An Exploration of the Neural Network of Lance-Adams Syndrome: a Case Report

Lance-Adams syndrome (LAS) is a rare neurological disorder that may occur after cardiopulmonary resuscitation. The LAS is usually caused by hypoxic changes.Neuroimaging studies show that the brain pathology of LAS patients is not uniform, and the pathophysiology of the myoclonus can vary from patient to patient. Our case study contributes to this etiological heterogeneity by neuroimaging and transcranial magnetic stimulation (TMS). In patients with rare brain conditions such as LAS, a combination of brain stimulation methods, such as TMS, and diffusion tensor imaging can provide insights into this condition's pathophysiology. These insights can facilitate the development of more effective therapies.

Changes in Pharyngeal Width Over Time as an Indicator of Dysphagia in Stroke Patients

Objective@#To verify the pharyngeal width at rest as a measurement that could be used to assess changes in the degree of dysphagia over time in stroke patients. @*Methods@#In a cohort of stroke patients, we performed serial measurements of the pharyngeal width at the midpoints of the second (C2) and third (C3) cervical vertebral bodies using lateral neck X-rays while the patients were at rest. The JOSCYL width, a parameter named after the first initial of each developers’ surname and defined as the average value of the upper and lower pharyngeal widths, was used to formulate the JOSCYL scale, which was calculated as the JOSCYL width × 100eck circumference. All patients also underwent serial videofluoroscopic swallowing studies (VFSSs). The Spearman correlation analysis was used to detect correlations between the serial VFSS results, JOSCYL widths, and JOSCYL scale values. @*Results@#Over time, we observed significant positive and negative correlations of change in the JOSCYL width and scale with changes in the Penetration-Aspiration Scale and the Dysphagia Outcome and Severity Scale scores, respectively. @*Conclusion@#The JOSCYL width and JOSCYL scale clearly reflected changes in dysphagia in stroke patients over time. These parameters may provide an easier method for evaluating whether post-stroke dysphagia has been alleviated.

Diffusion Metrics as a Potential Prognostic Biomarker in Cervical Myelopathy

Diffusion tensor imaging (DTI) has a diagnostic value in cervical myelopathy. The usefulness of diffusion metrics as a potential prognostic biomarker was assessed in this review. Various diffusion metrics, such as fractional anisotropy, mean diffusivity, apparent diffusion coefficient, and radial diffusivity, were significant in correlation with functional recovery after surgery. Changes in diffusion metrics not only at the compression level, but also above and below the compression level were confirmed. However, it was difficult to confirm the results owing to the diversity of studies. Further efforts to make a consensus on spinal cord DTI are needed.

Predictive Value of Pharyngeal Width at Rest (JOSCYL Width) for Aspiration in Elderly People

OBJECTIVE: To develop a new tool for aspiration risk prediction based on pharyngeal width at rest in older adults with symptoms of aspiration. METHODS: Lateral cervical spine roentgenograms were obtained from 33 older adult patients who complained of dysphagia and from 33 healthy, age-matched controls. Pharyngeal width at rest was measured at two points. We named the average of these two pharyngeal widths ‘JOSCYL Width’, calculated ‘JOSCYL Scale’, and compared these parameters between dysphagia and control groups. Correlations of individual JOSCYL Width and JOSCYL Scale, with Penetration Aspiration Scale (PAS) and Dysphagia Outcome and Severity Scale (DOSS) scores were analyzed for the dysphagia group. To determine optimal cutoff points for predicting aspiration, a receiver operating characteristic curve analysis was performed on JOSCYL Width and JOSCYL Scale. RESULTS: Both JOSCYL Width and JOSCYL Scale of the dysphagia group were larger than those of the control group (p<0.001). The correlation between JOSCYL Width and severity of dysphagia was significant for the dysphagia group (PAS p=0.007; DOSS p=0.012). The correlation between JOSCYL Scale and the severity of dysphagia was also significant for the dysphagia group (PAS p=0.009; DOSS p=0.011). Optimal cutoffs for JOSCYL Width and JOSCYL Scale for predicting aspiration were 20.0 mm and 5.9, respectively. CONCLUSION: JOSCYL Width and JOSCYL Scale can be new indicators for predicting aspiration in older adults. They are both precise and easy to use.

