[Validation of the German Version of the Sunnybrook Facial Grading System]. / Validierung einer Deutschen Version des Sunnybrook Facial Grading Systems.

Background: The Sunnybrook facial grading system (SFGS) is frequently applied to evaluate facial function in patients with facial palsy, but still now there is no validated German version of this evaluation sheet. Methods: The original English version of the SFGS was translated and validated in accordance with international standards. The interrater reliability from 5 raters (speech therapy students) and the intrarater reliability from repeated ratings at 2 time points using video tapes of 18 patients with different types of facial palsy were analyzed by calculating the intraclass correlation coefficient (ICC) and other reliability measures. Results: ICC for the interrater reliability for the 4 components of the SFGS, resting symmetry, symmetry during voluntary movements, synkinesis, and the composite score were ICC 0.845; 0.903; 0.731 and 0.918, respectively, for the first evaluation and ICC 0.881; 0.932; 0.818 and 0.940, respectively, for the second evaluation. The mean intrarater reliability for the 4 SFGS scores was ICC=0.791; 0.906; 0.770 and 0.905. Discussion: There is now a valid German version of the SFGS available that can be used even by novices. The German version is suitable for evaluation of facial palsies in clinical routine and studies to allow a better comparability of German patients with results of the international literature.

Respiratory Muscle Assessment in Acute Guillain-Barré Syndrome.

PURPOSE: Guillain-Barré Syndrome (GBS) is a life-threatening disease due to respiratory muscle involvement. This study aimed at objectively assessing the course of respiratory muscle function in GBS subjects within the first week of admission to an intensive care unit. METHODS: Medical Research Council Sum Score (MRC-SS), vigorimetry, spirometry, and respiratory muscle function tests (inspiratory/expiratory muscle strength: PImax/PEmax, sniff nasal pressure: SnPna) were assessed twice daily. GBS Disability Score (GBS-DS) was assessed once daily. On days one (d1) and seven (d7), blood gases and twitch mouth pressure during magnetic phrenic nerve stimulation (Pmo,tw) were additionally evaluated. RESULTS: Nine subjects were included. MRC-SS, vigorimetry, PImax, and SnPna increased between d1 and d7. GBS-DS, spirometry and Pmo,tw remained unaltered. Only SnPna correlated closely with the MRC-SS on both d1 (r = 0.77, p = 0.02) and d7 (r = 0.74, p = 0.02). CONCLUSION: SnPna was the only parameter that correlated with MRC-SS, while the current gold standard of spirometry measurement did not.

Daily iTBS worsens hand motor training--a combined TMS, fMRI and mirror training study.

INTRODUCTION: Repetitive transcranial magnetic stimulation (rTMS) is used to increase regional excitability to improve motor function in combination with training after neurological diseases or events such as stroke. We investigated whether a daily application of intermittent theta burst stimulation (iTBS; a short-duration rTMS that increases regional excitability) improves the training effect compared with sham stimulation in association with a four-day hand training program using a mirror (mirror training, MT). The right dorsal premotor cortex (dPMC right) was chosen as the target region for iTBS because this region has recently been emphasized as a node within a network related to MT. METHODS: Healthy subjects were randomized into the iTBS group or sham group (control group CG). In the iTBS group, iTBS was applied daily over dPMC right, which was functionally determined in an initial fMRI session prior to starting MT. MT involved 20 min of hand training daily in a mirror over four days. The hand tests, the intracortical excitability and fMRI were evaluated prior to and at the end of MT. RESULTS: The results of the hand training tests of the iTBS group were surprisingly significantly poorer compared with those from the CG group. Both groups showed a different course of excitability in both M1 and a different course of fMRI activation within the supplementary motor area and M1 left. CONCLUSION: We suggest the inter-regional functional balance was affected by daily iTBS over dPMC right. Maybe an inter-regional connectivity within a network is differentially balanced. An excitability increase within an inhibitory-balanced network would therefore disturb the underlying network.

Global tracking in human gliomas: a comparison with established tracking methods.

PURPOSE: Global tracking (GT) is a recently published fibre tractography (FT) method that takes simultaneously all fibres into account during their reconstruction. The purpose of this study was to compare this new method with fibre assignment by continuous tracking (FACT) and probabilistic tractography (PT) for the detection of the corticospinal tract (CST) in patients with gliomas. METHODS: Tractography of the CST was performed in 17 patients with eight low grade and nine anaplastic astrocytomas located in the motor cortex or the corticospinal tract. Diffusions metrics as fractional anisotropy (FA), mean (MD), axial (AD) and radial diffusivity (RD) were obtained. The methods were additionally applied on a physical phantom to assess their accuracy. RESULTS: PT was successful in all (100 %), GT in 16 (94 %) and FACT in 15 patients (88 %). The case where GT and FACT, both, missed the CST showed the highest AD and RD, whereas the one where FACT algorithm, alone, was not successfully showed the lowest AD and RD of the group. FA was reduced on the pathologic side (FApath 0.35 ± 0.16 (mean ± SD) versus FAcontralateral 0.51 ± 0.15, pcorr < 0.03). RD was increased on the pathologic side (RDpath 0.67 ± 0.29 × 10(-3) mm(2)/s versus RDcontralateral 0.46 ± 0.08 × 10(-3) mm(2)/s, pcorr < 0.03). In the phantom measurement, only GT did not detect false positive fibres at fibre crossings. CONCLUSION: PT performed well even in areas of increased diffusivities indicating a severe oedema or disintegration of tissue. FACT was also susceptible to a decrease of diffusivities and to a susceptibility artefact, where GT was robust.

