Hypoplastic Left Atrial Appendage: A Case Report and Literature Review.

BACKGROUND The left atrial appendage (LAA) has considerable variations in its size, shape, and spatial relationship with other cardiac structures. Absence of the LAA is a congenital cardiac condition usually identified by an imaging modality intended for other purposes. Absence of the LAA has been described in a total of 19 case reports so far; however, no cases of "hypoplastic" LAA in a real sense have ever been reported. CASE REPORT We herein report a case of hypoplastic, but not truly absent, LAA in a 76-year-old man scheduled for catheter ablation against atrial flutter. Preprocedural transesophageal echocardiography (TEE) performed in this patient to exclude intracardiac thrombosis failed to detect the LAA, although Doppler color-flow mapping revealed a jet signal spewed out into the main LA around where the LAA would be located. The LAA was also not detectable by routinely developed tomographic images from computed tomography (CT) angiography. Eventually, however, the multiplanar reconstruction into 3-dimensional volume rendering via the CT angiography identified a very small LAA. Those findings by TEE and CT led to a diagnosis of hypoplastic LAA. CONCLUSIONS Hypoplastic LAA should be kept in mind when considering LAA interventions as well as anticoagulation treatment. Multiple imaging modalities are necessary to recognize morphological aberration of the LAA.

The Effect of Monaural Auditory Stimulus on Hand Selection When Reaching.

This study investigated the effect of monaural auditory stimulus on hand selection when reaching. Healthy right-handed participants were asked to reach to a visual target and were free to use either the right or left hand. A visual target appeared at one of 11 positions in the visual field between -25 and 25 degrees of the horizontal visual angle. An auditory stimulus was given either in the left or right ear 100 ms after the presentation of the visual target, or no auditory stimulus was given. An auditory stimulus in the right ear increased right hand selection, and that in the left ear slightly increased left hand selection when reaching to a target around the midline of the visual field. The horizontal visual angle, where the probabilities of right hand selection and left hand selection were equal when reaching, shifted leftward when an auditory stimulus was given in the right ear, but the angle did not shift in either direction when an auditory stimulus was given in the left ear. The right-ear-dominant auditory stimulus effect on hand selection indicates hemispheric asymmetry of cortical activity for hand selection.

Corticospinal Excitability in the Hand Muscles is Decreased During Eye Movement with Visual Occlusion.

Corticospinal excitability in the hand muscles decreases during smooth pursuit eye movement. The present study tested a hypothesis that the decrease in corticospinal excitability in the hand muscles at rest during eye movement is not caused by visual feedback but caused by motor commands to the eye muscles. Healthy men (M age = 28.4 yr., SD = 5.2) moved their eyes to the right with visual occlusion (dark goggles) while their arms and hands remained at rest. The motor-evoked potential in the hand muscles was suppressed by 19% in the third quarter of the eye-movement period, supporting a view that motor commands to the eye muscles are the cause of the decrease in corticospinal excitability in the hand muscles. The amount of the suppression was not significantly different among the muscles, indicating that modulation of corticospinal excitability in one muscle induced by eye movement is not dependent on whether eye movement direction and the direction of finger movement when the muscle contracts are identical. Thus, the finding failed to support a hypothetical view that motor commands to the eye muscles concomittantly produce motor commands to the hand muscles. Moreover, the amount of the suppression was not significantly different between the forearm positions, indicating that the suppression was not affected by proprioception of the forearm muscles when visual feedback is absent.

Corticospinal Modulations during Bimanual Movement with Different Relative Phases.

The purpose of this study was to investigate corticospinal modulation of bimanual (BM) movement with different relative phases (RPs). The participants rhythmically abducted and adducted the right index finger (unimanual (UM) movement) or both index fingers (BM movement) with a cyclic duration of 1 s. The RP of BM movement, defined as the time difference between one hand movement and the other hand movement, was 0°, 90°, or 180°. Motor evoked potentials (MEPs) in the right flexor dorsal interosseous muscle elicited by transcranial magnetic stimulation (TMS) were obtained during UM or BM movement. Corticospinal excitability in the first dorsal interosseous muscle during BM movement with 90° RP was higher than that during UM movement or BM movement with 0° or 180° RP. The correlation between muscle activity level and corticospinal excitability during BM movement with 90° RP was smaller than that during UM movement or BM movement with 0° or 180° RP. The higher corticospinal excitability during BM movement with 90° RP may be caused by the greater effort expended to execute a difficult task, the involvement of interhemispheric interaction, a motor binding process, or task acquisition. The lower dependency of corticospinal excitability on the muscle activity level during BM movement with 90° RP may reflect the minor corticospinal contribution to BM movement with an RP that is not in the attractor state.

Time and direction preparation of the long latency stretch reflex.

This study investigated time and direction preparation of motor response to force load while intending to maintain the finger at the initial neutral position. Force load extending or flexing the index finger was given while healthy humans intended to maintain the index finger at the initial neutral position. Electromyographic activity was recorded from the first dorsal interosseous muscle. A precue with or without advanced information regarding the direction of the forthcoming force load was given 1000ms before force load. Trials without the precue were inserted between the precued trials. A long latency stretch reflex was elicited by force load regardless of its direction, indicating that the long latency stretch reflex is elicited not only by muscle stretch afferents, but also by direction-insensitive sensations. Time preparation of motor response to either direction of force load enhanced the long latency stretch reflex, indicating that time preparation is not mediated by afferent discharge of muscle stretch. Direction preparation enhanced the long latency stretch reflex and increased corticospinal excitability 0-20ms after force load when force load was given in the direction stretching the muscle. These enhancements must be induced by preset of the afferent pathway mediating segmental stretch reflex.

