transient aphasia and persistent amnesia caused by a subcortical hematoma in the left occipital lobe. She appeared to have aphasia, although it disappeared within 3 weeks. It is noteworthy that she had a lesion in the left retrosplenial region but exhibited both verbal and non-verbal memory impairment. However, her intelligence, remote memory and digit span were normal. She had no topographic disturbance. Computed tomography and magnetic resonance imaging revealed a subcortical hematoma in the left occipital lobe including the retrosplenial region. Single photon emission CT showed a low perfusion area in the retrosplenial region and in the left thalamus. We concluded that the retrosplenial amnesia might be caused by the interruption of hippocampal input into the anterior thalamus.

Relationships between event-related potentials and neuropsychological tests in neurologically healthy adults

The aim of this study was to investigate the relationship between conventional neuropsychological tests and an event-related potential (P300). Subjects were 118 neurologically normal healthy adults 18-74 years old with no history of neurological, neurosurgical, or psychiatric disorders. We administered a neuropsychological test battery and recorded auditory P300 in all subjects. A significant correlation was seen between P300 latency and age, but not between amplitude and age. While significant negative correlations were apparent between some neuropsychological tests and age and P300 latency, stepwise regression analysis to assess the significance of each factor determined that age alone correlated with P300 latency. We therefore concluded that P300 measurements cannot be replaced by neuropsychological tests; rather, brain function should be evaluated by both methods.

Transient aphasia and persistent amnesia after surgery for internal carotid artery--posterior communicating artery aneurysm

We report a case of transient aphasia and persistent amnesia after clipping of a ruptured cerebral aneurysm to treat a subarachnoid hemorrhage. Postoperatively, aphasia was identified and magnetic resonance imaging (MRI) showed an abnormal intensity area in the left anterior thalamus. Single photon emission computed tomography (SPECT) revealed a wider area of low perfusion surrounding the left thalamus and left frontotemporal lobe than that shown by the MRI. His aphasia resolved over the subsequent 12-week period. He was left with an isolated disturbance of memory; in the absence of any dementia, aphasia or disturbance of consciousness, his condition was classified as one of amnesia. SPECT 14 weeks after admission revealed an area of low perfusion limited to the left thalamus. These findings suggest that the persistence of amnesia in this case was caused by the infarction of the mammillothalamic tract, and the recovery from aphasia may have resulted from the disappearance of surrounding edema.

Unilateral spatial neglect in patients with cerebral hemorrhage: the relationship between hematoma volume and prognosis

We examined patients with cerebral hemorrhage to determine the correlations between unilateral spatial neglect (USN) and neurological deficits, the site of lesions, and performance on activities of daily living (ADL) tests at discharge. Thirty-two right-handed patients with right hypertensive intracerebral hemorrhage (putamen 16, thalamus 16) were examined for neurological and neuropsychological deficits in addition to USN, and they received CT scans. USN was revealed in 26 of the patients (81.3%), of which 13 cases were putaminal hemorrhage and the other 13 were thalamic hemorrhage. The 32 patients were subdivided into three groups: those without USN, those with transient USN, and those with persistent USN. Among the patients with putaminal hemorrhage, the presence and persistence of USN seemed to be largely dependent on the size of the hematoma. Of the 7 cases with hematoma volume greater than 40ml, 4 revealed persistent USN; the other 3 cases, each of whom was under 50 years of age, showed transient USN. No cases with hematoma smaller than 20ml revealed USN. Among the thalamic hemorrhages, the size of the hematoma had no relation to the presence of USN. All 13 cases of USN caused by thalamic hemorrhage were transient. Among all the patients, those with USN showed lower ADL scores on admission than patients without USN. At discharge, ADL among patients with transient USN had improved more than the ADL of patients without USN. Therefore, we suspected that improvement in ADL might be affected by USN.

Medial medullary infarction: a role of diffusion-weighted magnetic resonance imaging for stroke rehabilitation

We report a patient with medial medullary infarction who could be diagnosed in an early stage, and we discuss the role of diffusion-weighted magnetic resonance imaging (MRI) for stroke rehabilitation. In the case of our patient, the infarction was difficult to diagnose because the patient had atypical features and a past history of head injury. Nonetheless, we could diagnose the medial medullary infarction easily using diffusion MRI within several hours of onset. Then, a rehabilitation program was started the day after onset. We believe that diffusion MRI can be used as a useful method for very early stage diagnosis and to execute rehabilitation for early stroke patients.

