Yosuke Kudo

Cilostazol versus aspirin therapy in patients with chronic dizziness after ischemic stroke

BACKGROUND Chronic dizziness is frequently reported by patients in the chronic stage after ischemic stroke. The aim of this study was to determine the efficacy of cilostazol versus that of aspirin for the chronic dizziness that follows ischemic stroke. METHODS We performed a prospective, randomized, open-label, blinded endpoint trial. One hundred six patients who suffered supratentorial ischemic stroke within the previous 1-6 months and subsequently complained of persistent dizziness without other obvious sequelae were enrolled. Patients were randomly given cilostazol (200mg/day) or aspirin (100mg/day) for 6 months. Rates of improvement in the dizziness were then evaluated. Changes in fixation suppression of the vestibulo-ocular reflex (an indicator of cerebral control over the brainstem reflex related to balance), regional cerebral blood flow (CBF) in the cerebrum, cerebellum, and brainstem; and the Zung Self-Rating Depression Scale (SDS) were also evaluated. RESULTS Dizziness was significantly improved in the cilostazol group versus the aspirin group (P<0.0001) after the 6-month therapy. The capacity for fixation suppression of the vestibulo-ocular reflex was improved (P<0.0001), and regional CBF in the cerebrum (relative to that in the brainstem [P=0.003] and to that in the cerebello-brainstem [P=0.012]) was increased only in the cilostazol group. There was no statistical difference in the change in SDS scores between the two groups. CONCLUSION Cilostazol improves the chronic dizziness that follows ischemic stroke and increases supratentorial CBF and cerebral function for adaptation of the brainstem reflex related to the sense of balance.

Isolated unilateral oculomotor paresis in pure midbrain stroke.

BACKGROUND AND PURPOSE Pure midbrain stroke can cause isolated unilateral oculomotor paresis. We attempted to determine whether there is a difference in the oculomotor paresis pattern between pure midbrain infarction and midbrain hemorrhage. METHODS Pure midbrain stroke patients who presented with isolated unilateral oculomotor paresis were identified from a group of 2447 consecutive patients hospitalized for acute cerebral infarction or hemorrhage during the period May 2008 through April 2014. Detailed oculomotor findings were evaluated in the identified patients per the cause of the stroke. RESULTS Five patients with infarct and 1 with hemorrhage became our study subjects. Lesions were located in the paramedian area of the midbrain involving the oculomotor fascicles. The pupillary sphincter and inferior rectus muscles were selectively spared in the infarct patients, whereas these muscles were selectively affected in the hemorrhage patient. CONCLUSION Fibers in the oculomotor fascicle that innervate the levator palpebrae, superior rectus, and inferior oblique muscles appear to be more susceptible to ischemic damage than those that innervate the pupillary sphincter and inferior rectus muscles. Isolated impairment of the pupillary sphincter and inferior rectus muscles may be suggestive of a non-ischemic process.

Spinal cord infarction with cervical angina

Cervical angina is defined as chest pain resembling true cardiac angina but originating from disorders of the cervical spine. Cervical angina is caused by cervical spondylosis in most cases. A 66-year-old man presented with bilateral arm palsy after chest pain resembling angina pectoris. Neurological examination revealed motor and sensory disturbances of the C7 to T1 level, and magnetic resonance imaging showed a hyperintense spinal cord lesion on T2-weighted imaging. Spinal cord infarction was diagnosed. Severe sinus bradycardia was identified on admission, and improved over the course of 5 weeks. Sympathetic afferent fibers from the heart and coronary arteries generally have their cell bodies in the dorsal root ganglia of the C8 to T9 spinal segments. Electrical stimulation of cardiopulmonary afferent fibers excites spinothalamic tract cells in the T1 to T6 segments of the spinal cord. Spinal cord injury can result in the loss of supraspinal control of the sympathetic system and can cause bradycardia, as commonly seen in patients with severe lesions of the cervical or high-thoracic (T6 or above) spinal cord. Bradycardia in the present case suggested impairment of the sympathetic system at the cervical and thoracic levels. These findings indicated that cervical angina in this case was mediated through the sympathetic nervous system. This represents only the second report of cervical angina caused by spinal cord infarction.

Spontaneous, headshaking, and positional nystagmus in post-lateral medullary infarction dizziness

BACKGROUND AND PURPOSE Lateral medullary infarction (LMI) sometimes causes long-lasting dizziness. However, the characteristics of nystagmus in patients with post-LMI dizziness are unknown. We undertook a prospective, comparative study of nystagmus in patients with and without post-LMI dizziness to determine the characteristic pattern of nystagmus of chronic post-LMI dizziness. METHODS We evaluated and compared nystagmus under spontaneous, head-shaking, and positional testing conditions in 12 patients with post-LMI dizziness and in 6 patients without post-LMI dizziness. RESULTS In the dizziness group, contralateral spontaneous nystagmus, ipsilateral head-shaking nystagmus, and horizontal direction-changing geotropic positional nystagmus were observed in patients in whom the LMI had occurred <60days previously (subacute period). In patients with dizziness in whom the LMI had occurred >90days previously (chronic period), the nystagmus was ipsilateral under all conditions. In the non-dizziness group, ipsilateral nystagmus was observed in 1 of the 2 subacute patients only after head-shaking and in 1 of the 4 chronic patients only during positional testing. CONCLUSIONS Ipsilateral nystagmus observed under all spontaneous, head-shaking, and positional testing conditions characterizes chronic post-LMI dizziness.

