Weight and Abdominal Pressure-Induced Shunt Trouble in Patients With Shunted Normal Pressure Hydrocephalus: A Comprehensive Study on Pressure Environment of Shunt System.

Objectives: We identified a new type of shunt malfunction (SM) in patients with normal pressure hydrocephalus (NPH). It is induced by weight change and can be treated with valve readjustment. There were two types of SM as follows: Underdrainage induced by the weight gain and overdrainage induced by the weight loss. This study aims to elucidate this mechanism by assessing the shunt pressure environment. Methods: The total pressure environment of the shunt system was prospectively studied in patients with shunted NPH at Osaka Medical College Hospital from 1999 to 2005. We measured the pressure environment during the initial pressure setting of the valve by the intracranial pressure (ICP) guide, after setting the valve, and when SM was suspected. We evaluated ICP, intra-abdominal pressure (IAP), and hydrostatic and perfusion pressures of the shunt system in the sitting and supine positions. The target ICP for valve setting was empirically set at the range from -8 to -13 mm Hg in the sitting position, referring to the external auditory meatus. During the study period, we identified five cases of SM induced by weight change and assessed the changes in the pressure environment across pre-SM, SM, and post-SM. Results: In four cases of underdrainage, gait disturbance worsened with an average weight gain of 6.8 ± 1.2 kg. With weight gain, IAP and ICP increased by 8.8 ± 1.6 and 4.8 ± 1.0 mm Hg, respectively. Consequently, ICP increased to -6.5 ± 1.9 mm Hg. One overdrainage patient developed an asymptomatic chronic subdural hematoma (CSDH) with a weight loss of 10 kg. With the weight loss, both IAP and ICP decreased by 5 mm Hg, and concomitantly, ICP decreased to -18 mm Hg. In all patients, the valve readjustment restored their ICP to the target pressure. After the valve readjustment, the gait disturbance improved immediately, and the CSDH disappeared after 1 month. Conclusion: In patients with shunts, the weight change was linked to ICP via IAP. Due to the weight change, the underdrainage occurred when ICP was above the target pressure, and the overdrainage occurred when ICP was below it. We named this SM as the weight and abdominal pressure-induced shunt trouble. The patients with SM along with weight changes should be the first to be tried for the valve readjustment.

Guidelines for Management of Idiopathic Normal Pressure Hydrocephalus (Third Edition): Endorsed by the Japanese Society of Normal Pressure Hydrocephalus.

Among the various disorders that manifest with gait disturbance, cognitive impairment, and urinary incontinence in the elderly population, idiopathic normal pressure hydrocephalus (iNPH) is becoming of great importance. The first edition of these guidelines for management of iNPH was published in 2004, and the second edition in 2012, to provide a series of timely, evidence-based recommendations related to iNPH. Since the last edition, clinical awareness of iNPH has risen dramatically, and clinical and basic research efforts on iNPH have increased significantly. This third edition of the guidelines was made to share these ideas with the international community and to promote international research on iNPH. The revision of the guidelines was undertaken by a multidisciplinary expert working group of the Japanese Society of Normal Pressure Hydrocephalus in conjunction with the Japanese Ministry of Health, Labour and Welfare research project. This revision proposes a new classification for NPH. The category of iNPH is clearly distinguished from NPH with congenital/developmental and acquired etiologies. Additionally, the essential role of disproportionately enlarged subarachnoid-space hydrocephalus (DESH) in the imaging diagnosis and decision for further management of iNPH is discussed in this edition. We created an algorithm for diagnosis and decision for shunt management. Diagnosis by biomarkers that distinguish prognosis has been also initiated. Therefore, diagnosis and treatment of iNPH have entered a new phase. We hope that this third edition of the guidelines will help patients, their families, and healthcare professionals involved in treating iNPH.

A multi-center, prospective study on the progression rate of asymptomatic ventriculomegaly with features of idiopathic normal pressure hydrocephalus on magnetic resonance imaging to idiopathic normal pressure hydrocephalus.

