Ib R. Odderson

Motor cortex activation is preserved in patients with chronic hemiplegic stroke

Many central nervous system conditions that cause weakness, including many strokes, injure corticospinal tract but leave motor cortex intact. Little is known about the functional properties of surviving cortical regions in this setting, in part because many studies have used probes reliant on the corticospinal tract. We hypothesized that many features of motor cortex function would be preserved when assessed independent of the stroke‐affected corticospinal tract. Functional MRI was used to study 11 patients with chronic hemiplegia after unilateral stroke that spared regions of motor cortex. Activation in stroke‐affected hemisphere was evaluated using 3 probes independent of affected corticospinal tract: passive finger movement, a hand‐related visuomotor stimulus, and tapping by the nonstroke index finger. The site and magnitude of cortical activation were similar when comparing the stroke hemisphere to findings in 19 control subjects. Patients activated each of 8 cortical regions with similar frequency as compared to controls, generally with a smaller activation volume. In some cases, clinical measures correlated with the size or the site of stroke hemisphere activation. The results suggest that, despite stroke producing contralateral hemiplegia, surviving regions of motor cortex actively participate in the same proprioceptive, visuomotor, and bilateral movement control processes seen in control subjects.

Hyperhidrosis Treated by Botulinum A Exotoxin

background. Hyperhidrosis, or excessive sweating, can be emotionally challenging and socially and professionally disruptive, and there have been few effective treatments. Recently, botulinum toxin has been demonstrated to be an effective treatment for hyperhidrosis of the axillae and palms and for gustatory sweating. objective. This article reviews the current treatments and outcomes achieved with chemodenervation of the eccrine sweat glands. results. The antihydrotic response lasted 6–17 months for gustatory sweating, 2–8 months for axillary sweating, and 13 weeks to 12 months for palmar sweating. conclusions. Intracutaneous injections of botulinum toxin offer a simple, safe, and effective alternative to other conservative and surgical options.

Brain Function Early after Stroke in Relation to Subsequent Recovery

This study aimed to characterize brain activation and perfusion early after stroke within cortical regions that would later change activation during recovery. Patients were studied serially after stroke (mean t1, = 16 days after stroke, t2 = 3.5 months later) using perfusion-weighted imaging and functional magnetic resonance imaging during finger movement. Controls (n = 7) showed no significant change in regional activation volumes over time. Among stroke patients (n = 8), however, recovery was accompanied by several patterns of functional magnetic resonance imaging change, with increased activation volumes over time in five patients and decreased in two. Most regions increasing activation over time were in the stroke hemisphere. Of the five patients showing increased activation over time, specific activation foci enlarged at t2 were already activated at t1 in four patients, and at least one focus growing from t1 to t2 was in a different arterial distribution from the infarct in all five patients. Perfusion of sensorimotor cortex at t1 was generally not reduced in the stroke hemisphere (94% of noninfarcted hemisphere). Improved clinical outcome was related to increased activation within sensory cortices of both brain sides, including bilateral secondary somatosensory areas. Early after stroke, cortical activation that will later increase in parallel with recovery is often already identifiable, can be remote from the vascular territory of the infarct, and is not likely hindered by reduced perfusion. The findings may be useful for restorative interventions introduced during the weeks after a stroke.

Development of a short form and scoring algorithm from the validated actionable bladder symptom screening tool