An Aerodynamic Study of Phonations in Patients With Parkinson Disease (PD)

BACKGROUND The precise comparison of the voice characteristics of Parkinson disease (PD) patients with age-matched normal subjects is still one of the important research projects. The present study aimed at comparing the voice characteristics in sustained phonations of PD patients with an age-matched control group. METHODS The subjects were 30 Japanese PD patients (15 males and 15 females). The control group consisted of 30 age-matched normal Japanese subjects (15 males and 15 females). Each subject was required to phonate into a mouthpiece attached to Vocal Function Analyzer (PS-77E; Nagashima Medical Instrumental Corporation, Tokyo, Japan) with the airway interruption system, and expiratory lung pressure, mean flow rate, fundamental frequency and intensity of voice, and pitch range were measured. Maximum phonation time was also assessed. RESULTS The highest pitch level was significantly lower in the PD group than that of the control group in both sexes, whereas the lowest pitch level was significantly higher in the PD group only in males. In both sexes, the pitch range was significantly narrower in the PD group than in the control group. There was no significant difference in intensity, mean flow rate, expiratory pressure, or maximum phonation time between the two groups, for both males and females. CONCLUSION Only remarkable difference in the voice characteristics between PD patients and age-matched normal elderlies was limited to the narrowing of the pitch range in PD patients. The restriction in pitch regulation in PD patients was considered to be because of difficulty in reciprocal control of the laryngeal muscles secondary to latent rigidity.

Wrong-way deviation: Contralateral conjugate eye deviation in acute supratentorial stroke

BACKGROUND AND PURPOSE Supratentorial stroke can cause conjugate eye deviation directed contralateral to the affected side (wrong-way deviation). It is rare and thought to be associated exclusively with hemorrhagic stroke. We prospectively investigated the clinical features and prognostic significance of this wrong-way deviation. METHODS Subjects were 12 patients who manifested wrong-way deviation subsequent to supratentorial stroke. These patients were from a group of 968 consecutive patients hospitalized for acute supratentorial stroke during the period April 2007 through March 2010. Clinical features of wrong-way deviation were evaluated. RESULTS The overall incidence of wrong-way deviation was 1.2%. The causative lesion was a huge intracranial hemorrhage (n=7) or an extensive hemispheric infarction (n=5). Left-sided lesions were most frequent (66.7% of patients). Wrong-way deviation usually appeared a few days after the initial insult and was frequently accompanied by transient downward eye deviation (58.3% of patients). Although the outcomes for patients treated conservatively were generally poor, patients who underwent surgical decompression regained consciousness. CONCLUSION Wrong-way deviation can result not only from hemorrhagic but also ischemic stroke if the stroke is extensive. Secondary damage to the adjacent rostral brainstem where oculomotor pathways cross over from the contralateral hemisphere can explain the phenomenon, its temporal evolution, and associated eye signs. Immediate surgical decompression may be necessary to improve the prognosis in such cases.

Vestibular examinations in apogeotropic positional nystagmus caused by cerebellar tumor