INTRODUCTION: Our previous community-based study demonstrated that some individuals with AVIM [asymptomatic ventriculomegaly with features of idiopathic normal pressure hydrocephalus (iNPH) on magnetic resonance imaging (MRI)] progressed to iNPH in several years. In this hospital-based study, we investigated the progression rate from AVIM to iNPH and its possible predictors. METHODS: We conducted a prospective study of participants with AVIM from several medical institutions/hospitals in Japan. AVIM is defined as "asymptomatic ventriculomegaly with features of iNPH on MRI"; in the present study, asymptomatic was defined as "0 (no symptoms) or 1 (presence of only subjective, but not objective, symptoms) on the iNPH Grading Scale (iNPH-GS)." We also measured possible predicting factors for AVIM-to-iNPH progression, including age, sex, body weight, blood pressure, diabetes mellitus, dyslipidemia, history of mental disease/head injury/sinusitis/smoking/alcohol-intake, Evans index, and the presence of DESH (disproportionately enlarged subarachnoid-space hydrocephalus) findings on brain MRI, and analyzed these potential predictive values. RESULTS: In 2012, 93 participants with AVIM were registered and enrolled in the study. Of these, 52 participants were able to be tracked for three years (until 2015). Of the 52 participants, 27 (52%) developed iNPH during the follow-up period (11 definite, 6 probable, and 10 possible iNPH), whereas 25 participants remained asymptomatic in 2015. Among the possible predictive factors examined, the baseline scores of iNPH-GS predicted the AVIM-to-iNPH progression. CONCLUSIONS: The multicenter prospective study demonstrated that the progression rate from AVIM to iNPH was ~17% per year, and the baseline scores of iNPH-GS predicted the AVIM-to-iNPH progression.

Plasma brain natriuretic peptide level on admission predicts long-term outcome in patients with non-traumatic subarachnoid hemorrhage.

INTRODUCTION: Non-traumatic subarachnoid hemorrhage (SAH) is a type of stroke that still has a high mortality rate. Some patients with SAH have electrocardiography (ECG) abnormalities or asymptomatic left ventricular apical ballooning, and requires intervention by cardiologists. However, the impact of cardiac abnormalities after SAH onset remains unclear. We investigated whether ECG abnormalities, myocardial damage, sympathetic nervous activity or echocardiographic left ventricular wall motion abnormalities (WMA) could provide additional risk stratification in patients with SAH. METHODS: We studied 118 SAH patients (78 women, age 63 ± 15) without a history of heart disease. Neurological grade (Hunt and Kosnik Grade) and clinical factors were evaluated. A standard 12-lead ECG, echocardiography and blood samples were obtained within 48 h after SAH onset. ECG abnormalities were defined as abnormal Q wave, ST elevation, giant T-wave inversion or QT prolongation. RESULTS: Twenty of 118 patients (17%) died during the follow-up (35 ± 31 months). Death was significantly associated with higher age (p < 0.0001), neurological grade (p < 0.0001), elevated BNP level (p < 0.0001), increased plasma norepinephrine levels (p < 0.0001) and WMA (p = 0.0070), while ECG abnormalities were not significantly associated. Neurological grade (p < 0.0001), age (p = 0.0047) and BNP (p = 0.0014, hazard ratio 1.0255 for each 1 pg/mL increase in BNP, 95%CI 1.0088 to 1.0499) were independently associated with death. Patients with BNP ≥ 96.6 had a higher risk of death (log- rank p < 0.0001). CONCLUSION: Plasma BNP might provide an additional risk stratification in patients with non-traumatic SAH that requires intervention by cardiologists for both its prevention management after onset.

Cervical Myelopathy Due to Direct Cord Compression by Posterior Inferior Cerebellar Artery Associated with Aberrant Vertebral Artery.