Global Synchronization Index as an Indicator for Tracking Cognitive Function Changes in a Traumatic Brain Injury Patient: A Case Report

Traumatic brain injury is a main cause of long-term neurological disability, and many patients suffer from cognitive impairment for a lengthy period. Cognitive impairment is a fatal malady to that limits active rehabilitation, and functional recovery in patients with traumatic brain injury. In severe cases, it is impossible to assess cognitive function precisely, and severe cognitive impairment makes it difficult to establish a rehabilitation plan, as well as evaluate the course of rehabilitation. Evaluation of cognitive function is essential for establishing a rehabilitation plan, as well as evaluating the course of rehabilitation. We report a case of the analysis of electroencephalography with global synchronization index and low-resolution brain electromagnetic tomography applied, for evaluation of cognitive function that was difficult with conventional tests, due to severe cognitive impairment in a 77-year-old male patient that experienced traumatic brain injury.

The Effect of Repetitive Arm Cycling Training Priming with Transcranial Direct Current Stimulation on Post-Stroke: Pilot Study

Transcranial direct current stimulation (tDCS) is a noninvasive method that may increase the rehabilitation effects in stroke. The objective of the study was to test whether tDCS priming with training on an arm ergometer boosts motor performance in chronic stroke patients. Three chronic subcortical stroke patients had continued a sole unilateral stroke 30–36 months formerly. They had some voluntary control of the arm in the affected side underwent a cycling training on an arm ergometer for 20 minutes a day, during 5 days a week priming with cathodal tDCS stimulation of unaffected hemisphere. They were tested during 4 sessions 1 week before, at the beginning, at the end, and 1 week after the end of the training priming with tDCS. We executed; 1) Rivermead Motorik Assessment (global function, arm and leg), 2) the Modified Ashworth Scale of the elbow flexors and extensors, 3) the minimum torque on the lesion side, 4) grip strength, and 5) pegboard performance at each time of testing the patients. All patients tolerated tDCS very well during experiment. Patients showed significant (p = 0.01) improved of force and spasticity (p = 0.03). The grip strength and pegboard performance improved significantly too after DCS priming with training. These results showed that cathodal tDCS is a useful device for rehabilitation when priming with motor training in stroke patients. These patients proved the clinical relevance of the results.

Brain & NeuroRehabilitation is Now the Official Journal of AOSNR

No abstract available.

Changes in Diffusion Metrics of the Red Nucleus in Chronic Stroke Patients With Severe Corticospinal Tract Injury: A Preliminary Study

OBJECTIVE: To explore plastic changes in the red nucleus (RN) of stroke patients with severe corticospinal tract (CST) injury as a compensatory mechanism for recovery of hand function. METHODS: The moderate group (MG) comprised 5 patients with synergistic hand grasp movement combined with limited extension, and the severe group (SG) included 5 patients with synergistic hand grasp movement alone. The control group (CG) included 5 healthy subjects. Motor assessment was measured by Motricity Index (MI). Diffusion tensor imaging was analyzed using fractional anisotropy (FA) and radial diffusivity (RD) in the individual regions of interest (ROIs)—bilateral internal capsule and anterior pons for CST injury and bilateral RN for rubrospinal tract (RST) injury. RESULTS: The SG showed a significantly lower MI score than the MG mainly due to differences in hand subscores. Significantly reduced FA was observed in both MG and SG compared with CG, while SG showed increased MD and RD in the affected ROIs of CST, and increased FA on the unaffected side compared with CG. However, in the RN ROI, a significantly increased FA and decreased RD on the unaffected side similar to the affected side were found only in the SG. The relative index of FA was lower and RD in SG was higher than in CG in RST. CONCLUSION: The diffusion metrics of RST showed changes in patients with severe CST injury, suggesting that RST may play a role in the recovery of hand function in patients with severe CST injury.

Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016

“Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” is the 3rd edition of clinical practice guideline (CPG) for stroke rehabilitation in Korea, which updates the 2nd edition published in 2014. Forty-two specialists in stroke rehabilitation from 21 universities and 4 rehabilitation hospitals and 4 consultants participated in this update. The purpose of this CPG is to provide optimum practical guidelines for stroke rehabilitation teams to make a decision when they manage stroke patients and ultimately, to help stroke patients obtain maximal functional recovery and return to the society. The recent two CPGs from Canada (2015) and USA (2016) and articles that were published following the 2nd edition were used to develop this 3rd edition of CPG for stroke rehabilitation in Korea. The chosen articles' level of evidence and grade of recommendation were decided by the criteria of Scotland (2010) and the formal consensus was derived by the nominal group technique. The levels of evidence range from 1++ to 4 and the grades of recommendation range from A to D. Good Practice Point was recommended as best practice based on the clinical experience of the guideline developmental group. The draft of the developed CPG was reviewed by the experts group in the public hearings and then revised. “Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” consists of ‘Chapter 1; Introduction of Stroke Rehabilitation’, ‘Chapter 2; Rehabilitation for Stroke Syndrome, ‘Chapter 3; Rehabilitation for Returning to the Society’, and ‘Chapter 4; Advanced Technique for Stroke Rehabilitation’. “Clinical Practice Guideline for Stroke Rehabilitation in Korea 2016” will provide direction and standardization for acute, subacute and chronic stroke rehabilitation in Korea.

Correction: Risk Factors for Delirium During Acute and Subacute States of Various Disorders in Patients Admitted to Rehabilitation Units

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Cortical Thickness and White Matter Integrity are Associated with CTG Expansion Size in Myotonic Dystrophy Type I

PURPOSE: Myotonic dystrophy type 1 (DM1) is characterized by progressive muscular weakness with symptoms caused by involvement of the brain. The aim of this study was to delineate global changes in cortical thickness and white matter integrity in patients with DM1, compared to age-matched healthy controls, and in brain areas highly correlated with CTG repeat size. MATERIALS AND METHODS: Cortical thickness and white matter integrity were compared in nine adult DM1 patients and age matched healthy controls using T1-weighted and diffusion tensor imaging. The patients' intelligence quotient (IQ) and CTG repeat size were measured in each individual. RESULTS: Cortical thickness was significantly reduced in the frontal, temporal, and occipital cortices, while tract-based spatial statistics showed decreased diffusion metrics in widespread areas, including the bilateral orbitofrontal, anterior frontal, insular, external capsule, and occipital cortices in DM1 patients, compared to controls. Additionally, thickness was negatively correlated with the number of CTG repeats in those areas. White matter integrity was negatively correlated with CTG repeats in the left entorhinal, anterior corona radiata, orbitofrontal, and lateral occipital areas. No statistically significant correlation was found between IQ scores and the size of CTG repeats. CONCLUSION: Our results suggest that DM1 is associated with wide distributions of network changes in both gray and white matter. Some of areas related to cognition showed significant correlations with CTG repeats.

Risk Factors for Delirium During Acute and Subacute Stages of Various Disorders in Patients Admitted to Rehabilitation Units

OBJECTIVE: To assess the risk factors for delirium in patients admitted to a rehabilitation unit for acute or subacute neurological or musculoskeletal disorders. METHODS: We reviewed the medical records of 537 patients admitted to a rehabilitation unit and selected 398 patients in the acute or subacute stage of various neurological or musculoskeletal disorders. Among them, patients who had suffered from delirium were categorized into the delirium group (n=65), and the other patients were categorized into the non-delirium group (n=333). As potential risk factors for delirium, the patients' diagnosis, underlying disease, demographic data, hospital stay duration, surgery, and laboratory findings were reviewed, and the differences between the two groups with respect to independent risk factors were analyzed. RESULTS: The average age in the delirium group was higher; the hospital stay and pre-transfer periods were longer. A large proportion of the patients were admitted for musculoskeletal disorders, and many patients had diabetes mellitus, dementia, and depression as underlying diseases. Laboratory tests revealed increases in the white blood cells (WBC), glucose, blood urea nitrogen (BUN), total bilirubin, aspartate transaminase (AST), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) levels in the delirium group, while the hemoglobin, calcium, phosphorus, protein, albumin, and potassium levels were decreased. Depression, musculoskeletal disorders, traumatic brain injury, elevated WBC, BUN, AST, and CRP levels, and decreased potassium and phosphorus levels were identified as independent risk factors for delirium. CONCLUSION: Risk factors treatable before delirium onset were identified in rehabilitation patients in acute and subacute stages of various disorders. Early diagnosis and prevention of these risk factors could decrease delirium occurrence and increase rehabilitation effectiveness.