Monaural Auditory Cue Affects the Process of Choosing the Initial Swing Leg in Gait Initiation.

The authors investigated the effect of an auditory cue on the choice of the initial swing leg in gait initiation. Healthy humans initiated a gait in response to a monaural or binaural auditory cue. When the auditory cue was given in the ear ipsilateral to the preferred leg side, the participants consistently initiated their gait with the preferred leg. In the session in which the side of the monaural auditory cue was altered trial by trial randomly, the probability of initiating the gait with the nonpreferred leg increased when the auditory cue was given in the ear contralateral to the preferred leg side. The probability of choosing the nonpreferred leg did not increase significantly when the auditory cue was given in the ear contralateral to the preferred leg side in the session in which the auditory cue was constantly given in the ear contralateral to the preferred leg side. The reaction time of anticipatory postural adjustment was shortened, but the probability of choosing the nonpreferred leg was not significantly increased when the gait was initiated in response to a binaural auditory cue. An auditory cue in the ear contralateral to the preferred leg side weakens the preference for choosing the preferred leg as the initial swing leg in gait initiation when the side of the auditory cue is unpredictable.

The effect of tonic contraction of the finger muscle on the motor cortical representation of the contracting adjacent muscle.

This study examined the effect of tonic contraction of the finger muscle on the motor cortical representation of the contracting adjacent muscle. A representation map of the motor evoked potential (MEP) in the first dorsal interosseous (FDI) and abductor digiti minimi (ADM) muscles was obtained with the subject at rest or during tonic contraction of the ADM muscle while the FDI muscle was tonically contracted. The center of gravity (COG) of the MEP map in the FDI muscle shifted medially during contraction of the ADM muscle. Motor cortical excitability in the motor cortical representation of the FDI muscle that did not overlap with the motor cortical representation of the ADM muscle was suppressed, but motor cortical excitability in the motor cortical representation of the FDI muscle overlapping with the motor cortical representation of the ADM muscle was not suppressed during contraction of the ADM muscle. The motor cortical representation of the FDI muscle not overlapping with the motor cortical representation of the ADM muscle was located lateral to that of the FDI muscle that did overlap with the motor cortical representation of the ADM muscle. Medial shift of the COG of the motor cortical representation of the contracting finger muscle induced by tonic contraction of the adjacent finger muscle must be due to suppression of motor cortical excitability in the lateral part of the representation, which is not shared by the adjacent representation.

Asymmetry of anticipatory postural adjustment during gait initiation.

The purpose of this study was to investigate the asymmetry of anticipatory postural adjustment (APA) during gait initiation and to determine whether the process of choosing the initial swing leg affects APA during gait initiation. The participants initiated gait with the leg indicated by a start tone or initiated gait with the leg spontaneously chosen. The dependent variables of APA were not significantly different among the condition of initiating gait with the preferred leg indicated by the start tone, the condition of initiating gait with the non-preferred leg indicated by the start tone, and the condition of initiating gait with the leg spontaneously chosen. These findings fail to support the view that the process of choosing the initial swing leg affects APA during gait initiation. The lateral displacement of the center of pressure in the period in which shifting the center of pressure to the initial swing phase before initiating gait with the left leg indicated by the external cue was significantly larger than that when initiating gait with the right leg indicated by the external cue, and significantly larger than that when initiating gait with the leg spontaneously chosen. Weight shift to the initial swing side during APA during gait initiation was found to be asymmetrical when choosing the leg in response to an external cue.

Bimanual coordination of force enhances interhemispheric inhibition between the primary motor cortices.

The purpose of this study was to elucidate whether bimanual coordination of force affects interhemispheric inhibition (IHI) between the primary motor cortices (M1s). IHI with the index fingers isometrically abducted against a fixed plate (AAP task) was compared with IHI with the index fingers isometrically abducted against each other (AAF task). The index fingers were held stationary at the midline and activity levels of the first dorsal interosseous muscles were equalized between the tasks. The abduction force of each index finger was individually controlled during the AAP task, and bimanually coordinated during the AAF task. IHI during the AAF task was significantly higher than that during the AAP task. IHI between the M1s is related not only to the suppression of unwanted activity of the M1 contralateral to the active M1 but also to bimanual coordination of force.

Different corticospinal control between discrete and rhythmic movement of the ankle.

We investigated differences in corticospinal and spinal control between discrete and rhythmic ankle movements. Motor evoked potentials (MEPs) in the tibialis anterior and soleus muscles and soleus H-reflex were elicited in the middle of the plantar flexion phase during discrete ankle movement or in the initial or later cycles of rhythmic ankle movement. The H-reflex was evoked at an intensity eliciting a small M-wave and MEPs were elicited at an intensity of 1.2 times the motor threshold of the soleus MEPs. Only trials in which background EMG level, ankle angle, and ankle velocity were similar among the movement conditions were included for data analysis. In addition, only trials with a similar M-wave were included for data analysis in the experiment evoking H-reflexes. Results showed that H reflex and MEP amplitudes in the soleus muscle during discrete movement were not significantly different from those during rhythmic movement. MEP amplitude in the tibialis anterior muscle during the later cycles of rhythmic movement was significantly larger than that during the initial cycle of the rhythmic movement or during discrete movement. Higher corticospinal excitability in the tibialis anterior muscle during the later cycles of rhythmic movement may reflect changes in corticospinal control from the initial cycle to the later cycles of rhythmic movement.