BACKGROUND: The effectiveness of surgical microvascular decompression (MVD) of the vertebral artery (VA) for treating conditions such as trigeminal neuralgia or hemifacial spasm is well known. However, the use of MVD for a case in which the posterior inferior cerebellar artery (PICA) is directly compressing the high cervical cord has not been reported. CASE DESCRIPTION: A 48-year-old male was diagnosed with a rare case of myelopathy due to the PICA directly compressing the high cervical cord. The patient had a C-2 segmental type of VA that penetrated the intradural space at the C1 level. The VA-PICA portion was located just after where the intradural space was penetrated, and the branching PICA strongly and vertically compressed the high cervical cord. CONCLUSIONS: MVD of the PICA was performed, and the patient experienced rapid improvement of myelopathy. The patient immediately improved postoperative day 1 and was doing well at his 1-year follow-up. This is a rare case of the PICA directly compressing the cervical cord and causing myelopathy. MVD of the PICA resulted in good patient recovery.

Physical Activity: A Viable Way to Reduce the Risks of Mild Cognitive Impairment, Alzheimer's Disease, and Vascular Dementia in Older Adults.

A recent alarming rise of neurodegenerative diseases in the developed world is one of the major medical issues affecting older adults. In this review, we provide information about the associations of physical activity (PA) with major age-related neurodegenerative diseases and syndromes, including Alzheimer's disease, vascular dementia, and mild cognitive impairment. We also provide evidence of PA's role in reducing the risks of these diseases and helping to improve cognitive outcomes in older adults. Finally, we describe some potential mechanisms by which this protective effect occurs, providing guidelines for future research.

Shunt Devices for the Treatment of Adult Hydrocephalus: Recent Progress and Characteristics.

Various types of shunt valves have been developed during the past 50 years, most of which can be classified into the following categories: (1) fixed differential pressure valves; (2) fixed differential pressure (DP) valves with an antisiphon mechanism; (3) programmable DP valves; (4) programmable DP valves with an antisiphon mechanism; and (5) programmable antisiphon valves. When considering the myriad of possible postoperative condition changes, such as the onset of accidental non-related diseases or trauma in adults, and changes in normal physiological development or anticipation of future shunt removal in children, it has become standard to use the programmable valve as a first choice for cerebrospinal fluid shunting. However, it is still unclear what type of shunt valve is suitable for each individual case. Based on the results of SINPHONI and more recently SINPHONI 2 trials, the programmable DP valve is recommended as the first line shunt valve. The programmable DP valve with an antisiphon mechanism is thought to be beneficial for tall, slender patients, who have a tendency for easily developing complications of overdrainage, however, this type of valve must be used cautiously in obese patients because of the increased risk of underdrainage. Although the current evidence is still insufficient, the programmable antisiphon valve, which costs the same as the programmable DP valve, is also thought to be the first line shunt valve. The quick reference table is applicable for most shunt valves, and for patients with either the ventriculoperitoneal or the lumboperitoneal shunt.

Increased Resting Energy Expenditure after Endovascular Coiling for Subarachnoid Hemorrhage.

BACKGROUND: Appropriate nutritional care from the acute stage is essential for improved functional outcomes and reduced mortality in patients with subarachnoid hemorrhage (SAH). Although endovascular coiling is increasingly being used as an alternative to neurosurgical clipping and craniotomy for ruptured aneurysms, the resting energy expenditure (REE) of patients treated with this new technique has not been systemically evaluated. METHODS: We measured REE values by indirect calorimetry in 12 SAH patients treated with endovascular coiling. We averaged the REE measurements obtained on days 1 and 7 after endovascular coiling, and then we statistically compared the mean REE values with those in 30 patients with acute cerebral infarction (ACI) by the Wilcoxon rank-sum test (P <.05). Next, we calculated the ratio of measured REE values to the values estimated using the Harris-Benedict equation to adjust for demographic differences in sex, weight, height, and age between the groups. RESULTS: The ratios were significantly higher in SAH patients (median value, 1.12; interquartile range, 1.05-1.23) than in ACI patients (median value, 1.02; interquartile range, .97-1.09). CONCLUSIONS: Because endovascular coiling is less invasive than neurosurgical clipping, the observed increase in REE was attributed to metabolic changes after SAH. To provide optimal nutritional care to SAH patients from the acute stage, clinicians should be aware of this change in REE.

Arteriovenous malformation of the vestibulocochlear nerve.