Chronometry TMS in Language Network

The purpose of this review is to introduce a new mapping technique, the chronometry transcranial magnetic stimulation (TMS), which can be used to delineate detailed time information of specific functioning target network by transiently creating a 'virtual brain lesion', thus disrupting the function of a given cortical target at different time window. Unlike neuroimaging methods such as functional magnetic resonance imaging (fMRI), chronometry TMS provided information about which language area contributes to performance of some specific task, and at what precise moment the contribution is critical. We shall highlight two aspect of chronometry TMS, that is used in language research either for understanding time course of language processing in normal subject or for measuring plastic reorganization of functioning network.

Cognitive Dysfunction in Drug-induced Parkinsonism Caused by Prokinetics and Antiemetics

The use of prokinetics/antiemetics is one of the leading causes of drug-induced parkinsonism (DIP) observed in neurology clinics. Cognitive dysfunction in DIP has recently been recognized, but pathologies related with cognitive dysfunction is unknown. Among our retrospective cohort of 385 consecutive parkinsonian patients enrolled in our parkinsonism registry, 14 patients were identified who satisfied our inclusion criteria: parkinsonism caused by prokinetics/antiemetics, existing T1-weighted 3D volumetric MR images, and normal [18F]-N-3-fluoropropyl-2-beta-carboxymethoxy-3-beta-(4-iodophenyl) nortropane PET scan images. For the comparison of volumetric MR data, 30 age- and sex-matched healthy individuals were included in this study. Among 14 patients with DIP, 4 patients were diagnosed with dementia, and all other patients had mild cognitive impairment (MCI). Comparisons of MR volumetric data between DIP patients with MCI and controls show that cortical gray matter volumes are reduced bilaterally in DIP (P=0.041) without changes in either total white matter volume or total intracranial volume. Among subcortical structures, the volume of the right hippocampus is reduced in DIP patients compared with controls (P=0.011, uncorrected). In DIP, cortical thickness is reduced in the bilateral lingual (P=0.002), right fusiform (P=0.032) and part of the left lateral occipital gyri (P=0.007). Our results suggests that cognitive dysfunction in DIP caused by prokinetics/antiemetics is common. Structural changes in the brain by 3D MRI may be associated with cognitive decline in DIP.

Modulating Neural Network through rTMS

Repetitive transcranial magnetic stimulation (rTMS) is a non-invasive method to produce potent changes in cortical excitability. Therefore, the application of rTMS was recently proposed to promote functional recovery in stroke patients, owing to the induced neuroplasticity. It is important to note that stimulating the brain at a specific site does not only affect the neuronal activity at that site, but the activity throughout the entire neural network. In this review, both local and distant effect of rTMS through related network will be discussed based on previous neuroimaging evidences showing network plasticity. We'd like to extend the discussion to stroke patients, which would be useful for application of rTMS in the clinical rehabilitation field.

Novel Information on Anatomic Factors Causing Grasp Reflex in Frontal Lobe Infarction: A Case Report

We report a patient with a severe limitation of function in the right hand resulting from grasp reflex following a stroke affecting the left anterior cerebral artery region. We describe, using diffusion tensor tractography (DTT), a disconnection between the bilateral frontal lobes via the corpus callosum. The patient could not control his right hand at all, even though his bilateral corticospinal tracts were intact. We noted that over the infarcted lesion on DTT, the white matter was invisible from the corpus callosum to the prefrontal cortex. These findings reflected a unique pattern of white-matter disconnection between the ipsilateral medial frontal lobe and ipsilateral and contralateral frontal cortex causing hand function deterioration in the form of severe grasp reflex.

