Akihiro Yugeta

Effects of STN stimulation on the initiation and inhibition of saccade in Parkinson disease

Objectives: The basal ganglia (BG) play an important role in controlling saccades. Deep brain stimulation (DBS) of the subthalamic nucleus (STN) is widely used as a treatment of Parkinson disease (PD) by altering the function of the BG. Nevertheless, the effects of STN DBS on saccade performance are not fully clarified in a systematic manner. In this study, we examined the effects of bilateral STN DBS on both the initiation and inhibition of saccades in PD. Methods: Thirty-two patients with PD performed 4 oculomotor tasks. Two tasks (visually guided saccades and gap saccades) were reflexive and 2 (memory-guided saccades [MGS] and antisaccades) were volitional. While taking their regular doses of antiparkinsonian drugs, patients performed these tasks under 2 conditions: during DBS (DBS-on condition) and without DBS (DBS-off condition). Fifty-one age-matched subjects served as controls. Results: In the DBS-on condition, parameters of saccade initiation were improved in all tasks, with shorter latencies and increased amplitudes, except for MGS latency. STN DBS improved the ability to suppress unwanted saccades to the cue stimulus in the MGS task. However, it did not suppress prosaccades during the antisaccade task. Conclusions: These results suggest that deep brain stimulation (DBS) of the subthalamic nucleus (STN) affects the neural pathway common to both reflexive and volitional saccades, possibly by acting on the STN–substantia nigra pars reticulata–superior colliculi pathway. STN DBS may set the functional level of the superior colliculi appropriate for both saccade initiation and inhibition through this pathway. These findings provide novel insights into the pathophysiology of Parkinson disease and may yield better treatment strategies.

Origin of facilitation in repetitive, 1.5 ms interval, paired pulse transcranial magnetic stimulation (rPPS) of the human motor cortex

OBJECTIVE Repetitive paired-pulse TMS (rPPS) given at an interstimulus interval (ISI) of 1.5 ms has been reported to induce a lasting motor evoked potential (MEP) facilitation. This after-effect was considered to be a cortical event because F-waves were not affected by the same rPPS. To confirm its cortical facilitation, we compared the after-effects of rPPS on MEPs to single pulse TMS over the motor cortex (motor cortical MEPs) with those to brainstem stimulation (brainstem MEPs). METHODS Subjects were 10 healthy volunteers. Suprathreshold paired-pulse TMS at an ISI of 1.5 ms was applied to the motor cortex for 30 min at a rate of 0.2 Hz. After intervention, we measured motor cortical MEPs for 30 min. We also studied brainstem MEPs in five subjects. RESULTS Motor cortical MEPs were facilitated to about 190% of baseline (p<0.001) for 10 min post rPPS intervention and returned to the baseline at 10-15 min post intervention. Brainstem MEPs were not affected by the intervention. CONCLUSIONS The facilitation of MEPs after rPPS at an interval of 1.5 ms occurs at the motor cortex. SIGNIFICANCE rPPS at an interval of 1.5 ms is an effective method for increasing motor cortical excitability.

Difference in intracortical inhibition of the motor cortex between cortical myoclonus and focal hand dystonia

OBJECTIVE The short interval intracortical inhibition (SICI) of the motor cortex (M1) is reduced in both cortical myoclonus and focal hand dystonia. This reduction has been attributed to the dysfunction of GABAergic system within the motor cortex. However, the precise mechanisms underlying the reduction may not be entirely identical in these two disorders, being due to primary pathological involvement in M1 or secondary to functional changes outside M1. The aim of this study was to elucidate possible differences in intracortical inhibition between these two disorders. METHODS Subjects were 11 patients with benign myoclonus epilepsy, 7 with focal hand dystonia, and 11 normal volunteers. We studied SICI using anterior-posterior (AP) directed and posterior-anterior (PA) directed induced currents in the brain. RESULTS In both disorders, SICI with PA-directed currents was reduced as reported previously. In contrast, SICI studied with AP currents was normal in patients with focal hand dystonia, but reduced in patients with cortical myoclonus. CONCLUSIONS The difference between the two disorders might reflect the underlying pathological difference. In cortical myoclonus, the inhibitory interneurons of the motor cortex are affected, whereas the same interneurons are intact in dystonia. The difference in SICI induced by AP and PA directed currents in dystonia may be explained by the following possibilities: the difference in composition of I-waves contributing to EMG generation and the difference in modulation of the interneuronal activity by voluntary contraction. These changes may be secondary to dysregulation of the motor cortex by the basal ganglia or related cortices in dystonia. SIGNIFICANCE The SICI using AP directed currents together with the conventional SICI using PA directed currents was able to demonstrate some difference in the intrinsic circuits of M1 between myoclonus and focal hand dystonia. SICI using AP directed currents can provide additional information about the motor cortical excitability changes over those obtained by the previously reported methods.