We describe a rare case of an arteriovenous malformation (AVM) embedded in the vestibulocochlear nerve presenting with subarachnoid hemorrhage (SAH) treated by microsurgical elimination of the main feeding artery and partial nidus volume reduction with no permanent deficits. This 70-year-old woman was incidentally diagnosed 4 years previously with two small unruptured tandem aneurysms (ANs) on the right anterior inferior cerebral artery feeding a small right cerebellopontine angle AVM. The patient was followed conservatively until she developed sudden headache, nausea and vomiting and presented to our outpatient clinic after several days. Magnetic resonance imaging demonstrated findings suggestive of early subacute SAH in the quadrigeminal cistern. A microsurgical flow reduction technique via clipping between the two ANs and partial electrocoagulation of the nidus buried within the eighth cranial nerve provided radiographical devascularization of the ANs with residual AVM shunt flow and no major deficits during the 2.5 year follow-up. This is only the second report of an auditory nerve AVM. In the event of recurrence, reoperation or application of alternative therapies may be considered.

Comparisons of Predictive Equations for Resting Energy Expenditure in Patients with Cerebral Infarct during Acute Care.

BACKGROUND: Estimation of resting energy expenditure (REE) is essential in planning nutrition support. Several equations are used for this estimation in the clinical setting. The purpose of this study was to compare the predictive accuracy of existing equations for REE in patients with cerebral infarct during acute care. METHODS: We assessed the Harris-Benedict, Mifflin, Owen, Japanese simplified, Wang, and Cunningham equations. The Owen and Japanese simplified equations use sex and weight as explanatory variables, the Harris-Benedict and Mifflin equations include sex, weight, age, and height, and the Wang and Cunningham equations use fat-free mass (FFM) measured using bioelectrical impedance technology. Actual REE values were measured by indirect calorimetry on days 2 and 7 and were then averaged. Applying analysis of variance, predictive accuracy was assessed by comparing the predicted and actual values. RESULTS: A total of 30 patients were analyzed. Actual REE values ranged from 796 to 1637 kcal (mean, 1109). The standard deviation of these values was the smallest with the Harris-Benedict equation (99), followed by the Cunningham (165), and Wang (181) equations. The Mifflin equation underestimated REE in females, whereas the Owen and Japanese simplified equations tended to overestimate it. CONCLUSIONS: Based on our results, the Harris-Benedict equation provides the most accurate prediction of REE. In addition, the Cunningham and Wang equations may be useful in long-term care settings involving patients at risk of malnutrition resulting in uneven loss of FFM relative to weight.

Outcome assessment of hemiparesis due to intracerebral hemorrhage using diffusion tensor fractional anisotropy.

BACKGROUND: This study aimed to evaluate the prognostic efficacy of magnetic resonance diffusion tensor fractional anisotropy (FA) for patients with hemiparesis due to intracerebral hemorrhage. METHODS: Diffusion tensor FA brain images were acquired 14-21 days after putaminal and/or thalamic hemorrhage. The ratio of FA values within the cerebral peduncles of the affected and unaffected hemispheres (rFA) was calculated for each patient (n = 40) and assessed for correlation with Brunnstrom stage (BRS, 1-6), motor component of the functional independence measure (FIM-motor, 13-91), and the total length of stay (LOS) until discharge from rehabilitation (P < .05). Ordinal logistic regression analyses were conducted to determine the relationships between rFA and specific outcomes as measured by BRS range (poor, BRS 1 or 2; moderate, BRS 3 or 4; and good, BRS 5 or 6; P < .05). RESULTS: The rFA values were .571-1.043 (median, .856) and BRS scores were 1-6 (median, 4) for shoulder/elbow/forearm, 1-6 (median, 4) for hand, and 2-6 (median, 4) for lower extremities. FIM-motor scores were 58-86 (median, 78) and LOS ranged from 42 to 225 days (median, 175.5 days). Correlation coefficients were statistically significant between rFA and shoulder/elbow/forearm BRS (.696), hand BRS (.779), lower extremity BRS (.631), FIM-motor (.442), and LOS (-.598). Logistic model fit was moderate for shoulder/elbow/forearm BRS (R(2) = .221) and lower extremity BRS (R(2) = .277), but was much higher for hand BRS (R(2) = .441). CONCLUSIONS: Diffusion tensor FA values are predictive of clinical outcome from hemiparesis due to putaminal and/or thalamic hemorrhage, particularly hand function recovery.