Horizontal, direction changing apogeotropic positional nystagmus (HAPN) is known to be associated with cerebellar lesions [1]. However, the pathophysiologic mechanism of cerebellar HAPN is unknown. We encountered a patient with a metastatic cerebellar tumor who presented with HAPN that disappeared after tumorectomy. Hyperactive vestibular reflexes, indicated by the results of electrophysiologic examinations, might have been the mechanism underlying the HAPN in this patient. A 70-year-old woman with a 2-month history of progressive dizziness and difficulty in walking was admitted to our hospital. She presented with truncal ataxia and HAPN but no other neurologic or neuroophthalmologic abnormalities. Contrast brain MRI revealed a well-enhanced cerebellar tumor. Because chest X-ray and CT showed a left lung tumor suggestive of lung cancer, a cerebellar metastasis was diagnosed. The cerebellar tumor was removed surgically 10 days after the patient’s admission. Pathologic examination of the surgical specimen revealed adenocarcinoma. After the tumorectomy, the HAPN was fully resolved, and the truncal ataxia was improved. The horizontal angular vestibulo-ocular reflex (A-VOR), cervical vestibular-evoked myogenic potential (C-VEMP), and ocular vestibular-evoked myogenic potential (O-VEMP) were evaluated before (when the HAPN was present) and 10 days after tumorectomy (when the HAPN had disappeared). A-VORs were recorded in darkness by means of a video-oculography-basedVORrecording and analysis system (IRN-2, Morita Mfg. Corp., Kyoto, Japan), with the patient seated on a rotating armchair with a headrest [2]. The chair was rotatedmanually in sinusoidal fashion for 20 s (frequency 0.5–0.75 Hz, amplitude 20 ) [2]. VOR gain, i.e., the eye velocity to head velocity ratio, was analyzed. C-VEMP was recorded from the tonically contracting ipsilateral sternocleidomastoid muscle during monaural stimulation with 105-dB clicks or short tone bursts (MEB 2312 testing system, Nihon Kohden, Tokyo, Japan; bandwidth 20–2,000 Hz, 200 averaged signals). Latencies of the first positive wave (p13) and second negative wave (n23) and peak-to-peak p13–n23 amplitude were measured. O-VEMP was recorded from the lower eyelids (inferior oblique muscles) during stimulation with 105 dB clicks or short tone bursts (MEB 2312, Nihon Kohden, Tokyo, Japan; bandwidth 20–2,000 Hz, 200 averaged signals). The patient was instructed to continue looking straight ahead and upward 30 . Because O-VEMP was not adequately elicited by monaural stimulation, binaural sound stimulation was applied. Latencies of the first negative wave (n1) and second positive wave (p1) and peak-to-peak n1–p1 amplitude were measured. Absolute A-VOR gains were reduced in both directions after the tumorectomy (Table 1). Cand O-VEMP amplitudes were also reduced on almost all recordings after tumorectomy (Table 1). Latencies of Cand O-VEMPs did not change. A-VOR is mediated by a semicircular-ocular pathway. C-VEMP reflects the vertical linear vestibulo-ocular reflex Electronic supplementary material The online version of this article (doi:10.1007/s10072-015-2086-4) contains supplementary material, which is available to authorized users.

Bedside evaluation of smooth pursuit eye movements in acute sensory stroke patients

BACKGROUND AND PURPOSE Unilateral saccadic pursuit is reported to be suggestive of a pontine lesion in sensory stroke patients. We attempted to verify this eye sign in just-hospitalized pontine sensory stroke patients. METHODS Horizontal smooth pursuit eye movements were evaluated upon hospital arrival in 4 pontine sensory stroke patients and were compared with those in 6 thalamic sensory stroke patients. Eye movements were evaluated with the patient lying down on the emergency room or stroke care unit bed by means of a newly developed video-oculography-based eye movement recording system equipped to project a moving laser pointer onto the ceiling. RESULTS Laterality of horizontal smooth pursuit gain in pontine sensory stroke patients was evident upon arrival; in thalamic sensory stroke patients, horizontal smooth pursuit gain was equal in both directions. These characteristics were easily detected at bedside. CONCLUSION Unilateral saccadic pursuit in pontine sensory stroke patients may be a practical diagnostic sign that can be detected even in the emergency room. The video-oculography-based recording system equipped to project a moving laser pointer onto the ceiling may be useful for detecting this eye sign.

Gaze palsy and exotropia in internuclear ophthalmoplegia

BACKGROUND AND PURPOSE Unilateral gaze palsy associated with internuclear ophthalmoplegia (INO), i.e., one-and-a-half syndrome, is well known. Exotropia can also be associated with INO, but it has been reported only rarely. We sought to determine the frequencies and courses of gaze palsy and exotropia in INO. METHODS Patients hospitalized with acute-onset INO during the period January 2009 through December 2013 were identified from our clinical registry. Associated gaze palsy and exotropia were evaluated in the identified patients. RESULTS Twenty-five patients with unilateral INO and 7 patients with bilateral INO were included in this study. Of the 25 patients with unilateral INO, 4 (16.0.0%) had ipsilateral gaze palsy (one-and-a-half syndrome), 8 (32.0%) had exotropia (non-paralytic pontine exotropia), and 6 (24.0%) had both ipsilateral gaze palsy and exotropia (paralytic pontine exotropia). Six (85.7%) of the 7 patients with bilateral INO had exotropia. The gaze palsy persisted more than 1 week in 40.0% of patients, whereas the exotropia disappeared within 1 week in 92.9% of patients when the INO was unilateral. CONCLUSION Exotropia is not uncommon in the acute stage of INO. However, it is often overlooked because of its short duration.

Dementia and capsular genu ischemia in patients with severe bacterial meningitis

Infarction in the genu of the internal capsule causes dementia that is characterized by abulia, lethargy and memory loss without obvious motor palsy (capsular genu syndrome). We found infarction or decreased cerebral blood flow in the genu of the internal capsule in 6 of 13 patients with severe bacterial meningitis. Four of these six patients developed post-meningitis dementia, characterized by abulia, lethargy, and memory loss. Of 24 patients with viral meningitis, none developed capsular genu ischemia or post-meningitis dementia. In patients with severe bacterial meningitis, capsular genu ischemia may play some role in the development of post-meningitis dementia. In patients with viral meningitis, absence of such ischemia may explain, at least in a part, the rarity of post-meningitis dementia.