Silent cerebral infarction and cognitive function in middle-aged neurologically healthy subjects

We sought to clarify whether apparently silent cerebral infarcts and periventricular hyperintensities are associated with depressed cognitive function in middle-aged subjects. Subjects were 84 middle-aged neurologically normal adults who wished to undergo a screening examination of the brain. We performed magnetic resonance imaging (MRI) of the brain and neuropsychologic tests in all subjects. Silent cerebral infarcts and periventricular hyperintensities, respectively, were detected in 21 and 14 of 84 subjects. Mini-mental state (MMS) and Raven's colored progressive matrices (RCPM) scores were significantly lower in subjects with than without silent cerebral infarcts. By two-factor analysis of variance, MMS score was affected by silent cerebral infarcts or periventricular hyperintensities, with interactions between the two lesion types (P < 0.05). Silent cerebral infarcts may be an independent factor in the pathogenesis of intellectual dysfunction, but truly independent analysis is difficult because many subjects with silent cerebral infarcts also have periventricular hyperintensities.

Transcortical mixed aphasia due to cerebral infarction in left inferior frontal lobe and temporo-parietal lobe

We present a case of transcortical mixed aphasia caused by a cerebral embolism. A 77-year-old right-handed man was admitted to our hospital with speech disturbance and a right hemianopia. His spontaneous speech was remarkably reduced, and object naming, word fluency, comprehension, reading and writing were all severely disturbed. However, repetition of phonemes and sentences and reading aloud were fully preserved. Although magnetic resonance imaging (MRI) showed cerebral infarcts in the left frontal and parieto-occipital lobe which included the inferior frontal gyrus and angular gyrus, single photon emission CT revealed a wider area of low perfusion over the entire left hemisphere except for part of the left perisylvian language areas. The amytal (Wada) test, which was performed via the left internal carotid artery, revealed that the left hemisphere was dominant for language. Hence, it appears that transcortical mixed aphasia may be caused by the isolation of perisylvian speech areas, even if there is a lesion in the inferior frontal gyrus, due to disconnection from surrounding areas.

Quantitative assessment of impairment in constructional ability by cube copying in patients with aphasia

Constructional apraxia was evaluated in patients with aphasia using a cube-copying task. It was assessed whether quantitative assessment of cube copying could be used to estimate the performance intelligence quotient (IQ) according to neuropsychological tests. Abnormality in the cube-copying test was observed in 42 of 46 patients (91.3%). Performance according to Raven's coloured progressive matrices and the revised Wechshler adult intelligence scale (WAIS-R) in patients with poor cube copying was significantly lower than in the other four patients. Numbers of the connections completed and plane-orientation errors made in the cube-copying test were significantly correlated with performance IQ on the WAIS-R, correlating particularly with block design, digit symbol, and object assembly in performance IQ subtests. The quantitatively scored cube-copying test, then, can roughly predict non-verbal IQ in patients with aphasia.

Relationships between event-related potentials (P300) and activities of daily living in Parkinson's disease

The correlation between event-related potentials (P300) and activities of daily living was studied in Parkinson's disease. The P300 of 30 patients with Parkinson's disease and 118 normal subjects were recorded. All patients were evaluated by the Mini-Mental State, Kana-hiroi Test, word fluency, Raven's Coloured Progressive Matrices, Osaka Memory Scale, revised Wechsler Adult Intelligence Scale, self-rating depression scale, state-trait anxiety inventory, and Functional Independence Measure. Eight patients showed prolonged P300 latencies. P300 latency showed relationships to the Mini-Mental State (p < 0.05) and cognitive items of the Functional Independence Measure (p < 0.05). P300 amplitude showed a relationship to performance IQ (p < 0.005), Raven's Coloured Progressive Matrices (p < 0.01) and motor items of the Functional Independence Measure (p < 0.05). It was concluded that P300 should be useful in predicting difficulties with activities of daily living in patients with Parkinson's disease.

Transient crossed aphasia and persistent amnesia after right thalamic haemorrhage

A 45-year-old right-handed woman suffered transient aphasia and persistent amnesia after a right thalamic haemorrhage. This patient appeared to have crossed aphasia, although it disappeared within 8 weeks. It is noteworthy that the patient had a unilateral right thalamic lesion but exhibited both verbal and non-verbal memory impairment. Computed tomography and magnetic resonance imaging revealed cerebral haemorrhage in the right thalamus involving the ventral anterior nucleus, medioventral nucleus, mamillothalamic tract, internal medullary lamina, and mediodorsal nucleus. An amytal test was performed and suggested that the right hemisphere was dominant for language functions and the left hemisphere was dominant for visuospatial functions. Single photon emission CT revealed a low perfusion area only in the right thalamus. These findings suggest that the right hemisphere might be dominant for both verbal and non-verbal memory function in this patient, although visuospatial function was lateralized in the left hemisphere.

Memory impairment and spatial disorientation following a left retrosplenial lesion

We treated a patient in whom a left retrosplenial lesion resulted in memory impairment and spatial disorientation. A 31 year old, right handed man was admitted to our hospital after the sudden onset of headache. He was alert, attentive and cooperative, and showed no motor or sensory deficits. Although intelligence was preserved, memory was obviously deficient. The patient proceeded in wrong directions after he left his hospital room and subsequently his home. Neuroimaging revealed a subcortical hematoma in the left cingulate isthmus, while single-photon emission computed tomography demonstrated decreased perfusion in the splenium and left parietal lobe.