Multiple left ventricular thrombi in a patient with dilated cardiomyopathy and cerebral infarction: a case report.

INTRODUCTION: It is not clear whether patients with sinus rhythm and reduced left ventricular function should be treated with anticoagulation therapy during or after treatment for heart failure. CASE PRESENTATION: A 67-year-old Japanese man was hospitalized at our institution with heart failure due to dilated cardiomyopathy. On day after discharge, he developed cerebral infarction and showed persistence of multiple left ventricular thrombi. His paralysis completely improved at 2 days after edaravone and heparin administration; however, his left visual field defect persisted. CONCLUSION: Patients in sinus rhythm with reduced left ventricular function might benefit from anticoagulation therapy during treatment for heart failure.

Relationship between diffusion tensor fractional anisotropy and long-term motor outcome in patients with hemiparesis after middle cerebral artery infarction.

BACKGROUND: Magnetic resonance diffusion tensor fractional anisotropy (DTI-FA) is often used to characterize neural damage after stroke. Here we assessed the relationship between DTI-FA and long-term motor outcome in patients after middle cerebral artery (MCA) infarction. METHODS: Fractional anisotropy (FA) maps were generated from diffusion tensor brain images obtained from 16 patients 14-18 days postinfarction, and tract-based spatial statistics (TBSS) analysis was applied. Regions of interest were set within the right and left corticospinal tracts, and mean FA values were extracted from individual TBSS data. Hemiparesis motor outcome was evaluated according to Brunnstrom stage (BRS: 1-6, severe-normal) for separate shoulder/elbow/forearm, hand, and lower extremity functions, as well as the motor component score of the Functional Independence Measure (FIM-motor: 13-91, null-full) 5-7 months after onset. Ratios between FA values in the affected and unaffected hemispheres (rFA) were assessed by BRS and FIM-motor scores. RESULTS: rFA values were .636-.984 (median, .883) and BRS scores were 1-6 (median, 3) for shoulder/elbow/forearm, 2-6 (median, 3) for hand, and 3-6 (median, 5) for the lower extremities. FIM-motor scores were 51-90 (median, 75). Analysis revealed significant relationships between rFA and BRS data (correlation coefficient: .687 for shoulder/elbow/forearm, .579 for hand, and .623 for lower extremities) but no significance relationship between rFA and FIM-motor scores. CONCLUSIONS: The results suggest that DTI-FA is applicable for predicting the long-term outcome of extremity functions after MCA infarction.

White matter characteristics of idiopathic normal pressure hydrocephalus: a diffusion tensor tract-based spatial statistic study.

Using magnetic resonance-diffusion tensor imaging (DTI), we examined white matter changes within the brains of patients diagnosed with idiopathic normal pressure hydrocephalus (INPH). We analyzed data for 24 INPH patients who were presented with typical clinical symptoms (gait disturbance, dementia, and/or urinary incontinence) and Evans index > 0.3, and compared these with the control data from 21 elderly persons (≥ 60 years). DTI brain images were obtained with a 3T scanner. Fractional anisotropy (FA) brain maps were generated using a computer-automated method, and tract-based spatial statistics (TBSS) were then applied to compare the FA brain maps of the INPH and control groups in standard space. The TBSS data were further investigated using region-of-interest (ROI) analyses. ROIs were set within the corpus callosum, the posterior limb of the internal capsule (PLIC), and the cerebral peduncle in reference to a standard brain template. Compared with the control group, FA values in the INPH group were significantly lower in the corpus callosum and just significantly higher in the PLIC, but no significant differences were evident in the cerebral peduncle. The much lower FA values in the corpus callosum, but not the slightly higher FA values in the PLIC, were associated with more severe clinical symptoms such as gait disturbance. The lower FA values in the corpus callosum may offer a clue to solve the pathophysiology of INPH.

Endoscopic surgery for hemorrhagic pineal cyst following antiplatelet therapy: case report.