Reduction of Continuous Theta Burst Stimulation-Induced Motor Plasticity in Healthy Elderly With COMT Val158Met Polymorphism

OBJECTIVE: To delineate whether cortical plasticity induced by continuous theta burst stimulation (cTBS) differed according to catechol-O-methyltransferase (COMT) gene polymorphism in healthy older adults. METHODS: Eighteen healthy older volunteers (mean age 73.78+/-5.04; 12 females and 6 males) were recruited. Volunteers randomly assigned in either a sham-first or real cTBS first group participated in two separate TMS visits with at least a 2-day wash-out period. Genotyping was carried out at baseline by a separate researcher who was blinded. cTBS was delivered in a hot spot over M1 at an active motor threshold of 80%. Motor evoked potentials (MEPs) were obtained at 120% of the resting motor threshold before and after sham/cTBS. RESULTS: The relative MEP to baseline was significantly decreased 0 and 10 minutes post-stimulation and increased 40 minutes post-stimulation, as compared with the sham condition. Immediately after cTBS, the Val/Val group had a significantly reduced relative MEP value, as compared with the MET carrier group. CONCLUSION: In healthy older persons, cTBS-induced motor plasticity was reduced in the COMT Val/Val group as compared with the 158Met carrier group.

Videofluoroscopy-Guided Balloon Dilatation for the Opening Dysfunction of Upper Esophageal Sphincter by Postoperative Vagus Nerve Injury: A Report on Two Cases

Dysphagia secondary to peripheral cranial nerve injury originates from weak and uncoordinated contraction-relaxation of cricopharyngeal muscle. We report on two patients who suffered vagus nerve injury during surgery and showed sudden dysphagia by opening dysfunction of upper esophageal sphincter (UES). Videofluoroscopy-guided balloon dilatation of UES was performed. We confirmed an early improvement of the opening dysfunctions of UES, although other neurologic symptoms persisted. While we did not have a proper comparison of cases, the videofluoroscopy-guided balloon dilatation of UES is thought to be helpful for the early recovery of dysphagia caused by postoperative vagus nerve injury.

The Concept of Metaplasticity

The concept of metaplasticity entails a change in the physiological or biochemical state of synapses that alters their ability to generate synaptic plasticity by integrating individual synaptic events. The characteristics of metaplasticity would be the fact that those synaptic changes last in certain period time with association of activity in time, homosynaptically or heterosynaptically. Recently introduced non-invasive brain stimulation enables us to observe the metaplastic changes in vivo, which would give us a insight in developing new effective therapeutic approach based on synaptic plasticity and metaplasticity.

Clinical Practice Guideline for Stroke Rehabilitation in Korea 2012

"Clinical Practice Guideline for Stroke Rehabilitation in Korea 2012" is a 2nd edition of clinical practice guideline (CPG) for stroke rehabilitation in Korea, which updates the 1st edition published in 2009. After 1st stroke rehabilitation CPG, many studies concerning stroke rehabilitation have been published and the necessity for update has been raised. The Korea Centers for Disease Control and Prevention supported the project "Development of Clinical Practice Guideline for Stroke Rehabilitation" in 2012. Thirty-two specialists in stroke rehabilitation from 18 universities and 3 rehabilitation hospitals and 10 consultants participated in this project. The scope of this CPG included both ischemic and hemorrhagic stroke from the acute to chronic stages. The purpose of this CPG is to provide guidelines for doctors and therapists to make a decision when they manage stroke patients and ultimately, to help stroke patients obtain maximal functional recovery and return to the society. "Clinical Practice Guideline for Stroke Rehabilitation in Korea 2012" consists of 'Chapter 1; Introduction of Stroke Rehabilitation', 'Chapter 2; Rehabilitation for Stroke Syndrome, 'Chapter 3; Rehabilitation for Return to the Society', and 'Chapter 4; Advanced Technique for Stroke Rehabilitation'. Both the adaptation and de novo development methods were used to develop this 2nd edition of CPG. The appraisal of foreign CPGs was performed using 'Korean appraisal of guidelines for research and evaluation II' (K-AGREE II); moreover, four CPGs from Scotland (2010), Austrailia (2010), USA (2010), Canada (2010) were chosen for adaptation. For de novo development, articles that were published following the latest foreign CPGs were searched from the database system, PubMed, Embase, and Cochrane library. Literatures were assessed in the aspect of subjects, study design, study results' consistency, language and application possibility in the Korean society. The chosen articles' level of evidence and grade of recommendation were decided by the criteria of Scotland (2010) and the formal consensus was derived by the nominal group technique. The levels of evidence range from 1++ to 4 and the grades of recommendation range from A to D. GPP (Good Practice Point) was recommended as best practice based on the clinical experience of the guideline developmental group. The draft of the developed CPG was reviewed by the experts group in the public hearings and then revised.