Hyun Im Moon

Ultrasonography of palm to elbow segment of median nerve in different degrees of diabetic polyneuropathy

OBJECTIVE To identify the relationship between the ultrasonographic cross-sectional area (CSA) of the median nerve and electrophysiologic findings in diabetic patients. METHODS Sixty diabetic patients, 30 patients with carpal tunnel syndrome (CTS) and 30 healthy volunteers participated. The participants were divided into 4 groups: Control Group; Group I, diabetic patients without diabetic polyneuropathy (DPN); Group II, diabetic patients with DPN; and Group III, patients with CTS. Group II was subdivided into II-1 and II-2 according to DPN severity. The median nerve CSA was measured at 4 levels, and the wrist-to-forearm ratio (WFR) was calculated. RESULTS The median nerve CSAs were larger in Group II than in Group I and the Control Group. There were significant differences in the CSA between Group I and Group II-2 and between Group II-1 and II-2. There was no significant difference in the WFR among these groups. The CSAs at the wrist levels and WFR were significantly greater in Group III. CONCLUSIONS The median nerve CSA was greater in patients with DPN and was related to DPN severity. Diffuse increase in median nerve CSA without change in the WFR might be compatible with DPN. Ultrasonography could be applied for the diagnosis of DPN, especially in advanced cases. SIGNIFICANCE Ultrasonography might have value in the differential diagnosis of DPN and entrapment neuropathy.

Correlation between Location of Brain Lesion and Cognitive Function and Findings of Videofluoroscopic Swallowing Study

Objective To investigate whether patterns of swallowing difficulties were associated with the location of the brain lesion, cognitive function, and severity of stroke in stroke patients. Method Seventy-six patients with first-time acute stroke were included in the present investigation. Swallowing-related parameters, which were assessed videofluoroscopically, included impairment of lip closure, decreased tongue movement, amount of oral remnant, premature loss of food material, delay in oral transit time, laryngeal elevation, delay in pharyngeal triggering time, presence of penetration or aspiration, and the amount of vallecular and pyriform sinus remnants. The locations of brain lesions were classified into the frontal, parietotemporal, subcortical, medulla, pons, and cerebellum. The degree of cognitive impairment and the severity of stroke were assessed by the Mini Mental Status Examination (MMSE) and the National Institute of Health Stroke Scale (NIHSS), respectively. Results An insufficient laryngeal elevation, the amount of pyriform sinus, and vallecular space remnant in addition to the incidence of aspiration were correlated with medullary infarction. Other swallowing parameters were not related to lesion topology. Lip closure dysfunction, decreased tongue movement, increased oral remnant and premature loss were associated with low MMSE scores. A delayed oral transit time were associated with NIHSS scores. Conclusion In-coordination of the lip, the tongue, and the oropharynx were associated with the degree of cognitive impairment and the stroke severity rather than with the location of the lesion, whereas incomplete laryngeal elevation and aspiration were predominant in medullary lesions.

Sonography of the median nerve in carpal tunnel syndrome with diabetic neuropathy.

ObjectiveThe aim of this study was to determine the criteria for ultrasonographic measurement of the cross-sectional area (CSA) of the median nerve and differential diagnosis of patients with carpal tunnel syndrome (CTS) with or without diabetic polyneuropathy (DPN). DesignOne hundred eighty-seven patients were divided into five groups: healthy controls, CTS, diabetes with CTS but without DPN, DPN only, and both DPN and CTS. The CSAs of the median nerve were measured at four levels, and cutoff values to diagnose CTS with DPN were obtained. ResultsAll the CSAs were larger in the DPN group compared with those in the control group. The CSAs of the median nerve at the wrist revealed no significant differences among the groups with CTS; however, these groups demonstrated larger CSAs at the wrist and a higher wrist/forearm ratio compared with the DPN only group. The cutoff value for the CSA at the wrist that yielded the highest sensitivity and specificity was 11.6 mm. ConclusionsThe CSA of the median nerve at the wrist and the wrist/forearm ratio could be useful for diagnosing the comorbidity of CTS with DPN.

