Association of mild kidney dysfunction with silent brain lesions in neurologically normal subjects.

BACKGROUND: Chronic kidney disease (CKD) has been closely associated with stroke. Although a large number of studies reported the relationship between CKD and different types of asymptomatic brain lesions, few comprehensive analyses have been performed for all types of silent brain lesions. METHODS: We performed a cross-sectional study involving 1,937 neurologically normal subjects (mean age 59.4 years). Mild CKD was defined as an estimated glomerular filtration rate between 30 and 60 ml/min/1.73 m(2) or positive proteinuria. RESULTS: The prevalence of mild CKD was 8.7%. Univariate analysis revealed an association between CKD and all silent brain lesions, including silent brain infarction, periventricular hyperintensity, subcortical white matter lesion, and microbleeds, in addition to hypertension and diabetes mellitus after adjusting for age and sex. In binary logistic regression analysis, the presence of CKD was a significant risk factor for all types of silent brain lesions, independent of other risk factors. CONCLUSIONS: These results suggest that mild CKD is independently associated with all types of silent brain lesions, even in neurologically normal subjects.

A discrepancy between clinical course and magnetic resonance imaging in a case of non-herpetic acute limbic encephalitis.

We report the case of a 64-year old man who presented memory disturbance, low-grade fever, weight loss, and bilateral hand tremors for three months. He was diagnosed with non-herpetic acute limbic encephalitis (NHALE). Follow-up magnetic resonance imaging (MRI) revealed new lesions after symptomatic improvement following steroid pulse therapy. This may indicate that there is a time lag between the disturbance or recovery of neurons and astrocytes. Thus, other lesions might occasionally appear during convalescence in patients with NHALE, even if only minimal lesions were found on the initial MRI.

The effect of ropinirole on apathy and depression after herpes encephalitis.

We describe a 76-year-old man with herpes encephalitis whose symptom of severe apathy was improved by the dopamine D2/D3 receptor agonist ropinirole. Brain magnetic resonance imaging had shown lesions in the patient's right mesial temporal cortex, right insula, and bilateral medial frontal regions. During treatment with acyclovir, he had developed severe apathy and depression. On neuropsychological assessment, he scored 21/30 points on the Mini-Mental State Examination, 30/42 on the Starkstein Apathy Scale (cutoff score =16), and 59/80 on the Zung Self-Rating Depression Scale (cutoff score=40). We then started him on ropinirole 0.25 mg/day. Over the next 10 days, his apathy and depression gradually improved. On day 10 of treatment, follow-up testing showed that his Apathy Scale score had improved to 25 points. This case suggests that a low dose of a dopamine receptor agonist may be an effective treatment for patients who develop apathy and depression after encephalitis.

Cerebral embolism associated with left atrial myxoma that was treated with thrombolytic therapy.

We present a case of cerebral embolism associated with a left atrial myxoma that was treated with intravenous thrombolytic therapy. A 79-year-old right-handed man with no history of neurological or psychiatric illnesses was referred to our hospital because of confusion. He had been self-supported in the activity of daily living and could enjoy gardening until just before his admission. He had aphasia, left conjugate deviation, right hemiparesis, and right pathological reflexes. His NIHSS score was 24. Cranial DWI showed hyperintense lesions in the left middle cerebral artery territory, and MRA revealed left middle cerebral artery occlusion. We started treatment with the recombinant tissue plasminogen activator alteplase intravenously 3 h after the onset. However, the therapy was ineffective, and the NIHSS score was 25 on the second day. A transthoracic echocardiogram and heart MRI showed a left atrial myxoma. However, surgery was contraindicated because of the patient's poor general condition. Although intravenous recombinant tissue plasminogen activator is a reasonable treatment for stroke patients, even with a cardiac myxoma, we cannot always expect good effects, especially if the emboli are parts of the tumor itself. In this case, we could not perform an endovascular mechanical embolectomy; however, we speculate that mechanical embolus retrieval in cerebral ischemia might be effective in such cases.

Successful treatment of post-stroke apathy by the dopamine receptor agonist ropinirole.

Dopamine D2/3 receptor agonists have been widely used to treat motor symptoms in Parkinson's disease and are also reported to improve cognitive and emotional disturbances. Here we describe a patient who developed severe apathy after cerebral infarction in the prefrontal cortex. After administration of ropinirole, his verbal output and spontaneity in daily life was improved remarkably. This improvement was associated with increased blood flow in the prefrontal cortex and basal ganglia. We suggest that ropinirole may be a treatment option for deficits in motivated behavior after prefrontal damage.

[Efficacy of tissue plasminogen activator in older patients].

AIM: To evaluate the efficacy, outcome, and side effects of tissue plasminogen activator for cerebral infarction in patients aged 75 years or older. METHODS: Subjects consisted of 30 patients who had been treated with tissue plasminogen activator between October, 2005 and March 2009, in Shimane University Hospital. We divided the patients into two groups: those less than 75 years old and those 75 years old and older, and evaluated the pattern of disease, therapeutic efficacy, side effects of bleeding, and factors affecting the modified Rankin Scale on discharge. RESULTS: There was no significant difference between groups in the improvement level of NIH Stroke Scale (p=0.66), but modified Rankin Scale 2 or lower patients on discharge were significantly fewer (p=0.02). Multivariate analysis found that age was a factor in significant outcome deterioration (p=0.04, OR1.2). In the older patient group, there were significantly more unfavorable outcomes with anterior infarction. However, there was no significant difference between groups in outcome in patients with ASPECTS-DWI (Alberta Stroke Programme Early CT Score-Diffusion Weight Imaging) > or =8. There was no difference in the rate of hemorrhagic side effect between the two groups. CONCLUSION: We can expect effects similar to those in patients younger than 75 years if the ischemic lesions of older patients are narrow when coming to the hospital.