Jargonagraphia with severe aphasia due to a right hemisphere lesion: case report

The authors report a case of a patient who developed jargonagraphia, severe aphasia, unilateral spatial neglect and apraxia due to a right hemisphere lesion. Jargonagraphia with severe aphasia, unilateral spatial neglect and apraxia is quite rare. The mechanisms of jargonagraphia remain unknown. A possible mechanism underlying this case of jargonagraphia is discussed.

Unilateral spatial neglect associated with chronic subdural haematoma: a case report

A 69-year-old right-handed man who exhibited unilateral spatial neglect in association with a chronic subdural haematoma, presented with mild left arm and leg weakness first noted 4 weeks prior to admission. Neurologic examination on admission revealed a mild left hemiparesis, including the face. Neuropsychologic examination revealed left unilateral spatial neglect, but no language disturbance. Minimal support was necessary to maintain activities of daily living. Computed tomography revealed a large right temporoparietal, extraaxial hypodense fluid collection containing scattered hypodense foci. The haematoma was evacuated via a right parietal burr hole. Following surgery, the patient dramatically improved neurologically and neuropsychologically, as well as in independent performance of daily activities. It is suggested that the improvement in ADL provides a behavioural correlate of improvement in the latter, represented a behavioural correlate of improved cerebral function, and that either direct compression by the chronic subdural haematoma or an interhemispheric pressure difference had caused unilateral spatial neglect. Such neglect is an unusual consequence of chronic subdural haematoma.

Factor analysis of the components of 12 standard test batteries, for unilateral spatial neglect, reveals that they contain a number of discrete and important clinical variables

The aim of this study was to investigate a conventional battery of tests capable of assessing the presence of the component and extent of the lesions in patients with unilateral spatial neglect. Ninety-four patients who had unilateral spatial neglect with a stroke in right hemisphere were assessed on 12 traditional neglect batteries 4 weeks after the onset. Computerized tomography was also performed to investigate the possible anatomical relationships with each neglect battery. Factor analysis showed that the tests loaded significantly on five factors. There are not only visual scanning factors but also factors of imaging, visual judgement, visual cognition and effectiveness from left hemisphere in the unilateral spatial neglect. There are high correlations between each neuropsychological test and neglect batteries. Furthermore, lesions in the paraventricular white matter were associated with clock and person drawing tasks. Lesions in the occipital lobe were associated with reading, explaining and visual counting tasks. Lesions in the temporal lobe and the posterior limb of the internal capsule were associated with line bisection tasks. It is suggested that it is possible that there are some different components in unilateral spatial neglect. Failure in some tasks may predict different lesions in terms which include localization.

Apraxia and cerebral haemorrhage: the relationship between haematoma volume and prognosis

In this study, we examined twenty-five patients with left putaminal haemorrhage to investigate the relations between ideational apraxia (IA) and intracerebral haemorrhage. Apraxias were determined at 1 and 6 months after the stroke onset. Extension and volume of haematoma were examined with CT scan within 2 days of stroke onset. IA was present in 10 cases at 1 month and disappeared in 6 cases (transient IA) and persisted in 4 cases(persisted IA) at 6 months from the onset. Although the haematoma volume related to the existence of IA, there was no significant difference between transient and persistent IA. All three patients with the haematoma volume larger than 40 ml in the transient IA group were younger than 50 years old. All cases with persistent IA were older than 50 years old. Consequently, the existence of IA seems to be partially dependent on the haematoma volume which may cause the organic damage of subcortical white matter. However, patient's age is also important to determine the prognosis of IA. This maybe related to the nature of the haemorrhage and the mode of the onset. These factors remain to be determined.

[Dural arteriovenous fistula at the cranio-cervical junction presenting transient ischemic attack: a case report]

A 58-year-old male was admitted to our hospital because of repeated transient ischemic attack of right hemiparesis and speech disturbance. A CT scan did not demonstrate any remarkable findings. No significant cerebral arterial stenosis or occlusion was found on angiography. However, dural arteriovenous fistula fed by the radiculo-meningeal artery was found at the cranio-cervical junction on left vertebral angiography. The shunt flow from the arteriovenous fistula drained into the superior petrosal sinus and sigmoid sinus in a retrograde fashion. On the angiographic findings when his transient ischemic attack (TIA) had disappeared, the venous drainage had returned to its normal fashion. Venous hypertension around the brain stem was supposed to have caused the transient ischemic attack in this case. We performed coagulation of the draining vein and fistula surgically. After surgery, the patient's TIA completely disappeared. We report the first case of dural arteriovenous fistula at the cranio-cervical junction presenting transient ischemic attack.