Pineal cysts of the third ventricle presenting with acute obstructive hydrocephalus due to internal cystic hemorrhage are a rare clinical entity. The authors report a case of a 61-year-old man taking antiplatelet medication who suffered from a hemorrhagic pineal cyst and was treated with endoscopic surgery. One month prior to treatment, the patient was diagnosed with a brainstem infarction and received clopidogrel in addition to aspirin. A small incidental pineal cyst was concurrently diagnosed using magnetic resonance (MR) imaging which was intended to be followed conservatively. The patient presented with a sudden onset of headache and diplopia. On admission, the neurological examination revealed clouding of consciousness and Parinaud syndrome. Computerized tomography (CT) scans demonstrated a hemorrhagic mass lesion in the posterior third ventricle. The patient underwent emergency external ventricular drainage with staged endoscopic biopsy and third ventriculostomy using a flexible videoscope. Histological examination revealed pineal tissue with necrotic change and no evidence of tumor cells. One year later MR imaging demonstrated no evidence of cystic lesion and a flow void between third ventricle and prepontine cistern. In patients with asymptomatic pineal cysts who are treated with antiplatelet therapy, it is important to be aware of the risk of pineal apoplexy. Endoscopic management can be effective for treatment of hemorrhagic pineal cyst with obstructive hydrocephalus.

Relationship between diffusion tensor fractional anisotropy and motor outcome in patients with hemiparesis after corona radiata infarct.

This study examined the relationship between fractional anisotropy (FA) values of magnetic resonance-diffusion tensor imaging (DTI) and motor outcome (1 month after onset) in 15 patients with hemiparesis after ischemic stroke of corona radiata lesions. DTI data were obtained on days 14-18. FA values within the cerebral peduncle were analyzed using a computer-automated method. Motor outcome of hemiparesis was evaluated according to Brunnstrom stage (BRS; 6-point scale: severe to normal) for separate shoulder/elbow/forearm, wrist/hand, and lower extremity functions. The ratio of FA values in the affected hemisphere to those in the unaffected hemisphere (rFA) was assessed in relation to the BRS data (Spearman rank correlation test, P<.05). rFA values ranged from .715 to 1.002 (median=.924). BRS ranged from 1 to 6 (median=4) for shoulder/elbow/forearm, from 1 to 6 (median=5) for wrist/hand, and from 2 to 6 (median=4) for the lower extremities. Analysis revealed statistically significant relationships between rFA and upper extremity functions (correlation coefficient=.679 for shoulder/elbow/forearm and .706 for wrist/hand). Although slightly less evident, the relationship between rFA and lower extremity function was also statistically significant (correlation coefficient=.641). FA values within the cerebral peduncle are moderately associated with the outcome of both upper and lower extremity functions, suggesting that DTI may be applicable for outcome prediction in stroke patients with corona radiata infarct.

Endoscopic third ventriculostomy for hydrocephalus due to unruptured pineal AVM: case report and review of the literature.

INTRODUCTION: Arteriovenous malformations (AVM) are considered to be static congenital lesions; however, a subset may possess dynamic pathophysiological capabilities of growth, regression or other morphological changes with time. We report on an adult patient harboring a pineal AVM who presented with progressive symptoms of obstructive hydrocephalus and was successfully treated by endoscopic third ventriculostomy (ETV). CLINICAL PRESENTATION: This 63-year-old man was incidentally diagnosed 8 years previously with an asymptomatic unruptured pineal AVM and followed conservatively until he developed a progressive impairment in consciousness with gait apraxia and incontinence over a period of 2 months. Magnetic resonance imaging (MRI) revealed obstructive hydrocephalus due to nidal compression at the level of the aqueduct. Treatment by ETV resulted in resolution of neurological deficits and ventriculomegaly without evidence of complications at 18-months follow-up. CONCLUSION: Treatment by ETV in adults with obstructive hydrocephalus due to deep pineal AVMs is a reasonable option in selected cases. A discussion of the pathological mechanisms and therapeutic options for this rare entity is presented.