Neural substrates of lower extremity motor, balance, and gait function after supratentorial stroke using voxel-based lesion symptom mapping

IntroductionStroke impairs motor, balance, and gait function and influences activities of daily living. Understanding the relationship between brain lesions and deficits can help clinicians set goals during rehabilitation. We sought to elucidate the neural substrates of lower extremity motor, balance, and ambulation function using voxel-based lesion symptom mapping (VLSM) in supratentorial stroke patients.MethodsWe retrospectively screened patients who met the following criteria: first-ever stroke, supratentorial lesion, and available brain magnetic resonance imaging (MRI) data. MRIs of 133 stroke patients were selected for VLSM analysis. We generated statistical maps of lesions related to lower extremity motor (lower extremity Fugl-Meyer assessment, LEFM), balance (Berg Balance Scale, BBS), and gait (Functional Ambulation Category, FAC) using VLSM.ResultsVLSM revealed that lower LEFM scores were associated with damage to the bilateral basal ganglia, insula, internal capsule, and subgyral white matter adjacent to the corona radiata. The lesions were more widely distributed in the left than in the right hemisphere, representing motor and praxis function necessary for performing tasks. However, no associations between lesion maps and balance and gait function were established.ConclusionMotor impairment of the lower extremities was associated with lesions in the basal ganglia, insula, internal capsule, and white matter adjacent to the corona radiata. However, VLSM revealed no specific lesion locations with regard to balance and gait function. This might be because balance and gait are complex skills that require spatial and temporal integration of sensory input and execution of movement patterns. For more accurate prediction, factors other than lesion location need to be investigated.

Sonography of Carpal Tunnel Syndrome According to Pathophysiologic Type: Conduction Block Versus Axonal Degeneration: Sonography of Carpal Tunnel Syndrome According to Pathophysiologic Type

The purpose of this study was to investigate sonographic findings according to the pathophysiologic type in patients with carpal tunnel syndrome.

Lesion location associated with balance recovery and gait velocity change after rehabilitation in stroke patients

PurposeImpaired gait function after stroke contributes strongly to overall patient disability. However, the response to rehabilitation varies between individuals. The aims of this study were to identify predictors of gait velocity change and to elucidate lesion location associated with change of balance and gait function.MethodsWe reviewed 102 stroke patients. The patients were divided into two groups according to gait ability post-rehabilitation, and we analyzed differences in their characteristics, such as demographic information, lesion factors, and initial balance function. Multivariate regression analyses were performed to examine the predictors of rehabilitation response. Lesion location and volume were measured on brain magnetic resonance images. We generated statistical maps of the lesions related to functional gains in gait and balance using voxel-based lesion symptom mapping (VLSM).ResultsThe group of patients who regained independent ambulation function showed a smaller lesion size, a shorter duration from stroke onset, and higher initial balance function. In the regression model, gait velocity changes were predicted with the initial Berg balance scale (BBS) and duration post-onset. Absolute BBS changes were also correlated with the duration post-onset and initial BBS, and relative BBS changes were predicted by the baseline BBS. Using VLSM, lesion locations associated with gait velocity changes and balance adjusting for other factors were the insula, internal capsule, and adjacent white matter.ConclusionInitial balance function as well as the interval between stroke onset and the initiation of therapy might influence balance recovery and gait velocity changes. Damage to the insula and internal capsule also affected gait velocity change after rehabilitation.

Lesions Responsible for Delayed Oral Transit Time in Post-stroke Dysphagia

IntroductionSome stroke patients show oral phase dysphagia, characterized by a markedly prolonged oral transit time that hinders oral feeding. The aim of this study was to clarify the clinical characteristics and lesions responsible for delayed swallowing.MethodsWe reviewed 90 patients with stroke. The oral processing time plus the postfaucial aggregation time required to swallow semisolid food was assessed. The patients were divided into two groups according to oral transit time, and we analyzed the differences in characteristics such as demographic factors, lesion factors, and cognitive function. Logistic regression analyses were performed to examine the predictors of delayed oral transit time. Lesion location and volume were measured on brain magnetic resonance images. We generated statistic maps of lesions related to delayed oral phase in swallowing using voxel-based lesion symptom mapping (VLSM).ResultsThe group of patients who showed delayed oral transit time had significantly low cognitive function. Also, in a regression model, delayed oral phase was predicted with low K-MMSE (Korean version of the Mini Mental Status Exam). Using VLSM, we found the lesion location to be associated with delayed oral phase after adjusting for K-MMSE score. Although these results did not reach statistical significance, they showed the lesion pattern with predominant distribution in the left frontal lobe.ConclusionDelayed oral phase in post-stroke patients was not negligible clinically. Patients’ cognitive impairments affect the oral transit time. When adjusting it, we found a trend that the lesion responsible for delayed oral phase was located in the left frontal lobe, though the association did not reach significance. The delay might be related to praxis function.