Optical illusion alters M1 excitability after mirror therapy: a TMS study.

The contralesional primary motor cortex (M1) has been suggested to be involved in the motor recovery after mirror therapy, but whether the ipsilesional M1 is influenced by the contralesional M1 via transcallosal interhemispheric inhibition (IHI) is still unclear. The present study investigated the change of IHI as well as the intracortical inhibition and intracortical facilitation of both M1 induced by training in a mirror with the use of transcranial magnetic stimulation (TMS). In this 2 × 2 factorial design (time × group), healthy subjects exercised standardized motor skills with their right hand on four consecutive days. Either a mirror (mirror group) or a board (control group) was positioned between their hands. Before and after training TMS was applied along with training tests of both hands. Tests were the same motor skills exercised daily by both groups. Tests of the untrained left hand improved significantly more in the mirror group than in the control group after training (P = 0.02) and showed a close correlation with an increase of intracortical inhibition of M1(left). IHI did not show any difference between investigation time points and groups. The present study confirms the previous suggestion of the involvement of the "contralesional" left-side (ipsilateral to the hand behind the mirror) M1 after mirror therapy, which is not mediated by IHI. Even with the same motor skill training (both groups performed same motor skills) but with different visual information, different networks are involved in training-induced plasticity.

Lesion-induced and training-induced brain reorganization.

INTRODUCTION: A stroke may modulate motor cortex excitability. We examined if distinct ischemic brain lesions are associated with a specific pattern of excitability changes. We also investigated the effects of a rehabilitative therapy on motor excitability. METHODS: In stroke patients, the consequences of a) a lesion in the central somatosensory system, b) a cerebellar lesion and c) a two week period of Constraint-induced movement therapy (CIMT), on motor cortex excitability were studied. Transcranial magnetic stimulation techniques and functional magnetic resonance imaging (fMRI) were employed. RESULTS: Patients with a lesion in the primary somatosensory cortex or in the ventroposterolateral nucleus of the thalamus had a decreased intracortical inhibition on the affected side. Patients with lesions in the territory of the superior cerebellar artery had a loss of intracortical facilitation and an increase of intracortical inhibition. Patients with cortical lesions undergoing CIMT had a loss of intracortical inhibition prior to therapy. After CIMT, changes of ICI were stronger in the lesioned than in the non-lesioned hemisphere but could result either in an increase of ICI or a reduction of ICI. In three patients fMRI results showed that cortical activation was less post CIMT as compared to pre-treatment activation. In parallel, ICI was reduced after treatment. CONCLUSIONS: Our results suggest that, physiologically, central somatosensory influence on the motor cortex is inhibitory. In contrast, the cerebellum normally exerts a facilitatory influence on the motor cortex. CIMT induces changes of intracortical excitability mainly in the affected hemisphere.

Structural and functional cortical abnormalities after upper limb amputation during childhood.

Functional reorganization has been well documented in the human adult brain after amputation of the arm. To assess the effects of amputation on the developing brain, we investigated six patients with upper limb amputation in early childhood and one with right dysmelia. Transcranial magnetic stimulation indicated contralateral cortical disinhibition and enlargement of the excitable area of the stump. FMRI data corroborated these plastic changes and also showed an ipsilateral functional reorganization. In the T1-weighted MRI, we found structural deformities of the contralateral and ipsilateral central sulcus in three patients and a contralateral atrophic parietal lobule in two patients. Therefore, arm amputation in childhood affects functional organization as well as anatomical structure in both hemispheres.

Surface orientation discrimination activates caudal and anterior intraparietal sulcus in humans: an event-related fMRI study.

Perception of surface orientation is an essential step for the reconstruction of the three-dimensional (3D) structure of an object. Human lesion and functional neuroimaging studies have demonstrated the importance of the parietal lobe in this task. In primate single-unit studies, neurons in the caudal part of the intraparietal sulcus (CIP) were found to be active during the extraction of surface orientation through monocular (two-dimensional) cues such as texture gradients and linear perspective as well as binocular (3D) cues such as disparity gradient and orientation disparity. We used event-related fMRI to study the functional neuroanatomy of surface orientation discrimination using stimuli with monocular depth cues in six volunteers. Both posterior (CIP) and anterior (AIP) areas within the intraparietal sulcus showed a stronger activation during surface orientation as compared with a control (color discrimination) task using identical stimuli. Furthermore, the signal changes in CIP showed a greater performance effect than those in AIP, suggesting that CIP is tightly linked to the discrimination task.

Motor cortex disinhibition of the unaffected hemisphere after acute stroke.

We studied motor cortex excitability in the nonlesioned hemisphere of patients with a large cortical infarction. Patients with a severe hemiparesis due to a stroke were compared with age-matched, healthy controls. Paired transcranial magnetic stimuli were applied over the unaffected hemisphere to investigate intracortical inhibition and facilitation. In the patient group, intracortical inhibition was reduced. We suggest that this disinhibition is due to an impairment of transcallosal fibers and may affect recovery.

Reversible changes in echo planar perfusion- and diffusion-weighted MRI in status epilepticus.

Perfusion imaging (PI) demonstrated increased perfusion and diffusion-weighted imaging (DWI) showed high signal limited to the left temporoparietal cortex in a 68-year-old man with nonconvulsive status epilepticus. The EEG showed a slow delta-wave focus. The patient recovered and PI, DWI and EEG changes completely resolved.