Relationship between diffusion-tensor fractional anisotropy and long-term outcome in patients with hemiparesis after intracerebral hemorrhage.

We assessed the relationship between fractional anisotropy (FA) values of magnetic resonance-diffusion tensor imaging (DTI) and long-term outcome (3-7 months after onset) in patients with hemiparesis after intracerebral hemorrhage (N = 12). DTI data were obtained on days 14-18. FA values within the cerebral peduncle were analyzed using a computer-automated method. Motor outcome of hemiparesis was evaluated using Brunnstrom stage (six-point scale: severe to normal) for separate shoulder/elbow/forearm, wrist/hand, and lower extremity functions when patients were discharged from a long-term rehabilitation facility 3-7 months after onset. In addition, the motor component of the functional independence measure (FIM-motor) was scored. The ratio of FA values in the affected hemisphere to those in the unaffected hemisphere (rFA) was assessed in relation to the clinical data (Spearman's rank correlation test, P < 0.05). Analysis revealed a statistically significant relationship between rFA and upper extremity function (R = 0.863 for shoulder/elbow/forearm; 0.834 for wrist/hand). Although statistically significant, the relationship between rFA and lower extremity function was less evident (R = 0.609). In contrast, analysis of rFA and FIM-motor scores did not reveal statistical significance. FA values within the cerebral peduncle are tightly associated with long-term outcomes of upper extremity function.

Hemorrhagic colloid cyst with intraventricular extension.

Colloid cysts of the third ventricle presenting with acute obstructive hydrocephalus due to intracystic and intraventricular hemorrhage are extremely rare. The authors report a case of a 43-year-old man with a hemorrhagic colloid cyst that was treated using endoscopic surgery. A small colloid cyst of the third ventricle was initially diagnosed in the patient, and he was treated conservatively at that time. On admission to the authors' institution he presented with sudden headache onset without neurological deficits. Computed tomography and MRI demonstrated a round hemorrhagic mass lesion in the third ventricle with bilateral intraventricular hemorrhage. Endoscopic resection was performed using a flexible videoscope. Only partial removal of the cyst was performed because of a tough cyst wall with highly viscous, hemorrhagic cystic contents. Histological examination revealed a typical colloid cyst wall and hemorrhage mixed within a mucinous substance. Postoperative serial neuroimaging demonstrated a gradual reduction in the residual cyst size and normalization in the lateral ventricle size.

Diffusion tensor imaging for intracerebral hemorrhage outcome prediction: comparison using data from the corona radiata/internal capsule and the cerebral peduncle.

BACKGROUND: Magnetic resonance-diffusion tensor imaging (DTI) was used to predict motor outcome for patients with intracerebral hemorrhage. We compared the predictive accuracy of data sampled from the cerebral peduncle with data from the corona radiata/internal capsule. This study included 32 subjects with thalamic or putaminal hemorrhage or both. METHODS: DTI data were obtained on days 14 to 18. Mean values of fractional anisotropy (FA) within the cerebral peduncle and the corona radiata/internal capsule were analyzed using a computer-automated method. Applying ordinal logistic regression analyses, the ratios between FA values in the affected and unaffected hemisphere (rFA) were modeled in relation to motor outcome scores at 1 month after onset, assessed using the Medical Research Council (MRC) scale (0 = null to 5 = full). RESULTS: For both cerebral peduncle and corona radiata/internal capsule, the relationships between rFA and MRC matched logistic probabilities. While cerebral peduncle rFA values had statistically significant relationships with MRC scores (upper extremity R(2) = 0.271; lower extremity R(2) = 0.191), rFA values for the corona radiata/internal capsule showed less significant relationships (upper extremity R(2) = 0.085; lower extremity R(2) = 0.080). When estimated cerebral peduncle rFA values were <0.7, estimated probability of MRC 0 to 2 was close to 85% for the upper and 60% for the lower extremities. Meanwhile, when estimated rFA values were >0.9, estimated probability for MRC 4 to 5 nearly equaled 50% for the upper and 60% for the lower extremities. CONCLUSIONS: FA values from within the cerebral peduncle more accurately predicted motor outcome and is a promising technique for clinical application.