[A case of probable cytomegalovirus encephalitis who restored from persistant disturbance of consciousness].

A 50-year-old woman presented with confusion, fever and drowsiness following an episode of headache and dizziness. On admission, neurological examination found positive pyramidal tract signs, meningeal irritation, and bilateral myoclonus in her arms. Laboratory tests revealed liver dysfunction, positive inflammatory reaction, elevated serum IgM antibody against cytomegalovirus, and increased cerebrospinal fluid protein of 67 mg/dl. MRI of brain by diffusion weighted imaging showed a wide spread hyperintense lesion in white matter and limbic areas. We administered aciclovir, ganciclovir and steroid pulse therapy that showed a limited effect in the initial stage. In spite of all these therapies, she suffered from status epilepticus, followed by persistent disturbance of consciousness for about 2 months. However, her level of consciousness and motor deficit were gradually improved by continuous administration of ganciclovir. The present case indicates that prolonged disturbance of consciousness due to cytomegalovirus encephalitis could be restored with continuous ganciclovir administration.

Somatosensory disinhibition and frontal alien hand signs following medial frontal damage.

We report augmentation of somatosensory evoked potentials (SEP) in a patient with frontal alien hand signs after left medial frontal lobe damage. The SEP components occurring later than 30 msec post stimuli were enhanced over the parietal and frontal scalp sites of the lesioned hemisphere. This finding suggests that deficits in inhibitory control of somatosensory processing in parietal and frontal lobes contributes in some way to frontal alien hand signs.

Effect of one-shot intravenous 0.42 mega unit urokinase therapy in patients with acute ischemic stroke.

We evaluated the efficacy of intravenous (IV) urokinase (UK) treatment for acute ischemic stroke patients. We treated 45 patients with 0.42 mega units of IV UK and 201 patients with other conventional agents. Clinical severity and outcome were evaluated using National Institutes of Health Stroke Scale (NIHSS) scores and modified Rankin scale (mRS). We defined clinical improvement as a reduction of NIHSS score of > 4 points between admission and discharge. The rate of improvement, as defined earlier, was significantly higher in the UK group (27/45; 60%) than in the non-UK group (67/201, 33%) (P = .0009; chi(2) test). The rate of mRS 0-2 (good outcome) on discharge in the UK group (28/45; 62%) was slightly (but not significantly) higher than that in the non-UK group (99/201; 49%). Baseline characteristics, including risk factors, did not differ between the 2 groups, except for time to treatment and length of hospitalization. We conclude that treatment of acute ischemic stroke patients with 0.42 mega units of IV UK shows better clinical improvement than conventional therapy.

Silent brain infarction and subcortical white matter lesions increase the risk of stroke and mortality: a prospective cohort study.

Silent brain infarction (SBI) and white matter lesions (periventricular hyperintensity [PVH] and subcortical white matter lesions [SWML] are detected in both stroke patients and normal elderly persons. We prospectively examined the association between these lesions and the risk of subsequent stroke and mortality in neurologically normal adults. Magnetic resonance imaging scans were performed in 2,684 neurologically normal subjects with no history of stroke (mean age, 58 +/- 7 years old at entry) who underwent our health screening of the brain. After the brain screening, we obtained information about clinical stroke onset and death using a questionnaire sent annually to all subjects. When a subject suffered from medical events, we confirmed the detailed information in a telephone interview and by asking the attending physician. SBI was defined as a focal T2-hyperintensity and T1-hypointensity lesion > 3 mm. PVH and SWML were graded according to their severity. The average follow-up period was 6.3 years. Stroke occurred in 102 subjects (3.8%), and 93 subjects died during follow-up. The incidence of clinical stroke was significantly higher in the subjects with SBI than in those without SBI. Marked PVH and marked SWML independently increased the risk of stroke (for SBI, stroke risk factor-adjusted odds ratio [OR] = 3.66, 95% confidence interval [CI] = 2.28-5.89; for marked PVH, stroke risk factor-adjusted OR = 2.08, 95% CI = 1.04-4.17; for marked SWML, stroke risk factor-adjusted OR = 2.73, 95% CI = 1.32-5.63). Regarding mortality, SBI and marked PVH increased the risk of death (for SBI, stroke risk factor-adjusted OR = 1.95, 95% CI = 1.16-3.29; for PVH, stroke risk factor-adjusted OR = 4.01, 95% CI = 1.91-8.45). Death attributable to stroke occurred more frequently in those subjects with SBI, marked PVH, and marked SWML. We conclude that SBI, marked PVH, and marked SWML are important risk factors for clinical stroke and that SBI and marked PVH also increase the risk of mortality.

Electroencephalographic activity in a flanker interference task using Japanese orthography.

The neural activities for color word interference effects were investigated using event-related brain potentials (ERPs) recorded in a flanker-type interference task. Kanji words (Japanese morphograms) and kana words (Japanese phonograms) were used as the flanker stimuli to obtain insights about hemispheric specialization for processing two types of Japanese orthographies. Interference effects in reaction time were larger when kanji words were presented in the left visual field and when kana words were in the right visual field. ERPs were modulated by the incongruent flankers, which generated a negative ERP component with the different onset and offset depending on flanker attributes. Consistent with the behavioral data, the interference-related negativity was observed for kanji words presented in the left visual field and for kana words in the right visual field. The negativity distributed maximally over the fronto-central site. The early part of the negativity distributed strongly over the frontal midline area, whereas it extended bilaterally over the frontal area in the late phase. The present results support the view of preferential processing of kanji in the right hemisphere and that of kana in the left hemisphere. The temporal profile of scalp topographies for the interference-related neural activity suggests that the medial and dorsolateral prefrontal regions may be involved in maintaining attentional set and conflict resolution.