Association between cervical lordotic curvature and cervical muscle cross-sectional area in patients with loss of cervical lordosis: Extensor Weakness in Loss of Cervical Lordosis

Disruption of the cervical lordotic curve can cause undesirable symptoms such as neck pain, and cord compression. The purpose of this study was to investigate the biomechanics of loss of cervical lordosis by measuring the cross‐sectional area (CSA) of the cervical muscles using magnetic resonance imaging (MRI), and to determine the relationship between cervical lordosis angle and cervical muscle status. The cervical lordosis angle was measured on standing lateral plain radiography using the posterior tangent technique in patients who complained of neck pain. The CSAs of the cervical flexor muscles including the longus cervicis and longus capitis, the cervical extensor muscles including the splenius capitis and semispinalis capitis, and the sternocleidomastoid muscle, were measured at the maximum levels by axial T1‐weighted MRI. We compared neck muscle CSAs between the two groups, the correlation with cervical lordosis angle, and muscle status including CSA and imbalance. The CSA of the semispinalis capitis was significantly lower in the loss of cervical lordosis group, and the ratio of cervical flexor to extensor was significantly different between the two groups (P < 0.05). Partial correlation analysis revealed that the cervical lordotic angle was significantly positively correlated with the ratio of flexor to extensor muscle CSAs (P < 0.05). There is a significant relationship between cervical muscle imbalance, including extensor muscle weakness, and loss of cervical lordosis. An exercise program focusing on cervical extensor muscle strengthening and restoring the balance of flexor and extensor muscles is recommended for patients with loss of cervical lordosis. Clin. Anat. 31:710–715, 2018.

Investigating the Dose-Related Effects of Video Game Trunk Control Training in Chronic Stroke Patients With Poor Sitting Balance

Objective To investigate the dose-related effect of trunk control training (TCT) using Trunk Stability Rehabilitation Robot Balance Trainer (TSRRBT) in chronic stroke patients with poor sitting balance. Methods This was a retrospective study of 38 chronic stroke patients with poor sitting balance that underwent TCT with TSRRBT. The participants were assigned either to the low-dose training (LDT) group (n=18) or to the highdose training (HDT) group (n=20). In addition to the conventional rehabilitation therapy, the LDT group received 5 sessions of TSRRBT intervention per week, whereas the HDT group received 10 sessions of TSRRBT intervention per week. The outcome measures were the scores on the Trunk Impairment Scale (TIS) and its subscales, Berg Balance Scale (BBS), Functional Ambulation Classification (FAC), and the Korean version of Modified Barthel Index (K-MBI). All outcome measures were assessed before the training and at the end of the 4-week training. Results After the 4-week intervention, TIS, BBS, FAC, and K-MBI scores showed improvement in both LDT and HDT groups. Furthermore, the improvements in TIS scores and its subscales were significantly greater in the HDT group than in the LDT group (p<0.05). Conclusion TCT using TSRRBT could be an additional treatment for the conventional rehabilitation therapy of chronic stroke patients with poor sitting balance. HDT may provide more beneficial effects on improving patients’ sitting balance than LDT.

Neuroanatomical Mechanism of Cerebellar Mutism After Stroke

Cerebellar mutism (CM) is a rare neurological condition characterized by lack of speech due to cerebellar lesions. CM is often reported in children. We describe a rare case of CM after spontaneous cerebellar hemorrhage. The patient showed mutism, irritability, decreased spontaneous movements and oropharyngeal apraxia. Diffusion tensor imaging revealed significant volume reduction of medial frontal projection fibers from the corpus callosum. In Tracts Constrained by UnderLying Anatomy (TRACULA) analysis, forceps major and minor and bilateral cingulum-angular bundles were not visualized. Cerebello-frontal pathway reconstructed from the FMRIB Software Library showed continuity of fibers, with decreased number of fibers on qualitative analysis. These results suggest that cerebello-frontal disconnection may be a neuroanatomical mechanism of CM. Damage of brain network between occipital lobe, cingulate and cerebellum caused by hemorrhage may also have role in the mechanism of CM in our case.