Small saccades restrict visual scanning area in Parkinson's disease.

The purpose of this study was to investigate abnormalities in visual scanning when Parkinsons disease patients view images of varying complexity. Eighteen nondemented Parkinsons disease patients and 18 normal subjects participated in the study. The ocular fixation position during viewing visual images was recorded using an eye‐tracking device. The number of saccades, duration of fixation, amplitude of saccades, and scanned area in Parkinsons disease patients were compared with those in normal subjects. We also investigated whether the number of saccades, duration of fixation, or amplitude of saccades influenced the scanned area. While scanning images of varying complexity, Parkinsons disease patients made fewer saccades with smaller amplitude and longer fixation compared with normal subjects. As image complexity increased, the number of saccades and duration of fixation gradually approached those of normal subjects. Nevertheless, the scanned area in Parkinsons disease patients was consistently smaller than that in normal subjects. The scanned area significantly correlated with saccade amplitude in most images. Importantly, although Parkinsons disease patients cannot make frequent saccades when viewing simple figures, they can increase the saccade number and reduce their fixation duration when viewing more complex figures, making use of the abundant visual cues in such figures, suggesting the existence of ocular kinesie paradoxale. Nevertheless, both the saccade amplitude and the scanned area were consistently smaller than those of normal subjects for all levels of visual complexity. This indicates that small saccade amplitude is the main cause of impaired visual scanning in Parkinsons disease patients.

Magnetic stimulation of the cauda equina in the spinal canal with a flat, large round coil.

Magnetic round coil stimulation over the spinal enlargement activates the spinal nerves at the neuro-foramina level. However, activation of the cauda equina in the spinal canal has never been described in the literature. This study, for which 40 healthy subjects were recruited, activated the cauda equina using a round 20-cm-diameter coil designated as a Magnetic Augmented Translumbosacral Stimulation (MATS) coil. Magnetic stimulation placing the edge of the coil over the L1 and L3 spinous processes elicited compound muscle action potentials (CMAPs) from the abductor hallucis muscle. The CMAPs were compared with those elicited through high-voltage electrical stimulation. The CMAP latencies to L1 level MATS coil stimulation were not significantly different from those evoked by electrical stimulation at the same level. The CMAP latencies to L3 level MATS coil stimulation were varied in each subject. In fact, the L1 level MATS coil stimulation is considered to activate the cauda equina at the root exit site from the conus medullaris; the L3 level MATS coil stimulation activates some mid-part of the cauda equina or the distal cauda equina by spreading current. The MATS coil facilitates evaluation of spinal nerve conduction in the cauda equina.

Magnetic lumbosacral motor root stimulation with a flat, large round coil

OBJECTIVE The aim of this paper is to develop a reliable method for supramaximal magnetic spinal motor root stimulation (MRS) for lower limb muscles using a specially devised coil. METHODS For this study, 42 healthy subjects were recruited. A 20-cm diameter coil designated as a Magnetic Augmented Translumbosacral Stimulation (MATS) coil was used. Compound muscle action potentials (CMAPs) were recorded from the abductor hallucis muscle. Their CMAPs were compared with those obtained by MRS using a conventional round or double coil and with those obtained using high-voltage electrical stimulation. RESULTS The MATS coil evoked CMAPs to supramaximal stimulation in 80 of 84 muscles, although round and double coils elicited supramaximal CMAPs in only 15 and 18 of 84 muscles, respectively. The CMAP size to the MATS coil stimulation was the same as that to high-voltage electrical motor root stimulation. CONCLUSIONS MATS coil achieved supramaximal stimulation of the lumbosacral spinal nerves. SIGNIFICANCE The CMAPs to supramaximal stimulation are necessary for measurement of the amplitude and area for the detection of conduction blocks. The MATS coil stimulation of lumbosacral motor roots is a reliable method for measuring the CMAP size from lower limb muscles in spinal motor root stimulation.