BackgroundThe majority of multiple sclerosis (MS) patients develop some form of lower urinary tract dysfunction, usually as a result of neurogenic detrusor overactivity (NDO). Patients identify urinary incontinence as one of the worst aspects of this disease. Despite the high prevalence of NDO, urological evaluation and treatment are significantly under-accessed in this population. The objectives of this study were: 1) to adapt the previously validated Actionable Bladder Symptom Screening Tool (ABSST) to a short form for ease and brevity of application in a clinical setting that is clinically meaningful; and 2) to develop a scoring algorithm that would be interpretable in terms of referring/considering precise diagnosis and treatment.MethodsA US-based, non-randomized, multi-center, stand-alone observational study was conducted to assess the psychometric properties of the ABSST among patients who have MS with and without NDO. Mixed psychometric methods (e.g., classical statistics (Psychometric theory (3rd ed.). New York: McGraw-Hill; 1994) and item response methods (Applying the Rasch Model: Fundamental Measurement in the Human Sciences. New Jersey: Lawrence Earlbaum Associates; 2001)) were used to evaluate the predictive and clinical validity of the shortened form. The latter included clinicians flagging clinically meaningful items and associated response options which would indicate the need for further evaluation or treatment.ResultsA total of 151 patients, all with MS and with and without NDO, were recruited by 28 clinicians in various US geographical locations. Approximately 41% of patients reported a history of or currently having urinary incontinence and/or urinary urgency. The prediction model across the entire range of classification thresholds was evaluated, plotting the true positive identification rate against the false positive rate (1-Specificity) for various cut scores. In this study, the cut-point or total score of greater than or equal to 6 had a sensitivity of approximately 85%, and specificity of approximately 93% (i.e., 85% patients would warrant being referred to a urologist and 93% of the patients whose symptoms would not warrant urologist referral).ConclusionsOverall the short form ABSST demonstrated sensitivity and specificity as it maintained the integrity of the longer form tool. Concurrent validity for each subscale as well as predictive and concurrent validity of the total shortened instrument was demonstrated. This instrument provides a new method for assessing bladder problems among MS patients, and may facilitate earlier and more precise diagnosis, treatment, and/or referral to a specialist.

OnabotulinumtoxinA Injection for Poststroke Upper-Limb Spasticity: Guidance for Early Injectors From a Delphi Panel Process

OnabotulinumtoxinA reduces muscle hypertonia associated with poststroke spasticity (PSS). PSS manifests as several common postures.

OnabotulinumtoxinA for Lower Limb Spasticity: Guidance From a Delphi Panel Approach

OnabotulinumtoxinA is approved for the treatment of upper and lower limb spasticity in adults. Guidance on common postures and onabotulinumtoxinA injection paradigms for upper limb spasticity has been developed via a Delphi Panel; however, similar guidance for lower limb spasticity has not been established.

Use of Sonography in Thoracic Outlet Syndrome Due to a Dystonic Pectoralis Minor

Objective. For patients with thoracic outlet syndrome (TOS), it is important to determine the location of the neurovascular compression to achieve effective intervention. Methods. The diagnostic workup for a 39‐year‐old man with TOS included a selective anesthetic block of the pectoralis minor muscle and duplex sonography before and after the block. Results. The subclavian artery peak systolic flow velocity decreased after the block from 208 to 63 cm/s when the arm was in the abduction and external rotation position, indicating a reduction in the severity of focal arterial compression. Also, the arterial diameter increased by 10% after the block (from 0.80 to 0.88 cm). His level of discomfort was reduced from 6 to 2 on a scale of 1 to 10 (66%). Conclusions. The pectoralis minor block resulted in an improvement in subclavian artery blood flow and symptoms and confirmed the diagnosis of pectoralis minor TOS. This suggests that selective anesthetic muscle blocks and duplex sonographic studies may be useful before chemodenervation and surgery.

Hypoglycemic coma associated with brain infarcts

Hypoglycemic hemiplegia may lead to a mistaken diagnosis of stroke, although the symptoms resolve with correction of the hypoglycemia. We report a 27-year-old white man with insulin-dependent diabetes who developed right hemispheric infarcts and left hemiplegia associated with hypoglycemic coma. This report discusses the possible role of hypoglycemia in causing the stroke.

Stroke in the spinal cord injured.

Advances in treatment of patients with spinal cord injury (SCI) have contributed to prolongation of their life expectancy. As a result, this population is becoming more prone to the diseases commonly associated with advanced age and a sedentary lifestyle. The purpose of this study was to test the hypothesis that the SCI population has an increased incidence of stroke, and to identify stroke risk factors unique to SCI patients. A retrospective, computer assisted medical chart review of all admissions from 1980 to 1990 was conducted. Of more than one thousand patients who had a stroke and two thousand paraplegic/quadriplegic patients, we identified only two instances involving stroke in patients with traumatic SCI. We conclude that the SCI population does not appear to have a higher incidence of stroke, although further prospective studies involving a larger patient population are recommended. Possible protective factors and causes for under-reporting stroke in the SCI population are discussed.

Treatment of hyperhidrosis and drooling with botulinum exotoxin.

The treatment of focal hyperhidrosis and drooling with neurolysis of the neuroglandular junction is a relatively new and useful technique for managing such obvious conditions and improving the patients quality of life. The treatment is safe, minimally invasive, and an effective alternative to other treatment modalities.