Postural tremor in X-linked spinal and bulbar muscular atrophy†

Postural tremor is a common initial symptom in spinal and bulbar muscular atrophy (SBMA), but its pathophysiological mechanisms remain to be studied. This study was undertaken to examine the physiological mechanisms underlying postural tremor in SBMA. For eight patients (36–63 years old) with genetically confirmed SBMA, we recorded surface electromyograms (EMGs) from the forearm muscles and hand movements with an accelerometer (ACC) while maintaining a posture with and without a weight load. We then analyzed their power spectra and coherence. The peak tremor frequency was 6–9 Hz in seven patients and 2–3 Hz in one patient. Oscillatory movements were associated with EMG activity in five patients, but not in three patients. Weight loads and postural changes affected the tremor frequency in all patients. Tremor was classified as “reflex tremor” in five patients and “mechanical tremor” in three patients. These results suggest that peripheral factors play important roles in tremor genesis in SBMA, although its clinical features resemble essential tremor. Subclinical sensory disturbance or a decrease of motor unit numbers might be candidates for such peripheral factors contributing to tremor genesis in SBMA.

Effects of thirty-minute mobile phone exposure on saccades.

OBJECTIVE To investigate whether exposure to pulsed high-frequency electromagnetic field (pulsed EMF) emitted by a mobile phone has short-term effects on saccade performances. METHODS A double blind, counterbalanced crossover design was employed. In 10 normal subjects, we studied the performance of visually guided saccade (VGS), gap saccade (GAP), and memory guided saccade (MGS) tasks before and after exposure to EMF emitted by a mobile phone for thirty minutes or sham exposure. We also implemented a hand reaction time (RT) task in response to a visual signal. RESULTS With the exception of VGS and MGS latencies, the parameters of VGS, GAP and MGS tasks were unchanged before and after real or sham EMF exposure. In addition, the latencies of VGS and MGS did not change differently after real and sham exposure. The hand RT shortened with the repetition of trials, but again this trend was of similar magnitude for real and sham exposures. CONCLUSIONS Thirty minutes of mobile phone exposure has no significant short-term effect on saccade performances. SIGNIFICANCE This is the first study to investigate saccade performance in relation to mobile phone exposure. No significant effect of mobile phone use was demonstrated on the performance of various saccade tasks, suggesting that the cortical processing for saccades and attention is not affected by exposure to EMF emitted by a mobile phone.

Prominent cauda equina involvement in patients with chronic inflammatory demyelinating polyradiculoneuropathy

In chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), it has not been well known which segment of the peripheral nerves, distal or proximal, is more often involved in electrophysiological examination. This study compares nerve conductions at proximal segments with those at distal segments in 11 patients with CIDP. To obtain cauda euqina conduciton time (CECT), compound muscle action potentials (CMAPs) were elicited by magnetic stimulation using a MATS coil from the abductor hallucis muscle. CECT was prolonged in 9 patients (81.8%), whereas the ankle-knee conduction was delayed in 4 (36.4%). The proximal segments are more frequently involved than the distal segments in this disorder.

Is multiple system atrophy with cerebellar ataxia (MSA-C) like spinocerebellar ataxia and multiple system atrophy with parkinsonism (MSA-P) like Parkinson’s disease? – A saccade study on pathophysiology

OBJECTIVE Patients with multiple system atrophy (MSA) are classified into those mainly manifesting cerebellar ataxia (MSA-C) and those mainly manifesting parkinsonism (MSA-P). Pathophysiological bases of these subtypes remain unclear. We hypothesized that MSA-C patients would resemble spinocerebellar degeneration patients and MSA-P patients would resemble Parkinsons disease (PD) patients in saccade abnormalities. METHODS We recorded visually guided and memory guided saccades (MGS) in 27 MSA-C and 15 MSA-P patients, as well as 50 age-matched normal subjects, 14 spinocerebellar degeneration patients showing pure cerebellar symptoms (SCD) and 61 Parkinsons disease (PD) patients. RESULTS Saccade parameters of both tasks showed similar changes with progressing disease in SCD and MSA-C patients, as did those of MSA-C and MSA-P patients, although hypometria was slightly more pronounced in MSA-P. In both subtypes of MSA, latency and success rate of MGS were stable throughout disease stages, whereas they deteriorated progressively with progressing disease in PD. CONCLUSIONS Pathophysiology underlying MSA-C and MSA-P is similar as viewed from saccade performance. The MGS performance in MSA was preserved. However, MSA-P patients showed more marked hypometria, suggesting a mixture of basal ganglia pathophysiology. SIGNIFICANCE The similarity of saccade performance between MSA-C and MSA-P may reflect common olivopontocerebellar pathology, while the direct pathway of the basal ganglia is relatively spared compared with PD, even in MSA-P.